Commission For Health Improvement Research Articles

Frank Dobson: Labour politician who became “best UK health secretary since Aneurin Bevan”

Photo credit: Glenn Corpus/Shutterstock Frank Dobson was the first Labour health secretary for nearly 20 years when Tony Blair appointed him after the landslide general election victory of 1997. He...

The effect of costs on quality of care

by the Healthcare Commission’s predecessor—the Commission for Health Improvement. Amid austerity elsewhere in the public sector, the CQC has been one of the few public bodies actively recruiting for expansion. Now, amid an overall promise to protect NHS spending and inject at least an extra £8 billion over the next few years, the CQC has been asked, like most of the rest of the public sector, to model cuts of 25 % and 40 % in its funding, even as its remit for hospital inspections is being broadened to take into account not just the quality of care being provided, but how well the hospital uses its resources—territory that overlaps with what we must not learn to call NHS Improvement (the old Monitor and Trust Development Authority). In other words, the pendulum of inspection is swinging once again. A 25 % cut, let alone a 40 % one, will mean, inevitably, fewer inspectors and more reliance on data for riskassessment, although the distinction should not be taken too far. The CQC quizzes plenty of data. The cuts, of course, may not be as bad as that, but if they are on anything like that scale, one has to have sympathy for anyone trying to run an organisation whose size goes in and out like a concertina, and whose role in life is so subject to political fashion— jumping from a demand for more inspection to less inspection to more and back again. At the heart of this is a lack of clarity first from Labour, then from the coalition, and now from the Conservatives about exactly what they expect inspection to achieve, and over how it should be done. Clearly, inspection is meant to stop bad things happening, but beyond some very basic levels of health and safety, it is not clear that inspectors do that. Values and culture within organisations are far more important and they are notoriously hard to inspect on a consistent external basis. An ability to intervene when bad things come to light is clearly needed, but is routine inspection the way to prevent them in the first place? There is a real conundrum here, which governments appear still to be a long way from solving. So the pendulum swings without it being entirely clearly quite what is being achieved—and whether spending more money on this, or less money, alters the quality of care for those receiving the service. It looks as though the CQC is about to go around that course again. BJHCM Nick Timmins, senior fellow at the Institute for Government and the King’s Fund, asks what effect the cuts to the Care Quality Commission may have. The effect of costs on quality of care

Consumer satisfaction with private child and adolescent mental health services in Buenos Aires

The assessment of consumer satisfaction (CS) in child and adolescent mental health services (CAMHSs) is becoming more important due to the increasing emphasis on consumer involvement in mental health services. The majority of the research has been carried out in high income countries (HICs), such as the UK, however, and there is a distinct lack of similar research in low and middle income countries (LMICs), such as Argentina. This is typical of mental health research more generally (the so-called 10/90 Gap, e.g. Saxena, Paraje, Sharan, Karam, & Sadana, 2006). The aims of this study were as follows: 1) Test the viability of carrying out a CS study outside of the HIC context by transferring the methodology of a UK based study (Barber, Tischler & Healy, 2006) to Argentina. 2) Introduce an original Spanish version of the self-report, English Experience of Service Questionnaire (Commission For Health Improvement, 2001). 3) Generate findings about CS in Argentina, of relevance to this context. Specifically, to explore the relationship between young persons' symptoms and their satisfaction with three private CAMHSs in Argentina, and examine the relationship between CS and the age of the children and adolescents, the types of problems with which they presented, and the impact of these problems. Data were elicited from participants using the new Spanish ESQ. In the three CAMHSs which participated, the practice of seeking user feedback was found to be viable, with sufficient data gathered for analysis to provide meaningful results. The Spanish ESQ was also found to be a viable measure, with satisfactory internal reliability and no difficulties for participants in completing the instrument. Specific findings about CS in the Buenos Aires CAMHSs showed that while high levels of CS were reported for all groups, they were significantly higher for parents than for children and adolescents. There were no significant differences found in CS for different age groups. Children and adolescents who reported behavior problems were less satisfied with CAMHSs, as were those who rated their problems as having a significant impact on their lives. Also, those parents who reported their child as having behavioral problems and lack of pro-social behaviors showed lower levels of CS. The results highlight the viability of CS research in LMIC CAMHSs, the viability of the Spanish ESQ, and the need to address those areas of lower satisfaction revealed by the study by exploring further the needs and expectations of young people and their parents who present behavioral problems in order to improve the quality of CAMHSs. Further research should also extend this small sample of the Argentine child mental health services by carrying out similar studies in other private sector services, other geographical regions and also in the public sector, where findings (along with the expectations of users) may differ.

A Successor Body to the Mental Health Act Commission

<p>“The Mental Health Act Commission (MHAC) has a major role in protecting the interests of patients<br />who are subject to the provisions of the 1983 Act. Its principal functions are to:<br />• appoint Second Opinion Appointed Doctors<br />• review treatments given under sections 57(2) or 58(3)(b) of the Act, ie treatment that requires a second opinion<br />• visit detained patients and investigate complaints<br />• keep under review the exercise of statutory powers relating to detained patients<br />• submit proposals for a code of practice<br />• look into matters relating to informal patients, when directed to do so by the Secretary of State,<br />and<br />• report to the Secretary of State every two years on the operation of the Act.”</p><p>This is the summary of the functions of the MHAC contained in the Green Paper on Reform of the Mental Health Act 1983. In this brave new world of the Modern NHS, with much enhanced arrangements for local quality assurance and clinical governance, the Commission for Health Improvement, the Commission for Care Standards, the National Institute for Clinical Excellence, the establishment of Patient Advocate and Liaison Services, and the numerous other ways of increasing patient participation which are outlined in the National Plan for England, is a successor body to the Mental Health Act Commission really necessary ?</p>

Service user satisfaction with individual psychotherapy for people with intellectual disabilities

Purpose – Psychological therapies are increasingly being made available to adults with intellectual disabilities. However, little is known about service user satisfaction with this type of intervention. The aim was to ascertain quantitative and qualitative data on user satisfaction with the psychological therapy they had received. Design/methodology/approach – In total, 20 recipients of psychological therapy completed the Satisfaction with Therapy and Therapist Scale – Revised (STTS-R; Oei and Shuttleword, 1999) and the Experience of Service Questionnaire (Commission for Health Improvement, 2002). The scales were adapted for language and administered in an assisted completion format by an independent researcher after a course of psychological therapy had been completed. Descriptive statistics were used to analyse the quantitative data and thematic analysis was used to analyse the qualitative data. Findings – Generally, recipients were highly satisfied with their therapist and the therapy they received. Originality/value – The results confirm previous findings from two small-scale qualitative studies. Service user satisfaction is a key quality outcome measure and can be collated in routine practice for people with intellectual disabilities. The collation of qualitative responses in addition to quantitative measures is important to enable the expression of dissatisfaction and greater detail in order to inform service improvement.

Mental health services accreditation in Italy

This paper deals mainly with health services peer accreditation in Italy, but a preliminary brief description of governmental accreditation is done, inasmuch as peer initiatives must take into account - and build upon - institutional accreditation requirements and practices. In Italy, no independent agency, such as the 'Commission for Health Improvement' or the 'Health Advisory Service' is operating. In the field of mental health services, two major peer accreditation programmes have been carried out. The paper focuses on the most original features of both programmes and reports examples of standards belonging to the more recent accreditation manual. In the manual, because of a lesser need to reach a consensus between services with widely different outlook, professional standards are more detailed and the importance that they should be based on the principle of evidence-based mental health is more stressed. The Italian peer accreditation approach in mental health may raise interest also in other countries.

Changing paradigms of governance and regulation of quality of healthcare in England

This paper outlines the way in which professional self regulation of quality of healthcare was integral to the creation of the National Health Service (NHS) in 1948, and to the way the NHS was organized for the next 50 years. It describes the crisis in quality that emerged in the late 1990s. It describes the government's initial responses to that crisis, which were to require NHS organizations to implement systems of clinical governance, and create the Commission for Health Improvement (CHI) to inspect its implementation through visits to each NHS organization. The paper discusses Reports from Inquiries into three scandals, and considers the further changes made to governance and regulation of quality with the abolition of CHI and the National Care Standards Commission, which inspected the private sector, to be succeeded by the Healthcare Commission with a new approach to regulation. It examines three promises of that new approach: the use of national standards; being ‘light touch’ and proportionate using ‘intelligent’ (or ‘smart’) information, as opposed to being organized on a comprehensive programme of visits; and developing a common approach to the NHS and private sectors.

Gathering data for health care regulation: learning from experience in England and Wales

Between 2000 and 2004, the Commission for Health Improvement (CHI) undertook a comprehensive programme of reviews of progress with clinical governance in National Health Service trusts (provider organizations) in England and Wales. An internal retrospective evaluation of the main instruments and processes used to gather evidence for these reviews was undertaken to identify lessons for the future development of health care regulation methods. A multimethod retrospective study involving review of data-gathering tools previously undertaken by CHI, an intranet-based survey and confidential interviews with CHI staff. The study reviewed 11 instruments and processes used to gather information about trusts from routine data-sets, internal documents, staff, patients and the public, local statutory bodies, and community and voluntary stake-holders. Analysis focused on inputs required (skills and resources required to use the approaches effectively and challenges associated with their use) and value obtained (relevance and quality of the information obtained and its contribution to clinical governance review conclusions). Most of the instruments and processes evaluated had the potential to elicit worthwhile information for clinical governance reviews, but in practice their value varied considerably. A range of factors, within and beyond CHI, was found to affect the quality of the data obtained. Based on this learning, lessons are identified whose implementation would help optimize the quality of data gathering for health care regulation.

Structure and logic of regulation and governance of quality of health care: was OFSTED a model for the Commission for Health Improvement?

The Labour Government elected in 1997 faced similar problems in health care to those faced by the Conservative Government in schools in the early 1990s. And the policies developed for health care in the late 1990s echoed those that had been implemented for schools. This paper considers one of those common policies, namely the creation of new central inspectorates required to visit all organizations over a four-year period: the Office for Standards in Education (OFSTED) to inspect the quality of teaching in schools, and the Commission for Health Improvement (CHI) to review the implementation of the systems and processes of clinical governance in every organization in the National Health Service (NHS). At its creation, CHI was described as an OFSTED for the NHS. This paper compares these two inspectorates; describes origins of policies and institutions; considers their rhetoric and practices; describes the processes the two organizations used and considers their impacts. It argues that structural differences meant that CHI could never have been an OFSTED for the NHS; relational distance is a key aspect of inspection/regulation; and that the key to effective regulation in the case of the NHS was the relational proximity between CHI and the NHS, with the added weight of a strong performance management regime.

The professional status of psychiatrists: good but not great

There are concerns in Britain about the recruitment and retention of medical doctors, especially psychiatrists ([Commission for Health Improvement, 2003][1]). One potential explanation is that the profession of psychiatry is stigmatised ([Mears et al , 2004][2]) and neglected - mental health is

Learning from regulatory interventions in healthcare

PurposeThis paper aims to present the findings from research commissioned by the Commission for Health Improvement (CHI), which set out to examine the impact of CHI's clinical governance reviews on NHS trusts in England.Design/methodology/approachThis paper, giving a stratified random sample of 30 NHS trusts, was taken from a set of 75 trusts reviewed by CHI during a period from 2001 to 2003. Documents from these trusts' reviews were analysed. A postal questionnaire was sent to key stakeholders with an involvement or direct interest in each trust's review. Semi‐ structured telephone interviews were held with five to six people from each of four trusts selected as case studies.FindingsIn this paper the clinical governance review process was characterized by wide variability in methods, application and effects, in the initial CHI visit and report, and the subsequent NHS trust action plan and SHA progress review. The recommendations made by reviews for change in an NHS trust were often of a nature or expressed in terms, which made measuring their subsequent implementation and impact problematic. CHI recommendations concentrated on management and support processes rather than on direct patient care and outcomes. Trusts were generally willing to accept and then enact CHI review recommendations.Practical implicationsThe paper concluded that a more focused and controlled review process would support greater change and improvement. There was evidence to suggest that this kind of regulatory intervention can have largely positive impacts on the organisational performance of NHS trusts, although these positive effects were mainly indirectly related to the delivery of patient care and health improvement. Any future review or inspection processes should place a greater focus upon patient outcomes if such reviews are to demonstrate their value in making a contribution to improving health.Originality/valueThe paper shows that, internationally, there have been few empirical studies analysing the work of health care regulators and their impact on the organisations they regulate. While the work of CHI has been examined by others, this study is the first empirical and largely quantitative analysis of CHI's regulatory regime and its impact within the English NHS. The article is also published at a time when there is much debate about regulatory functions and forms for health and social care.

Assessment for improvement: Healthcare Commission consults on new approach

The Healthcare Commission has announced its proposed new approach to assessing the performance of health-care organizations in England and that 2005 will be the last year of Star Ratings. The Healthcare Commission (Commission for Healthcare Audit and Inspection, or CHAI) was established under the Health and Social Care (Community Health and Standards) Act 2003 and came into existence in April 2004. It is a new body and took over the functions of Commission for Health Improvement (CHI), the Mental Health Act Commission and some value-for-money studies of the Audit Office.

Learning from Rowan ward ‐ developing an audit tool to improve the systems and processes for quality of care and safety of service users

A report by the Commission for Health Improvement into alleged poor care provided the stimulus for the development of an audit tool in a strategic health authority to assess and improve systems and processes of care.

NICE and the public health

Although NICE was established in 1999 [1], its origins go back to two earlier government ‘white papers’[2, 3]. These outlined plans to establish, within the National Health Service (NHS), two new bodies: the National Institute for Clinical Excellence (NICE) to set clinical standards, and the Commission for Health Improvement (CHI) to monitor the performance of NHS organizations in relation to their responsibilities for clinical governance. Failure to incorporate (or ‘translate’) the results of clinical research into routine care has become a global problem. As a consequence there are: inappropriate variations in clinical practice inconsistent access to treatments of established clinical and cost effectiveness (so-called ‘postcode prescribing’) failure to adopt new practices of proven clinical and cost effectiveness failure to discontinue old practices of proven clinical or cost ineffectiveness. The apparent global underachievement, by health professionals, is not due to perversity but to three interrelated problems. First, the clinical community is exposed to an explosion of knowledge about best clinical practice, to the extent that it has now become impossible for a single individual to keep up-to-date. Second, the essential infrastructure needed to support high-quality care (particularly, but not exclusively, in the NHS) has too often been unavailable. And, third, health professionals face apparently irreconcilable tensions between quality and efficiency, equity and choice, and demand and resource. The creation of NICE was the British solution to resolving this difficulty. The Institute was formed, in 1999, with one fundamental aim [1]: ‘To provide health professionals in England and Wales with advice on securing the highest attainable standards of care for National Health Service patients’. Scotland, with its devolved administration, has established its own arrangements although there are close, and effective, interactions with the Institute. Northern Ireland adopts NICE guidance but does not, as yet, have a formal relationship with the Institute.

Achieving progress through clinical governance? A national study of health care managers' perceptions in the NHS in England.

A national cross sectional study was undertaken to explore the perceptions concerning the importance of, and progress in, aspects of clinical governance among board level and directorate managers in English acute, ambulance, and mental health/learning disabilities (MH/LD) trusts. A stratified sample of acute, ambulance, and mental health/learning disabilities trusts in England (n = 100), from each of which up to 10 board level and 10 directorate level managers were randomly sampled. Fieldwork was undertaken between April and July 2002 using the Organisational Progress in Clinical Governance (OPCG) schedule to explore managers' perceptions of the importance of, and organisational achievement in, 54 clinical governance competency items in five aggregated domains: improving quality; managing risks; improving staff performance; corporate accountability; and leadership and collaboration. The difference between ratings of importance and achievement was termed a shortfall. Of 1916 individuals surveyed, 1177 (61.4%) responded. The competency items considered most important and recording highest perceived achievement related to corporate accountability structures and clinical risks. The highest shortfalls between perceived importance and perceived achievement were reported in joint working across local health communities, feedback of performance data, and user involvement. When aggregated into domains, greatest achievement was perceived in the assurance related areas of corporate accountability and risk management, with considerably less perceived achievement and consequently higher shortfalls in quality improvement and leadership and collaboration. Directorate level managers' perceptions of achievement were found to be significantly lower than those of their board level colleagues on all domains other than improving performance. No differences were found in perceptions of achievement between different types of trusts, or between trusts at different stages in the Commission for Health Improvement (CHI) review cycle. While structures and systems for clinical governance seem well established, there is more perceived progress in areas concerned with quality assurance than quality improvement. This study raises some uncomfortable questions about the impact of CHI review visits.

Prescribing how NHS trusts "do" quality: a recipe for committees but little action?

The jury is still out as to whether the current clinical governance model is the best way to improve quality Clinical governance, together with a number of national bodies to support and monitor it, was established in the NHS in 1997.1 Seven years on, it seems a good time to reflect on how effective this national quality assurance/improvement strategy has been, particularly in the light of subtle changes in the UK government’s attitude to quality. The recent publication of a new standards framework,2 the replacement of the Commission for Health Improvement (CHI) with the Healthcare Commission from April 2004, and insistence that trusts will have greater local autonomy2 all suggest a change in the wind—although the direction of the change is not quite clear. In the initial guidance on the duty of NHS trusts to implement clinical governance,3,4 the government set out the mandatory components of clinical governance (variously …

United Kingdom National Health Service. Cancer Services Collaborative “Improvement Partnership”,: Redesign of cancer services A national approach

ABC Access, Booking and Choice (MA Programme) AC Association of Coloproctology BAUS British Association of Urological Surgeons (www.baus.org.uk) BASO British Association of Surgical Oncologists (www.baso.org) BE Barium Enema BGS British Society of Gastrology (www.icr.ac.uk/research) BGS British Gynaecology Society (www.bspoga.ukgateway.uk) BSP Breast Screening Programme BX Biopsy CA 1. Calcium 2. Cancer 3. Carcinoma CAT Cancer Action Team C and D Capacity and Demand CHART Continuous Hyperfractionated Accelerated Radiation therapy CHI/CHAI Commission for Health Improvement (www.healthcarecommission.org.uk) Commission for Healthcare Audit and Inspection CSC-IP Cancer Services Collaborative-Improvement Partnership CT Computerised tomography (Radiology), a type of body scan

Are You Looking Out For the Lone Worker?

ow safe are your staff who work alone in the community? If someone were in a dangerous situation would they have any way of calling for help? And if they did not return from an appointment, how long would it be before anyone noticed they were missing? This is something that might one day come to your attention in a way you would rather it did not. A survey carried out by the Commission for Health Improvement (CHI, 2004) found that almost one in six NHS staff had experienced physical violence at work in the last year, mostly from patients. Staff most at risk are those who work alone in the community and mental health staff are the most at risk of all. It is surprising, then, that many health managers appear to take a head-in-the-sand approach to lone-work security, preferring not to think about it than face the fact that their staff who work in the community may be under-protected. Many incidents go unreported, so many may be falsely reassuring themselves that the worst is not going to happen. Cost, the complications of putting a system in place and no one seeing it as their particular responsibility are all barriers to something being done to protect lone workers. But which cashstrapped NHS trust wants a lawsuit on their hands? And trusts do have a duty of care to their staff to have a loneworker policy in place. There is also pressure from the top, with the government’s NHS zero tolerance campaign urging NHS management to put violence against staff at the top of their agenda. Often it is not that a trust doesn’t have a lone worker policy, but that staff are not aware of it. I have attended meetings with trusts when a group of senior managers have been uncertain as to whether they have a loneworker policy or not. And even if they do have a policy, a document is not going to do much to help a worker facing an armed and angry patient. When questioned on the issue, most trusts, particularly mental health trusts, know this is an issue they need to address but unfortunately it is often very far down the list of priorities. If anything is going to encourage trusts to look at a H solution for protecting lone workers it has got to be something they can set in motion with the minimum of fuss for both management and users. That was our thinking behind the development of LookOut call, which aims to be the practical side of the lone-worker policy. We have developed it to be: ■ simple to use ■ easy to install ■ flexible enough to meet the needs of any NHS trust ■ fully computerised, so there is no possibility of human error.

The triumph of NICE

The National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) were both introduced in the NHS plan of 1998. Six years on, CHI is dead but NICE is conquering the world. NICE worked but “nasty” (as CHI was initially known) failed—perhaps because it wasn't nasty enough. NICE may prove to be one of Britain's greatest cultural exports, along with Shakespeare, Newtonian physics, the Beatles, Harry Potter, and the Teletubbies. Cynical about government and trained to be sceptical, the BMJ was cautious in its welcome to NICE (BMJ 1999;318: 823). We believed that a body was needed to lead on rationing …

Commission for Health Improvement and mental health Services

The Commission for Health Improvement (CHI) ceased to function at the end of March 2004. This provides the opportunity to review its contribution and achievements as a new body, the Commission for Healthcare Audit and Inspection (CHAI), takes over its functions∗. CHI recently published its assessment of mental health services (http://www.chi.nhs.uk/eng/news/2003/dec/11.shtml). The report is based on the 35 clinical governance reviews, in England and Wales, published between July 2001 and October 2003; two investigations into serious service failures; and a report on safeguarding arrangements for children in England and a self-audit of child protection arrangements. CHI concluded that mental health services lag behind acute health services in developing clinical governance systems and processes that promote high-quality care and continuous improvement. It specifically highlighted the shortages of psychiatrists and in-patient nurses, and the reliance on agency nurses and locum staff; the unsuitability of buildings and facilities; the pressures on in-patient beds; the lack of management capacity and poor information systems; and the low priority given to services for children and older people.