Assessments of quality 2010/11

Care Quality Commission's proposals for the assessment of commissioners and providers of health and social care (April 2010)

1. Introduction

  • Blind and partially sighted people have told RNIB they believe this consultation fails to address their needs.
  • We agree with the general framework being proposed. It is important to assess the quality of our health and social care services.
  • However, only a Special Review can address the gaps in care and support for people at risk of, and living with sight loss.
  • There are systemic failings in health and social care support. People with sight loss too often feel "abandoned", especially soon after diagnosis.
  • RNIB therefore calls on the Care Quality Commission to agree to a review of the care pathway experienced by blind and partially sighted people.

1.1 The Royal National Institute of Blind People (RNIB) hopes that assessments of quality will motivate commissioners and providers to take a person-centred approach to securing and delivering services for their local communities. Registration will assure taxpayers and the public that services meet essential standards of quality and safety. We understand the added value of assessments of quality since they are designed to stretch health and social care services so they proactively deliver improvements over time.

1.2 Notwithstanding this the RNIB views this consultation as a missed opportunity. Blind and partially sighted people are disappointed that the Commission has set out thirteen possible topics for special reviews or studies in 2010/11 and 2011/12 but the consultation does not include any topic in relation to people at risk of, or living with sight loss.

1.3 We understand the cornerstone of the Commission's regulatory activity is to ensure that essential standards are met. However, the challenges faced by people at risk of, and living with sight loss are numerous. We have evidence of systemic failings in health and social care provision. The Commission states that it expects commissioners to work with providers and people who use services to ensure joined-up provision.

1.4 Yet care services are woefully equipped to meet the needs of blind and partially sighted people. Too many people fall through the gaps following a diagnosis of sight loss. For example nearly a quarter (23 per cent) of blind and partially sighted people leave the eye clinic not knowing, or unsure of, the name of the eye condition that caused them to lose their sight. In fact the scale of these failings call out conclusively in our view for a Special Review on the "care pathway" experienced by blind and partially sighted people. Our case is largely premised on the fact that significant numbers of people at risk of sight loss and those who are blind or partially sighted are having their needs overlooked altogether.

2. Vision

Question 1. "Do you support our aims for assessments of quality?"

2.1 The aims appear to us to be very sound. So for example it is absolutely right that the Commission, with its widened remit to consider the integration of health and social care, should evaluate patient pathways. In other words we agree with the organising principle that health and social care services should work together to meet people's needs. Unfortunately research shows that individuals certified blind or partially sighted typically wait long periods to hear from social services or to receive a community care assessment.

2.2 It strikes us that one additional aim would involve the Commission assessing where commissioners and providers fail to provide any meaningful service to a particular group of service users. Making judgements on quality rather assumes every group with health or care needs is getting some sort of service; that the function of regulators is to assess the quality of services currently available or provided to a community.

2.3 Assessments run along these lines would in our view fail to register that quality is put at significant risk when PCTs fail to provide a particular type of service. World class commissioning guidance on eye health (July 2009) and guidance from the Royal College of Ophthalmologists on the treatment of age-related macular degeneration (AMD) outline the need for emotional support and integrated support at "the point of diagnosis". The Royal College's guidance on AMD specifically recommends patient pathways based on access to an Eye Clinic Liaison Officer, a dedicated professional providing one-to-one support to patients diagnosed with the condition.

2.4 Yet our evidence suggests significantly less than half the country's eye clinics provide patient support services. We should also consider adult social services' interpretation of guidance on eligibility criteria. This often has the effect of screening out blind and partially sighted people from receiving personal care, so assessments of quality need to pay close attention to those services not even being commissioned or provided in the first place.

2.5 We welcome the proposed aim to assess individual services and not rely too much on overall ratings for an organisation. This is a crucial development. To genuinely focus on outcomes and listen to people's needs, judgements need to be made about quality and risk in individual services, for example in hospital eye clinics. The outpatient with glaucoma that hears their eye clinic has yet again cancelled their follow-up appointment would expect inspectors to evaluate the quality of care provided in ophthalmology, not to base its assessments on its overall impression of a PCT or an NHS Trust.

Question 2. "What more could we do to promote efficiency and streamlining of our approach to assessments, so as to reduce the costs while maintaining the benefits?"

2.6 RNIB is generally pleased with the framework being proposed. It is clear how assessments relate to Government policies and priorities and there is an obvious focus on people's own experiences of care. We understand that better regulation principles highlight the need for proportionate inspection and assessment regimes. We would, however, be concerned to see the Commission's plans for assessments of quality cut back in any significant way.

2.7 There are pressures on public sector budgets and the Commission clearly needs to operate in this context but we do not want to see the Commission being forced to make unrealistic economies. So for example we would be displeased to see the Commission scaling periodic reviews back so much that all commissioners and providers need concern themselves with is compliance with core registration standards. Ultimately cuts in regulation impact on the people that rely on health and social care services most. This includes people at risk of, and living with sight loss.

3. Commissioners

Question 3. "Do you support the general direction of our approach for assessing councils as commissioners? What changes would you like to see so that our assessments are as effective as possible in promoting improvement in the performance of councils?"

3.1 RNIB supports the general direction of the Commission's approach but we would contend more still needs to be done to ensure councils deliver the mix of services their communities need. The 2008/9 figures, which revealed 95% of councils performed "excellently" or "well", bring into close focus the need for robust and challenging assessments. We know that three quarters of councils restrict care services to people deemed to have critical or substantial needs (with some confining support to "critical only"). It is generally accepted that the tightening of eligibility criteria has resulted in resources being targeted increasingly at those assessed as having the most acute need.

3.2 One problem regarding the operation of Fair Access to Care Services was the apparently very low awareness among assessors of the impact of vision loss, resulting in large numbers left outside the top two eligibility bands. Assessors mistakenly grouped blind and partially sighted people as if their needs were uniform, with scant acknowledgement of the range of support needs in this population group. In its 2008 report 'Cutting the Cake Fairly' the Commission for Social Care Inspection (CSCI) acknowledged that certain groups, including blind and partially sighted people, remain marginalised in the care system. It is still too early to judge whether 'Prioritising need in the context of Putting People First', the new guidance on eligibility criteria published in February 2010, is making a positive difference.

3.3 Challenging assessments would of course evaluate how far councils have come in implementing Putting People First guidance and their performance against the National Indicator Set. Specifically they would consider action taken since the Department of Health published guidance on the identification, referral and registration of sight loss in December 2003. It is useful to note that councils will be assessed in greater depth where special reviews and studies highlight or signal particular problems in the care system. There are limitations with this approach, however.

3.4 RNIB recommends the Commission sharpen up its regulatory approach by assessing how councils perform for those groups whom it is argued remain "hidden" to the care system (CSCI specifically mentioned blind and partially sighted people, people with fluctuating conditions and people with Asperger's/autism, among others). None of the national indicators specifically govern local authorities' provision of care services for blind and partially sighted people. The special reviews under consultation do not seek to address the problems experienced by blind and partially sighted people struggling along on their own. It is difficult therefore to gauge the extent to which these assessments can hope to measure councils' role as a commissioner of services for people living with sight loss.

3.5 In conclusion the narrative accounts the Commission promises will need to dig deep to examine the experiences of those groups routinely screened out from receiving state-funded care services. This of course means consulting Local Involvement Networks, Overview and Scrutiny Committees but also consulting people who have been deemed ineligible for publicly funded personal care. Putting People First envisaged everyone with care needs would be able to access a universal information, advice and advocacy service by March 2011 (the end of the Spending Review period). This would be available to even those individuals and carers that were considered ineligible for publicly funded care. Anecdotal evidence indicates too few blind and partially sighted people in this situation are sign-posted or referred on to information, advice and advocacy services.

3.6 We look forward to the potential establishment of a National Care Service, but at the time of writing it is far from certain this service will be set up in the way the Government outlined in its White Paper in March 2010. So in 2010/11 we would encourage assessments of councils to evaluate performance on a few fundamental issues, perhaps primarily the question of access and the arrangements councils put in place for individuals deemed ineligible for publicly-funded care. One key question should consider whether blind and partially sighted people receive information, advice and advocacy services. The Commission plans to highlight where things are going well and where there are serious issues that need to be addressed. As far as blind and partially sighted people are concerned, this means establishing whether access to publicly funded care is so limited that the Commission's strategic priorities are compromised.

Question 4. "Do you support the general direction of our approach for assessing PCTs as commissioners? What changes would you like to see so that our assessments are as effective as possible in promoting improvement in the performance of PCTs?"

3.7 Again, we generally welcome the direction being proposed, but we have a number of specific concerns. Since the Government has largely devolved commissioning decisions in health to primary care organisations (in England most recently by devolving responsibility for the General Ophthalmic Services budget to PCTs) appropriate governance is key.

3.8 Unfortunately, monitoring of the effectiveness of resource allocations in the area of eye care is poor. The performance frameworks governing the provision of health care in England make almost no reference to eye care. The NHS Operating Framework and 'national priorities' represent powerful levers for change, but historically these have failed to pay attention to the needs of people at risk of, and living with sight loss. Relying too much on these sources of information will lead to a partial understanding of PCTs' performance as commissioners.

3.9 A telling indicator of the fact that PCTs lack understanding of people's needs in the area of eye health is the absence from most Joint Strategic Needs Assessments of any references to the eye health and low vision support needs of their population. We are pleased the Commission plans to identify areas of particular risk and to do this on an ongoing basis. For this to work effectively, however, the Commission needs to pay close attention to Joint Strategic Needs Assessments and in areas where the eye health needs of the population are being overlooked, to question PCTs on their plans.

3.10 RNIB recognises that it is difficult for local inspection teams to achieve a detailed understanding of all the problems and gaps in the commissioning of health services. Consulting people who use health services will be very important. Local societies of blind and partially sighted people also have a detailed appreciation of the services available to people at risk of, and living with sight loss so they are another potential source of information. At the very least we would expect assessments of quality to consider PCTs' implementation of the world class commissioning guidance on 'Improving eye health services' published in July 2009.

4. Providers

Question 5. "Do you support the general direction of our approach for assessing NHS trusts and PCTs as providers? What changes would you like to see so that our assessments are as effective as possible in promoting improvement in the performance of NHS trusts and PCT providers?"

4.1 Once again RNIB notes that Special Reviews are an important component in the regulatory framework. Assessments of quality, in this case assessments of NHS Trusts and PCTs in their role as providers will be informed by these reviews. Further below (in section 5) we consider in greater detail what a Special Review might mean for blind and partially sighted people. Our immediate thought is that without a Special Review, it appears particularly unlikely other elements of the system (including assessments of NHS Trusts and PCTs) will accurately reflect blind and partially sighted people's experiences of health and social care. We also question a point repeatedly put to RNIB that Special Reviews constitute a small aspect of the Commission's regulatory framework, since so many other assessments will draw on the findings of these reviews.

4.2 The first statutory Quality Accounts will be published by June 2010. If primary providers have to produce Accounts, these are expected one year later. We anticipate with interest what these accounts will say about the quality of NHS services accessed by people at risk of and living sight loss. We know they will cover Trusts' record on safety and there will be space for patient experiences' to be communicated too. Our hope is that these will be rigorously monitored and the Commission feels it has sufficient powers to seek clarification or corrections where necessary. From our perspective, it is crucial the Commission builds up enough intelligence through its own Quality and Risk profiles to challenge NHS Quality Accounts with incomplete information.

4.3 Many hospital eye clinics have no system in place to monitor appointments by disease and are therefore unable to react adequately to problems with cancellations or delays of follow-up appointments. This is worrying, not least because the National Patient Safety Agency issued an alert in April 2009 highlighting cases of unnecessary blindness through glaucoma in patients who had not been seen at the appropriate intervals.

4.4 RNIB believes that hospital eye clinics should at least be required to collect data that allows them to analyse how many patients they are catering for in each of the most common eye diseases to ensure that adequate services are put in place to meet their needs. If they do not collect data in this way, this raises serious questions about whether core questions on safety and financial management can be addressed. It also highlights why the Commission is right not to attempt to "boil down" the assessment of large, complex organisations into a single grade. Individual services, including hospital eye clinics need to be properly scrutinised. Quality Accounts might include detailed evidence on what needs to change within an NHS Trust or PCT, but we cannot necessarily depend on this being the case.

4.5 RNIB sees the Commission having an extremely important role to play here. Of course it must analyse providers' performance against the NHS Operating Framework and other national priorities but the Commission must not forget that to genuinely modernise, it must rely on other sources of information. This includes engaging with patients, organisations of blind and partially sighted people, professional organisations such as the National Patient Safety Agency and NICE, which has published clear guidelines on healthcare for patients with common eye diseases, including glaucoma. To truly be dynamic, the Commission's periodic reviews must seek out information NHS Trusts and PCTs might not readily provide, on safety, information management and value for money. With respect to eye health and sight loss services, RNIB has evidence that a number of providers would currently be found to be lacking in these areas.