4 Transparency in service redesign

Resolution submitted by the RCN Northern Board

That RCN Congress calls on Council to lobby the Department of Health and the devolved administrations to mandate NHS service providers to publish all risk assessments and patient quality impact assessments in advance of any service redesign

Progress reports

Submitted by: Northern Board
Council lead and committee assigned: Cate Wooley-Brown (until October 2011), Hamish Kemp (from October 2011), Nursing Practice and Policy Committee
Committee decision: New work
Members involved: Christopher Piercy, RCN Council member since October 2011 and North of Tyne Branch

Final summary update at May 2012

Following Congress 2011, research was undertaken to determine what information was already available supporting risk and quality impact assessments.

In Northern Ireland, the Department of Health, Social Services and Public Safety (DHSSPS) quality strategy (Quality 2020) requires that quality is a focus for the agenda of all boards and top management teams within health and social care. The RCN has said it will support changes that promote safe and effective care and continues to stress this in relation to the implementation of the recent Review of Social Care.

In Wales, the RCN contributed its views to the Government’s Guidance for engagement of consultation on changes to health service and called for longer and more meaningful consultation periods and to give community health councils stronger rights.

NHS boards in Scotland have to involve the communities they serve. The Scottish Government and the Scottish Health Council have developed guidance on this and there are policies and legislation around patients and the public influencing the design and delivery of services. The RCN notes that the effect of this is yet to be seen.

The RCN has committed a significant amount of time and effort lobbying for changes to the Health and Social Care Bill, including matters relating to the provision of information about service reconfiguration. The work of the RCN’s Frontline First campaign has continued and the RCN has sought to hold employers to account for the workforce planning decisions that impact on nursing and patients. Through the campaign, the RCN has forced employers to justify these decisions, particularly those that involve cuts in staff numbers or the closure of services.

Debate report

This debate proved to be a passionate and informative exchange of members’ personal experiences as well as their opinions. Cate Wooley-Brown from the RCN Northern Ireland Board, proposer of this item, stated the NHS was facing “unprecented challenges” and that has never been so important to hold service providers to account.  Susan Warner, West Midlands Branch, referred to “a demographic time bomb and an economic crisis, the likes of which we have never seen”.

Members felt that transparency and accountability are imperative in service re-design to ensure patient safety and service quality are not negatively affected. It was stated that service changes must be subject to both risk assessments and patient quality impact assessments and the results made public.
Linda Bailey from the RCN Public Health Forum queried whether the item should extend to  commissioners as well, not just service providers. The proposer confirmed this in her right of reply. 
One member took the debate a step further saying it was also about the overall outcomes, not just the assessments themselves, while the proposer finished by saying there was very little central control and accountability in this area and called for “clear, clinical evidence to support change”.

Result

For:        93.84% (396)
Against:  6.16% (26)
Abstain:       (37)

Background

Clinical risk assessment is defined as the systematic collection of information to determine the degree to which harm (to self or others) is likely at some point in time (O’Rourke & Bird 2001), while risk management is one of a number of organisational systems and processes concerned with creating and maintaining safe systems of care and aims to improve the quality of health care (Vincent 2001).

A health impact assessment is defined as a structured combination of procedures by which a policy, programme or project may be judged as to its potential effects on the health of a population and the distribution of those effects within the population (WHO 1999).

In England, NHS trusts are not mandated to conduct health impact assessments (patient quality impact assessments). While some do carry out risk assessments and equality impact assessments, these documents are not publically available and are highly varied in terms of robustness, consistency and detail. Often superficial and simplistic, such documents rarely include the positive and negative aspects of potential impact. Similarly, in Scotland and Wales the RCN has called for more transparent and available data to support better decision making in relation to service redesign.

Risk assessments that clearly identify hazards and/or risk, anticipate consequences, and identify control measures and mitigation processes that are evidence-based and routinely monitored and evaluated is just part of the issue. There is a lack of transparency and accountability from health service providers when consulting on reorganisation and restructuring in service provision, delivery and workforce planning. Finally, there are no clear standards on risk assessments within the NHS and furthermore these risk assessments are not monitored or assessed regularly by regulators such as the Care Quality Commission. This lack of availability and access to robust documents means that the ability of those involved in service redesign to make informed decisions is impaired. In the face of the proposed NHS reforms, this lack of capability may prove crucial.

Through its Frontline First campaign the RCN has already called for NHS organisations to conduct a thorough impact assessment prior to any reconfiguration to a service or workforce in light of the potential impact to patient care.

References and further reading

O’Rourke, M. And  Bird, L. (2001) Risk management in mental health, London: Mental Health Foundation.
Vincent, C. (2001) Clinical risk management: enhancing patient safety, London: BMJ Publications.
World Health Organization (1999) Health impact assessment, Geneva: WHO Available at: http://www.who.int/topics/health_impact_assessment/en/ (Accessed 11/2/11) (Web)