Response to the key recommendations of the independent evaluation of the cancer peer review programme 2004-2007 undertaken by Safe Quality Care in December 2007
Stephen Parsons, National Coordinator, Cancer Peer Review
6/4/2008
- Introduction
This paper summarises the key recommendations made by the independent evaluators of the national cancer peer review programme 2004 to 2007 and gives the response from the National Coordinator for Cancer Peer Review to those recommendations. The recommendation is shown in a plain black font and the response is shown in a red italic font.
- Overall Comment
There is strong support for Peer Review to continue, particularly in order to drive further improvements in cancer services but in order to maintain support from those participating, the process must be redesigned. There is a view that the process has become unwieldy and too bureaucratic and that it needs to be streamlined and simplified to keep it meaningful and valued.
The National Cancer Action Team is pleased to read the conclusion reached by those conducting the evaluation that there is continuing strong support for peer review. The National Programme Review, commissioned by the Office of Strategic Health Authorities, endorsed the continuation of peer review, and made a set of recommendations to ensure that NCPR:
-meets the requirements of those who are commissioning it,
-continues to act as a catalyst for improvement in cancer services in conjunction with other agencies such as the Cancer Services Collaborative and
-represents value for the resources that are invested in it.
The peer review programme has provided commissioners, providers, statutory regulators and service users with an independent, comprehensive disease specific profile of individual teams and services across England. As a result of the review process every Cancer Network and Acute Trust in England now has an action plan to address any shortcomings in the organisation and delivery of cancer services that have been identified.
However the national and zonal coordinating teams have recognised that the process of peer review does need to be redesigned to ensure that it retains the support of key stakeholders, especially clinicians, to ensure that it represents value for money, that it continues to act as a driver for change and that it is able to be extended to include other disease areas. A new approach to peer review, together with a revised infrastructure is currently being developed and is scheduled to be launched in October 2008.
The evaluation has been extremely helpful in confirming that the coordinating teams have identified the appropriate areas where change is needed.
- Self-assessment
The process of self-assessment should continue but the Peer Review process should not rely solely on this. In designing the future process for self-assessment we recommend that the national team ensure that the process:
- captures the information required by teams to enable them to improve
- provides useful and relevant annual information for stakeholders (commissioners, service users, the Healthcare Commission etc)
- enables the whole MDT to be involved to gain ownership
- is less time consuming
- is open to checking by the Peer Review zonal team
It is recognised that peer review needs to be a mechanism which supports quality assurance processes within teams and organisations, rather than being an externally driven activity that results in varying degrees of ownership by those being reviewed. It is recognised that there needs to be different elements to the peer review process which can be summarised as follows:
- A programme of comprehensive reviews will be undertaken whenever new measures are issued in response to newly published NICE Improving Outcomes Guidance (IOG). This will eventually include a comprehensive review of all services for skin cancer, children and young people with cancer, sarcoma and brain and central nervous system.
- Cancer Network Directors have developed a model cancer service specification which includes a requirement for annual self assessments to be undertaken by all providers of cancer services.
- Peer Review Visits
Peer review visits are an important part of driving quality improvements in cancer services and of spreading good practice and allowing clinicians to learn about the whole pathway of care. We recommend that the visits continue to all services as supportive assessments, validating the quality of cancer services and helping services develop and improve.
The Cancer Peer Review Coordinating Teams agree that peer review visits are a vital part of the review process but will be consulting on the proposal that there should be a more proportionate, targeted approach to visits. It is proposed that in future there should be various factors which will trigger a peer review visit and these will include, for example: a significant variation between the self assessment and the validation; failure to comply with the IOG or to achieve the necessary milestones; a good or poor level of improvement since the last review; a request for a visit or the provision of soft intelligence from the Network, Commissioners or Trust. It will also be important to visit teams that are demonstrating high levels of compliance with the measures to ensure that good practice is highlighted and shared. Where new measures are published for a specific tumour type, it is proposed that all teams providing services for that tumour will be subject to a peer review visit.
- Accountability for action following a review visit
Peer review is about driving improvements and reducing risk in cancer services, it is therefore vital that services implement the findings from the review visit in particular where they relate to risks and concerns. Further work is needed by the national team to review current guidance and to provide clarity to those who hold this responsibility and are accountable. We would recommend that a process of more frequent targeted visits by a small expert group (including users and carers) is developed, based on information from the review visit and the subsequent annual self-assessment reports to check on progress against key risks and concerns.
One of the challenges in the current peer review process is the one of ensuring that teams/organisations take appropriate remedial action following a peer review report. Peer review is one of the tools available to a Health Authority/PCT in carrying out its performance management responsibilities and therefore responsibility for ensuring that appropriate remedial action is taken following a peer review sits with those organisations.
We will be recommending that each cancer network consider how, with the drive towards stronger commissioning ,responses to the findings of self assessment and peer review can be made more robust, to include the possibility of remedial action plans following a peer review being built into annual service specifications. The failure of a Network/Trust/Team to take remedial action within an appropriate timescale would be one of the factors that could trigger a peer review visit.
- Consistency of approach
For Peer Review to deliver the quality improvements and changes required in the new cancer strategy we believe that there needs to be a clear line of accountability from the national team to the zones. We recognise the benefits of the zones being able to be creative and innovative in their approach to Peer Review and this must not be lost, but rather framed within the national approach. We therefore recommend that in strengthening the line of accountability it is made clear which elements of Peer Review must have a consistent national approach and where the zones can be flexible. There would also be benefit in clarifying the arrangements between the national team, the zones and the Strategic Health Authorities, making sure that the needs of the SHAs are met by the zones.
The National Steering Group for Cancer Peer Review has agreed that the infrastructure for peer review should be reorganised and this agreement has now been endorsed by the NHS Cancer Programme Board and the Office of Strategic Health Authorities. One of the key drivers for change has been the need to strengthen the management of the peer review process, ensuring national consistency in both the design and delivery of peer review. The new infrastructure will be made up of 4 regional/zonal teams each reporting to the National Coordinator, with each team led by a f/t Quality Director post who will be part of an Executive Team for Peer Review. That Executive Team, led by the National Coordinator will be responsible for the operational leadership of peer review and for reporting to the National Steering Group for Cancer Peer Review on matters of national consistency and for bringing to their attention issues where zonal flexibility might be acceptable.
The opportunity is also being taken to review both the terms of reference and membership of the National Steering Group for Cancer Peer Review. It is considered important to ensure that the Steering Group includes appropriate representation from SHAs, PCTs, Specialist Commissioners and Cancer Networks, in addition to existing representation from patients and carers.
One of the key roles for the new Quality Directors will be to liaise with Chief Executives and Directors of SHAs, PCTs and Trusts to ensure familiarisation and understanding of the peer review programme and its ethos and to ensure appropriate monitoring and follow up of agreed remedial action.
It is further intended that all peer review staff will be employed by a single host strategic health authority but the details of that have still to be agreed.
- Purpose and leverage
The issue of leverage is important to those participating in Peer Review and in designing the process for the future consideration should be given to ensuring that the reports have impact and that service improvements follow. To achieve this we would recommend that the report following a visit is formally presented to the trust board and to commissioners of the service by the zonal team.
The Peer Review visit is clearly about quality improvement and learning for those involved. The output from the visit is about driving change and performance monitoring, providing a national picture. At present the process is not used for regulation or accreditation although there are those would support this as a next stage. We therefore recommend that the national team consider the purpose of the different aspects of the Peer Review process in the design of the process in future.
As part of the existing peer review process there is an expectation that peer review reports will be in the public domain and Trusts are asked to ensure that reports are presented during the public part of their Board meeting. Reports are also published on CQuINS and copies are sent to the Healthcare Commission. Discussions are currently taking place with the Healthcare Commission with a view to developing an information sharing agreement which will underpin closer working between the two organisations and will ensure that the intelligence gained from the various reviews of services is available to both.
However it is recognised that more could be done to ensure that more is done to make information from peer review more readily available to assist the decision making of commissioners and to support patients to make informed choices. It is intended therefore that information from peer review will form a significant part of the Commissioning Toolkit that is currently being developed by the Cancer Action Team and will also be used by the NHS Choices web-site to give patients and the public information about the performance of different teams and services.
- CQuINS
Given the potential benefits of an improved web facility, and the frustrations with the present system expressed in this evaluation, we recommend that the national team take action to develop and improve CQuINS.
In recent months there have been a number of developments to CQuINS, including the introduction of a function which enables users to track the changes that have occurred in the functioning of a team/service between one peer review and the next. The system has also been upgraded to significantly reduce the time required to upload documents. However a review of CQuINS is being undertaken by the National Coordinating Team to address anyother shortcomings of the system and to ensure that it is “fit for purpose” both in terms of the new process to be introduced and the anticipated extension of peer review to other disease areas.
- MDTs
MDTs are central to the delivery of cancer services and we believe that there should be a regular, for example an annual assessment of team performance conducted in a way that gains ownership within the MDT and is constructive in helping them learn and improve. There are a number of ways of assessing team working through self-assessment surveys or through observation using a structured assessment tool and we would recommend that the national team examine these different approaches and develop tools for use by MDT‘s. In this way the self-assessment can ask for evidence of this assessment and of an action plan developed by the MDT to improve their performance. In assessing MDT‘s performance it is important that consideration is given to the support that will then be available to MDT‘s to help them improve and we strongly recommend that the national team do further work to look into ways of doing this. There are many interventions that can help teams improve their performance and there is a growing literature on the effectiveness of interventions. We would recommend that nationally this literature is reviewed and successful methods are examined in order to be able to provide advice to Trusts and networks about the best methods to support MDT‘s improve their performance.
As mentioned earlier,it is intended that commissioners will develop service specifications thatwill require providers to undertake annually, and preferably continuously, a programme of self assessment against peer review measures both as part of the national programme and as a demonstration of internal quality assurance. The National Cancer Action Team is currently undertaking a piece of work to identify what further support can be provided for MDTs.
The National Cancer Action Team has developed a number of programmes in support of team training including rectal (Pelican) prostate MDT training and sentinel node breast team training.
- The measures
We recommend that the national team set up a process for reviewing the existing measures involving all those in the MDT. This process should deliver:
A smaller set of key measures
Improved ways of demonstrating compliance
A agreed system that reviews and updates the measures on an ongoing basis that has wide participation by those required to implement them
A system that aligns the measures to those used in other clinical quality assurance and accreditation systems
A working group has been established with the task of:
- Agreeing the principles to be applied in revising existing measures and developing new ones
- Identifying those measures that are no longer appropriate/necessary
- Identifying where there are gaps in the current measures e.g. audit and data collection
- Identifying where existing measures need to be further developed
The working group is scheduled to report on the progress it has made in addressing these tasks by early June 2008.
Separate pieces of work are being undertaken to review and where appropriate revise the measures dealing with the administration of intrathecal chemotherapy, to consider developing measures concerned with the management of complications around chemotherapy and to identify a set of key clinical indicators.
- Patient safety
Patient safety is one of the top government priorities and we recommend that Peer Review strengthens this aspect of its work in future.
The National Coordinating team will give consideration as to how this recommendation can be addressed in the light of pending legislation on matters of patient safety.
- Outcome measures
We recommend the national team set up a process for gaining consensus from key stakeholders as to what these measures should be and that this process includes the views of users and carers and commissioners.
The Cancer Reform Strategy recognises the need to collect anduse high quality data on clinical outcomes, including survival, withadjustments for co-morbidity and stage ofdisease.The strategy comments that collecting information on clinical outcomes can in itself be a key driver for improvements in quality. A National Cancer Intelligence Network(NCIN) is being set up building, maintaining and quality assuring a new national repository of cancer data The peer review programme will start to use this resource as a means of informing its review activities, but will also act as a source of information for the NCIN. At present peer review focuses largely on measures of structure and process, although a number of the existing measures are concerned with participation in audit activities and the need to ensure comprehensive and timely data collection.However the Cancer Reform Strategy states that over time, as reliable measures of outcome become available, there should be a shift in emphasis.