Scotland's way to guarantee qualityBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7227.78 (Published 08 January 2000) Cite this as: BMJ 2000;320:78
With Scotland's Clinical Standards Board about to produce its first standards for consultation, Bryan Christie meets its chairman, Lord Naren Patel
It's not NICE and it has no intention of emulating its bigger sibling south of the border. The Clinical Standards Board for Scotland believes it has developed its own effective framework for providing the public with assurances about the safety and quality of the country's health service.
The Scottish system is very different from the model adopted in England, where the National Institute for Clinical Excellence (NICE) will work alongside the Commission for Health Improvement (CHI) in identifying best practice and ensuring its delivery. That is largely because many of the building blocks for a system of quality assurance were already in place in Scotland, before England's institute was established.
The Scottish Intercollegiate Guidelines Network (SIGN), set up by the royal medical colleges, has been working since 1993 to produce treatment guidelines, and the Clinical Resource Audit Group (CRAG) has ensured that audit work is well advanced. The national data on clinical outcomes have produced a wealth of comparative information on performance across the country.
The missing ingredient in all of this was an organisation that ensured that central advice was being adopted locally. Lord Patel, a former president of the Royal College of Obstetricians and Gynaecologists, who has been appointed chairman of the Clinical Standards Board for Scotland, says that the board completes the picture.
It has two principal functions—the setting of clinical standards, which can be used to measure particular services, and a process of external inspection to ensure that the standards are being met. Although that may sound simple, it is in fact a complex process and one that Lord Patel believes is unique.
“There was no model that could just be taken down off the shelf. I looked at all other international, so called accreditation and inspection systems, but most of them are organisational and not clinical. People have shied away from setting clinical standards because it's not an easy thing to do.”
The standards adopted by the board will be based on 20–30 key quality indicators that a clinical service can be measured against to see whether it is functioning well. Lord Patel said: “Some of them will be evidence based—drawing from audit, guidelines, and outcome indicators—while others will be soft in the sense that they cannot have numbers put to them.”
There will be mandatory standards, which all services should meet, and higher level standards, which everyone should aspire to. The standards will be agreed after wide consultation with both professionals and the public.
Lord Patel hopes that clinicians will examine the standards and then carry out self assessments to see how their service compares: “We want to encourage that process of self assessment because that is clearly where improvements can come.”
However, the system will not rely on professionals making their own improvements. Hospital services and general practices will be visited and assessed against standards. If a service is found to be failing, discussions will be held on how it can be improved and a timescale laid down for these improvements to be made.
Lord Patel said that in extreme cases if a service was found to be “quite awful,” immediate steps could be taken in reporting the matter to the Scottish health department to ensure that patients come to no harm. Reports of all these visits are to be made publicly available.
The board also intends to produce “corporate reports” looking at how conditions such as coronary heart disease are treated in Scotland compared with other countries. Lord Patel said that if a service is found to be constrained because of resource problems, the board will have no qualms about stating that publicly.
There have been fears expressed by health professionals that the board could become another stick to beat them with, but Lord Patel has tried to dispel such notions. He said the board wants to work in partnership both with professionals and with the public in improving services.
“We want to do this with a gentle hand on the tiller in an atmosphere of helping and promoting the improvement of health care and not as an inspectorate or a watchdog.”
Some patients' groups are also concerned that what has been created in Scotland is a toothless organisation whose powers are restricted to the issuing of reports. Lord Patel is convinced, however, that not only will it be able to detect poor practice but it will put improvements in place to tackle the problem.
He also believes that the system will pick up problems that may otherwise go unnoticed: “If a bad event happens only rarely, you have to go a long time before it comes around. The advantage of this kind of standard setting and external review is that you don't have to wait for a long time to know that the system is not right and just waiting for a disaster to happen.”
The board came into existence last April, but it has taken several months to recruit staff and begin the work in earnest. Lord Patel admitted that he is now getting frustrated with the situation and wants to get some tangible return from the work that has gone in.
That should come next month when the first standards are produced for consultation. These are expected to cover the operation of coronary care units, the secondary prevention of heart disease, and the management of certain cancers. He admits that the board is exploring new territory without a map and there will be problems along the way.
“We will make lots of mistakes, but we intend to learn from them,” he declared.