This report covers 2020/21 (and gives an overview of previous years)
Contents
Foreword from our Chief Inspector
Overview of inspections in Year 4
Key findings from Year 4 inspections
DMSR-led assurance audits in Year 4
Summary of inspection outcomes across Years 1-4 of the programme
Themes from inspections across the programme
- Common features of DMS services rated as good
- The role of the specialist advisor in improvement
- Improvements over the four-year programme
- Areas that need to improve
- Safety Review Panels
Foreword from the Chief Inspector
I am pleased to present CQC’s annual report of the quality of care in Defence Medical Services (DMS) for 2020/21. This report sets out the findings from inspections in Year 4 of this programme. It also discusses some common themes that we have identified through our work over the four-year programme so far.
In Year 4, we were faced with new challenges presented by the COVID-19 pandemic, which meant we had to reduce the amount of inspection work and change how we approached this. Our inspection work has been limited to ‘desk-top’ inspections to follow up our previous findings to prioritise the safety of patients and staff. We therefore carried out follow-up inspection work that we could deliver digitally (in line with our agreed methods for other services). This comprised six follow-up inspections of dental centres and nine follow-up inspections of medical centres, with no inspections of regional rehabilitation units or military departments of community mental health.
Our inspection team has also taken the opportunity to work with the Defence Medical Services Regulator (DMSR) team to develop an assurance audit approach that could be tested at a time when no other regulatory options were available. DMSR led this work, which was entirely virtual in nature. The learning curve has been steep, and the technological challenges have provided barriers at times, but we have laid the foundations to understanding whether a similar approach might work in hard-to-reach service locations. Overall, we agreed that the approach is effective in delivering sound judgements, although it did sometimes lack some evidence or rely on uncorroborated information on what services told us.
As we complete Year 4, it is a timely opportunity to reflect on a programme of work that has been the catalyst for improvements in healthcare for military personnel and their dependants. Colleagues in the Defence Medical Service Regulator have used our judgements and recommendations from our inspections to work with their Defence Medical Service colleagues to drive change and deliver improvements.
The formation of the DMSR team within the Defence Safety Authority is a welcome and positive development and a key driver in ensuring both clarity of purpose and in driving improvements in health care. CQC has provided support to DMSR in terms of assurance, critical challenge and a response to our reports. This approach is proving to be increasingly effective and is supported by the alignment of DMSR’s regulations to the Health and Social Care Act (2008) (Regulated Activities) Regulations 2014. Our relationship has evolved from one with DMS to one with both the Defence Safety Authority and DMSR, and we see scope for future development that reflects smarter and more flexible approaches to regulation.
The aim of our inspections is to highlight both notable practice and problems, and to allow DMSR to ensure that military health services address any issues for the benefit of patients and the staff working in them. Over the four years of this programme, we have followed up any concerns that we found to ensure that the necessary improvements have been delivered – almost all services have made improvements.
I am pleased that DMSR, the Director General and Defence Medical Services continue to recognise the value of CQC’s inspections and the resulting improvements to care. I would also like to commend military and civilian personnel for their hard work and commitment to delivering high-quality, safe and effective care.
DMSR, the Director General, and CQC continue to be committed to ensuring that armed forces personnel and their families have access to the same high-quality care as the rest of society.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Introduction
The Care Quality Commission (CQC) and its predecessor, the Healthcare Commission, previously inspected DMS military medical facilities* in 2008 and 2011. This followed the recommendations of the Defence Audit Committee (DAC), Joint Forces Command (JFC), the Surgeon General’s Non-Executive Director and the then Chair of the Healthcare Commission. The Surgeon General stated that the DMS community should benefit from the same scrutiny of their health service as the rest of the population.
The Care Quality Commission (CQC) was invited by the Surgeon General, in his role as the Defence Authority, to deliver a fully-funded inspection programme of DMS medical facilities to inform the Defence Medical Services Regulator (DMSR) and the people who use these services about the quality of care being provided. ‘Medical facilities’ is the collective term to describe all medical, dental, rehabilitation and mental health treatment facilities in the DMS.
We started a programme of inspections for health care and medical operational capability in April 2017. Building on the positive impact of the initial inspection programme and the excellent working relationship, DMSR requested that CQC provide ongoing external inspection support in line with the existing programme of work. This allows DMSR to work with us to develop its assurance programme to cover all DMS healthcare provision.
The Director General for Defence Medical Services came into post in summer 2019 and shares the same commitment to the CQC inspection programme as the former Surgeon General.
DMS medical facilities are not required to register with CQC under the Health and Social Care Act (2008) (Regulated Activities) Regulations 2014. Therefore, these services are not subject to inspection by CQC and we have no powers of enforcement. However, to benchmark its services against those provided for NHS patients, the DMS commissioned CQC to undertake a comprehensive programme of inspections of all military primary and community healthcare services.
In 2019, responsibility for the CQC inspection programme was passed from Headquarters DMS to Headquarters Defence Safety Authority (DSA) as part of the transition of DMSR into a fully independent regulator. DMSR now manages the service level agreement with CQC on behalf of DSA and works with CQC to deliver an effective inspection programme of DMS medical facilities.
Where we find shortfalls in the quality of services, we escalate these concerns swiftly to the DMSR so they can initiate action to improve or enforce standards.
Although CQC is the independent regulator of health and adult social care in England only, the service level agreement between CQC, the DMS, DSA and DMSR enables us, at the DMS’s request, to inspect military healthcare services in Scotland, Wales, Northern Ireland and overseas.
Defence Medical Services Regulator
The Defence Medical Services Regulator (DMSR) was established as an independent regulator within the Defence Safety Authority in December 2017. DMSR is committed to enhancing the safe delivery of health care and medical operational capability, providing independent advice on patient safety, and evidence-based assurance, through regulation where appropriate.
DMSR has responsibility for the regulation, assurance and enforcement of healthcare delivered by the Defence Medical Services (DMS). Through inspection, oversight and continuous surveillance, DMSR aims to provide the Secretary of State for Defence, through the Director General DSA, with the necessary assurance that appropriate standards of patient and DMS staff safety are maintained in delivering healthcare across Defence activities. There is organisational separation between those regulating and assuring the Defence Medical Services, and those who deliver Defence healthcare.
Defence Medical Services
The Defence Medical Services (DMS) comprises the Royal Navy Medical Service, Army Medical Service, the Royal Air Force Medical Service and the Headquarters DMS Group (HQ DMS GP). The primary role of the DMS is to promote, protect and restore the health of the UK armed forces to ensure that they are ready and medically fit to go where they are required in the UK and throughout the world.
Service personnel and civilians work side by side as medical, dental and allied healthcare professionals and with other personnel with the relevant business and technical skills. The range of services provided by the DMS includes primary healthcare, dental care, rehabilitation, occupational medicine, community mental healthcare and specialist medical care.
Defence Medical Services (DMS) is the collective term for all healthcare services that are within the responsibility of the Director General DMS, which is the functional leader and owner for healthcare and operational medical capability for defence. They are responsible for the promotion, preparation, sustainment and restoration of the health of the Defence population, and are tasked to:
- generate, deliver and assure medical operational capability for operations and fixed tasks
- provide and commission a safe, effective and efficient healthcare service for all armed forces personnel
- provide policy and advice on health, healthcare and medical operational policy.
They are also the professional Head of all UK military medical staff, supported in this role by the Surgeon General, the senior uniformed officer within the DMS. The HQ DMS Group and the wider DMS provide healthcare to the UK Armed Forces deployed on operations across the world and primary care to serving personnel and other entitled people in the firm base. Defence Medical Services (DMS) is the collective term for all healthcare services that are within the responsibility of the Director General DMS.
Defence Primary Healthcare (DPHC)
The purpose of DPHC is to sustainably deliver and commission safe and effective health care which meets the needs of the patient and the Chain of Command and provides value for money. DPHC enables force preparation and force generation by providing health advice, preventive medicine, medical force protection such as vaccinations and antimalarial chemoprophylaxis, and medical risk assessments. It provides services across primary medical care, dental, rehabilitation, mental health, and occupational health.
Approach to DMS inspections
Defence Primary Healthcare delivers a rolling programme of healthcare governance and assurance of the safety of their facilities, while the single services (the Royal Navy, the Army, and the Royal Air Force deliver this governance and assurance within their AORs. The military Common Assurance Framework (CAF) is a governance and assurance support tool available to all DMS units for both first and second party assurance. It underpins the Healthcare Governance Assurance Visit (HGAV) approach as a way of recording the real-time compliance of individual services against a set of indicators.
CQC’s third party inspection methodology shares many common aims with the HGAV approach, including:
- seeking assurance that effective governance systems are in place
- ensuring that appropriate policies and guidance are being followed
- ensuring that key performance indicators are being met
However, CQC’s approach differs as it focuses primarily on the quality of care for the patient, their experience, and whether their needs are being met. Both approaches provide evidence of safe healthcare and DMSR considers them to be complementary. Work is currently ongoing within the DMS to adapt and use CQC’s key questions methodology within a military context.
See more detail in the regulations that CQC uses to ensure quality of care across NHS providers.
CQC's quality ratings
CQC’s ratings are designed to give a clear indication to patients and the public about the quality of services. For all services that we regulate, we ask five key questions: are they safe, effective, caring, responsive to people’s needs and well-led? We give a rating of either: outstanding, good, requires improvement or inadequate. To decide on a rating, the inspection team also asks: does the evidence demonstrate a potential rating of good? If yes, does it exceed the standard of good and could it be outstanding? If it suggests a rating below good, does it reflect the characteristics of requires improvement or inadequate? We rate each of the five key questions and aggregate them to give an overall rating for a service.
The ratings also act to encourage improvement, as they enable services rated as requires improvement or inadequate to understand where they need to make improvements and aspire to achieve a higher overall rating.
Ratings are based on a combination of what we find during an inspection, what patients tell us, key performance data and information from the service provider itself. Inspectors use all the available evidence and their professional judgement to reach a rating. Following a thorough quality assurance process, we publish the inspection report on our website.
Overview of inspections in Year 4
In 2020/21, the COVID-19 pandemic meant we could not carry out on-site inspection visits. To prioritise the safety of staff, patients and the public, in consultation with DMSR, we made a decision to postpone face-to-face work.
We therefore carried out only follow-up inspection work that could be delivered virtually (in line with our agreed methodology):
- 6 virtual follow-up inspections of dental centres
- 9 virtual follow-up inspections of medical centres
We did not carry out any inspection work for regional rehabilitation units (RRUs) or military departments of community mental health (DCMH).
At the request of DMSR, we helped develop and then implemented a pilot model for an assurance audit approach. DSMR led this work, which was carried out in an entirely virtual way. The aim was to develop a way to provide assurance while physical inspections were not possible. The methodology was also recognised to be of potential value for DMSR in securing assurance for deployed medical facilities, such as ships and regimental aid posts. The aim was to find a way to gain assurance where physical inspections were not possible and in response to the restrictions resulting from the COVID-19 pandemic. We produced reports for each of the DMSR-led assurance audits, which included recommendations for improvement, but no rating. We shared the reports with the medical and dental centres but have not published them on our website. We supported six DMSR-led assurance audits in 2020/21 of three medical centres and three dental centres.
All inspection reports for DMS medical facilities are published on our website.
Key findings from inspections in Year 4
Medical centres
All military personnel, some dependants and some civilian staff are entitled to the services of a military GP practice. Unlike most NHS patients, military staff do not have the right to register with a GP practice of their choice but must register at the location where they are assigned.
To meet the COVID-19 safety restrictions, we were unable to carry out any on-site inspection visits at medical centres. This reflected our approach in NHS services. However, our methodology allowed us to carry out nine follow-up inspections without visiting a location (these services were initially rated as good overall, with only one key question rated as requires improvement). We gathered the evidence through telephone interviews and reviewing documentation. Where the service had met requirements, we were able to re-rate the one key question. Eight of these inspections showed the medical centre had made improvements, so all key questions are now rated as good. One medical centre was unable to deliver the required improvements, so the safe key question remains rated as requires improvement, largely as a result of shortfalls in medicines management (figure 1).
Figure 1: Ratings for medical centres following re-inspections in Year 4
| Service | Key question | Previous rating | New rating |
|---|---|---|---|
| Brize Norton Medical Centre | Safe | Requires improvement | Good |
| Chester Medical Centre | Safe | Requires improvement | Good |
| Corsham Medical Centre | Effective | Requires improvement | Good |
| Culdrose Medical Centre | Safe | Requires improvement | Requires improvement |
| Fort George Medical Centre | Safe | Requires improvement | Good |
| Holywood Medical Centre | Safe | Requires improvement | Good |
| Lisburn Medical Centre | Effective | Requires improvement | Good |
| Shrivenham Medical Centre | Safe | Requires improvement | Good |
| Yeovilton Medical Centre | Safe | Requires improvement | Good |
Dental services
We inspect 10% of high street dental services each year and do not formally rate these providers. We follow a similar approach in the DMS inspections where, although there is no rating, we judge whether the service is meeting standards and we make recommendations in the inspection report.
As we were unable to carry out any on-site inspection visits at dental centres, we carried out six follow-up inspections without a location visit by gathering the evidence required virtually through telephone interviews and reviewing documentation. The initial inspection for these services resulted in improvement action being required in one key question only. Where the service had met the requirements, we were able to publish a report to confirm this. Five of these follow-up inspections showed that improvements had been delivered. One dental centre had been unable to deliver the required improvements so there is still outstanding action under the safe key question (figure 2). This was because planned work had not been carried out on the infrastructure and facilities used to decontaminate dental equipment. As a result, the minimum standards issued by the Department of Health - Health Technical Memorandum (HTM) 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’ had not been met.
Figure 2: Outcomes of follow-up inspections of dental centres in Year 4
| Service | Key question | Standards met | Standards met on follow-up |
|---|---|---|---|
| Aldergrove Dental Centre | Effective | Not met | Met |
| High Wycombe Dental Centre | Safe | Not met | Met |
| Holywood Dental Centre | Safe | Not met | Met |
| Lisburn Dental Centre | Safe | Not met | Met |
| Warminster Dental Centre | Safe | Not met | Met |
| Wittering Dental Centre | Safe | Not met | Not met |
DMSR-led assurance audits - Year 4
As face-to-face work has not been possible during the COVID-19 pandemic, DMSR developed an interim way to gain assurance around care delivered at the medical and dental centres that we have not yet inspected. DMSR set up and led a pilot, which we supported, that allowed some assurance work to be carried out virtually. There is also potential to use this approach to gain assurance around services that are geographically remote and hard to reach. We played a support role in delivering the assurance audits and made recommendations for improvements in reports that were shared with the services. We have not published these reports.
The work has been an opportunity to test what can be achieved virtually at a time when there were very limited regulatory options. The pilot work was largely successful, although there were a number of challenges and barriers including intermittent broadband connectivity and acquiring evidence around vaccine storage, infection prevention and control and emergency medicines. Currently, an entirely virtual approach is not in line with CQC’s own methods, although a move to gather more evidence in this way where appropriate has been an inevitable outcome of the COVID-19 pandemic. Nevertheless, the approach is useful when securing assurance around services where on-site access is impossible.
We supported the following DMSR-led assurance audits in Year 4:
- Cranwell Medical Centre (pilot)
- Minley Medical Centre (pilot)
- Larkhill Medical Centre
- Weeton Medical Centre
- Chivenor Dental Centre (pilot)
- Halton Dental Centre
Summary of inspection outcomes across medical centres Years 1-4
Medical centres
When considering data in this report, it is important to note that we have inspected only 90 medical centres. It is therefore not appropriate to draw direct comparison with ratings across NHS GP inspections, where we have been rating GP providers for eight years and have an established baseline of quality, with around 8,000 NHS GP practices being rated at least once. Military general practice and NHS general practice are different in several ways, for example:
- DMS practice populations are much smaller than in NHS practice
- providing services for families is far less common
- there is a greater focus on delivering occupational health throughout the DMS.
The epidemiology is also different for military medical centres, where staff see significantly higher numbers of patients with musculoskeletal injuries and fewer patients with chronic conditions.
Across the four-year programme, we have carried out 90 first comprehensive inspections of medical centres.
- 12% were rated as outstanding overall (11 services)
- 41% were rated as good overall (37 services)
- 30% were rated as requires improvement overall (26 services)
- 14% were rated as inadequate overall (13 services)
Three overseas inspections were unrated as these were run as pilot inspections.
Ratings for medical centres by key question, Years 1-4
- Safe: Inadequate 28%, requires improvement 28%, good 42%, outstanding 2%
- Effective: Inadequate 12%, requires improvement 33%, good 47%, outstanding 8%
- Caring: Inadequate 1%, requires improvement 5%, good 89%, outstanding 5%
- Responsive: Inadequate 1%, requires improvement 14%, good 77%, outstanding 8%
- Well-led: Inadequate 13%, requires improvement 31%, good 39%, outstanding 17%
We have consistently found most concerns in the safe key question. This aligns with our findings across NHS GP practices. At initial inspection, 56% of medical centres were rated either as inadequate or requires improvement for safety. Where we find concerns around safety, this is often as a result of shortfalls in leadership capacity and/or capability, which accounts for 44% of medical centres being rated either as requires improvement or inadequate. Nevertheless, 17% of all medical centres inspected for the first time were rated as outstanding for leadership, and ratings for the caring and responsive key questions were largely positive.
Where we identify shortfalls in the quality of care, we return to re-inspect to ensure that the service has made sufficient improvement. Across the four-year inspection programme, the improvement journey for some medical centres has been longer and broader than for others. Many medical centres have implemented recommendations that require a second and occasionally a third inspection to enable us to assess that improvements have been delivered and are sustainable. Where the improvement journey has taken longer it is often as a result of shortfalls in leadership capacity or capability or where infrastructure concerns are outside the influence of DPHC.
Medical centres requiring three or four follow-up inspections
Boulmer Medical Centre
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Inadequate | Requires improvement | Good | Requires improvement | Requires improvement | Requires improvement |
| Second inspection | Inadequate | Inadequate | Not inspected | Requires improvement | Inadequate | Inadequate |
| Third inspection | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
Chester Medical Centre
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| Second inspection | Requires improvement | Good | Good | Good | Good | Good |
| Third inspection | Good | Not inspected | Not inspected | Not inspected | Not inspected | Good |
Fort George Medical Centre
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Inadequate | Inadequate | Good | Requires improvement | Inadequate | Inadequate |
| Second inspection | Requires improvement | Good | Good | Good | Good | Good |
| Third inspection | Requires improvement | Good | Not inspected | Not inspected | Not inspected | Good |
| Fourth inspection | Good | Not inspected | Not inspected | Not inspected | Not inspected | Good |
Hounslow Medical Centre
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Requires improvement | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| Second inspection | Inadequate | Inadequate | Good | Good | Inadequate | Inadequate |
| Third inspection | Requires improvement | Requires improvement | Good | Good | Good | Requires improvement |
Northwood Medical Centre
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Inadequate | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| Second inspection | Requires improvement | Good | Not inspected | Not inspected | Good | Good |
| Third inspection | Good | Not inspected | Not inspected | Not inspected | Not inspected | Good |
Shrivenham Medical Centre
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Requires improvement | Good | Good | Requires improvement | Good | Requires improvement |
| Second inspection | Requires improvement | Not inspected | Not inspected | Good | Not inspected | Good |
| Third inspection | Requires improvement | Not inspected | Not inspected | Not inspected | Not inspected | Good |
| Fourth inspection | Good | Not inspected | Not inspected | Not inspected | Not inspected | Good |
Woolwich Medical Centre
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Inadequate | Requires improvement | Good | Good | Requires improvement | Requires improvement |
| Second inspection | Inadequate | Requires improvement | Good | Good | Inadequate | Inadequate |
| Third inspection | Good | Good | Good | Good | Good | Good |
Dental centres
Across the four-year programme we have carried out 40 first comprehensive inspections of dental centres. In line with our NHS oral health work, these inspections do not result in a rating. We found 73% of dental centres inspected for the first time had complied with standards, while 27% had at least one area of non-compliance. Of these:
- 29 had met all standards
- 11 had not met standards in at least one key question
We also inspected three dental centres in Cyprus as part of an overseas pilot, but had agreed that we would not formally rate pilot inspections.
As with medical centres, most non-compliance related to issues around safety. We found a number of dental centres that were unable to comply with standards regarding decontamination. Due to poorly designed and maintained buildings, these dental centres were unable to achieve ‘best practice’ as detailed in guidelines issued by the Department of Health and Social Care – Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
We noted the maturity of governance processes across dental services. The dental service has been operating as a joint (RAF, Navy and Army) service for 25 years and the benefits of operating together are clear, with consistently used standardised operating procedures and centralised guidance. There is also a strong focus on preventative health promotion work through delivering Project MOLAR/MOLAIR, a treatment strategy used to improve the dental health of personnel entering military service. The project ensures that recruits have protected time for dental assessment and treatment during their training.
Standards met across dental centres by key question
- Safe: 77% met, 23% not met
- Effective: 95% met, 5% not met
- Caring: 100% met
- Responsive: 100% met
- Well-led: 100% met
As with all DPHC facilities, dental centres are unable to address environmental or infrastructure concerns themselves, relying on the station's Health and Safety Team or Regional Headquarters to bid for funding for improvement work. We re-inspected some dental centres, but it was only after essential building work that they were able to follow national infection prevention and control and decontamination guidance, and after a third inspection we were assured that they met all the standards.
Ongoing non-compliance in dental centres with infrastructure concerns
Catterick Dental Centre
| Inspection | Safe key question |
|---|---|
| First inspection | Standards not met |
| Second inspection | Standards not met |
| Third inspection | Standards met |
Drake Dental Centre
| Inspection | Safe key question |
|---|---|
| First inspection | Standards not met |
| Second inspection | Standards not met |
| Third inspection | Standards met |
Leeming Dental Centre
| Inspection | Safe key question |
|---|---|
| First inspection | Standards not met |
| Second inspection | Standards not met |
| Third inspection | Standards met |
Regional rehabilitation units
Regional Rehabilitation Units (RRUs) are facilities provided by the Defence Primary Healthcare (DPHC) Unit that deliver intermediate rehabilitation within the Defence Medical Rehabilitation Programme (DMRP).
We have inspected 10 regional rehabilitation units over three years of the four-year programme. Of these locations, seven received ratings in line with our legal powers to rate.
In Year 4, we were unable to carry out any on-site inspection visits because of the safety restrictions as a result of the COVID-19 pandemic.
Key question ratings across regional rehabilitation units to date
| Service | Safe | Effective | Caring | Responsive | Well-led |
|---|---|---|---|---|---|
| Aldershot | Good | Good | Good | Good | Good |
| Catterick | Good | Good | Good | Good | Requires improvement |
| Cosford | Not rated | Not rated | Not rated | Not rated | Not rated |
| Colchester | Good | Good | Good | Good | Good |
| Cranwell | Good | Good | Good | Good | Good |
| Edinburgh* | Not rated | Not rated | Not rated | Not rated | Not rated |
| Honington | Good | Good | Good | Good | Outstanding |
| Portsmouth* | Not rated | Not rated | Not rated | Not rated | Not rated |
| St Athan | Good | Good | Good | Outstanding | Good |
| Tidworth | Requires improvement | Good | Good | Good | Good |
* These services were not rated. At the time of the inspection CQC did not have the powers to rate equivalent services under the Health and Social Care Act
Three rehabilitation units still require a first inspection (RRU Halton, RRU Plymouth and RRU Aldergrove), and we will carry out a follow-up inspection of the well-led key question at RRU Catterick and the safe key question at RRU Tidworth, allowing for COVID-19 restrictions.
We found very few areas of concern with no specific themes across all the inspections. At RRU Catterick, we identified some concerns regarding oversight of risk and actions taken to resolve the risk. At RRU Tidworth, we identified concerns around the storage of patient outcome records and how the duty of candour was being applied, as there was a lack of openness and transparency with patients when things went wrong.
Departments of community mental health
Defence medical services provide occupational mental health assessment, advice and treatment through a network of departments of community mental health (DCMHs) and mental health teams.
We began these inspections in October 2017. To date, nine services have had an initial inspection and eight were rated in line with our legal powers to rate (we did not give a rating for the overseas inspection of the mental health team based in Cyprus). One service was rated as inadequate overall, three services rated as requires improvement, three rated as good overall, and one was rated as outstanding.
Ratings across DCMH services to date
| Service | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| Aldershot | Good | Good | Good | Good | Good | Good |
| Brize Norton | Requires improvement | Good | Good | Requires improvement | Requires improvement | Requires improvement |
| Colchester | Good | Outstanding | Outstanding | Good | Outstanding | Outstanding |
| Digby and Marham | Good | Good | Good | Good | Requires improvement | Good |
| Plymouth | Requires improvement | Good | Good | Requires improvement | Good | Requires improvement |
| Portsmouth | Good | Good | Good | Good | Good | Good |
| Scotland | Requires improvement | Good | Good | Inadequate | Inadequate | Inadequate |
| Tidworth | Requires improvement | Good | Good | Good | Requires improvement | Requires improvement |
In line with our findings for medical practices, the first inspection visits resulted in four being rated as requires improvement for the safe key question and four were rated as requires improvement or inadequate for the well-led key question. All services visited were found to be caring and they provided effective care and treatment.
Where we identify shortfalls in the quality of care, we return to re-inspect to ensure that the service has made sufficient improvement. To date, we have re-inspected DCMH Scotland and DCMH Brize Norton. We found improvement and that our previously identified concerns were being addressed.
Re-inspections of DCMH services
Scotland
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Requires improvement | Good | Good | Inadequate | Inadequate | Inadequate |
| Second inspection | Good | Good | Good | Requires improvement | Requires improvement | Requires improvement |
Brize Norton
| Inspection | Safe | Effective | Caring | Responsive | Well-led | Overall |
|---|---|---|---|---|---|---|
| First inspection | Requires improvement | Good | Good | Requires improvement | Requires improvement | Requires improvement |
| Second inspection | Good | Good | Good | Good | Good | Good |
As with all our other dental inspections, we were unable to carry out any on-site inspection visits at departments of community mental health as a result of the COVID-19 pandemic. Three departments of community mental health still require a first inspection and we are due to carry out four follow-up inspections to check on progress, depending on the status of COVID-19 restrictions.
Themes from inspections across the programme
Common features of DMS services rated as good
Safe care
- Staff are trained (to the appropriate level for their role) to understand their accountabilities around safeguarding vulnerable adults and children. They know how to take action and work in close partnership with the Chain of Command and welfare and pastoral teams to safeguard personnel and their families.
- A local baseline assessment of safe staffing levels and skills mix ensures staffing resilience through a balance of military and civilian expertise.
- Staff have the information they need to deliver safe care and treatment. Clinicians take care to ensure that individual care records are written and managed in a way that keeps patients safe, and this information is shared with other services and agencies.
- Safe medical centres have failsafe systems and a documented approach to managing test results. Staff audit referral letters to ensure they include the necessary information and send them to the right person or department. Primary care, mental health and rehabilitation services work with each other to communicate treatment plans post-referral, and to ensure that patients do not fall into the gaps between services.
- Safe medical centres own failsafe systems to manage and recall patients with long-term conditions and patients who take high-risk medicines.
- There is a good safety culture among staff. Staff are aware of their responsibilities and understand how to report incidents. There are changes to practice as a result of learning from reportable incidents.
- In departments of community mental health, staff clinically triage referrals to determine whether a more urgent response is needed and to monitor whether patients’ risks have increased. Individual patient risk assessments are proportionate to their risks and there is a process to share concerns about patients in crisis or whose risks have increased.
Effective care
Effective care across DMS services shares some common features:
- Staff understand the challenges around Read coding and are committed to applying codes consistently through ongoing review.
- Clinical teams work together across services to discuss patient issues (including holistic needs), agree treatment plans, and ensure that they understand and apply new national guidance.
- There is a comprehensive and broad cycle of improvement work, which is relevant to the patient population and delivering demonstrable improved outcomes for patients.
- Staff receive proactive and extensive support to develop the skills they need for their role, including an open and transparent approach to peer review.
- There is a comprehensive approach to supporting patients to achieve a healthy lifestyle, coupled with a targeted programme of health assessments and screening.
Regional rehabilitation units: Across RRUs, patients’ clinical needs were assessed in line with national clinical standards and their care was planned in person with them. A multidisciplinary team of medical and physiotherapy staff and exercise rehabilitation instructors carried out the assessment, which included podiatry staff where necessary.
We saw that multidisciplinary team working was particularly effective and embedded in all the regional rehabilitation units inspected. Most units used outcome measures to assess the effectiveness of treatment as well as structured formal course assessments that involved patients.
Departments of community mental health: clinicians were aware of current evidence-based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines. Staff make specific reference to evidence-based decisions in treatment records and patients can access a wide range of psychological therapies as recommended in NICE guidelines.
As occupational mental health services, the role of departments of community mental health is to assist patients to retain their occupational status or to support them as they leave the armed services. To assist this, teams work closely with Military Welfare Services, the NHS Veterans Mental Health Transition, Intervention & Liaison Service (TILS), the NHS and a wide range of third sector organisations to ensure effective support with employment, housing and wider welfare.
Compassionate and confidential care
We have found most DMS services to be caring. Staff put patients at the heart of their services. Confidentiality is particularly significant in military settings as clinicians provide occupational health support to military patients alongside meeting their health and welfare needs. We noted many examples of healthcare staff ensuring patient confidentiality at all times (where this does not pose a risk to safety). Over the four-year programme, we have seen how services have more proactively identified and supported patients who are carers. For example, providing links with carers’ organisations and ensuring that the carer’s emotional and healthcare needs are met.
Regional rehabilitation units: Across the RRUs all interactions we observed between staff and patients were appropriate. Staff demonstrated empathy towards patients and took appropriate steps to maintain their privacy and dignity, including chaperones, where necessary. Patient satisfaction was generally very high. There were a number of formal and informal opportunities for patients to provide feedback, and unit staff actively encouraged this. The patients we spoke with all indicated that they were involved in decisions about their care. There were very few complaints made at any of the units
Departments of community mental health: Staff in departments of community mental health work in partnership with patients to reduce their anxiety and behavioural disturbance. This includes finding creative solutions to providing practical and emotional support and involving other services to consider the wider support needs of people who are struggling to cope with military life.
Responsive care
Good quality care is organised so that it responds to, and meets, the needs of the local population. This includes access to appointments and services, choice and continuity of care and meeting the needs of different people, including those in vulnerable circumstances. DPHC has yet to undertake a comprehensive system-wide baseline assessment of the needs of its patient population as a tool to ensure services are fully meeting people’s needs. However, some individual services have carried out extensive work to ensure they understand the needs of their patients.
Where we judged care to be good, services understood the needs of their patient population. They had gathered feedback from patients and staff and used this knowledge to ensure that care was convenient and accessible. We found that services offered longer appointments to patients who needed them and were proactive in meeting the additional and holistic needs of patients.
Responsive services anticipated patients’ unmet needs and endeavoured to address them, for example, by giving information to all patients on how to get advice and support with domestic abuse, self-harm, concealed pregnancy, fabricated illness, child sexual exploitation and female genital mutilation.
Medical centres: Responsive medical centres worked in close partnership with rehabilitation facilities to enable timely access to physiotherapy and exercise rehabilitation. They also worked closely with DCMH facilities to ensure that patients were comprehensively assessed and quickly referred for professional mental health support as required. Medical centres also worked with a number of internal and external stakeholders to identify and meet the needs of personnel who were being medically discharged and military veterans who were in the surrounding communities.
Departments of community mental health: We have found DCMH services to be generally responsive, working in partnership with medical centres to ensure that patient referrals are appropriate and timely.
Regional rehabilitation units: The rehabilitation units provide bespoke services. Their purpose is an occupational one, to support injured service personnel to achieve functional fitness. Access to services was good. Referral pathways worked between the primary care rehabilitation facilities and the regional rehabilitation units. The majority of rehabilitation units met their access targets, and facilities had the correct equipment to provide rehabilitation.
Well-led services
Effective leadership focuses not only on the decisions and work of a single service, but it encourages and enables partnership working with internal and external stakeholders to deliver meaningful improvements for patients. Strong leadership across not only front line, but also regional teams and headquarters, underpins success within the first four key lines of enquiry (safe, effective, caring and responsive). Strong leaders have the capacity, experience and skillset to lead, teams are resilient, and deputies are able to support during periods of high demand or where key staff were deployed.
Well-led services foster a culture where challenge and transparency allows teams to fulfil their duty of candour. Civilian staff often provide stability and continuity of care in a medical centre and they may provide many years of care at the same place. Well-led services will acknowledge and make good use of the knowledge and advice that civilian staff can bring to their work. In return, teams will benefit where civilian staff quickly engage with, and guide and support new military staff who often move location every two years.
Strong leadership teams often benefit from the rotation of military staff who bring new ideas and share best practice, coupled with the stability of civilian staff. Across our four years of inspection work, we have found outstanding leadership delivered by both civilian and uniformed clinical leaders. The key to their success is an underlying team ethos that empowers all team members to influence and improve the processes and issues they deal with on a daily basis.
Well-led medical centres had built strong relationships with key partners, particularly welfare teams, local NHS emergency departments, DCMH staff, local safeguarding teams and organisations that represent veterans. We have inspected a number of medical centres working together in group arrangements and seen evidence that, where formal terms of reference are firmly in place, this mutually supportive approach can deliver solutions and improve resilience through shared staffing, shared best practice and leadership capacity.
In regional rehabilitation units, leadership was generally exemplary, with staff engaged in the development and leadership of the units. Staff groups were cohesive and worked well together to provide a high-quality service. Leaders were visible and all staff were encouraged to share their views and take part in developing the service. The governance arrangements included clear lines of accountability and reporting. Quality improvement was encouraged, both through feedback from patients and audit outcomes.
The role of the specialist advisor in improvement
Since we started our programme of inspections, we have recruited a bank of military and civilian specialist advisors (SpAs) who have played a crucial role in gathering evidence that inspectors use to base their judgements on. We have recruited and trained a total of 129 SpAs across general practice, dental practice, mental health and regional rehabilitation over the four-year programme. Some of them have since left military service, have been deployed or are no longer working as CQC SpAs.
Specialist advisors recruited for the programme to date:
- 29 DMS doctors - general practitioner
- 25 DMS nurses
- 18 DMS physiotherapists
- 17 DMS dental officers
- 13 DMS practice managers
- 10 DMS pharmtech/pharmacists
- 9 DMS dental practice managers
- 6 DMS mental health nurses
- 1 DMS doctor - consultant (psychiatry)
- 1 DMS exercise rehabilitation instructor
We asked SpAs to tell us about their experiences of working on this inspection programme. A number have told us how their work with CQC has led to them sharing best practice in their own services and also across regions. They have also outlined how the inspection work has been useful for their own professional development.
One SpA explained how their role inspecting medical centres had allowed them to gather best practice ideas and innovative solutions and take them back to their own service. Through their work as a CQC SpA, they had become familiar with the inspection methodology and were more aware of essential national guidance, with a better understanding of what makes a medical centre caring and well led. When we inspected the medical centre where this SpA worked as a Senior Medical Officer, it was clear that they had shared their learning, which was reflected in our rating for that service.
Another SpA who works at a regional level has joined a number of our inspections. They told us their SpA work had given them early insight into new themes and areas of concern or interest that CQC may consider requires closer scrutiny across DMS facilities. They have been able to share those trending themes with Regional Headquarters (RHQ) colleagues (specifically area managers, regional pharmacists and regional nurse advisors). This Spa described how they used this knowledge to host quarterly meetings with practice managers and governance leads in the regional medical facility, where they updated on the latest trends and areas of good practice and also shared areas of poor practice to highlight how things can go wrong if systems are not in place. They confirmed a shift in mindset and improved understanding within RHQ that if a facility fails, it is generally because RHQ has not given adequate support and its own governance programmes have not been thorough.
In the words of another SpA:
“In my opinion, there has definitely been an improvement in collaborative working within regions and across DPHC as a result of CQC’s inspection programme and this will undoubtedly have led to developments and improvements within the Healthcare Governance Workbook and, more crucially, in patient care.”
The role of the SpA as part of our DMS inspection approach has been a key lever for improvement through sharing best practice and highlighting areas for improvement. Our SpAs also ensure that DMS inspections focus on what matters to DMS healthcare services. Maintaining a cohort of SpAs who are suitably qualified, experienced and clinically current has never been more challenging than during the COVID-19 pandemic. Work will be required in Year 5 to ensure that we have sufficient skilled SpAs to provide credible and professional insight to our inspections.
Improvements over the four-year programme
Managing high-risk medicines
We have highlighted some poor practice in relation to the management of high-risk medicines over the four years. But as the inspection programme has progressed, we have found improved systems to manage patients prescribed high-risk medicines and fewer patients without a shared care protocol. Nevertheless, we still found some patients had not received the monitoring required to maintain their health and wellbeing.
Central Alerting System
Early in our inspection programme, we identified the need for services to implement a safe system to ensure that they acted on alerts from the Central Alerting System (CAS) at patient level. This included ensuring that alerts and updates from the Medicines and Healthcare products Regulatory Agency (MHRA) were received, disseminated, and appropriately actioned for each patient. We now find that all services have implemented a system to manage CAS, but there are gaps in terms of ensuring that this system is followed. This includes the way that alerts are discussed, cascaded and actioned and the recording of these steps within the DMICP record.
Managing test results
At the start of the inspection programme we identified services that did not have a failsafe system to manage test results. More recently we have found that test results management systems are in place across medical practices. However, incidents can happen when deputising arrangements are inadequate when staff go on leave or because significant events do not lead to embedded learning.
Safeguarding
Early in the programme, we found services that were not fulfilling their duties to safeguard vulnerable people, including children. More recently we have noted improvement in the way vulnerable patients are recorded, and alerts applied in the patient record system. Mental health teams now have access to policy guidance and training in protecting vulnerable adults. However, pockets of poor performance remain.
Identifying and supporting patients who are carers
There is evidence that DMS services now more proactively identify and support patients who are carers, for example by providing links with carers’ organisations and ensuring that the carer’s emotional and healthcare needs are met.
Accessible services
We have noted an increase in access audits for premises, as defined in the Equality Act 2010.
Complaints management
We have identified improvements in complaints management, including a move to record and act on verbal as well as written complaints. Services are also increasingly using analysis of trends resulting from complaints as opportunities to improve care.
Care planning
In early inspections (particularly in DCMH services), we found that care and treatment plans were not always available. Services now develop care and treatment plans which they discuss and agree with patients.
Consent
During initial inspections we found that staff did not always formally discuss consent to treatment with patients. This was an issue particularly in DCMH services. In later inspections, we found a consent to treatment form has been introduced and patients have told us that consent to treatment was clearly explained to them.
Areas that need to improve
Healthcare management information
Complete and accurate healthcare information is a key requirement for providing safe and effective patient care. Services need reliable validated data to provide an effective health needs analysis, which shapes how they operate. They also need ongoing access to timely, validated information to manage performance, and to ensure that they are successfully meeting baseline key performance indicators.
DPHC does not currently have an information system in place that provides a comprehensive suite of performance indicators across its medical services as recommended by National Institute for Health and Care Excellence (NICE) guidance.
There has been no full health needs assessment for patients using Defence Medical Services, so DPHC cannot be assured that its services are meeting the needs of patients.
Across the four-year programme, and in previous annual reports, we have indicated concerns with the completeness and accuracy of patient records at some services:
- the accuracy of Read coding is variable and clinical summarisers are not raising the quality of clinical coding
- clinical diagnoses can be unclear and hidden within numerous screens, resulting at times in summarisation deficits
- clinical templates are sometimes used inconsistently, leading to gaps in reviews for some patients.
There are specific issues around the interface between Defence Medical Information Capability Programme (DMICP) and DMICP DEPLOY and DMICP HYBRID (used for example on ships and overseas). Maintaining accountable oversight for patients who are deployed, particularly those with a chronic condition, is challenging when patients move between several versions of the clinical recording system.
A number of services have raised concerns around failures in IT networks and power. In some cases, these resulted in extended periods without access to the military patient records system. Where this has happened, in line with policy, clinical staff have only seen patients with urgent needs and those with a routine appointment had to wait until access to patient records was restored. There are clear risks around both delaying appointments and seeing patients without access to their records.
The move to CORTISONE (a new patient records system) will begin with a pilot of sample records in 2021. It will be vital for this new system to ensure improved clinical search facilities, more accurate Read coding and built-in performance management capability.
Resource management
Across the four-year programme we have consistently identified concerns around shortages in the workforce and the resulting challenges in delivering safe and effective care. Services with poorer ratings tend to have more vacancies and posts that have not been covered by locums. Healthcare teams face staffing gaps when military healthcare staff are deployed, sometimes at short notice, on operational duty and Navy/Army/RAF tasks, and the lack of available civilian and locum staff means that some services struggle to deliver continuity of service.
We have acknowledged that DPHC does not have the structures and processes to manage the deployment of military personnel while maintaining a safe level of service at firm base. It is vital that an embedded governance structure and a flexible approach to staff resource ensures that the safety and quality of care are not affected where medical personnel are deployed.
Defence Medical Services have yet to undertake a comprehensive baseline assessment of the staffing establishment and skills mix that is necessary to deliver safe care within each of its care services. It is outside the remit of the individual service to decide the baseline requirement for its staffing.
Some services told us that they are unable to easily influence and change the historical staffing establishments already in place. Coupled with staff shortages due to deployment or posts that have not been filled, some medical centres find themselves without adequate resource to deliver a consistent service that meets the occupational and healthcare needs of its patients. Specialist staff are not always being placed optimally to address the needs of patient populations. Over half of DPHC healthcare staff are civilian, whose terms and conditions of service do not allow easy redeployment to areas of high need. As well as this, access to training is sometimes a barrier to ensuring appropriate skills mix across medical centres at all times.
In mental health services, recruitment is challenging, and the teams rely heavily on the availability of locum staff. In some cases, staffing levels were insufficient to meet the demand of the service, which had resulted in missed assessment targets and long waiting lists for treatment – particularly for psychiatric appointments or high intensity treatment. Some services had tried to address these problems by developing therapeutic groups or by using the psychiatrist’s time in different ways. We also saw that some services had commissioned external IAPT (Improving Access to Psychological Therapies) services to increase capacity.
Governance and ownership
While strong in some areas, governance systems are not always effective and do not support services to deliver consistently high-quality care. Problems included:
- staff not always knowing about standardised policy and procedure and not being able to demonstrate that they are following them
- unclear lines of accountability where staff do not know the arrangements for lead roles and deputies
- lack of planned improvement programmes focused around delivering meaningful and improved outcomes for patients
- services not always understanding and monitoring their own performance
- ineffective arrangements to identify, record, and manage risks and issues, and implement mitigating actions; in these cases, meetings do not always achieve the desired outputs, either due to poor attendance, irregularity or poor agenda management, and discussions do not always include standing agenda items, recent clinical guidance, patient safety alerts and risk registers, so actions are overlooked.
Our inspections indicate that in some service areas (notably dental and regional rehabilitation), there are standardised operating procedures (SOPs) to ensure consistent policy and protocols around issues such as lone working, sterilisation of equipment and confidentiality of patient information. In these cases, DPHC has created and agreed SOPs through working groups and cascaded these to be used as standard. However, some service areas (particularly medical centres) lack consistent SOPs, leading staff to create their own localised policies and procedures, which then differ from other services regionally and nationally. For example, we have seen numerous different chaperone policies across different services, which has resulted in gaps in training, gaps in recording chaperone activity and inconsistency in the chaperone offer made to patients. DPHC staff working in multiple locations can find themselves working with conflicting SOPs. Delivering consistent DPHC SOPs across safety-critical areas could efficiently deliver global improvements in clinical safety.
We have noted examples of strong governance around learning from complaints and Automated Significant Events Reporting (ASERs) at a local service level. However, there is scope to widen this learning through both regional and national trend analysis. Similarly, there is potential to share good practice and innovation through regional healthcare governance meetings.
Infrastructure
We have seen some specific issues across the four-year programme:
- the need to improve infrastructure to meet national infection control guidance
- inaccessibility of some mental health team bases for people with a disability, and insufficient treatment rooms at some services
- poor quality sound-proofing and shared facilities compromising people’s privacy.
Issues around infrastructure require action from station commanders and Defence Infrastructure Organisation; DPHC alone cannot influence positively where responsibility for taking action lies elsewhere in DMS or the wider MOD. In Years 3 and 4 of our inspection programme, we re-inspected a number of services for the third (and occasionally for the fourth) time and saw that, although the journey had been slow, required improvements to buildings have been delivered. We identified infrastructure concerns at a number of services on initial inspection but have been unable to carry out follow-up inspection work due to the restrictions around COVID-19. We are planning to complete this follow-up work in Year 5.
Leadership capacity and capability
We have previously identified professional isolation and lack of resilience as issues at some services, particularly medical centres. Small practice teams, often with a lone GP at the helm or NHS GPs contracted in to provide a service, find it difficult to implement and maintain strong governance systems to deliver safe and effective care continuously. Small practice teams are also disproportionately affected by gaps in staffing.
Nevertheless, the size of a service does not necessarily indicate the quality of care – we have found those services that collaborate, affiliate and share resource are more resilient to overcome challenges and are more likely to deliver consistently good care. There is a need to formally recognise arrangements for group practices and to ensure that a comprehensive and jointly agreed memorandum of understanding is in place.
Across the inspection programme we have identified a lack of leadership and management training for senior personnel. There are no systems to ensure that those in leadership roles have the qualifications, competence, skills and experience necessary for the relevant office or position or the work for which they are employed.
Practice managers within DMS typically attend a two-week practice management course and then learn on the job (including those with no practice management or healthcare experience). Similarly, Senior Clinical Officers and Regional Clinical Directors have, to date, learned on the job and received little if any formal leadership training. We welcome the Defence Medical Leadership programme, which is due to start with the first cohort of clinical leaders arriving in July 2021.
Risk management
DPHC does not hold a comprehensive register of risks across its healthcare services. Healthcare governance assurance visits, alongside CQC inspections, can highlight concerns and the need for intervention or additional resource at a service at a specific time. However, the shifting burden of risk is not routinely captured through comprehensive and consistently applied key performance indicators or other similar measures. This acts as a barrier to taking prompt remedial action when issues arise and can lead to deterioration in healthcare standards going unnoticed. It also means that assurance and inspection work is not always based on risk.
Prompting improvement
CQC does not have enforcement powers within Defence Medical Services, so where we have found concerns, we have escalated them to the Defence Medical Services Regulator, (DMSR), who then decides what action to take to trigger improvement.
Safety Review Panels
The DMSR established the Safety Review Panel (SRP) to regulate the safety of medical services across Defence services. It is a decision-making group empowered to review evidence, determine risk, and, if necessary, carry out enforcement action to improve safety for patients and staff. The SRP considers evidence that identifies non-compliance with Defence Regulations – CQC inspection reports are one way of gathering this evidence. To ensure the SRP is reviewing current information at the time of decision-making, DMSR routinely requests updates from facilities or regions that are taking corrective action to address safety concerns. The SRP then makes decisions based on any residual safety risk, which can result in enforcement action being served on an accountable person if sufficient progress is not evident. A growing number of medical facilities are now demonstrating good progress against their Corrective Action Plans, with solid evidence that prevents enforcement action.
To date, 52 facilities have been presented to the SRP under the following process:
- The criteria for presentation to the SRP is a CQC rating lower than good overall and/or lower than good for the safe key question.
- The SRP uses a decision tree to help determine the appropriate level of enforcement, which ensures transparency, accountability, proportionality and consistency.
- The SRP then works with HQ DPHC to ensure that an agreed, robust Corrective Action Plan is in place to resolve the breaches of regulations, and regularly reviews evidence of progress against these Corrective Action Plans.
CQC re-inspects all services where any key question is rated lower than good, following on from any action that DMSR might take.
Next steps
The inspection programme has suffered unavoidable delays in its fourth year and was suspended in March 2020 in response to the outbreak of COVID-19. It has not been possible to follow up a number of services where we previously identified a need for improvement. In Year 5 of the programme, we will prioritise these re-inspections, especially those services rated as inadequate overall.
Nevertheless, where we have been able to re-inspect services virtually, we can conclude that there is a positive direction of travel within DPHC. Where we have identified issues with the quality of care, these have mostly been addressed and services have improved. Where organisational lessons are being identified and shared, there is evidence that this is leading to improved quality in healthcare services. Sharing best practice and innovation across some services has reaped significant benefits for staff and patients. There remains scope to broaden this shared learning to benefit the whole DMS-wide patient population.
In response to the pandemic, CQC and DMSR have worked in partnership to design and deliver an assurance audit programme, which allows us to gather evidence using digital methods. Connectivity and disparity in the software used have posed challenges to gathering some evidence. However, the pilot has successfully demonstrated that, where it is impossible to visit a location that we have inspected previously, a digital approach can be used to gain some assurance around the safety and effectiveness of care.
Taking a broad view across the four-year programme so far, our inspections highlight a number of internal factors that contribute to high-quality care, as well as factors that may inhibit it. Military personnel and entitled dependants continue to receive timely access to almost all services, and most experience a very short wait to see a healthcare professional. Clinical staff across all services engage their specialist skillset to balance the delivery of effective occupational healthcare alongside meeting the individual needs of patients. Respecting the confidentiality of patient information is key to ensuring that military personnel feel confident to step forward and ask for support when they need it. Medical facilities led by staff with the right skills mix and with the right leadership experience will have good governance systems in place to facilitate the delivery of safe and effective care.
Where we have identified poor-quality care, the contributory factors range from lack of training in leadership and governance, absence of effective performance management to measure changes in patient outcomes, ineffective workforce management, poor governance systems and ongoing and sometimes longstanding poor infrastructure.
Looking forward to Year 5, DMSR and CQC are working to develop additional methods to highlight and address known risks. Firstly, we are developing an inspection approach to assess the effectiveness of leadership structures across DMS and to identify and remove key barriers to improve communication and decision making. We are also developing key lines of enquiry to capture and address risks around pre-hospital emergency care delivered by some medical centre staff. A key part of our work in Year 5 will be to re-inspect services where we have previously identified a need for improvement and to visit services that we have not yet managed to inspect.