Quality in Optometry England Introduction

Clinical Governance is all about maximising quality of care, patient safety and service delivery on an on-going basis. It covers many aspects of practice, from Health and Safety to clinical interactions. It is not new to optometry since many aspects of clinical governance are enshrined in legislation or regulation as well as in the College of Optometrists' Code of Ethics and Guidance on Professional Conduct and in other guidance documents. In many ways it might be analogous to the quality control exerted by a major supermarket chain on their suppliers, or by airlines and railways to ensure passenger safety, all of which most people would regard as good things. Although originating within the NHS, clinical governance is a quality framework and, as such, is clearly applicable to all practice, both NHS and private. Given the current trends for litigation and fraud investigation, operating an effective clinical governance framework can provide a safer working environment for the practice owner and staff as well as the patient.

Contract Compliance is about ensuring that a practice complies with all aspects of the GOS contract. In England little has changed in the new GOS Contract as compared with the old Terms of Service, but it has brought an increased focus from PCTs on compliance with the contract. NHS Primary Care Contracting have recently (2009) developed a Framework for Contract Compliance which comprises a list of points that PCTs should consider when carrying out regular (usually 3-yearly) practice visits. The English Level 1 of Quality in Optometry has been changed to bring it completely into line with this new Framework. The Level 1 section of the website will lead you through the issues a visiting advisor will raise. It offers help, advice and directs you to supporting documents allowing you to be completely prepared for a visit. If your PCT is not using the PCC framework your LOC should ask why, since this national help and advice is geared around the national framework which was itself developed with input from the optical representative bodies.

There has sometimes been confusion as to where contractual requirements end and clinical governance begins. This is now very clear — clinical governance begins at Level 2.

Audit covers a wide range of activities but is essentially concerned with checking and maintaining standards or compliance. The 3 audits contained within QiO allow the contractor to audit the basic record keeping activities of their performers, as well as their own compliance with infection control and information governance. Record keeping is a fundamental part of contract compliance and falls within QiO Level 1. Whilst some elements of hygiene and infection control are covered within Level 1, the completion of an audit and generation of the resulting compliance statement is a QiO Level 2 activity. This may be required for some enhanced services; otherwise it is a funded clinical governance activity.

The same applies to Information Governance. In this case almost all the elements are contained within QiO Level 1, but the audit draws them together into a compliance statement. This may be required for some enhanced services but is otherwise a funded clinical governance activity.

The Practitioner Checklist enables optometrists to check that they have the right level of knowledge for working within English General Ophthalmic Services today. Additionally, a statement of knowledge can be printed and provided to an employer.

Enhanced Services

Most PCTs will require some level of clinical governance included in any service agreement/local contract for enhanced services – indeed this requirement is built into the LOCSU model contracts. The question is what level of clinical governance should be included?

It is important to understand the process that resulted in the Quality in Optometry (QiO) framework. Standards for Better Health (SfBH) were the published standards for clinical governance in the NHS yet it was clear that optometry had not been considered to any great extent when developing the standards. Simply using checklists developed for other health professions resulted in some bizarre questions eg a requirement for amalgam separators!

QiO results from carefully checking each SfBH standard and presenting it in a manner relevant to optometry and optometric practices. Level 1 covers GOS contract compliance in England and level 2 now covers clinical governance with a particular emphasis on enhanced services. This level of clinical governance should be funded, either as a part of the costs of an enhanced service or separately. It is the view of the optical representative and professional bodies that the only levels 1 and 2 of QiO are required for participation in Enhanced Services.

Level 3 is advanced governance. This should not be required for enhanced services and should be funded.

The History of Quality in Optometry

The concept of clinical governance in the NHS began in 1998 with the publication by the Department of Health of the document "A First Class Service: Quality in the NHS" which provided the following, and now widely used definition of clinical governance:

"A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish."

Initially clinical governance was seen to consist of a series of processes for improving quality and ensuring that professionals were accountable for their practice. These processes, known as the 7 pillars, were CPD, evidence-based practice, audit, dealing with poor performance, managing risk, monitoring clinical care, and patient involvement.

More recently the focus of clinical governance has changed significantly in the light of reports such as the Kennedy report on Bristol children's hospital (2001) and "Building a Safer NHS for Patients" (2001). These reports, and the launch of the National Patient Safety Agency in September 2001, mapped out the quality agenda in terms of the NHS plan's objective of a patient-centred NHS.

Thus, from the perspective of Primary Care Trusts in England, their current focus on standards has moved on from the 7-pillars approach and is now driven by this more recent government thinking as detailed in "Standards for Better Health" (there is a similar document for Wales). Primary Care Trusts and Health Boards (PCOs as a generic) are required to engage in clinical governance with, amongst others, all their contractors and they are monitored on their performance by the Healthcare Commission.

The standards cover the following subject areas:

• Safety
• Clinical and Cost Effectiveness
• Governance
• Patient Focus
• Accessible and Responsive Care
• Care Environment and Amenities
• Public Health

When commissioning new services, PCOs already expect service providers to meet the core standards outlined in "Standards for Better Health" (levels 1 and 2 in the England Contractor Checklist). It is likely that this same requirement will extend to any additional services provided by optometrists in the future. Indeed, some PCOs already attach some clinical governance conditions to participation in shared care schemes.

In November 2005 the optical bodies jointly published a policy paper entitled "Primary Eyecare in England" which outlined their vision for the future role of optometry in the provision of eye care. Quality in Optometry now shows the core quality the optical bodies believe that optometric practices can offer when providing these future services. Indeed, quality in optometry is already very high. Practitioners are very highly trained, practices respond to the market environment by offering a high quality service and PCOs will already know that there very few patient complaints about optometry services.

We can expect government thinking on Clinical Governance or “Quality” to change further over time. Already there is use in medicine of “Key Performance Indicators” and the idea of a “dashboard” of measures for a quick overview of performance. Indeed, an example of this can be found in the clinical record audit guide in England Level 1.

Some of this is simply fashion in data presentation and some will be genuine advance. In all of these circumstances QiO has already been shown to stand the test of time and will be updated and enhanced from time to time as optical practice expands and develops and requirements change.