An external audit report of the NHS Lothian Paediatric Audiology Service by the British Audiology Academy (BAA)has identified significant failings in that service. Commissioned by NHS Lothian on the recommendation of the Ombudsman the report raises the possibility of the need to look at services across Scotland. With a national managed clinical networks (MCN) for children and young people (HINCYP) in place, the Scottish Government’s Chief Nursing Officer Directorate (CNOD) requested “information about MCNs and what assurance or challenge functions they can/cannot provide and how to ensure the most effective use of MCNs”. This paper provides information about MCNs in general as well as information specific to HINCYP.
Existing policy guidance in relation to MCNs at local, regional and national level is set out in Managed Clinical Networks Guidance (CEL(2012) 29). MCNs are defined as “linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, unconstrained by existing professional and Health Board boundaries, to enable equitable provision of high quality clinically effective services throughout Scotland”.
National MCN commissioning governance
Through NHS Scotland national commissioning processes and the National Specialist Services Committee (NSSC) NHS boards and Scottish Government Health and Social Care Directorates (SGHSCD) consider and fund proposals for service change, to be led and delivered through National MCNs. On the whole, they are reserved for driving improvements in quality and access to specialist care for the most rare and/or complex conditions. However, without delegated authority they are not empowered to direct NHS Boards to adopt improvements/ developments identified through their work and instead must achieve their aims through influence. Accountability for quality of service provision remains the responsibility of the NHS Board where the service is delivered.
All MCNs are required to operate in line with SGHSCD guidance in CEL(2012) 29, designed to ensure consistency and organisational effectiveness. National MCNs are held to account by National Services Division (NSD), as commissioners, through an annual cycle of performance management and reporting within a formal governance framework Every 3-5 years networks undergo formal, independent review to ascertain their effectiveness and inform a decision by NHS Boards and SGHSCD on continuing central funding and future status. NSD is accountable through the same governance framework for ensuring that networks are structured, organised and resourced to deliver a 3-5 year work programme agreed at designation.
National MCNs deliver improvements through four main areas of work;
- Clinical pathway development to reduce variation and ensure care is evidence based;
- Education to improve capability and capacity;
- Communication and engagement to involve and ensure stakeholder views inform service delivery;
- Continuous quality improvement (CQI) including data gathering and reporting to assess service quality and inform service planning and delivery.
Building the evidence base
Where evidence based clinical standards such as SIGN guidelines and KPIs exist national MCNs establish systems to assess services against these. For many national MCNs the conditions are so rare and patient numbers so small that the networks themselves develop and agree best practice and KPIs. Two models for gathering and reporting data are in place; national MCNs have authority and legal basis to gather and share patient identifiable data across NHS Board boundaries using the National Clinical Audit System (nCAS). However, for some networks it is more appropriate to seek the necessary permissions and establish mechanisms to utilise data held in other systems for network purposes or negotiate extensions to existing data sets to meet MCN needs. Anonymised, national level data, broken down by Board, is shared with services. Without authority to direct Boards the MCN role is limited to working with them to inform local improvement and the extent to which recommendations are adopted is subject to local governance structures and priorities.
The funding for the NMCN’s is top sliced from the Boards after ratification and agreement for their need by the NSSC. This funds clinical leadership and managerial and administrative support to enable achievement of each NMCN’s objectives. Typically this equates to around £75K/pa which includes a £5K operational budget for all meetings and stakeholder and education events.
Accountability and responsibilities
Accountability and responsibilities are set out in detail in individual service agreements. The role of the Lead Clinician is to provide clinical expertise and leadership in the ongoing development of the network and be accountable, on behalf of the Steering Group, for network performance in meeting agreed aims and objectives. These are sessional appointments, usually for 1-2 Programmed Activities (PAs) per week, for which they are accountable through a professional reporting line to the PCF Medical Director. Other members of the NMCN participate on a voluntary basis and in that capacity continue to be accountable to the NHS board or other employer holding their contract of employment
If, in carrying out its role the NMCN identifies areas of concern at individual or organisational level (e.g. regarding clinical practice or service delivery), while initial efforts focus on resolution through local clinical and other governance structures, the NMCN has a legitimate role in escalating these via the Lead Clinician and/or Programme Manager, as defined within the national commissioning governance arrangements in Appendix 1.
The case and funding for a national network for children and young people with hearing impairment was approved through national commissioning in April 2019. This was based on evidence from a scoping project commissioned by Scottish Government in 2015 to explore the current position in relation to paediatric audiology care and to consider and make recommendations for addressing ongoing issues of access and quality. The project concluded that a national MCN would provide the level of national leadership, structure, governance and accountability to achieve improvements for approximately 700 children with permanent, severe childhood deafness, ensuring that every child is identified as soon as possible and has access to services that meet NHS Scotland Paediatric Audiology Quality Standards(2009).
Since launching in March 2020, right at the start of the pandemic, key deliverables achieved include:
- establishing a national MCN and governance framework with appropriate stakeholder involvement
- establishing a mechanism whereby Local Record for Deaf Children (LRDC) data from two existing systems is extracted and submitted to the network (via the NHS Health Boards), on a quarterly basis to:
- support the continued roll out of the LRDC across NHS Health Boards
- deliver, for the first time, a national picture of the number of hearing impaired children known to NHS Audiology services
- support Health Boards to use this data for local audit and planning purposes
- completion of a service mapping exercise that maps Paediatric Audiology services across Scotland (including current workforce and associated agencies)
- delivery of a Learning Needs Assessment (LNA) to address the current gaps in education and training for professionals and multi-disciplinary staff involved in the care of deaf children
- a review of the existing nine Paediatric Audiology Quality Standards that set out the standards expected by service users and stakeholders
In 2021/22 the key priorities are to:
- formulate a National Pathway of Care for Audiology, using the existing nine Paediatric Audiology Quality Standards as the basis.
- implement the nine Paediatric Audiology Quality Standards across Scotland.
- develop plans to address any gaps identified from the service mapping exercise in Year 1.
The network has encountered two particular challenges:
- Ensuring appropriate and consistent clinical leadership; HINCYP has been without a
Lead Clinician since April 2021 following the retiral of the individual who was in post from October 2019. A contingency was established to mitigate risk and enable the network to progress its objectives while efforts continued to appoint a suitable successor. This arrangement, whereby steering group meetings are chaired by a Third Sector representative and clinical advice and expertise is provided by the MDT membership remains in place. Two separate and extended recruitment exercises have proved fruitless. While the pandemic is very likely to be a significant factor, if suitable clinical leadership arrangements cannot be established in the near future consideration would need to be given to whether the Network can continue .
- Ensuring robust LRDC data; while significant progress has been made in establishing a national picture of the number of deaf children, the first year has seen variability that statistically suggested that not everyone was counting cases consistently and standardisation of the collation of this data continues to be a work in progress.
HINCYP progress since its launch is in line with Service Level Agreement (SLA) requirements and other national MCNs; establishing a structure and governance; engaging its stakeholders and ascertaining learning needs; establishing baseline evidence and systems for gathering and reporting data at national level. Evidence gathered to date has not identified concerns in relation to service provision in any specific geographic area.
The network has a meaningful work plan going forward and is a recognised vehicle to take forward developments and improvements. However, there is a risk to the long term future of the network if suitable clinical leadership arrangements cannot be established.
National Services Division
Disclaimer: This information stands correct as of August 2023. It is anticipated that there will be a review of all national and regional networks across Scotland over 2023/24, which may result in some governance changes in the future which may also impact upon this network.
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