Ensuring corporate and quality assurance

Commissioners should ensure that the services they commission represent value for money and offer the best possible outcomes for patients. Commissioners need to set clear specifications for monitoring and assuring quality in the service contract.

Commissioners should ensure that they consider both the clinical and economic viability of the service, and any related services, and take into account patients' and carers' views and those of other stakeholders when making commissioning decisions.

A rheumatoid arthritis (RA) service needs to:

• be effective and efficient
• be responsive to the needs of patients and carers
• provide treatment and care based on best practice, as defined in NICE CG79 on rheumatoid arthritis
• deliver the required capacity for diagnosis, initial management to establish disease control and subsequent follow-up including annual review
• be integrated with other elements of multidisciplinary care for people with RA
• define agreed criteria for referral, local protocols and the care pathway for adults with RA
• be patient-centred and provide equitable access, ensuring that patients are treated with dignity and respect, are fully informed about their care and are able to make decisions about their care in partnership with healthcare professionals
• consider and respond to recommendations arising from any audit, serious untoward or patient safety incidents
• demonstrate how it meets requirements under equalities legislation
• demonstrate value for money.

Local quality assurance

Any mechanisms for quality assurance at a local level are likely to refer to the following.

• Service and performance targets, including estimated activity levels and case mix, waiting and referral-to-treatment times (ensuring that patients can access treatment ideally within 3 months of the onset of persistent symptoms), complaints procedures.
• Clinical governance arrangements, including incident reporting, especially reporting of serious untoward incidents.
• Clinical quality criteria: appropriateness of referral, consenting procedures, clinical protocols.
• Audit arrangements: frequency of reporting, reporting route and format, and dissemination mechanisms; arrangements should include auditing referral, treatment, monitoring, proportion of patients with a named member of multidisciplinary team and the provision of written information. Monitoring of patient outcomes and complications (see audit support for NICE clinical guideline CG79 on rheumatoid arthritis for further information).
• Health, safety and security: infection prevention, waste management, confidentiality procedures, legislative requirements.
• Equipment: testing and calibration.
• Accreditation requirements: for some or all elements of the service, the premises and/or staff.
• Patient and service-user experience: taking into account perspectives and perception of service provision to help shape services; engagement to inform commissioning decisions; complaints.
• Patient outcomes: DAS28 (a score which measures disease activity) at diagnosis and at agreed periods for example 3 months post diagnosis or following a flare-up, the number of flare-ups people with RA experience, work status, EQ5D (a standardised instrument to measure health outcomes) or SF-36 (a multi-purpose health survey).
• Staff competencies: individual and team baseline requirements, monitoring and performance, see also specific information.
• Information requirements including both patient-specific information (NHS number, referring GP, provision of high-quality information to patients/carers) and service-specific information (referral-to-treatment times at diagnosis and for flare-ups, workload trends, number of complaints). Providers should complete the British Society of Rheumatology biologics register, which tracks the progress of patients with severe RA and other rheumatic conditions who are taking biologic drugs.
• The process for reviewing the service with stakeholders, including decisions on changes necessary to improve or to decommission the service.
• Achieving targets associated with equalities legislation.

Further information

General information on quality and corporate assurance can be obtained from the following sources:

• National guidance on the Accreditation of GPs and pharmacists with a special interest.
• The National Patient Safety Agency (NPSA) oversees the implementation of a system to report and learn from adverse events and near misses occurring in the NHS. The publication ‘Seven steps to patient safety' provides an overview of patient safety and gives updates on the tools that the NPSA is developing to support patient safety across the health service.
• NHS Institute for Innovation and Improvement support for commissioners, includes Commissioning for Health Improvement products to accelerate the achievement of world class commissioning; The Productive Leader programme to enable leadership teams to reduce waste and variation in personal work processes, and Better care, better value indicators to help inform planning, to inform views on the scale of potential efficiency savings in different aspects of care, and to generate ideas on how to achieve these savings. Examples are available on self-management, direct-access rheumatology and telephone toxicity monitoring for disease-modifying anti-rheumatic drugs.

Specific information on quality and corporate assurance for a service for the diagnosis and management of rheumatoid arthritis in adults can be obtained from the following sources:

• A competency framework for general practitioners with a special interest in musculoskeletal/rheumatology practice has been developed.
• Better metrics is a pragmatic project that provides clinically relevant measures of performance to support the development of measurable local targets and indicators for local quality improvement projects. See older people metric 10 ‘population level of independence in activities of daily living by age bands 65 to 74, 75 to 84, 85 plus'.
• The Quality and outcomes framework (QOF) is a voluntary quality incentive scheme that rewards general practices for implementing systematic improvements in the quality of patient care.
• Skills for health works with employers and other stakeholders to ensure that those working in the sector are equipped with the right skills to support the development and delivery of healthcare services. See details of the clinical health skill, clinical imaging, long-term conditions case management and patient education competence framework.