A coordinated approach to audit and inspection in health
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A coordinated approach to audit and inspection in health National Audit Office Audit Commission Healthcare Commission January 2005 A coordinated approach to audit and inspection in health Introduction 1. The National Audit Office (NAO), the Audit Commission (AC) and the Healthcare Commission are signatories to the Concordat between bodies inspecting, regulating and auditing health care (June 2004). This important agreement underpins our commitment to working effectively together. 2. The preparation and implementation of the concordat has been led by the Healthcare Commission, which has a statutory duty to coordinate reviews of health and healthcare in 1the NHS in England. All 10 signatories are working together to: • deliver consistent and coherent programmes of inspection • improve services for patients, clients and their carers • eliminate unnecessary burdens of inspection on staff providing healthcare In addition, work is in hand to improve scheduling of reviews across all concordat partners and to extend the concordat to other bodies. 3. Within this context, the NAO, the AC and the Healthcare Commission have a shared aim of encouraging improvement in patient care and efficiency in the NHS through coordinated and complementary programmes of audit and inspection. With the public interest always in mind we are seeking to achieve this aim in two main ways: • by choosing topics for examination that make ...
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A coordinated approach to audit and
inspection in health
National Audit Office
Audit Commission
Healthcare Commission
January 2005
A coordinated approach to audit and inspection in health
Introduction
1. The National Audit Office (NAO), the Audit Commission (AC) and the Healthcare
Commission are signatories to the
Concordat between bodies inspecting, regulating and
auditing health care
(June 2004). This important agreement underpins our commitment to
working effectively together.
2. The preparation and implementation of the concordat has been led by the Healthcare
Commission, which has a statutory duty to coordinate reviews of health and healthcare in
the NHS in England. All 10 signatories
1
are working together to:
•
deliver consistent and coherent programmes of inspection
•
improve services for patients, clients and their carers
•
eliminate unnecessary burdens of inspection on staff providing healthcare
In addition, work is in hand to improve scheduling of reviews across all concordat partners
and to extend the concordat to other bodies.
3. Within this context, the NAO, the AC and the Healthcare Commission have a shared aim of
encouraging improvement in patient care and efficiency in the NHS through coordinated
and complementary programmes of audit and inspection. With the public interest always in
mind we are seeking to achieve this aim in two main ways:
•
by choosing topics for examination that make the best of each organisation’s distinct
remit and potential to contribute to improvement
•
by adopting processes that maximise the beneficial impact of our work, while
minimising costs for NHS organisations
4. We have established tripartite discussions to ensure our programmes are complementary
and identify opportunities for collaboration. We have aimed to reflect the priorities of
patients, the public and the NHS as providers of services. Recommendations arising out of
the programmes will therefore be at the heart of the challenges facing the NHS. It is our
intention to develop together a unified work programme for the NHS.
Targeting work to promote quality and efficiency
5. The forward programme at Appendix 1 brings together the programmes we have developed
for 2005/2006.
It shows how we plan to cover priority areas of patient services, as well as
key enablers of better services, such as staffing and IT.
6. The breadth and variety of the combined programme of work set out in Appendix 1 reflects
the distinct roles, contributions and reporting lines given to us by Parliament within the
health sector (summarised at Appendix 2). Given the range of complex issues and
challenges facing the NHS, it is not surprising that similar broad topic areas occur in our
respective forward programmes. This is not duplication but rather allows us to add value by
using our different powers and access to resources in a complementary way to benefit
patients and tax payers by looking at different dimensions of a given issue.
7. A good example of this is where we are working jointly on ‘delivery chain analysis’ of the
PSA target on childhood obesity, using our respective powers and expertise to support the
delivery of a challenging target. Another example relates to the National Programme for IT
1
The other signatories to the concordat are the Academy of Medical Royal Colleges, the Commission for
Social Care Inspection, the Health and Safety Executive, the Mental Health Act Commission, NHS Estates, the
NHS Litigation Authority, and the Postgraduate Medical Education and Training Board.
A coordinated approach to audit and inspection in health
(NpfIT) where NAO is currently conducting a review planned for publication in 2005/2006.
This will examine the planning and procurement process as well as early lessons from the
implementation phase. For the latter, NAO will draw on the findings of AC appointed
auditors, many of whom look at NPfIT as part of their local risk-based audit plans. The
Healthcare Commission will use both of the above to inform any use of technology issues
that arise from their service specific improvement reviews.
8. The breadth of the combined programme also takes into account the capacity of individual
health bodies to respond to our recommendations, by controlling the number of different
investigations that individual bodies need to respond to at any one time. In addition, we are
adopting a number of working practices that promote the benefits of complementary roles,
including:
a. coordinating work programmes and planning processes
b. collaborative reviews
c. reliance on the work and findings of partner organisations
9. This paper now looks at examples of how, by adopting these practices, we are working
together to provide more effective audit and inspection.
Coordinating work programmes and planning
processes
10. Our forward work programmes have been developed and are being scoped in the context of
early sharing of our approaches through:
a. quarterly high level tripartite meetings to discuss strategic direction and
opportunities for collaboration
b. quarterly operational meetings to share progress on respective programmes and
identify specific areas for collaboration for example, information sharing
c. representation on expert panels of each others’ development programmes
d. close liaison on specific areas of common interest, for example chronic disease
management and public health
e. running joint learning events on topics of mutual interest, for example National
Programme for IT and Payment by Results
11. We currently have different planning cycles and approval structures for determining our
respective programmes. The Healthcare Commission only came into being on April 1
st
2004
and has been working on its programme through the year. In the current year we have
worked hard to ensure that we identify areas of common interest in our existing
programmes and there has been close liaison to avoid duplication. Indeed, in pulling
together and scrutinising our programmes as part of this process, the lack of overlap has
been encouraging.
12. In the coming year, 2005/2006, we aim to build on this progress by holding a joint planning
event in May/June 2005 with a view to developing a single list of studies/reviews setting out
the contribution of each organisation in addressing major issues faced by the health service
in 2006/2007.
13. A wider process of collaboration and coordination, under the aegis of the Concordat and
involving all 10 signatories, is also well underway. The main achievements so far, the next
steps and proposed measures of success are outlined at Appendix 3. In the light of
A coordinated approach to audit and inspection in health
experience over the past six months, we have reviewed progress with the concordat and
propose to concentrate our main efforts in the next quarter on the following areas, with the
aim of ensuring not only that the practices in the concordat are visible to the NHS and
others affected by regulation, but that we are making a measurable difference:
•
the gathering, sharing and use of information
•
joint working and coordination (including better scheduling and more effective action
planning)
•
cost benefit analysis
•
further development of a ‘hotline’ for those affected by reviews
•
identifying any legislative barriers to cooperative and more streamlined working
•
developing measures of success
Collaborative reviews
14. We are already adding greater value by working together on a number of reviews. In so
doing, we are exploring a number of different ways of collaborating – ranging from
contributing to reviews led by one organisation to those in which we work together to
develop joint methods and approaches. The major benefit of such collaborative effort is that
by working together we are able to:
•
fulfil our own specific remits relating to different types of organisations, such as
performance ratings of local authority organisations and NHS trusts
•
jointly highlight issues in a way that is meaningful from the perspective of patients and
the public, to whom organisational boundaries are of limited interest
•
develop a fuller picture of a given issue (e.g. NPfIT) by bringing to bear our distinct
remits and skills, and sharing our knowledge bases
15. Examples include:
a. review of National Service Framework for Older Peoples (Healthcare Commission,
CSCI, AC), reflecting the critical importance of examining arrangements across the
boundaries between health and social care
b. an agreed approach to the audit and inspection of the National Programme for IT
c. a joint report on the financial management in the NHS in 2003/2004 incorporating
the findings of the Audit Commission’s appointed auditors of the individual local
NHS bodies and of the C&AG’s audit of the NHS summarised and resource
accounts
d. plans for a tripartite look at the childhood obesity PSA target so as to focus on the
responsibilities for public health and well being that run across both health
organisations and local authorities
e. acute hospital portfolio studies covering admissions to hospital, diagnostic services
and medicines management (Healthcare Commission, AC)
f.
joint area reviews of children’s services (led by OFSTED)
g. public health improvement reviews (Healthcare Commission, AC).
A coordinated approach to audit and inspection in health
Reliance on the work and findings of partners
16. Our study, audit and inspection methodologies draw on information and findings gathered
from the work of other agencies. This will make better use of resources and draw more
readily on topic-specific expertise. A significant example is the Healthcare Commission’s
proposed framework of assessment for the NHS. It will use Audit Commission appointed
auditors’ findings to populate the Use of Resources module of the new rating system. A
further example is the national review of the National Service Framework for Older People,
which has contributions from the Healthcare Commission, AC and CSCI teams.
17. The principle of reliance on others’ findings has led to close cooperation on development of
methods. For example, in developing a new approach to local audit in health, the Audit
Commission has worked with the Healthcare Commission to ensure the outputs from the
process are compatible with the Healthcare Commission’s proposed annual health check.
The benefit of this approach is that the problems of aligning approaches retrospectively are
avoided and such issues as duplicated information requests are overcome in the design
phase.
Conclusion
18. This paper has highlighted our common aim of promoting improvement in healthcare and
public health, our complementary roles and the variety of ways in which we are working
jointly to add greater value and minimise the burden on the NHS. Since the beginning of the
year, the three organisations have been in close contact and the process gathered pace in
our prominent contributions to work on the
Concordat
.
19. We have made positive progress in coordinating our work programmes, developing
collaborative reviews and exploring ways of relying on each other’s work and findings.
Future plans include greater sharing of our findings to inform each other’s reports. We will
now build on this progress in the coming year by further aligning our planning processes so
that we come to a common view of the major issues on which we should be focusing, how
each organisation can best contribute and the potential impact on the service, with a view to
developing a single schedule of studies/reviews for future years.
20. We would welcome the committee’s views on whether our forward programmes address
fully the main risks they perceive in relation to the NHS.
A coordinated approach to audit and inspection in health
Appendix 1
Our forward programmes
The accompanying Excel spreadsheet outlines a draft schedule of national reports for
2005/2006 from one or more of the three organisations. Each report is colour-coded to indicate
which organisations are involved (this in itself emphasises the range of collaborations between
the three organisations as well as a number of other partners, e.g. CSCI).
The reports have also been broken down across a number of categories to indicate the key
issue or sector with which each is primarily concerned. These categories are not mutually
exclusive so each report has been mentioned only once.
In the remainder of 2004/2005, forthcoming reports include the following:
Healthcare Commission
•
acute hospital portfolio report covering pathology, facilities management, information
and records, therapy and dietetics – with the Audit Commission
•
national report on implementation of the Coronary Heart Disease National Service
Framework
•
provision of cosmetic surgery in England – a report for the Chief Medical Officer
•
NHS staff survey 2004, key findings
National Audit Office
•
national value for money study - LIFT
•
national value for money study - choice at referral
•
national value for money studies – the Cancer plan and Cancer, the patient experience
•
national value for money study – patient safety
Audit Commission
•
financial management in the NHS – review of 2003/2004 accounts – with the National
Audit Office
•
early lessons from implementing Payment by Results
See accompanying Excel spreadsheet for draft schedule of national reports during 2005/2006.
Appendix 2
Statutory roles of the agencies in health
National Audit Office
•
scrutinise public spending on behalf of parliament, audit accounts of all government
departments and agencies
•
report to parliament on the spending of central government money
•
report nationally on value for money in public services
Audit Commission
•
appoint auditors of NHS bodies (NHS trusts, primary care trusts and strategic health
authorities). Appointed auditors audit the accounts, review corporate governance and
assess NHS bodies’ arrangements to secure economy, efficiency and effectiveness
•
quality assure the work of appointed auditors
•
report nationally on financial management in the NHS
Healthcare Commission
The Healthcare Commission’s fundamental purpose is to promote improvements in the
quality and value for money of healthcare and public health. Key roles in England include:
•
assess all NHS providers against national standards, producing an annual rating for
each organisation
•
inspect and license independent sector health providers
•
take the lead in promoting the coordination of audit and inspection activity in healthcare
•
investigate serious service failures
•
investigate unresolved complaints
•
report nationally on value for money in the NHS (formerly the role of the Audit
Commission)
•
improve the quality, accessibility and usefulness of information about healthcare
provision, for patients, the public and providers
•
report annually to Parliament on the state of the NHS and independent healthcare
provision
A coordinated approach to audit and inspection in health
Appendix 3
Implementing the Concordat
1.
This note summarises the wider work programme being carried out under the aegis of the
concordat, and sets out:
•
progress with implementation of the concordat
•
next steps
•
proposed measures of success
Progress
2.
The concordat was published in June 2004. Considerable progress has been made by the
ten signatories to the concordat to put its principles into practice. Action taken by signatories, either
collectively or individually, includes:
•
establishment from November 2004 of a
multi-agency team
within the Healthcare
Commission to spearhead implementation of the concordat
•
an information
gateway
by six signatories to manage better, and to help reduce, the flow of
communications with the front line
•
a `
hotline’
for chief executives of trusts
•
assessment of signatories’
visiting schedules
up to March 2005 to remove any duplication
•
development of
joint programmes of work
by the Healthcare Commission, the
Audit
Commission
(AC) and the
National Audit Office
(NAO) and coordinated planning
processes
•
increasingly close alignment (with a view to medium term integration) of the
Mental Health
Act Commission’s plans and systems
with those of the Healthcare Commission
•
planning
collaborative reviews
by the Healthcare Commission and a number of other
bodies, including the Commission for Social Care Inspection (CSCI), the National
Treatment Agency (NTA) and OFSTED
•
reducing burdens on the NHS
:
eg
the Healthcare Commission has reduced from 24 to
10 the number of performance indicators requiring special collections of data and its new
systems of assessment will target interventions where there is cause for concern, rather
than across the board
•
a seminar for sponsors of
peer review schemes
to discuss working in partnership
•
development of tools to facilitate the
sharing of information
and findings of reviews with
other organisations
•
development of an
action planning
template to provide a coherent approach to the
formulation and implementation of recommendations from reviews
•
development of a template to help ensure that
new initiatives proposed by inspecting
bodies comply with the concordat
•
facilitating exchange of good practice relating to
equality and human rights
A coordinated approach to audit and inspection in health
•
adoption by relevant signatories of the Cabinet Office’s
Enforcement Concordat
(CSCI is
due to do this also in January)
•
production of materials for partners to use for
communications
Next steps
3.
In the next three months (up to the end of March 2005) the Healthcare Commission,
and
other signatories where relevant, will have:
•
extended the number of signatories
to the concordat and
‘refreshed’/relaunched the
concordat
•
mapped the
local arrangements
of concordat partners, as well as arrangements for visits
and inspections relating to
education and training
, and begun applying the rigour of the
concordat at a local level through the development from early 2005 of the Healthcare
Commission’s regional and local presence
•
tracked, on a consistent basis,
individual implementation of the concordat
by its
signatories, drawing on mechanisms that signatories have already put in place
•
extended the information gateway to include
sector specific communications
•
extended the ‘hotline’
to all NHS staff
•
completed and piloted the
action planning template
•
developed an impact assessment of the Healthcare Commission’s new systems of
assessment methodology, to be used as a basis for an
inspectors’ impact assessment
•
developed a
web-based scheduling function
for visits to NHS organisations
•
settled the Healthcare Commission’s new approach to
systems of assessment
(consultation ends in February 2005). This will be targeted and proportionate, and
progressively use other organisations’ findings
•
following extensive consultation, published in January 2005 the Healthcare Commission’s
code of practice on confidential personal information
, as required by the 2003 Act, and
further developed
information sharing protocols
(a detailed one between the Healthcare
Commission and CSCI is at an advanced stage of preparation)
•
published a
code of practice/’action’ report
to support implementation of the concordat
and disseminate good practice
•
developed a
strategy for communications
to complement, among other things, the
Department of Health’s strategy on reduction of burden
•
developed
measures of success
and mechanisms for longer term systematic monitoring
of the concordat
•
identified any barriers
to progress arising from existing legislation (given that, although the
Healthcare Commission has a statutory role to coordinate reviews of health and health care
in the NHS in England and has legal duties to cooperate with some major partners, such as
CSCI, AC, and Monitor, the concordat programme as a whole relies principally on shared
commitment and goodwill)
Success measures
4.
Likely measures of success for the concordat include:
A coordinated approach to audit and inspection in health
•
that
signatories adhere to the principles
contained in the concordat
•
that
any new programme of inspection or review is mapped against the concordat
and adheres to its principles
•
that we encourage
other inspecting and reviewing bodies
, both at a national and
local level, to sign up to (or, in some instances, be associated with) the principles and
objectives contained in the concordat
•
that
NHS staff are aware
of the concordat and hold signatories to account against
delivery
•
that
front line staff perceive reductions in burden
and that, over time, there is
an overall
measurable
reduction in both the number of days that inspections take up NHS time
and (to the extent that this can be quantified)
the amount of new information that
organisations are asked to provide
to inspecting bodies
•
that
integrated approaches to action planning
lead to more systematic and coherent
implementation of recommendations from reviewers, with consequent benefits to patients
and staff
•
that the range of approaches anticipated by the concordat help to foster
more positive
attitudes generally to inspection and review
, here too, boosting their potential to bring
about improvements
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