Managing quality in community health care services

1 Managing quality in community health care servicesAuthorsCatherine FootLara SonolaLaura BennettBeverley FitzsimonsVeena RaleighSarah GregoryDecember 2014 Managing quality in community health care services51234 Contents 1 ContentsKey messages 2 Introduction 4 Scope, methods and sample 8 Findings and discussion 10 Self-assessment of current quality 10 Defining quality and setting quality priorities 11 Measuring quality 14 quality governance 23 Staff engagement in quality and quality improvement 25 Issues affecting quality in community services 28 Conclusions and recommendations 35 References 39 Acknowledgements 41 About the authors 4212345 Key messages 2 Managing quality in community health care services512341 Key messages This paper reports on the findings from a small primary research study exploring how community health services providers define, measure.

2 Manage and improve the quality of care . community health services are an essential component of providing person centred, co ordinated care . They are a diverse sector, providing a huge range of different services , and are run by a mixed economy of types and sizes of organisation, including standalone NHS community trusts, existing acute and mental health trusts, social enterprises and independent sector providers. community services providers told us how they were working hard to measure, manage and improve quality . There is considerable local activity to gather and use information on quality , and some providers have impressive systems of quality governance in place. However, community services providers are severely hampered by a lack of robust, comparable national indicators that would enable them to benchmark their performance. National datasets provide very limited insight into quality in community services , and the information technology and infrastructure are not well enough developed to support quality measurement.

3 This lack of data means that the quality of community services and the outcomes it is providing for patients remain to a large extent unknown at the national level. This problem is greatest for care provided by non NHS organisations. This is particularly dangerous in the coming years as community services providers experience significantly growing demand and face acute workforce challenges. There is a serious risk that poor or declining quality will not be identified promptly. Key messages 3 Managing quality in community health care services51234 Policy makers and service leaders aspire to a health care system that more effectively supports people to remain well and independent, and cares for people as close to home as possible. The community services sector should be integral to this vision.

4 However, there remains relatively little national policy focus on quality in community health care . This needs to change. If community health services are to fulfil their potential, and indeed to cope in the years ahead, greater attention must urgently be paid to ensuring that quality information and management systems in community services are developed and quality in community health care services Introduction 4512342 IntroductionCommunity health services are a vital part of the NHS for millions of people, with around 100 million contacts each year. They comprise approximately 10 billion of the NHS budget (Lafond et al 2014) and cover a huge range of essential services (see Table 1 for a list of some of the largest types of services provided in the community ).Table 1 Overview of some of the main community health services and their principal functionsCommunity nursingCommunity nursing involves district nurses, health visitors, mental health nurses and paediatric community nurses.

5 District nurses typically look after older people, those recently discharged from hospital and people who are terminally ill or who have physical disabilities, in their homes or community settings. care involves, for example, delivering intravenous antibiotics at home and caring for wounds. They help patients manage long-term conditions (eg, diabetes, stroke, COPD and dementia). community matrons work closely with patients to provide, plan and organise their care . They mainly work with those with a serious long-term or complex range of careDistrict nurses co-ordinate end-of-life care , assessing a patient s needs and deciding in consultation with the patient and family what support is required. Hospice or palliative care staff work alongside them. health visitingHealth visitors support families with children aged 0 to 5. They can refer families to specialist services and are trained to recognise risk of harm to a child. They work in people s homes, clinics, Sure Start centres and GP nursingSchool nurses can provide services including health and sex education, developmental screening, health interviews and immunisation programmes.

6 They also provide additional support for looked-after careThis involves supporting someone when they leave hospital, or helping prevent admission to hospital or residential care . It can be provided by a range of nurses and allied health professionals including community mental health nurses, physiotherapists, occupational therapists and speech therapists. Social workers and GPs can also be involved. Managing quality in community health care services Introduction 551234 ContinuedPhysiotherapyPhysiotherapists help people affected by illness, disability or injury to recover and stay independent. Treatment in the community might take place in a patient s home, a health centre or nursing home. It treats conditions like stroke, multiple sclerosis, Parkinson s, back pain and arthritis, and contributes to rehabilitation after heart attack.

7 It involves manual therapy, exercise and therapyOccupational therapists work in patients homes, nursing homes, community centres and GP practices with people of all ages, to help them overcome the effects of disability caused by physical or psychological illness, ageing or accidents, and to support them with everyday and language therapyThis is provided in community health centres, patients homes and day centres. It helps people who may have had a stroke or, cancer of the mouth, or have a learning disability who may have difficulties in producing and using speech or in understanding Podiatrists treat people with lower limb pain or who have problems walking, people needing minor surgery, those suffering with circulation problems caused by diabetes and those with nail problems. They can carry out minor surgery under health servicesSexual health services include contraception, STI testing and treatment and genito-urinary medicine servicesMultidisciplinary teams typically carry out specialist services .

8 For example, musculoskeletal conditions are treated by teams including GPs, physiotherapists and podiatrists. Treatment can include medication, support in self-management, physiotherapy and manual than any other part of the health care provider system, the community sector has been subject to repeated reorganisation (Imison 2009 and see box overleaf ). Most recently, the Transforming community services programme saw primary care trusts (PCTs) divesting themselves of the community health services they provided so that they could focus on commissioning (Department of health 2009). community services were transferred to a range of different organisational forms and structures. Some established themselves as standalone NHS trusts. Others were combined with existing acute or mental health trusts. Still others became charities or social enterprises, and others were taken over by private sector providers. Recent analysis from the Nuffield Trust indicates that the independent sector has become a significant provider of community services and that spending on non NHS providers is increasing rapidly.

9 In 2012/13, 69 per cent of the NHS spend on community services went to NHS providers, 18 per cent to the independent sector, and 13 per cent to voluntary organisations and social enterprises (Lafond et al 2014). Managing quality in community health care services Introduction 651234 This makes the community services sector distinctly more diverse than either the acute sector (where 96 per cent of spend is with NHS bodies) or the mental health sector (where NHS providers account for 81 per cent of spend) (Lafond et al 2014). community health services a history of reorganisation1948 community nursing and child health fell within remit of local authorities1974 community health services transferred to the NHS, to tackle poor co-ordination between hospital and community services1989 Working for patients NHS commissioner/provider split, community services increasingly established themselves as standalone trusts1997 PCTs established, integrated with community services 2005 Commissioning a patient-led NHS PCTs to contract out community services2008 Darzi next stage review recommended separation of PCTs commissioning and provider functions2009 Transforming community services required PCTs to come up with new model of provisionThe community sector is crucially important to achieving the transformation in services that we need to meet the current and future challenges facing our health care system (Ham et al 2012).

10 They are an essential component in efforts to provide person centred, co ordinated care , closer to people s homes, focusing on keeping people well and independent, and minimising hospital stays wherever possible. Several high priority national policies, such as the Better care Fund, are contingent on a larger role for the community , despite this crucial role, community services can seem strangely overlooked by the general national agenda around assuring and improving quality . The hospital sector has a relatively long and well established legacy of and system for monitoring quality , and serious failures in the quality of care in the acute hospital sector have further reinforced the focus on quality in recent years (Department of health 2008; National Advisory Group on the Safety of Patients in England 2013; Department of health 2013; Mid Staffordshire NHS Foundation Trust 2013). In contrast, Managing quality in community health care services Introduction 751234there is relatively little national policy focus on quality in community health care , and approaches to measuring and improving quality in community services are less well developed.