Enhancing standards – silver bullets can be expensive

In a speech to the Nuffield Trust a few years ago, the then-Secretary of State for Health, Andrew Lansley, turned to the failings of care at Mid-Staffordshire to motivate his argument for reform.

In defending the cause of clinically-led commissioning, Lansley said: ‘where were the GPs? I’ll tell you: the GPs were there, they sent the patients to the hospital’ but too often they had a culture of ‘refer and forget’.

One of the questions asked by the Francis Inquiry has been: ‘where were the primary care trusts?’ And the answer seems to be ‘they were there, they continued to purchase services from the hospital, but they didn’t properly monitor the quality of what they were buying’.

In responding to this long-recognised failing in commissioning (Smith, Porter and others 2013; Smith and Curry, 2011; Robinson and others, 2011; Donaldson and others, 2010), the Inquiry proposes the following: to require local commissioners, in tandem with the NHS Commissioning Board (now NHS England), to produce ‘enhanced standards’ around quality and incorporate them into commissioning contracts, leaving it to the clinical commissioning groups (CCGs) to then monitor conformity and set out any ‘redress’ for non-compliance.

As the Inquiry sees it then, the Care Quality Commission will police ‘fundamental standards’ – that is, those that form the minimum level of service that should be provided.

While CCGs will be responsible for policing requirements around quality ‘over and above the minimum standard’: i.e. those ‘enhanced standards’ that they themselves have contracted for.

For some, the introduction of more standards may be treated with a degree of scepticism. One of the issues here is compliance.

For example, even NICE’s guidance, which benefits from being both universally well-respected and legally-binding in certain cases, is not always followed by commissioners, providers and clinicians on the ground.

One may doubt, therefore, the potential effectiveness of commissioner-led enhanced standards, drawn-up in conjunction with the NHS Commissioning Board.

However, as I see it, the Inquiry’s recommendation has two important advantages. First, it places much of the responsibility for ensuring proper care of patients in any given local area with the care-purchasers; who are, after all, supposed to be our advocates.

Second, it prods providers in a particularly sensitive area – namely, their wallet. Nonconformity to NICE guidance, especially around the commissioning of certain pharmaceuticals, can be in a provider’s best financial interests; by comparison, nonconformity to ‘enhanced standards’ is likely to incur a financial penalty.

As with so much of the final report on Mid-Staffs, though, the real elephant in the room is the question of resources. Drawing up standards is relatively inexpensive. However, effective monitoring and enforcement costs time, money and expertise.

In fairness, the Inquiry notes such difficulties, writing that the NHS Commissioning Board and the local commissioners of services ‘must be adequately resourced to enable a proper scrutiny that providers are delivering the standard of service required under their contracts’, and that ‘the resource available to the commissioners to monitor the provision of contractual services should extend as necessary to the capacity to undertake audits, inspections and investigations, of individual cases…and of groups of cases’.

However, it is one thing to call for such resources and another to find them in the NHS’s already-tight financial budget.

The question the service must ask now is, how far is it willing to prioritise the enforcement of ‘enhanced standards’ of care, and at what cost?