Thursday, 15 March 2012

LINk London Meeting

With the future of patient and public involvement in the Health and Social Care Bill in a state of chassis - possible privatisation of public and patient involvement etc, this meeting next Wednesday of London's LINk is vitally important. LINks will be abolished soon but will be followed by what? The new Healthwatch system as envisaged in the Bill seems doomed. An important meeting for anyone involved in health and social care.

Wednesday, March 21st from 5.30pm to 7.30pm

Committee Room 4, Lower Ground Floor, City Hall, Greater London Authority,

The Queen's Walk, London SE1 2AA

Agenda –

Agenda Item
The Bill–outcomes, consequences and letters to David Cameron and from Earl Howe
Developing Healthwatch in London – priorities and challenges
Ian Winter, (Deputy Regional Director, Social Care Leadership and Partnerships, London Region)

See note from Lynda Tarpey - below
HealthWatch Advisory Group and Programme Board –
Nick, Jeremy, Nim, Malcolm
The LGA/DH Healthwatch Implementation Programme (attached)
Patient-led inspections – briefing paper (attached)
Gus Wilson - Stakeholder Manager - NHS Information Revolution Project  for London – My Health London
Agreement on dates of future


Very special thanks to Gus Wilson for organising the room at the GLA
Gus Wilson - Stakeholder Manager - NHS Information Revolution Project for London, Greater London Authority
020 7983 4120
07824 694 944

Establishing Patient-Led Hospital Inspections

Briefing Paper for Steering Group

15 March 2012


1.    On 6 January 2012, the Prime Minister announced the introduction of a new patient-led inspection regime in hospitals providing NHS funded care.  The announcement was made alongside a wider commitment to improved patient care.

2.    These inspections will replace the existing Patient Environment Action Team (PEAT) programme and will cover the same specific areas, namely privacy and dignity, food and cleanliness. The outcomes will be reported publicly to help drive up standards of care. A key feature will be the involvement of patients at all stages – system development, carrying out inspections and validating results.

3.    David Nicholson has asked the National Quality Board (NQB) to advise on the work – in particular its alignment with the rest of the new NHS.  The NQB scrutinised early plans at its meeting on 27 February, and made a number of helpful comments.  In particular, they wish the project team to:

  • Be as ambitious as possible
  • Strive to give real meaning to the term “patient-led”
  • Make the inspection scope wide, preferably including small hospitals of fewer than ten beds (not previously included in the PEAT process)
  • Ensure that all hospitals comply with the inspection regime

4.    A Steering Group has been established as a sub-group of the NQB, to help embed these principles within the project.  The Steering Group will guide the development of the new patient-led inspections process, providing advice to the teams responsible for its delivery.  The Chief Nursing Officer will Chair this group until the appointment of the NHS Commissioning Board (NHSCB) Chief Nurse, who will take this forward.  Draft Steering Group Terms of Reference (for agreement at first meeting) are below:

  • To ensure that the patient voice is integral to the new system
  • To provide advice on PLI project alignment within the wider system
  • To provide advice and guidance to the PLI Delivery Group as required
  • To promote and facilitate stakeholder communications, where appropriate
  • To advise on the new patient-led inspection system scope and coverage

5.    A project office has been established within the Department of Health’s Gateway Review, Estates and Facilities Directorate (GREFD) based in Leeds, with Dr Liz Jones as Project Director. 

6.    A fuller description of the project and its aims are at Annex A.  This includes some specific questions that we would like the Steering Group to address.

Liz Jones

Project Director
Annex A

Patient-led inspections of the hospital environment

1.    On 6 January 2012 the Prime Minister announced the introduction of a new patient-led inspection regime, covering privacy and dignity, food, and cleanliness in hospitals.  The results of these inspections (which will replace the current Patient Environment Action Team (PEAT) inspections from April 2013) will be reported publicly, to help drive up standards of care.  The key feature will be the involvement of patients or their representatives at all stages, including development of the system, the inspection process and validation of inspections.

2.    This annex:

  • provides a summary of latest thinking about how the new patient-led inspections process might work (informed by the NQB’s initial feedback)
  • identifies early decisions which require the Steering Group’s attention/advice


3.    The current PEAT process was designed in 2000 and overhauled in 2004.  It has contributed to the marked improvement in cleanliness across the NHS (in 2000, almost one-third of hospitals were judged to be “poor” or “unsatisfactory”, whilst today only a handful each year fall into these categories).  It has also tracked improvements in food quality and in delivering high standards of privacy and dignity.  It is entirely separate from inspections carried out by the Care Quality Commission (CQC), but is drawn on by them when creating their risk profiles.

4.    PEAT was established 12 years ago in a very different NHS.  It has served a useful purpose, but we now need an inspection regime that is aligned to the new service, and in particular to the commitment to reflect patients’ expectations.  The existing system does not adequately recognise the increasing plurality of healthcare provision, and nor does it reflect the needs of new organisations such as the NHSCB.  Whilst PEAT has always taken account of patient views (around 80% of inspection teams include a patient representative), such involvement has been varied and in some cases minimal. The new system needs to have patient opinions at its heart, and must ensure that their voice is heard.  The PEAT scoring system also needs refreshing to allow exceptional performance to be recognised.

Public commitment - a new system of patient-led inspections

5.    The DH will put in place a new system of patient-led inspections by April 2013, to give patients a strong voice in the assessment of privacy and dignity, food and cleanliness in hospitals offering NHS-funded care.

6.    The spending challenge facing the NHS means that the new system must be broadly cost-neutral once in place and must not represent a significantly greater overall burden than at present.  To achieve this, we plan to retain key features of the PEAT process (for example inspection frequency, publication of figures by the Health and Social Care Information Centre (HSCIC), web-based reporting and the avoidance of creating new “inspector” posts).  As now, the system will apply to hospitals only.  However, the scoring system will be different from PEAT, which will mean it is not possible to compare scores between the two systems. 

7.    Further, the data that the assessments generate must:

  • Meet the needs of patients, so that they can understand what standards they might reasonably expect in relation to the hospital environment, and judge their own local hospital in that light

  • Meet the information needs of a wide range of stakeholders involved in maintaining and improving quality, including the NHSCB, CQC and DH
  • Be aligned to (but not duplicate) other inspection and monitoring regimes

A strong system of governance and accountability

8.    The project’s governance structure (which models central Government best practice) is shown in Annex B.  Responsibility for delivery lies jointly with the Chair of the Steering Group and ‘senior responsible officer’, (Chris Beasley) and Pete Sellars (Deputy Director of GREFD) as head of the Division that will host the project.

9.    The Steering Group will meet quarterly, whilst the DH Delivery Group will meet monthly and its individual workstream groups will meet as required.

Early advice and direction needed

Patient engagement

10. The key feature of the new inspections is that they will be patient-led.  But “patient-led” can mean many things.  The NQB are keen to see that the term has real relevance, and the Steering Group’s take on this is important.

11. At the very least, “patient-led” has been taken to mean involvement in designing the system and carrying out inspections alongside other team members.  Over 80% of current PEAT inspections already involve a patient, but it is important that the new system has full involvement – and that this is more than tokenism.  Patients must genuinely lead the process and have their voices heard at the end of it.

12. However, we do not envisage that patients should have to shoulder the burden of planning or organising visits, nor of submitting reports to the HSCIC (they may well be involved in formulating the response).  Nor do we expect that patients will be the only members of the inspection team; hospital staff, including nurses, will continue to be heavily involved.  Contrary to some reports in the press, this regime does not provide patients with the right to “enter and view” premises – once established, such powers will be exercised through Local HealthWatch.

13. A variety of mechanisms are planned to select patients for involvement in the inspections process, both centrally and locally.  For instance, DH will use national focus groups or seminars to help develop the system, but individual hospitals will recruit patients locally to take part in inspections.  The details will be confirmed following stakeholder engagement, but we expect that Local HealthWatch will always be offered the opportunity to engage in inspections.  Where they decline to do so, organisations will be expected to use other approaches to deliver genuine patient engagement. 

14. Because patient involvement at a very early stage is so fundamental, we have already started our engagement work in respect of the design phase.  We are engaging a specialist communications professional (part-time) to develop our stakeholder strategy, and are also making use of existing engagement groups.

15. Our activities include:

  • Identifying stakeholders to support our engagement work, and who may wish to provide input to the project.  Individual groups may be involved in different ways – either directly or indirectly.  We welcome suggestions from the Steering Group for other organisations we should include.  Any organisation or individual who wishes to be involved will be welcomed
  • Extending an existing patient engagement project to look specifically at hospital inspections
  • Using existing mechanisms such as DH’s “Strategic Partners” group, and the NHS Institute’s patient reference groups
  • Undertaking an extensive literature review to tap into patient views from related work (eg information gleaned during DH projects to reduce HCAIs, and eliminate mixed-sex accommodation, and from NHS Institute work)

·         What other mechanisms might we use to make sure that the patient voice is pre-eminent at the design stage?  (We will seek advice about patient involvement in development, testing and implementation at the appropriate time)

The inspection process

16. When first introduced, PEAT inspections were carried out by independent assessors and were unannounced[1].  Since 2004, they have been self-assessments, and take place within a pre-announced three-month period.  This has kept costs down, and a reversion to independent, unannounced inspections would be prohibitively expensive – especially in terms of assuring patient representation.  Nonetheless, we could explore the feasibility of shortening the notice time.

·         How might we increase the elements of independence and short notice, within the financial constraints we face?

Scope of the inspection

17. The Prime Minister has confirmed that the new system should cover at least the same broad areas as the current regime.  These are the environment (including cleanliness), food (but not extending to nutritional care), and privacy and dignity. 

18. PEAT includes a small number of questions that are essentially clinical (eg questions about nutritional screening), but the main focus is on facilities and the environment.  In the past, there has been pressure to increase the number of clinical questions, especially where facilities management and care overlap.  This is particularly the case with the links between food quality and nutritional care. 

19. This has meant PEAT can generate information that would otherwise be unavailable and this has been especially helpful to CQC in allowing them to generate Quality Risk Profiles.  However, it has also distorted the original purpose of PEAT (to assess the non-clinical hospital environment).  There is an opportunity now to decide the scope of the new patient-led inspections process. It could continue to cover clinical content, although any significant increase in clinical questions would run counter to our commitment to cost-neutrality. Alternatively, it could be restricted to non-clinical topics only, but this may threaten alignment with CQC’s (and others’) needs.

·         Should the new inspections include a similar small number of clinical questions as now?

The scoring mechanism

20. PEAT assessments use a five-point scale – unacceptable, poor, satisfactory, good and excellent.  To emphasise the new focus on patient views (and thus distinguish these inspections from PEAT) a new scoring system needs to be developed.  Feedback from the NHS indicates a preference for a three-point scale – “clear pass”, “fail”, and “needs attention”, whilst the NQB has asked that we include a mechanism that allows a small number of hospitals to be recognised as outstanding.  We will be seeking patient views as part of our early engagement.

·         How might the new system recognise outstanding performance?
·         How might we categorise hospitals which, although meeting minimum standards, are in need of improvement?
·         How might we categorise hospitals which are not reaching their full potential, even though they may be good in comparison with others (“coasting” hospitals)?
·         Might there be hospitals that cannot achieve excellence because of issues of design or configuration (eg no 5* hotel is without a lift)?


21. The PEAT process is voluntary, but has extremely high compliance (all NHS hospitals of 10 beds or more participated last year, including all foundation trusts) and an increasing number of independent sector hospitals also take part (over 120 last year).  Other data collections (eg breaches of mixed-sex accommodation guidelines) require every hospital providing NHS-funded care to report, and this review would offer an opportunity to follow that same principle.  Mandating the data collection would not increase the cost to the NHS (as coverage is already universal), but independent providers wishing to take up NHS work might need to introduce inspection in order to comply with contracts.

22. Mandating patient-led inspections could only be carried out via the contracting process, and would therefore need to be included in the NHSCB’s instructions to commissioners.  An alternative would be to maintain the current voluntary approach.

·         How might we ensure that all hospitals participate in the new inspections?

Next Steps

23. Early stakeholder engagement should be completed by summer, allowing time to develop the technical specification and pilot the proposed model by autumn 2012.  This will give us time to make any amendments before the new system becomes operational in April 2013.

24. Because the current PEAT inspections fall within the ambit of Official Statistics, any change must be subject to public consultation.  This is expected to take place at around the same time as the pilots.  This consultation relates entirely to the new collection’s status within official statistics guidelines – the more fundamental issue of whether the collection meets the needs of patients and the service will be addressed much earlier by extensive stakeholder engagement.


25. Action is already under way to engage patients in the development of new hospital inspections.  We seek the input of the Steering Group to ensure that the patient voice is heard properly, and that the inspection regime delivers useful information.

Dr Liz Jones

Head of Patient Environment

Annex B

Governance Structure

[1] Note – “unannounced” means that less than 48 hours’ notice is given of the visit.  This is so that relevant staff can be available to meet the assessors.

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