How will CCGs assure the quality of care they commission?

First do no harm, has guided physicians and surgeons throughout the centuries. Sadly, all too often its fallibility has been laid bare. Quality and safety of care are multi-faceted, complex issues that have challenged the best commissioners. So how can we expect clinical commissioning groups to raise the bar?

Over the years we have developed complex systems of regulation focussing on organisations, checking and testing assurance processes and standards. But have we focussed enough on the individual practitioner’s responsibilities for quality of care and have we achieved the right balance between regulation and individual responsibility?

To redress this balance requires leadership from the medical professional bodies, but what can CCGs do? One place to start is to enquire and seek reassurance of providers that all their clinicians have had up to date appraisals and development plans.

This is an area that I suspect we all too often take for granted, indeed here lies an underlying issue in quality assurance: don’t assume: ask and test: appraisals are an absolutely essential foundation of good clinical practice.

Let’s consider how the regulatory challenge has changed over the years. Initially under CHI the approach was mainly of assessing internal governance structures, and we have now moved to a focus on standards.

Good governance is not just a series of structures and processes but an organisational behaviour: all too often it is delegated to a tick box assessment and this will lead to false assurance - assurance in name only but not in culture and it is the latter which protects.

Over the years we have lost our focus on this crucial aspect. Many boards have worked hard to embed this within their organisations, but sadly this is not uniform. Therefore another good place to look is into the nature of the governance processes. What are the board discussing? Are safety and quality at the top of their agendas? Do they seek patient feedback and involvement and are clinicians fully involved in these debates?  Finally and fundamentally, are these discussions open and transparent? These are good places for CCGs to shine their lights of curiosity.

We all know the importance of measurement and the well known phrase that if you don’t measure it you can’t manage it, yet sometimes we can fall into the trap of blindly watching the dials go red whilst we slip into collusion of justification .

While objectivity is crucial there’s something in here about human behaviours and interaction which doesn’t obey any of the niceties of logic. There is a pressing need to integrate different data sets both hard and soft so that a triangulated position can be constructed.

This will involve not only direct quality metrics such as numbers of never events, but also softer data such as staff satisfaction and patient complaints. Triangulation will give CCGs a much more rounded picture.

This picture would not be complete without the use of anecdote. This is a scientific no no; killed off at birth by statistical zeal. Yet in practice all too often I have seen anecdote summarily dismissed when it was clearly an early warning sign. So take it seriously, the response needs to be proportionate but it needs a response.

This leads me into another area, that of relationships. Organisations that have developed trust between themselves can have probing discussions on safety and quality: the providers will be keen to test out issues raised even by an anecdote. So what’s the relationship like between your CCG and providers?

This is all very nebulous: how can our fledgling CCG leaders assess whether their providers have a culture that is driving up quality and safety? This isn’t as tricky as it at first seems and we have some very clear markers.

Organisations that unite around clear values, not just created in isolation but owned by staff, and where clinicians and managers work seamlessly create a supportive environment. These organisations are clear in their purpose and will hold their members to account for delivering high quality care. They are usually organisations that seek feedback from their patients and continually review their own work and challenge themselves to drive up quality.

All these attributes can be assessed, largely, by CCGs getting out a bit more and observing and asking questions.

If we look at organisations that get into trouble there’s an almost predictable path. It will probably start with bubbling up of poor performance, subsequently leading to poor financial performance. Non-recurrent solutions creep in, management come and go in a constant churn and an attempt to find the magic leader who will sort it all out.

Clinicians start to disengage and retreat to huddles in corners and management retire to the security of their offices. Senior management visibility is almost absent and the organisation focuses internally becoming isolated and denying the magnitude of the issues. Blame rises and a spiral of self-perpetuation creeps in with the silence of cancer

Finally let’s explore the leadership challenge that is needed to ensure safety and quality are pursued with vigour. This work is everyone’s business, and requires everyone to share and own a single direction of travel.

Do our current leadership styles support this? It requires a devolved style that seeks ownership and enables individuals to challenge themselves. This requires an organisation that will challenge itself, it necessitates high levels of trusts and well-developed supportive relationships.

Machoism and heroes have no place in this environment. We have many excellent examples of such developmental leaders but all too often we focus on the task and miss the point.

Ensuring they commission high quality safe services is the first priority for CCGs. This is, I would argue, their core function: first do no harm.