Breaking down barriers into independent healthcare participation in national audits

IHPN’s Director of Regulation, Dawn Hodgkins, reflects on learning from HQIP’s study into breaking down barriers into the participation of independent healthcare providers in national audits.

Independent providers are rightly proud of the quality of care that they provide. Like their NHS counterparts, independent providers constantly look for ways to make continuous improvements across all the different domains of clinical quality.

The objectives of measuring and promoting safe, high-quality care have long been at the centre of IHPN’s mission. These goals inform all our activity, and are especially important for our clinical forum, comprised of clinical leaders from across the entire independent sector. That’s why our clinical forum was so keen to ensure that independent providers can take part in appropriate national clinical audits.

Inquiries such as the Independent Medicines and Medical Devices Safety (IMMDS) Review led by Baroness Cumberlege and the report from the independent inquiry set up following the conviction of surgeon Ian Paterson, further demonstrated the importance of including all sectors in audit programmes. And as the work with HQIP progressed, IHPN has in parallel worked closely with NHS England to ensure that new registries are appropriately structured to include independent providers by design.

As a sector, we have long recognised the importance of internal and external audit to understand and benchmark performance. In some areas such as orthopaedics, independent providers have a long history of high levels of participation. Indeed, since 2020, more procedures have been submitted to the National Joint Registry (NJR) by independent providers than by their NHS counterparts. However, in other clinical areas, there exist significant hurdles and barriers that prevent similar levels of participation.

IHPN was therefore pleased to initiate and fund a project led by the Healthcare Quality Improvement Partnership (HQIP) to better understand obstacles facing independent providers and to identify ways to increase participation. Although HQIP is the commissioner of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), the insights from this work are also relevant to other audits beyond that programme.

That project is the culmination of several years’ work and was completed earlier this year. Because independent providers carry out a diverse range of provision, from high-volume elective activity to much more specialist care, we chose to identify two areas that would capture the range of challenges posed by quite different types of work. We decided to focus on cataract activity as part of the National Ophthalmic Database (NOD) run by the Royal College of Ophthalmologists (RCOphth), and breast cancer in older patients, working with as was, Public Health England (PHE) and the Royal College of Surgeons (RCS).

As with so many areas over the past few years, Covid affected our initial plans, and so the project was temporarily paused shortly after its launch in 2020. As it became clear that PHE would have to focus elsewhere on responding to the pandemic, we switched our attention on low volume activity to another area, the National Vascular Registry which is run by the RCS.

Because the study ran over a longer period than anticipated due to the pandemic, we also saw several developments which were not originally anticipated. For example, some larger independent providers with high ophthalmology volumes began to participate fully in the NOD. This allowed us to focus on understanding barriers facing organisations yet to deploy specialist ophthalmology EMRs (Electronic Medical Records). We also experienced challenges testing data flows into the NVR which were largely down to changes in activity as independent providers flexed away from their usual case-mix to respond to changing local clinical demands in response to the pandemic.

Participation in audits is not something that is done lightly. Providers need to commit suitable resourcing which often means embedding new working practices and infrastructure. Having a clear framework within which to make and implement those plans is therefore essential.

The final project report explored numerous areas and identified several recommendations which broadly covered the following areas:

Defining what constitutes in-scope activity. While the NCAPOP run by HQIP comprises around 40 audits, registries and reviews, many are currently out of scope for the independent sector. For some audits, this is quite reasonably due to their focus on clinical areas that are rarely delivered by independent providers. However, in many cases, a clear specification of in-scope activity, readily available and defined by procedure or diagnostic code, would be hugely beneficial to identify relevancy and encourage participation.

Explicitly designing audits that welcome participation by all relevant providers. Requirements that inadvertently exclude independent providers should be proactively avoided as future iterations of existing surveys are commissioned. For example, high-volume minimum thresholds effectively rule out participation by independent sector hospitals which tend to be smaller than their NHS counterparts. Explicitly involving the full range of providers that deliver relevant care in the design process of audits from the outset would ensure that future iterations are inclusive by design, and do not inadvertently rule out independent sector providers.

Mechanisms to support data collection. Many independent providers are currently scaling up their digital capability, investing significant resources to procure EMRs and build their informatics and clinical support teams. NHS providers are also pursuing a similar transformation. As the NHS seeks to ensure all acute providers have fully functional EMRs within the next few years, which conform to a common set of interoperable standards, there is a clear opportunity to embed the collection of data for clinical audit into the fabric of the infrastructure that we are building as a nation. To support this, audit providers need to present a clear technical specification that is consistent with current and future standards. This presents a huge opportunity to improve the quality of data, to reduce avoidable administrative burdens and to increase audit participation across both NHS and independent sector.

Streamline information governance hurdles. As the public becomes ever more sensitive to privacy concerns, and independent providers rightly comply with wide ranging legal requirements to protect patient information, there is significant scope to reduce the range of administrative pre-requisites that determine how information can be safely and legally shared, through agreeing common templates and approaches that are applicable across the range of audits and registries.

Funding. We recognise that audit activity needs to be funded. It also imperative that funding mechanisms are appropriate for organisational structures that are often quite different from NHS institutions. For example, there is a diverse range of providers in the independent sector, some of which may operate from a single site, while others will have many hospitals and community-based locations within their group structure. We need greater clarity in fee structures that reflect how care is delivered in the sector. While it is reasonable for audits and registries to take approaches that reflect their different structures, underlying principles of fairness, proportionality and transparency should be common to all.

As this exploratory project closes, we look forward to progressing its recommendations. That will require full engagement by providers, audit providers, commissioners, regulators, and of course, IHPN.

As a next step IHPN has committed to convene a round table to discuss the policy implications of this work with the aim of identifying how regulators and other national bodies can advance this agenda.

With the pace of digitisation currently underway in the sector and more broadly in healthcare, initiatives to increase the safe sharing of data, together with significant changes underway in how providers are regulated and new reporting mechanisms for safety, all herald the way for much greater transparency across UK healthcare. It is essential that insights from audit, registries and reviews all fully contribute to that mosaic of information.