Archive for January, 2015

Consultant Outcomes Publication

Saturday, January 24th, 2015

Consultant Outcomes Publication (COP) is an NHS England initiative, managed by HQIP (Healthcare Quality Improvement Partnership), to publish quality measures at the level of individual consultant doctor using National Clinical Audit and administrative data. The data is published on NHS choices website (

The information published so far includes how many times each participating consultant has performed certain procedures and what their mortality rate is for those procedures. The data shows where the clinical outcomes for each consultant sit against the national average. The data is risk adjusted to ensure outcomes are calculated as if all consultants operated on the ‘average’ patient.

COP began in 2013. The medical specialties included in COP 2014 includes Adult Cardiac surgery, Bariatric surgery, Colorectal surgery, Head and neck surgery, Interventional Cardiology, Thyroid and Endocrine surgery, Orthopaedic surgery, Upper GI surgery, Urological surgery, Vascular surgery, Lung cancer, Urogynaecology and Neurosurgery.

The aim of COP is to drive up the quality of care in the NHS and improve transparency.

Prof Sir Bruce Keogh, National Medical Director of NHS England, said: ‘We know from our experience with heart surgery that putting this information into the public domain can help drive up standards. That means more patients surviving operations and there is no greater prize than that’.

The reporting of the data was led by Prof Ben Bridgewater from the Healthcare Quality Improvement Partnership (HQIP). Prof Bridgewater is a practising heart surgeon who leads the successful cardiac consultant-level reporting which paved the way for this work.

Prof Bridgewater said: ‘Ultimately there is one patient and one responsible consultant. This means the public can now know about the care given by each doctor and be reassured an early warning system is in place to identify and deal with any problems

Due to data protection legislation, consultants had to agree to have results from their operations published and around 98% have.  The names of those consultants who have not agreed to have data published and the trusts they work in can be seen on NHS choices website.

Some surgeons object to the principle of attributing surgical results to an individual when those results are dependent on effective teamwork between surgeon, anaesthetist, theatre and ward nurses and physiotherapists. Prof Sir Bruce Keogh counters that the patient enters the agreement for surgery with the surgeon and someone has to be accountable for the team’s outcomes.

What will the NHS do where consultants have high mortality rates?

Any hospital or consultant identified as an outlier will be investigated and action taken to improve data quality and/or patient care.

Duty of Candour

Saturday, January 24th, 2015

The General Medical Council (GMC) (with eight UK professional healthcare regulators) has underlined its commitment to a professional duty of candour for doctors in a statement issued in Oct 2014

Health professionals must be open and honest with patients when things go wrong. This is also known as ‘the duty of candour’.

Every healthcare professional must be open and honest with patients when something goes wrong with their treatment or care which causes, or has the potential to cause, harm or distress.


This means that healthcare professionals must:


•tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong;

•apologise to the patient (or, where appropriate, the patient’s advocate, carer or family);

•offer an appropriate remedy or support to put matters right (if possible); and

•explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.


Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. Health and care professionals must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest and not stop someone from raising concerns.

‘The awful reality that emerged from Mid Staffs and indeed other inquiries was that doctors knew about GMC guidance but were not empowered by it. They felt it was acceptable to ‘walk by the other side of the ward’ knowing that there was unsafe and unacceptable practice going on. We must all do what we can to make sure that does not happen again. The statement above is an important milestone and makes it clear that the professional duty of candour sits with every healthcare professional, regardless of their field of practice.


The government in Nov 2014 has introduced a further duty of candour on secondary care organisations registered with CQC – one required, and enforceable, by law.


This new statutory duty of candour will apply to all other care providers registered with CQC from 1 April 2015. The key principles are:


1. Care organisations have a general duty to act in an open and transparent way in relation to care provided to patients. This means that an open and honest culture must exist throughout an organisation.

2. The statutory duty applies to organisations, not individuals, though it is clear from CQC guidance that it is expected that an organisation’s staff cooperate with it to ensure the obligation is met.

3. As soon as is reasonably practicable after a notifiable patient safety incident occurs, the organisation must tell the patient (or their representative) about it in person.

4. The organisation has to give the patient a full explanation of what is known at the time, including what further enquiries will be carried out. Organisations must also provide an apology and keep a written record of the notification to the patient.

5. A notifiable patient safety incident has a specific statutory meaning: it applies to incidents where a patient suffered (or could have suffered) unintended harm that results in death, severe harm, moderate harm or prolonged psychological harm.

6. There is a statutory duty to provide reasonable support to the patient.

7. Once the patient has been told in person about the notifiable patient safety incident, the organisation must provide the patient with a written note of the discussion, and copies of correspondence must be kept.


Doctors are most likely to be the organisation’s representative under the statutory duty. It is important that you cooperate with your organisation’s policies and procedures, including the requirement to alert the organisation when a notifiable patient safety incident occurs.


An area of difficulty may be deciding whether an incident reaches the threshold for notification under the statutory duty. This may be confusing, as the threshold is low for the doctor’s ethical duty (any harm or distress caused to the patient) while the thresholds for the contractual and statutory duties are higher and slightly different (at least moderate harm).



Acute and emergency care: prescribing the remedy

Saturday, January 24th, 2015

Urgent and emergency care services face profound pressures that are most obviously experienced by patients and clinicians working in emergency departments and acute admission wards.

The Royal College of Physicians, the College of Emergency Medicine and the Royal Colleges of Surgeons and of Paediatrics and Child Health have produced a joint report, Acute and emergency care: prescribing the remedy, which provides 13 comprehensive local and national recommendations to address these challenges and to build safer, more effective and efficient urgent and emergency care services for all patients.

The recommendations are:

  • Every emergency department should have a co-located primary care out-of-hours facility- It is unreasonable to expect patients to determine whether their symptoms reflect serious illness or more minor conditions. Co-location enables patients to be streamed following a triage assessment.
  • Best practice that directs patients to the right care, first time, should be promoted across the NHS so as to minimise repetition of assessment, delays to care and unnecessary duplication of effort. Examples of best practice include:  stroke patients being transferred directly to stroke Units,  medical patients who have been assessed by a GP being taken directly to the medical admissions unit, patients with post-operative complications being returned to surgical care, GP-to-consultant advice lines, easy access to urgent clinics etc
  • All trainee doctors on acute specialty programmes should rotate though the emergency department.
  • Senior decision-makers at the front door of the hospital, and in surgical, medical or paediatric assessment units, should be normal practice, not the exception. It should include acute physicians, acute paediatricians, GPs, emergency care physicians, geriatricians and psychiatrists.
  • Emergency departments should have the appropriate skill mix and workforce to deliver safe, effective and efficient care. Where an emergency department does not have onsite back-up from particular specialties, there should be robust networks of care and emergency referral pathways.
  • At times of peak activity, the system must have the capacity to deploy or make use of extra senior staff.
  • Community and social care must be coordinated effectively and delivered 7 days a week to support urgent and emergency care services. The aim should be to facilitate the safe discharge and timely transfer of care of patients from the hospital to their own home or usual place of residence.
  • Community teams should be physically co-located with the emergency department to bridge the gap between the hospital and primary and social care, and to support vulnerable patients. Co-located teams should include primary care practitioners, social workers and mental health professionals.
  • The delivery of a seven-day service in the NHS must ensure that emergency medicine services are delivered 24/7, with senior decision makers and full diagnostic support available 24 hours a day, including appropriate access to specialist services. This will require additional resources.
  • The funding and targets systems for emergency department attendances and acute admissions are unfit for purpose and require urgent change.
  • Delivering 24/7 services requires new contractual arrangements that enable an equitable work–life balance.
  • It is essential that each emergency department and acute admissions unit has an IT infrastructure that effectively integrates clinical and safeguarding information across all parts of the urgent and emergency care system.
  • If configured properly with significant clinical involvement and advice, NHS 111, NHS 24, NHS Direct and equivalent telephone advice services can help to reduce the pressures on the urgent and emergency care system.


NHS Five Year Forward View

Saturday, January 24th, 2015

The NHS Five Year Forward View was published on 23rd Oct 2014. It sets out a vision for the future of the NHS. It was developed by the partner organisations that deliver and oversee health and care services including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority.

The purpose of the Five Year Forward View is to articulate why change is needed, what that change might look like and how we can achieve it. This was the first time the NHS as a whole had set out its vision to government rather than vice versa

Why change is needed?

The NHS had achieved considerable success in delivering efficiencies whilst maintaining services over recent years but this approach (e.g. pay restraint) could not be sustained indefinitely. Some of the fundamental challenges facing us:

  • Increasing Elderly population: we live longer, with complex health issues
  • Modern advances in treatments and technologies- transforming our ability to predict, diagnose and treat disease.
  • Increasing budget pressures due to the global recession.

NHS England have previously predicted that if we continue with the current model of care and expected funding levels, we could have a funding gap of £30bn a year by 2020/21 which will continue to grow and grow quickly if action isn’t taken.

The funding gap of £30bn supposes

•             Uncontrolled rising demand

•             No efficiency savings

•             No additional funding

Therefore the three strands of a sustainable solution proposed in the 5 year forward plan are:-

• Considerably greater emphasis on reducing demand through effective measures to prevent ill health (e.g. alcohol, obesity etc.) This will produce medium/longer terms benefits.

• Major changes in the models of care recognising the need for a path between a single centrally determined model and “letting a thousand flowers bloom” i.e. a limited menu of solutions to suit local needs.

•Additional funding from Government of £8bn a year


Key themes in the NHS Five year forward view are:


Radical upgrade in prevention and public health:

One in five adults still smoke. A third of us drink too much alcohol. A third of men and half of women don’t get enough exercise. Just under two thirds of us are overweight or obese. The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment. And we will advocate for stronger public health-related powers for local government and elected mayors.

New care models: Out of hospital care to be larger part of what the NHS does

  1. Patients will gain far greater control of their own care – including the option of shared budgets combining health and social care.
  2. NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases.
  3. England is too diverse for a ‘one size fits all’ care model to apply everywhere. But nor is the answer simply to let ‘a thousand flowers bloom’. One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care – the Multispecialty Community Provider. A further new option will be the integrated hospital and primary care provider – Primary and Acute Care Systems – combining for the first time general practice and hospital services.
  4. Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. Midwives will have new options to take charge of the maternity services they offer. The NHS will provide more support for frail older people living in care homes.
  5. The foundation of NHS care will remain list-based primary care. Given the pressures they are under, we need a ‘new deal’ for GPs. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services. The number of GPs in training needs to be increased as fast as possible, with new options to encourage retention.

The five year plan argues that there is nothing in their analysis that suggests that continuing with a comprehensive tax funded NHS is intrinsically un-doable. The five year plan argues that delivering on the transformational changes set out in the plan and the resulting annual efficiencies could – if matched by staged funding increases as the economy allows – could close the £30 billion gap by 2020/21.