Quality indicators to support commissioning of unscheduled care

1. Quality indicators to support commissioning of unscheduled care June 2009

2. Guidance for PCTs on commissioning a new delivery model for unscheduled care in London was published in October 2008. This document forms part of a toolkit developed to support PCTs in commissioning the new delivery model and to promote a consistent approach across London. Unscheduled care delivery model Unscheduled care is any unplanned contact with the NHS by a person requiring or seeking help, care or advice. It follows that such demand can occur at any time and that services must be available to meet this demand 24 hours a day. Unscheduled care includes urgent care and emergency care.

3. Identifying indicators of quality in unscheduled care Foreword In June 2008, High Quality Care For All (the NHS Next Stage Review Final Report) put quality at the heart of the NHS. Subsequent guidance on measuring for quality improvement outlines the importance of measuring three dimensions of care: safety, effectiveness and a good patient experience. There is a now a need to develop indicators which can demonstrate that the required quality and desired health outcomes are being achieved and improved. These indicators need to reflect not only volume throughput, which demonstrates the availability of care and performance of the system, but also the quality of the clinical episodes that comprise that throughput and the quality of the patient experience throughout the pathway of care including the health outcomes patients experience as a result of the care they receive. Quality practice is difficult to measure (numerically or otherwise) and, as a result, valid and easily recorded quality measures are rare in healthcare. Despite the difficulties in developing effective indicators, measuring quality and clinical outcomes is crucial to the current health agenda. Nowhere is this more necessary than in the management of unscheduled care. Users of these services are a heterogeneous group, frequently from disadvantaged communities, who present with a whole range of physical, mental health and social care problems, without warning, to a variety of NHS entry points with diverse service delivery models. In recognising these complexities and attempting to balance the achievement of meaningful, comparable quality indicators against an overly burdensome requirement for the collection of data, a number of metrics are proposed here. These have been developed on clinical principles and include a number of common clinical scenarios which are either direct or surrogate indicators of quality including, importantly, patient experience and outcomes. There are many other conditions and metrics that could be used, but after consideration of a large number, those listed here are considered to provide the most value when balanced against the demand levied on everyday clinical life and the effort required to obtain them. Dr Marilyn Plant, General Practitioner, Healthcare for London Clinical Advisory Group (Project Clinical Director) Professor Peter Hutton, Professor of Anaesthesia, Healthcare for London Clinical Advisory Group Professor Sir George Alberti, National Director for Emergency Access Dr Andy Parfitt, Consultant in Emergency Medicine, Healthcare for London Clinical Advisory Group Clinical members of the Unscheduled Care Project Board 3

4. Commissioning to improve quality in unscheduled care (1) Figure 1. Measuring quality at different points in the health system National Life expectancy Inequalities Pan-Londonquality indicators Including World Class Commissioning indicators Commissioning quality indicators within contracts (CQUIN) PCTs Quality Accounts NHS Choices Providers Clinical Quality Indicators PROMS Audit Clinical teams This guidance recognises these different roles and proposes measures for PCTs, providers and clinical teams with the expectation that commissioners will play an overarching role in encouraging and, where appropriate, incentivizing measurement as part of a wider evaluation framework. Improving unscheduled care at a system level will involve complex change. Learning and development cycles need to be an integral part of the change process and built in from the outset in order to understand whether the desired improvement goals are being achieved and sustained as well as the pace and scale of improvement. Commissioning is a key lever for driving improvements in quality. Following publication of guidance for PCTs on commissioning a new delivery model for unscheduled care in London (October 2008) this document gives guidance on outcome measures and quality indicators that can be used to support commissioning and implementation of the unscheduled care delivery model The delivery model guidance identified a strong case for change. Opportunities for improvement were grouped into five key themes: • More can be done to prevent people defaulting to the unscheduled care system to have their needs met • Access to care needs to improve and be more responsive to patients’ needs and expectations • The system needs to be less complex and easier to understand and navigate for patients and staff • Standards and quality can be more consistent and improved across the spectrum of care in community and hospital services • Improving the way the system works as a whole will improve care and patient experience and make better use of resources The drive for change is more likely to be achieved if there are consistent messages and consistency in approach across London. The London Commissioning for Quality Network1 has set out the context in which quality measurement and improvement should be undertaken in London and an approach involving local freedom and flexibility with support from regional and national levels. It has defined the roles of organisations as part of the wider health system, illustrated in Figure1. 1The Network was set up in October 2008 to support the joint work of PCTs in using commissioning as a lever for quality in London.. It works on behalf of the London Directors of Commissioning Group

5. Commissioning to improve quality in unscheduled care (2) • Next steps – recommendations for moving forward • The set of indicators proposed in this paper should be implemented and tested to consider their merit individually and collectively as indicators of quality improvement across the unscheduled care system. This process would involve in depth consideration of how and what indicators work in practice in order to refine the indicator set and inform future development. This would include developing and testing data collection instruments for indicators where these do not exist (or are not effective). This process could be carried out through a pilot project involving a number of PCTs across London or focused in one sector • In parallel, all PCTs should consider the indicators proposed and their use in the local context and select a minimum of 5-6 most relevant to local priorities for implementation; this will involve identifying necessary resources and allocating responsibilities to support the process locally (at PCT and sector levels). • PCTs should build these indicators into commissioning plans AND report them to the new London Quality Observatory (LQO) within Commissioning Support for London (CSL). • The LQO should provide technical support to PCTs e.g. data analysis and feedback of results for indicators reported; this could include benchmarking relevant indicators across PCTs to facilitate local assessment and to inform development of standards. • PCTs should consider what other support and expertise would be helpful in taking this work forward and whether this can be provided locally (e.g. through Public Health Departments, local partnership arrangements). CSL and the SHA should consider what support and expertise can be provided at a regional level e.g. expertise in developing PROMS, facilitating learning/sharing events across PCTs. Commissioning approach Successful implementation of the delivery model will require a coordinated commissioning approach across health and social care, covering primary, community, mental health, acute, ambulance and social services. This could be led at borough or sector level; either option will require a very strong interface between relevant borough and sector functions. The approach to quality improvement and learning needs to be built into this commissioning process. Following the establishment of sector acute commissioning units there is likely to be benefit in this function being led at a sector level. How PCTs can evaluate change A variety of approaches can be employed: • The use of measures e.g. to measure what is important to patients, to enable PCTs to understand how the whole system is working. These can be supplemented with demographic data to build a richer picture. A recommendation from this work is to chose sentinel indicators from the selection proposed. • Audit and case review – this could include a role for networks in supporting audits across services/the system as well as audits in a single service • Patient and professional experience of change – a range of methods can be used, including development of patient reported outcome measures • Use of PDSA2 tools to support a cycle of learning and feeding outcomes into future development plans; working with clinical networks with the aim of creating a self-generating quality improvement environment . 2 e.g. The Institute of Healthcare Improvement PDSA tool http://www.ihi.org)

6. Proposed outcome measures and indicators to support implementation and commissioning of the unscheduled care delivery model The approach involved a review of relevant work and opinion from a variety of sources The delivery model for unscheduled care in London (illustrated on page 2) is a tiered approach encompassing three broad responses to patients’ unscheduled care needs: rapid/moderate, urgent and emergency. A key feature of this model is that, regardless of location, services should function as a single system supported by shared processes and infrastructure. The model is underpinned by eight principles: • The approach to care should be shaped around patients’ and carers needs and expectations • Developments should aim to reduce inequalities in access and improve choice, patient experience and outcomes – and these should be continuously assessed • Services should be delivered within a whole-systems model • Collaborative working arrangements, common protocols and processes and consistent standards are essential features • Patients and carers should expect 24/7 consistent and rigorous assessment of the urgency of their need and appropriate and prompt response • The response should support patients and carers to access the most appropriate service to meet their assessed need within a suitable timeframe – and follow through to conclusion • Care should be delivered in community settings close to home wherever possible – and at home wherever appropriate • Specialised care should be concentrated in fewer centres to improve standards and outcomes These principles alongside the five improvement goals set out on page 4, set the framework for this work to identify outcome measures and quality indicators that support implementation and commissioning of the unscheduled care delivery model. Approach to this work The measures and indicators proposed have been informed by a process that included the following: Pages 7-8 draw out some key points from areas examined through this process. Key findings and recommendations are summarised on pages 9 and 10. Note 1: This involved reviewing: the outcome of interviews, focus groups and a workshop involving patients and the public in phase 1 of the unscheduled care project; responses to Consulting the Capital; relevant literature Note 2: Not just a matter of time: A review of urgent and emergency services in England (September 2008 Commission for Healthcare Audit and Inspection)

7. Experience and outcomes important to patients and the public in using unscheduled care services Priorities for patients and the public have been identified by drawing from a range of sources, including patient and public involvement in the unscheduled care project to date, and triangulating views expressed. The main sources were: • Responses to the Consulting the Capital consultation from PPI groups, individuals and community groups representing patients and the public • Reports informing the consultation process Consultation with Traditionally Under Represented’ Groupson the Healthcare for London Proposals March 2008’(Healthlink) Health Inequalities and Equality Impact Assessmentof ‘Healthcare for London: Consulting the Capital’ (London Health Commission, March 2008) • Findings from patient focus groups interviewed for A study of Unscheduled Care in 6 Primary Care Trusts (April 2008) • Findings from an Unscheduled Care Project consultation event on emerging proposals on a delivery model for London (Healthlink July 2008) • Relevant literature e.g. Patient Views of the Emergency and Urgent Care System, O’Cathain, A., Coleman, P. and Nicholl, J., ScHARR, 2007. • Not just a matter of time: a review of urgent and emergency services in England (Commission for Healthcare Audit and Inspection September 2008 ) These sources identified seven areas to be particularly important priorities for patients and the public in their use and experience of unscheduled care services. These are not presented in an order of priority.

8. Not just a matter of time: A review of urgent and emergency services in England (September 2008, Healthcare Commission) This review highlights the importance of good information on the performance and use of services for commissioning and as an enabler to effective relationships within networks. The review found that all PCTs monitor performance against national standards (e.g. response and waiting times) and look at trends in use of the main urgent and emergency care services. Other ways to measure the quality and outcomes of care were observed to be more limited. The report draws attention to the opportunity for commissioners and service providers to make better use of data both on the performance of individual services and on how well services are working together. This includes data on the quality of local services and comparative benchmarking data looking across services in different areas. The review reported finding limited data on how well resources are used by urgent and emergency care services. Where it does exist, this data shows significant variations. The review highlighted a requirement for better data on the cost, capacity, use and outcomes of services. While all PCTs have taken some action to try to build people’s understanding of services, opportunities to identify when this work makes a real difference are often lost, as its impact is not evaluated. This reinforces the importance of ensuring an evaluative approach is built into commissioning processes. The review placed significant emphasis on integration. Four of the seven recommendations refer specifically to improving information collection and reporting and outcomes. The report identifies various aspects of care that require better data to support integrated working (see opposite) http://www.healthcarecommission.org.uk/_db/_documents/Not_just_a_matter_of_time_A_review_of_urgent_and_emergency_care_services_in_England_200810155901.pdf

9. Key findings from this work – a variety of measures are needed to gauge quality improvements in unscheduled care; potential indicators exist http://www.shef.ac.uk/content/1/c6/05/91/14/Performance%20Indicators.pdf • Many indicators of unscheduled care quality and performance already exist • Around 130 different metrics, in use or in development, can be immediately located which relate to unscheduled care, drawing from the following sources: • NHS Institute Innovation & Improvement (Better care, better value metrics) • NHS Improvement Agency • Healthcare Commission (Annual Health check, Better Metrics, service reviews) • DH existing national targets (inc. 4 hr A&E target) • DH Vital Signs • National indicator set for local authorities and local • authority partnerships • Local Area Agreements • World Class Commissioning Outcomes • Quality Outcomes Framework • National Audit Office • Primary Care Foundation GP OOHs benchmarks • PCT/Acute specific data measured e.g. HES A range of measures are needed to understand the impact of commissioning decisions in improving the quality of unscheduled care. To be comprehensive this needs to include measures which demonstrate how services work together within a whole system to provide consistent, coordinated and high quality care to patients as well as indicators applicable to individual services. Increasingly, there should be consistency in measures used across the system to enable this. This work suggests that what is important to patients in the way they experience unscheduled care is not significantly different from people’s expectations of other health services. Better navigation and speed of access tend to be more important in accessing unscheduled care and situations requiring emergency and urgent care can be anxious and stressful times for patients and carers. Whilst there is a need for better data on the cost, capacity, use and outcomes of services, a significant amount of data is already available that could be used to measure improvements in unscheduled care and indicate performance of the unscheduled care system (see box opposite); most of the existing data focuses on specific clinical or service areas, rather than the whole system, although some proxy indicators for the latter are available. The aim should clearly be to measure what is important and not just what can be measured. Some outcome measures will require new data collection processes to be put in place; the practicalities and any added burden of data collection needs to be weighed against the benefit anticipated; however if the outcome and associated measure is considered an important one then the commissioning process should seek to ensure that mechanisms and, where necessary incentives, are put in place. Relevant work in this area is in development e.g. the Medical Care Research Unit, University of Sheffield, is examining indicators to measure the performance of emergency and urgent care systems as part of a Department of Health funded research programme. The Unscheduled Care Project Commissioning Group has expressed particular interest in this work.

10. Recommendations – take a pragmatic approach using data already available whilst developing a more robust way forward Involving patients and the public The proposed measures encompass some but not all of the areas that have been identified as particularly important by patients and the public for unscheduled care. These should be viewed as a starting point, to be developed and built on. Patient reported outcomes measures (PROMs) For unscheduled care, methods established by commissioners and service providers should embrace a whole system perspective as well as specific services and/or settings of care. Patients’ and the publics’ use of different services and referrals between services mean that they are likely to have the greatest insight into how well the unscheduled care system works as a whole – this is highlighted as an important consideration. Ways of receiving feedback on patient experience and effectiveness of care from a patient's perspective will need to be determined locally e.g. measured through patient reported outcome measures (PROMs). A variety of techniques can be used to explore patients’ and the publics’ views and experiences, however. Commissioners and providers are encouraged to examine and utilise different methods and to share and disseminate local work, particularly where the impact has been evaluated, to promote findings and to help raise the profile of involvement.A ‘Guide to Patient and Public Involvement in Urgent Care‘ (link below) http://www.nhscentreforinvolvement.nhs.uk/index.cfm?Content=220explores the range of techniques that are available. A further example of a tool is available at http://www.shef.ac.uk/content/1/c6/05/91/04/final%20report.pdf (section 4). A pan-London tool to assist in identifying key systems issues to focus on could be developed for local adaptation. Pan-London work to support development of PROMs may also be helpful. Proposed approach Taking account of the findings from this work the unscheduled care project recommends a pragmatic approach initially, focusing on a relatively small number of outcome measures and indicators that: • Include aspects of care important to patients and the public • Include quality markers of clinical care and patient outcomes • Show how the delivery model is being implemented e.g. shifts in care to new settings, access to new pathways • Have potential to signal improvements in the unscheduled care system i.e. integration, consistency • Could be implemented relatively easily and therefore could start to be used quickly e.g. do not require significant new data collection What should be measured? 14 measures are proposed as initial indicators of progress towards implementation of the unscheduled care delivery model. These are described in pages 11-14 and mapped against the delivery model on page 16. Potential developmental measures are shown on page 17. These measures are recommended alongside the following (and there may be some overlap): • National priorities and existing commitments, including vital signs, set out in the operating framework for 2009/10 • The target agreed for 2009/10 with the LAS for ambulance turnaround times under the Commissioning for Quality and Innovation (CQUIN) payment framework • Any other relevant measures being developed locally by PCTs

11. Indicators 1-3 The table below summarises each proposed quality indicator, the rationale for proposing it, comments on a potential metric and notes other relevant information. The indicators are categorised into three groups: outcome based indicators, process based indicators and system based indicators. They are mapped against the delivery model on page 16 to show where they apply in the overall system. 14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome

12. Indicators 4-7 14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome

13. Indicators 8-11 14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome 13

14. Indicators 12-14 14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome • Note • Method of extracting and reporting the • metric and frequency not yet established • Need to determine whether this should be a • specific standard or a benchmark?

15. Some of the indicators proposed need further refinement – e.g. in the form developed by the London Commissioning for Quality Network The Commissioning for Quality Network has considered the potential for using quality indicators at a strategic level across London. These indicators are not meant to replace the quality indicators that PCTs have been developing as part of their commissioning process with providers. Instead they are meant to shine a spotlight on a small number of quality issues that are key priorities for London and where progress on the specific issues identified would act as a clear marker for wider changes in quality outcomes for patients across London. Ten indicators have been developed; two summary examples are shown below. The ten quality indicators include interim quality indicators focussed on improvements to systems and process and data quality indicators developed to address areas where the quality of the data collected directly compromises the ability to assess the quality of care and outcomes for patients States which major aspects of quality covered by the Next Stage Review – Safe, Effective, and Patient Experience - are addressed by the indicator

16. Proposed outcomes and indicators mapped to the unscheduled care delivery model

17. Other potential outcome measures and quality indicators have been identified and could be developed for future use In considering outcome measures and quality indicators for unscheduled care, particularly for an unscheduled care system, a number of other areas have been identified as important however potential indicators and/or the means of collecting and reporting them need further consideration. These are identified below as “developmental” measures. Whilst they need further work, commissioners and providers may wish to explore their merit. The list includes aspects of care important to integrated working identified in the Healthcare Commission report Not just a matter of time: a review of urgent and emergency care services in England (see page 8). 17

18. Where benchmarking is in use– potential resources (1) NHS Benchmarking Club as at 2008 – website provides data analysis reports on various projects http://www.nhsbenchmarking.nhs.uk/projects.asp Completed projects: PMS Older people Community provision Asthma, diabetes and CHD in primary care Dental, Optometric, pharmaceutical Contribution to public health Health Improvement programmes Health Authority costs/finance PCG (primary care groups) Clinical Governance PCG Public Involvement PCG Performance HlmP performance Demand Management Current projects: PCT provider functions Shared services Older people – non-acute 10 High impact changes Diabetes Maternity Primary care indicators Prescribing Workforce Out of hours Planned projects: Primary Care Contracting - Benchmarking Medical Services (2009) 11 WCC competencies This page summarises resources (and web-links where relevant) that could be used to support improvements in unscheduled care delivery and inform commissioning. It is not exhaustive. • DH Essence of Care Benchmarking categories • http://www.dh.gov.uk/en/Publichealth/Patientsafety/Clinicalgovernance/DH_082929 • Communication • Privacy & Dignity • Records/ transfer of information • Safety of clients with mental health needs • Self-care and control of own health care • Everyone will be supported to make healthier choices for • themselves and others • People are confident that the care environment meets their • individual needs and preferences • NHS Institute - Productivity Metrics • http://www.productivity.nhs.uk/ • Accessed on line per SHA broken down into AHTs or PCTs or per all Foundation trusts: • Clinical categories – Acute Trusts/FTs: • Reducing length of stay • Increasing day case surgery rates • Reducing pre-operative bed days • Reducing DNA • New to follow up • Reducing emergency patient readmissions • Clinical categories PCTs: • Managing variation in surgical thresholds • Managing variation in emergency admissions • Managing variation in outpatient attendances • Managing variation in outpatient referrals

19. Where benchmarking is in use– potential resources (2) Primary Care Foundation GP OOHs benchmarking standards project http://www.primarycarefoundation.co.uk/ (Reports back to PCTs and hospital trusts in March 2009) Healthcare Commission Annual Healthcheck 2008/09 Benchmarking data from the review of urgent and emergency care in England (CD issued in February 2009 to all PCTs, NHS Trusts, NHS Foundation Trusts and SHAs in England). • The Information Centre provides information on line for the following primary care categories which provide a benchmark: • http://www.ic.nhs.uk/statistics-and-data-collections/primary-care • Pharmacies • Prescriptions • General practice • Dentistry • Eye care • Examples of reports accessed from this site include: • The Quality and Outcomes 2007/08 Exception Report • A summary of public health indicators using electronic data from primary care • Q research report on trends in consultation rates in General Practice 1995-2008 • The Quality and Outcomes Framework2007/08 • GP Practice Vacancies Survey 2008 • GP Survey 2007/08 http://www.gpps.ic.nhs.uk/results08/ College of Emergency Medicine http://www.collemergencymed.ac.uk/asp/subview2.asp?ID=196 Clinical Standards for Emergency Departments (January 2008)