Dr Kieran Sweeney, Medical Officer to the Primary Care Team, Commission for Health Improvement

The aim of the Commission for Health Improvement (CHI) is to improve the quality of care that patients receive in the NHS in England and Wales. The use of the word 'improve' is very important. It is not sufficient for CHI to 'inspect' the health service – it must also enable it to see how it can improve.

CHI was established by the Government in 1999 and is overseen by a board of 14 part-time Commissioners,:the majority of whom do not work in the health service.

CHI has been established at arm's length from the Government, and is not part of the health service. This independence is important to CHI. There will be times when what CHI says will make uncomfortable reading for the health service and the Government.

CHI was created partly to restore public confidence in the health service. There had been a number of serious failures in the service and these had received a lot of publicity.

There was also a widespread perception that the quality of health services varied across the country. The public needed reassurance that someone was checking that patient care was as good as it should be and getting better.

However, there was also a structural issue in the health service that needed to be tackled. At the time of CHI's inception the service was judged very much on financial and activity targets, not on how well it treated patients.

This is changing and there is now a statutory duty on the NHS to improve the quality of care as well as concentrating on how much care it provides and what that care costs. CHI is a lever by which the culture of the health service can be changed so that the patient is truly at the centre of its work.

CHI has four functions that will enable it to achieve its aim of improving patient care.

  • Clinical governance review
  • Investigation
  • National studies of health service standards
  • Provision of leadership and best practice.

CHI is responsible for conducting a routine, rigorous assessment of every NHS trust, health authority, primary care group/trust (England) and local health group (Wales) at least every 4 years.

CHI reviews are based on evidence not opinion, and look at the effectiveness of the organisation's clinical governance arrangements, identifying best practice and areas for improvement.

The assessment has three phases:

  • Data collection and analysis
  • An on-site visit
  • A report.

The visit is carried out by a team that includes a doctor, nurse, therapist and manager, all of whom will be currently employed in the NHS. The team also includes a member of the public recruited by advertisement. The team members are coordinated by a review manager who works permanently for CHI.

The visit takes a week and involves the team interviewing and observing staff in the organisation being assessed.

CHI's report is a public document and is accompanied by an action plan, written by the organisation, which spells out what the organisation intends to do to improve patient care as a result of CHI's visit.

The whole process takes about 24 weeks. Table 1 shows an approximate timetable of events.

Table 1: Clinical governance review – approximate timetable of events

Week 1 Letter sent to NHS organisation
Week 3 Review manager meets management team
Week 7 Stakeholder meetings
Week 8/9 Pre-visit brief produced
Week 14 Briefing of review team
Week 16 Review visit
Week 20 Feedback to organisation
Week 24 Final report published

When things go seriously wrong in the health service, CHI can be asked to find out why it happened, how it can be prevented from happening again, and what needs to be done to restore public confidence.

The methods for carrying out an investigation are similar to those for a clinical governance review, but the team members are selected for their particular experience in the area under investigation.

To give an idea of the sort of issues the CHI is asked to look at, the first two investigations covered the appalling abuse of elderly patients in a mental hospital and an incident in which a man had a healthy kidney removed rather than the diseased one.

Investigations are very high profile and it is important that the way they are reported reflects CHI's identity. The Health Service Journal, a respected health service management magazine, described CHI's first reports as 'tough but fair', which was an encouraging start.

As part of the modernisation of the health service, standards and guidelines are being drawn up to apply across the country. These may specify how services for a particular condition, e.g. heart disease, should be organised and provided, or they may give guidance on the most cost-effective way to carry out a procedure, e.g. the best artificial hip to use.

CHI's first study is looking at implementation of the Calman-Hine guidelines on cancer services, which, when published some years ago, set the framework in which cancer services should be provided.

It is commonly believed that there are many examples of excellent practice in the country, but relatively little sharing of good practice. CHI intends to develop a database of excellence which everyone in the health service will have access to.

One example of this will be guidelines for the health service on how to run an investigation when things go wrong. CHI is often asked to investigate after an internal inquiry has been held. The standard of such inquiries is variable, precisely because there are no national guidelines.

Through the exercising of these four functions in an ambitious work plan, CHI is confident that it will be able to demonstrate an improvement in patient care across the health service.

For further information on the work of CHI, visit the website at www.doh.gov.uk/chi.

Commission for Health Improvement

Set up

October 1999
Objectives To improve the quality of care that patients receive in the National Health Service in England and Wales
Status/funding Non-departmental public body funded by the Government
Key personnel Chairman: Dame Deirdre Hine
  Director for Health Improvement: Dr Peter Homa
  Director of Policy and Development: Dr Jocelyn Cornwell
  Director of Nursing: Mrs Elizabeth Fradd
  Medical Director: Dr Linda Patterson
  Director of Operations: Mr Steve Graham
  Director of Research and Information: Mr Gwyn Bevan
  Director of Human Resources: Mr Harry Hayer
  Director of Communications: Mr Matt Tee
Contact details Address: Commission for Health Improvement, 10th Floor, Finsbury Tower, 103-105 Bunhill Row, London EC1Y 8TG
  Tel: 020 7448 9200
  Fax: 020 7448 9222
  E-mail: information@chi.nhs.uk
  Website: http://www.doh.gov.uk/chi

Guidelines in Practice, January 2001, Volume 4(1)
© 2001 MGP Ltd
further information | subscribe