NHS Quality Improvement Scotland

Karen MacPherson

Abstract

NHS Quality Improvement Scotland (NHS QIS) was established as a Special Health Board on January 1st 2003 with a remit to improve the quality of healthcare in Scotland. It brought together five existing NHS bodies. The increasing complexity of the clinical effectiveness work being undertaken in Scotland, coupled with major government policy changes and initiatives necessitated the creation of such an organisation. The long term work plan of NHS QIS will be detailed in a strategic framework for improving the quality of patient care, to be published in April 2004. Information staff have a key role to play at the centre of the organisation.

Article

NHS Quality Improvement Scotland (NHS QIS) was established as a Special Health Board on January 1st 2003 with a remit to improve the quality of healthcare in Scotland. This article explores the history and rationale behind its formation and outlines its functions, structure and work programme. It also describes the role of the information scientist within the organisation.

The consideration of issues of quality in healthcare in Scotland first came to prominence in the mid 1980s, and in 1989 the Clinical Resource and Audit Group (CRAG) was created. CRAG became the lead organisation within the Scottish Executive promoting clinical effectiveness in Scotland.

During the late nineties the clinical effectiveness picture became more complex with the expansion of the Scottish Intercollegiate Guidelines Network (SIGN) programme and the creation in 1999 of the Clinical Standards Board for Scotland (CSBS)(1) and in 2000 of the Health Technology Board for Scotland (HTBS)(2). A number of other governmental and professional bodies involved in setting and checking standards, visiting and accrediting services, and monitoring safety were also increasingly influencing the quality of care delivered by NHSScotland. See Table 1 below.

Table 1: Examples of governmental and professional bodies involved in clinical effectiveness

UK WideRoyal CollegesSafety and Efficacy of New Interventional ProceduresMedicines Control AgencyMedicines Devices AgencyEnglandNational Institute for Clinical EffectivenessCommission for Health ImprovementScotlandScottish Health Advisory ServiceScottish Needs Assessment ProgrammeNursing and Midwifery Practice Development UnitScottish Medicines Consortium

As well as an increase in the number of organisations involved in clinical effectiveness issues, various major policy changes and initiatives were introduced during the late nineties that impacted upon quality in healthcare in Scotland. The concept of clinical governance first emerged in the 1997 White Paper ‘The new NHS: modern, dependable”(3) and this led on to the 1999 Health Act(4) making it a statutory requirement upon each Health Board to ‘put and keep in place arrangements for the purpose of monitoring and improving the quality of healthcare which it provides to individuals’. In Scotland the theme was taken up in “Rebuilding our National Health Service”(5) through the Performance Assessment Framework (PAF) and formal annual accountability reviews.

The Bristol Inquiry(6), the setting up of the National Patient Safety Agency, a need to improve the quality of information available to patients and the introduction of Managed Clinical Networks (MCNs) were also key contributing factors to the quality and clinical effectiveness arena.

By 2001 it was becoming clear that a single clinical effectiveness strategy was necessary to connect all the different projects taking place to Scotland’s clinical priorities, to allow the development of a prioritised work programme and to support the NHS Boards in meeting the new requirements laid upon them. “Our National Health: A plan for action; a plan for change”(7) stated that ‘the Chief Medical Officer will work with relevant interests to achieve better integration and co-ordination of those national organisations and professional bodies with an interest in clinical quality’.

In response to this, discussions were held with the key organisations with an interest in clinical quality and with patient representatives and a consultation document on “A Quality and Standards Board for Health in Scotland” produced. It was proposed that five existing organisations CSBS, HTBS, the Scottish Health Advisory Service (SHAS), CRAG and the Nursing and Midwifery Practice Development Unit (NMPDU) be brought together into one new special health board.

Statutory Instrument 2002/534(8) provided for the creation at the start of 2003 of NHS QIS. The instrument defined the role of the new organisation to be ‘(1) supporting, ensuring and monitoring the quality of healthcare provided by the National Health Service in Scotland …, providing quality assurance and accreditation and (2) the evaluation and provision of advice to the National Health Service in Scotland on the clinical and cost-effectiveness of new and existing health technologies including drugs’. “Partnership for Care”(9), published in February of this year conveyed these details to the service in Scotland and the public. To fulfil its assigned role, it was agreed that NHS QIS would have the following functions:

• developing a national audit strategy
• developing and commissioning/approving clinical effectiveness/audit programmes and projects
• assessing the clinical and cost effectiveness of health interventions, including commenting on the application in Scotland of guidance issued by the National Institute of Clinical Excellence (NICE)
• overseeing the collection, analysis and publication of clinical outcome and performance data
• agreeing key clinical datasets and data definitions
• data aspects of patient safety
• developing clinical and non-clinical standards
• supporting NHSScotland in implementing clinical governance (including supporting staff working on clinical governance and clinical effectiveness)
• facilitating practice development programmes, including developing, reviewing and revising best practice statements
• learning from and disseminating advice relating to adverse events and near misses
• assessing performance of NHSScotland through self-assessment, external peer review, accreditation and inspection
• investigating serious service failures
• responsibility for supporting and monitoring patient and public involvement in NHSScotland, with the new Scottish Health Council being established in April 2004 as part of NHS QIS but with a distinct identity

NHS QIS also acts as secretariat for the Scottish Medicines Consortium and commissions clinical guidelines from the Scottish Intercollegiate Guidelines Network (SIGN).

Extensive consultation took place to determine how to shape the former five organisations into a structure to carry out the functions detailed above and best fulfil the needs of the stakeholders. It was decided that the new organisation should comprise four directorates. These are Guidance and Standards, Performance Assessment and Practice Development, Patient and Public Involvement and Planning and Resource Management. The transition to the new structure is nearing completion. The organisation has more than 100 staff of whom about one third are based in Glasgow and the other two thirds in Edinburgh. The current locations are being considered as part of a Scottish Executive location review.

NHS QIS has been asked to produce a strategic framework for improving the quality of patient care which will be subject to extensive consultation before publication in April 2004. This will detail the long-term work plan. It is clear from looking at the work done by the separate organisations to date, how the different products complement each other. For example in cancer, clinical standards were produced in the areas of specialist palliative care(10), cervical screening(11) and breast cancer screening(12). Review visits to assess performance against these standards are now underway and will be completed during 2003. A health technology assessment(13) advised that a Positron Emission Tomography imaging facility, which can indicate if a tumour is still active, should be set up in Scotland as a national resource. Additionally work has been carried out to develop a framework relating to the nursing care of people with cancer. Clinical outcome indicators were published for lung cancer in Scotland(14), and work was carried out in partnership with NICE to provide consistent guidance to NHSScotland on the clinical and cost effectiveness of nine cancer treatments (www.nhshealthquality.org).

The activities associated with information, libraries and knowledge management have been grouped together and placed within a strategic planning unit, Planning and Quality Management, within the Directorate of Planning and Resource Management. In this central position, the information, libraries and knowledge management function can provide information support to all directorates, ensuring that products are evidence-based and that up-to-date quality information is provided to all who require it.

When an area of work is proposed to the organisation, information team staff normally undertake comprehensive searches to determine the existing evidence on that topic, hence allowing decisions to be made on the most appropriate manner in which to proceed with the work. Databases covering secondary research such as health technology assessments and systematic reviews are searched, as well as the web-sites of evidence-based centres and key evidence-based publications. The current situation in Scotland with regard to the particular topic is established and information regarding any ongoing research gathered. Searches of the economic literature are also carried out at this stage. During the course of projects, search strategies are developed in conjunction with the project team and extensive systematic literature searches are carried out as well as smaller ad hoc searches looking for specific information. Information team staff are also responsible for the coding, storage, and management of evidence related documentation, for which extensive use is made of Reference Manager™ bibliographic software, and for ensuring that finished products are correctly referenced.

The majority of literature searching taking place within the organisation is undertaken by information team staff, however it is important that other members of staff can make use of the information resources available to them for day to day queries and keeping up to date professionally. With this in mind, the information staff deliver information skills training and encourage all staff to use the NHSScotland e-library. Training is provided in searching particular resources such as Medline or the Cochrane Library, using Reference Manager™, current awareness, introducing the e-library and in other areas as required. A small library for use by all staff is maintained and a number of specialised journals are purchased and circulated round the organisation.

It is hoped in the future to consider the provision of current awareness to the organisation as a whole and investigate methods to effectively deliver this information. Other possible developments include contributing to an NHS QIS intranet and perhaps working on projects to facilitate the handling of information within the organisation in conjunction with the IT unit.

This introduction should serve to show how NHS QIS came into existence and how it stands currently. It is a very young organisation however, and it is likely to develop and evolve as it matures and responds to the needs of NHSScotland. Working in partnership with healthcare professionals and the public will be a key feature of the organisation in its development as it strives to improve the quality of healthcare in Scotland. Effective use of information will make an important contribution to its goal of improving patient care and hence the role of the information scientist is a challenging but exciting one.

Reference List

1. The Clinical Standards Board for Scotland Order. SI 1999/726(S.51). (1999) Edinburgh, The Stationery Office.
2. The Health Technology Board for Scotland Order. SI 2000/47. (2000) Edinburgh, The Stationery Office.
3. Department of Health. (1997) The new NHS: modern, dependable. Cm.3807. London, The Stationery Office.
4. Great Britian. (1999) Health Act 1999. Chapter c.8. London, The Stationery Office.
5. Scottish Executive Health Department. (2001) Rebuilding our National Health Service. Guidance to NHS Chairs and Chief Executives for implementing Our National Health: a plan for action, a plan for change. Edinburgh, Scottish Executive Health Department.
6. Bristol Royal Infirmary Inquiry. (2003) Learning from Bristol: the report of the Public Inquiry into children's heart surgery at Bristol Royal Infirmary. Cm.5207. London, The Stationery Office.
7. Scottish Executive Health Department. (2000) Our National Health: a plan for action, a plan for change. Edinburgh, The Stationery Office.
8. The NHS Quality Improvement Scotland Order. SI 2002/534. (2002) Edinburgh, The Stationery Office.
9. Scottish Executive Health Department. (2003) Partnership for care. Edinburgh, The Stationery Office.
10. Clinical Standards Board for Scotland. (2002) Specialist palliative care: clinical standards. Edinburgh, CSBS.
11. Clinical Standards Board for Scotland. (2002) Cervical Screening: draft clinical standards. Edinburgh, CSBS.
12. Clinical Standards Board for Scotland. (2002) Breast Screening: draft clinical standards. Edinburgh, CSBS.
13. Bradbury I., Bonnell E., Boynton J., Cummins E., Facey K., Iqbal K., Laking G., McDonald C., Parpia T., Sharp P., Single A. and Walker A. (2002) Positron emission tomography (PET) imaging in cancer management. Health Technology Assessment Report 2. Glasgow, HTBS.
14. Clinical Outcomes Working Group. (2002) Clinical outcome indicators. Edinburgh, Scottish Executive.

Karen Macpherson
Health Information Scientist
NHS Quality Improvement Scotland
Delta House
50 West Nile Street
Glasgow Tel: 0141 225 6982
kmacpherson@htbs.org.uk