Associate feature: Hospital inspections are changing

Alastair Delaney was appointed as Healthcare Improvement Scotland’s new Director of Quality Assurance just over a year ago to lead the organisation’s move to a new, broader and more comprehensive inspections regime.

He joined an organisation which already drives improvement through combining a number of functions which include inspections and reviews. Arriving as he did from leading Scotland’s new school inspections model for Education Scotland, Delaney came with some pedigree.

Indeed, Healthcare Improvement Scotland’s new Quality of Care approach, which was published in September after extensive consultation, closely resembles the system of improvement methodology practised by Education Scotland, councils, social care, emergency services and others in driving outcomes-focused changes. 

It is an approach which looks at the wider context of issues in a system, and will be a significant development in how improvements in health and care services are being supported by inspections and reviews.

Delaney jokingly describes the shift across the policy divide from education to health as “out of the frying pan and into the fire”, but it is clear he sees the parallels.

“I felt I wanted to use what I’d learned in 18 years involved in education inspection, and see how it applied in a totally different sector,” he says.

School inspections had changed dramatically in that time. An awareness of the public as well as professional audience also grew over the period.

“There was a time in education where we would write very weighty, long reports, and it was clear that parents, for example, were never reading any of those. They were turning to the back page and looking at the numbers.

“There’s also a move across all the scrutiny bodies to try to modernise, and one of the key elements of that is making sure scrutiny is improvement-focused. We’re trying to make things better, not just read the meter, if you like.”

Delaney says the current inspections, however, would eventually become an “outlier” compared to the approaches of other public organisations, something which would have potentially proved more complex as public bodies work more collaboratively.

“For perfectly proper reasons, there had been a focus on particular aspects of health. There had been challenges or specific issues in the system and that had spawned a reaction, which was to go and look at that everywhere. To create a set of standards and then check compliance against those standards. That drives inspection and the system in a very particular way.

“International theory will tell you that’s good when you’re trying to fix the basics, but when you want to go beyond the basics so that the system improves itself and is not relying on someone coming in and pointing out the flaws, then it is not as good.

“The new approach will enable us to respond to a wider set of information including, national and local data, self-evaluation, reports and intelligence in order to form key lines of enquiry with a provider and ultimately broaden the potential scope of inspections and reviews. Over time, this will also enable us to include areas such as primary care and mental health services, among others.

“Inspectors will also be able to have much more interaction with patients, and will help us review the overall experience of the care received and make recommendations for improvements across the spectrum of care being delivered. 

“I want to support providers to improve outcomes. But how they do that has got to reflect local circumstances.”

The ability for hospitals and health boards to “be creative” in improving themselves will be supported by an approach which uses the vast amount of data at NHS Scotland’s disposal and turns that into intelligence which identifies potential areas of risk. However, data is not to be the sole determinant of the inspection programme. 

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“For me, it can’t just be about data,” says Delaney. “Data can give you one source, but you also need to combine it with direct observation and patients’ experience.”

The new approach, however, does not change the organisation’s connection with public concerns. 

“We will always focus on the core issues that are important to the public, it’s how we do it that will change and improve,” says Delaney.

“If you take a hospital, for example, currently we have inspectors going into hospitals looking at hospital cleanliness and the care of older people. However, there could be people in corridors on trolleys, there could be ambulances queuing up at A&E and we wouldn’t have had the necessary focus in the inspection to comment on that. 

“We will now be able to look at the bigger picture, what’s really going on in an establishment or service and reporting on that.”

The new approach has been piloted at NHS Orkney and is also currently being tested at NHS Ayrshire and Arran. Delaney says it is already evolving. Evaluating the experience of patients, for example, has been taken out of the care setting and into the general public for the second pilot in Ayrshire and Arran.

“We worked with the Scottish Health Council, part of Healthcare Improvement Scotland, on innovative ways of contacting as many different people as possible. We would always want to talk to people in hospitals under the provision of care just now, but if you ask someone lying in a hospital bed what they think of their nurse, there is an in-built bias there, so we also wanted to broaden that approach.

“We held focus groups with targeted groups, we stood outside the local supermarket and talked to people there. We were doing a whole range of activities to try and find out what they believed about healthcare in that area.”

The results gave inspectors a “very strong impression” of what people in Ayrshire and Arran thought about their local services, he adds.

“For me, you need a narrative that reflects local circumstances. What we are saying to providers is that ‘we need to understand your story’, because every story is different. You have different pressures, different populations, different financial situations and different staffing situations. What we’re trying to do is place inspections and review within a local context.”

This is helped by speaking to as many people as possible, argues Delaney, as there are so many special interest groups and individuals who are heard in the system.

“You need to be careful to balance legitimate, strong voices and views about a poor experience of care with a broader view, from people receiving good care.”

In the first instance, those views and stories are shared with the “key players” in the relevant service. Leadership then explains the systems they have in place to respond, and inspectors will test the effectiveness of those systems. 

“We understand from the start what their issues are, why, and what they are doing about it,” says Delaney, “rather than applying a simple national template that we expect everyone to comply with.”

As well as being a methodology evidenced and practised elsewhere in the world, the system is being embraced by boards, according to Delaney. 

“I’ve introduced our thinking to boards over the last few months and talked about the direction of travel and everybody is generally happy with it. This issue now is how we implement in the best way possible.”

But why is the new methodology better? Delaney says it is internationally proven to reduce the burden of scrutiny but increase the impact.

“Inspection has three purposes: assurance, improvement and sharing best practice,” he says.

“The emphasis in health has been on the assurance side. That’s fine, but what we are trying to do with this is to redress the balance so that we are also making sure that when an inspection happens, improvement also happens as a result. It’s all very well going in and telling somebody that something is wrong, but you have to make sure they know what to do about it.

“We are doing these inspections, yes, to provide assurance, but also to secure improvement. And the last leg of the tripod, if you like, is that where there are clear inconsistencies across the whole of the country in Scotland, we have a role to play in showing where things are going really well and spreading that across the country.”

Spreading best practice has been a source of frustration for successive ministers, with current health secretary Jeane Freeman telling Holyrood last year that she listed picking up the pace of spreading good practice as one of her personal benchmarks for success. 

“We all have a tendency to protect our own patch and have our arm around the jotter, but that won’t do. If it’s working, we have no good reason not to apply it everywhere,” she said.

In his own way, spreading his learning from Education Scotland, Delaney appears to be doing exactly that. 

This article is in association with Healthcare Improvement Scotland