Indicators and Implementation – How this new work at NICE can help improve the quality of care

1. Indicators and Implementation – How this new work at NICE can help improve the quality of care Systems Team

2. Overview • Quality and Outcomes Framework • NICE quality standards • A few exciting extras • Shared learning • Evaluation

3. What is QOF? • Voluntary incentive scheme • Open to all primary medical care providers • Contains sets of clinical, organisational and patient experience indicators • Practices are assessed against the indicators and score points according to their achievement • Points generate income for the practices • The results are published online

4. What is NICE’s role? • Managing the process of developing clinical and health improvement indicators for the UK and reviewing current QOF • Ensuring consultation with individuals and stakeholder groups • Publishing an annual “menu” of new, evidence-based indicators • Recommendations about existing indicators

5. What is not NICE’s role? • Deciding which indicators are included in the QOF • this will continue to be negotiated by NHS Employers, the BMA and GPC • Developing organisational and patient experience indicators • this will continue to be responsibility of DH • RCGP practice accreditation and GP patient survey

6. Aims of QOF indicator programme • Give individuals and stakeholder organisations an opportunity to contribute • Ensure that indicators address topics of importance to patients, clinicians and the health of the public • Regularly review indicators included in the QOF • Develop, test and pilot proposed indicators

7. Aims of QOF indicator programme (2) • Ensure that all processes and methods are inclusive, open, transparent and consistently applied • Ensure that there are appropriate governance processes in place with all contributing organisations • Ensure all indicators are based on the best evidence of their clinical and cost effectiveness, where available

8. Cost effectiveness considerations • Cost effectiveness is just one element to be considered. But this is the first time it has explicitly been considered when setting indicators • The question is whether an indicator is worth incentivising when compared with other possible uses of the same resources • Methodology will be applied to all proposed new indicators and where data exists for existing indicators being reviewed

9. Cost effectiveness calculation • Indicators can be considered cost effective when net benefit is greater than zero. Net benefit = Monetised benefit - Delivery cost - QOF payment • The monetised benefit is derived from expected increase in quality adjusted life years (QALYs) valued at £25,000 per QALY • Delivery cost includes all costs to the NHS and social care system estimated to arise from increase in uptake • The QOF payment is considered to be additional to delivery cost as an incentive to increase evidence based care

10. Primary Care QOF Indicator Advisory Committee • Approx 30 members • All independent of NICE • Drawn from a range of expertise from across primary care including GPs, patients and carers, commissioners, pharmacists and public health specialists across 4 countries • Meets at least twice a year • Committee meeting agendas and minutes will be published on the NICE website

11. Role of Committee • Consider and prioritise previously developed potential indicators • Prioritise suggestions for new clinical or public health topics • Make recommendations for indicator development • Consider the outcome of piloting and consultation • Make final recommendations on proposed indicators • Review information on the uptake of indicators in the QOF and recommend whether any should be retired, considered for changes to points and/or thresholds, or be subject to further assessment

12. Development process • NICE gathers clinical and cost-effectiveness information to help prioritise new indicators for development • Evidence used from range of sources including NICE guidance and accredited sources of evidence via NHS Evidence • An independent Primary Care Indicator Advisory Committee prioritises these topics for inclusion in the QOF

13. Development process • The National Primary Care Research and Development Centre and York Health Economics Consortium (NPCRD/YHEC) develops the indicators • NPCRD/YHEC tests the indicators in a number of GP practices across the UK • NICE consults on the developed indicators across the UK • The indicators are validated and published on the NICE website

14. Flow chart 24 Months NICE Managed (NPCRDC/YHEC) Collation of information Prioritisation of evidence-based recommendations Indicator development, pilot process and consultation Validation and publication DH, GPC and NHS employers Changes to QOF indicators negotiated using the NICE menu

15. Piloting and consultation • All potential new indicators will be piloted across a representative cross-section of primary care organisations and practices • The pilot will explore: • feasibility, acceptability and implementation • reliability • validity • unintended consequences • Potential new indicators will be subject to UK-wide consultation with all stakeholders, including patients and professional groups

16. Involvement of individuals and stakeholders • Individuals and stakeholders can • use an online facility to suggest clinical or public health topics • register to be notified annually of the opportunity to comment on suggested topics • comment on draft indicators through the public consultation process

17. Equality • NICE is committed to promoting equality and eliminating unlawful discrimination • Organisations that represent groups protected by equality legislation will be encouraged to get involved in consultations • NICE and NPCRDC/YHEC will adopt a systematic approach to equality impact assessment at each stage of the QOF indicator development process • NICE’s equality scheme and other relevant information can be found here: http://www.nice.org.uk/aboutnice/howwework/NICEEqualityScheme.jsp

18. Further information • More information about the QOF Indicator Programme can be found on the NICE website (www.nice.org.uk). This includes: • Common questions about the programme, and the answers • The list of members of the Committee • Minutes of Committee meetings • Indicator documents • Guidance on proposed indicators • Final QOF guidance will be published on www.nhsemployers.org

19. NICE quality standards Proposed process for the pilot 2009/10

20. Definition • A quality standard is a set of specific, concise statements that: • act as markers of high-quality, cost-effective patient care across a pathway or clinical area; • are derived from the best available evidence; and • are produced collaboratively with the NHS and social care, along with their partners and service users

21. Components • Qualitative statements Descriptive statements (5 to 10) of the critical infra-structural and clinical requirements for high quality care as well as the desirable/expected outcomes. • Quantitative measures Indicator of the expected degree of adherence/achievement.

22. Quantitative measures • Quality assured national metrics will be highlighted where they exist • Wherever possible the quality standards will promote prospective measures derived from routinely available data • Potential areas for future metric development may be suggested, to be added to the quality standard in a future review • Audit criteria and measurements, for example from retrospective, case by case data may be proposed where appropriate

23. Guidance and related products Research and audit evidence Chronic Kidney Disease, an example NICE quality standards Could draw from ‘Key priorities for implementation’ listed in the NICE clinical guideline, with extra emphasis on patient experience and the whole clinical team NICE quality standards Guidelines and related products National Service Framework for renal services (2005) NICE clinical guideline on chronic kidney disease (2008)* Research and audit evidence 372 references cited in NICE clinical guideline 57 references cited in NSF for renal services * Accompanied by versions for patients, a quick reference guide, and a shorter version for healthcare professionals

24. Development overview Timing: 6-8 months following topic referral, depending on extent and nature of field testing/consultation

25. Process overview • National Quality Board (NQB) sequence topics annually • Library of around 100 quality standards • Parameters of standard set by NQB • Topic scoping • Review evidence base • Identify standards, indicators (DH assured menu) • Assess current practice • Audits • CQC reviews • Surveys/ expert opinion

26. Process overview (2) • Topic expert groups • Draft potential standards and indicators • Consensus methodology • Membership • Core NICE team and generalists • Topic experts (NCC and GDG) • Lay people • Commisioners • Service providers

27. Process overview (3) • Field testing • Testing of draft standards • Consultation • Through professional bodies and relevant organisations • Information on NICE website • Topic expert groups • Consider feedback from field testing and consultation responses • Refine standards

28. Process overview (4) • NICE Quality Standards Consistency Panel • Check process • Provide consistency and QA across topics • Recommend review dates • Endorse partners • Refer to NICE Guidance Executive • Members • NICE • SCIE • HQIP

29. Next steps June – July 2009 • Receive pilot topics from NQB • Engage and consult on proposed process • with co-producing organisations • public consultation (6 weeks) on interim process August 09 – March 2010 • pilot first 4 topics • first set of standards for publication Mar 2010 • receive next sequence of topics • consult on final process and methods in 2010

30. Publication • Standards can be made available through a number of routes: • The NICE website • Royal Colleges, SCIE and professional associations • NHS Evidence

31. Further information • More information about the QS Programme can be found on the NICE website (www.nice.org.uk)

32. Shared Learning • The purpose of the Shared Leaning database is to share learning among NHS, Local Authority and partner organisations about how they have implemented NICE guidance. • NICE has established a “Shared Learning Award.” Winners will present their work to their peers at the NICE conference. • There is £1,000 for the winner of each category, to support implementation projects in their organisation. • The three categories are: • projects covering general implementation • systems or approaches including • commissioning, financial planning and • audit and evaluation processes • guidance promoting implementation of health • and wellbeing • projects focused on implementing specific • clinical guidance. • The deadline for submissions is 30th September 2009. • To submit an example of putting NICE guidance into practice please visit: www.nice.org.uk/sharedlearning

33. Evaluation and uptake • Collect external work undertaken on uptake, e.g. CQC reviews • Work with Information Centre to analyse routinely collected NHS data and produce NICE implementation uptake reports • Evaluation and Review of NICE Implementation Evidence (ERNIE) database is repository on website for all uptake information www.nice.org.uk/ernie • Use uptake information to target implementation support and inform guidance review

34. Questions