Better_Metrics_full_report by Hesham Abdalla

The Better Metrics project

Version 8 published: November 2007 Authors: Project lead: Dr Paula Whitty, on secondment to the Healthcare Commission Section authorship: See individual sections for details

Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Acknowledgements Professor Bernard Crump was the project lead until April 2005, and continues to be a member of the project steering group. Since April 2005, the project has been funded by the Healthcare Commission, although responsibility for the content of each section of this document lies with the external author of the section. We would particularly like to thank the National Clinical Directors, their deputies and others who led on developing the metrics, their Department of Health policy teams and everyone who responded to consultation. We would also like to thank the project’s expert advisory group; Eastern Regional Public Health Observatory, for rapidly peer reviewing the data source information in version 1 of this document; members of the Integrated Performance Regime working group for supporting the project; and the Office of Strategic Health Authorities for hosting the document on their website. The Department of Health’s standards team and the National Clinical Governance Support team provided funding and administrative support for the project until March 2005. We gratefully acknowledge their support and that of the Department of Health’s Performance Policy and Delivery team.

Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Changes made since previous versions Version 2: relevant information from the Department of Health Technical Note (issued 10/11/2004) on Local Delivery Planning (LDP) for 2005–2008 was added. This resulted in changes to the introductory sections for some metrics only. Also minor changes to metrics 3.02 and 6.02. Version 3: relevant information from the supplementary Technical Note on LDP monitoring (issued 24/11/2004) added. Changes to the introductory sections for cardiovascular disease and cancer only. No changes to the metrics. Version 4: new contact names for the overall project and for children’s metrics; new paragraph added to patient experience section; re-numbering of patient experience core questions from page 115 ; substantial changes to metric 3.07; minor changes only to text in metrics 1.01, 1.07, 1.09, 1.12, 2.11, 3.05, 4.01, 4.07, 4.13, 6.04, 6.14; page numbering from page 120 onwards. Version 5: substantial changes to metric 1.01; additions to membership of the expert advisory group (Appendix A). Version 6: inclusion of an executive summary; contents page moved forward; list of all metrics at the beginning of the document; consequent change in page numbering; further changes to metric 1.01; changes to notes in metric 1.11; changes to notes in metric 4.03; minor changes to text in metrics 3.12, 10.02, 10.03, 10.04; change in heading of “cardiovascular disease” section to “heart disease and stroke”; some explanatory text for the awaited Public Health section. Version 7: extensive minor changes made which could not all be listed here. Major changes: inclusion of a chapter on metrics for long-term conditions; inclusion of refreshed metrics for cancer, heart disease, stroke, mental health and R&D, related to the Healthcare Commission’s consultation on assessment of developmental standards in 2006; merging of the Public health” and “Health inequalities” chapters. Version 7 (Nov 2006): temporary removal of “Children and maternity" chapter. Version 8: changes to metrics 5.03, 7.10, 7.11, 7.12 & 7.13; Appendix E updated and Appendix F removed; layout adjusted to portrait and extensive minor editorial changes.

Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Contents Executive summary .................................................................................................... 5 Background................................................................................................................. 6 Glossary.................................................................................................................... 11 List of metrics............................................................................................................ 12 1

Cancer ............................................................................................................ 24

Heart disease and stroke ................................................................................ 43

Children and maternity .................................................................................... 58

Diabetes.......................................................................................................... 59

Urgent care ..................................................................................................... 70

Public health and health inequalities............................................................... 77

Long-term neurological conditions .................................................................. 81

Learning disabilities ........................................................................................ 96

Mental health ................................................................................................ 104

Older people ................................................................................................. 126

Improving patient experience ........................................................................ 132

12 Primary care.................................................................................................. 142 12.1 General primary care................................................................................... 142 12.2 Primary care nursing ................................................................................... 144 12.3 Primary care dental services ....................................................................... 146 13

Research & development.............................................................................. 152

Appendix A – Membership of the expert advisory group ........................................ 158 Appendix B – Features of a good measure............................................................. 159 Appendix C – Shortened questionnaire for the National Cancer Patient Survey (NCPS) ................................................................................................................... 160 Appendix D – Selection from “Local basket of indicators to track progress on reducing inequalities in public services across a range of inequalities dimensions” .............. 161 Appendix E – Details of national patient experience surveys to date...................... 167

Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Executive summary Working with Department of Health National Clinical Directors (NCDs) and their colleagues, “Better Metrics” is a pragmatic project aimed at providing more clinically relevant measures of performance (metrics). The project has also produced some criteria for what makes a good metric, to assist local services in developing their own. We hope that these Better Metrics will be useful: • where the topic covered by a metric has been identified by a primary care trust (PCT) as an area within which a local target could be set, the metric could be the basis for defining the local target • as indicators for local quality improvement initiatives The Healthcare Commission is already using Better Metrics. Where relevant, and available from national data, the metrics are part of the core standards screening dataset for the annual health check. They have also been included within the assessment frameworks for relevant improvement reviews (for example, mental health, heart failure and diabetes). Indicators derived from the cancer, heart disease, stroke, mental health and research and development (R&D) metrics form the supporting data in the Healthcare Commission’s proposals for assessing trusts’ progress against developmental standards in clinical effectiveness from 2006/2007. The aims of the project also include sharing the metrics with the Connecting for Health (CfH) programme, so that the process for development of electronic patient records can consider how easily such metrics could be measured routinely in the future. The document is structured by NCDs’ areas of responsibility (with one or two additional sections from other areas, for example dentistry, where representatives requested to be involved). There is a list of all of the metrics at the front of the document for easy reference, although it will be necessary to consult individual sections for detail. The lead role of NCDs also explains why the metrics do not attempt to cover all clinical areas (i.e. where there is not a current NCD), and one of the longer term aims of the project is to include metrics for the forthcoming National Service Frameworks (NSFs) and other areas keen to engage with the project. The document suggests metrics for cancer, heart disease and stroke, children and maternity, diabetes, urgent care, health inequalities, long-term neurological conditions (LTNCs), learning disabilities, mental health, older people, patient experience, primary care (including primary care nursing and dental services) and R&D. This is very much work in progress and we are hoping to add metrics for renal services and ambulance services shortly. There is also ongoing work with ”Essence of care” to explore the potential for using it to derive metrics. We have also revised the metrics in response to comments, and aim to continue to respond to comments in future. We are very keen to hear what you think about this publication. Do also get in touch if you are willing to share your experiences of using the metrics. Contact details are provided within the document so please do get in touch with either Paula Whitty, project lead (p.m.whitty@ncl.ac.uk), or the contacts for individual metrics. Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Background Why a better metrics project? The Better Metrics project arose from discussions at the NHS’s ‘top team’ (the meeting of Strategic Health Authority (SHA) chief executives with the then NHS’s Chief Executive, Sir Nigel Crisp, and Department of Health NCDs, Directors and other lead officers). There had been a general concern that clinicians practising in the NHS, and practitioners in other agencies working closely with the NHS, had not always been engaged by the targets and other indicators used to performance manage and assess performance in the NHS. For example, local clinicians might not always be aware of the targets being measured, or the components of their organisation’s (then) star rating indicators, and were unlikely to be using them as part of their service quality improvement initiatives. This was despite widespread clinical support for central initiatives such as the NHS Plan and National Services Frameworks. One possible explanation for this was that some of the existing performance measures were not sufficiently relevant to clinicians’ day-to-day practice, or to the patients they were treating. So in January 2004, the top team agreed to support a project to develop more clinically relevant measures of performance. These measures have been termed “metrics” to avoid confusion with other terms such as targets, indicators or benchmarks – the aim is that the proposed metrics could be used for any of these purposes. The project also aimed to produce some criteria for what makes a good metric, to assist local services in developing their own.

Where does the Better Metrics project fit in the current NHS performance regime? The publication National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/2006–2007/2008 1 described the current performance regime for the NHS. This set out both a framework of core and developmental healthcare standards (“standards for better health”) and the national targets for 2005–2008. The document also reaffirmed the need to maintain existing commitments. As there are fewer national targets than in the previous planning round, there is an expectation that there will be headroom for primary care trusts (PCTs) to be able to set more local targets. SHAs are performance managing achievement of both local contributions to national targets, and local targets. The Healthcare Commission has developed assessment criteria to determine whether core standards have been met and is developing criteria that it will use to judge progress against developmental standards. 2 As well as progress against standards, the Healthcare Commission’s annual assessment of organisations’ performance is also looking at progress against targets, and development in other areas such as their leadership capability.

www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuida nce/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4086057&chk=ypF WoL 2 www.healthcarecommission.org.uk/InformationForServiceProviders/AnnualHealthC heck/fs/en?CONTENT_ID=4017483&chk=ub2qrx Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

When the Better Metrics project was launched, it was hoped that the metrics could assist with several of these activities, where relevant. Specifically, they were thought to be useful: • where the topic covered by a metric has been identified by a PCT as an area within which a local target could be set, the metric could be the basis for defining the local target • for the Healthcare Commission to inform the development of criteria to assess clinical effectiveness or other relevant standards in an area covered by a metric • as indicators for local quality improvement initiatives The Healthcare Commission is already making use of the metrics in three main areas: • core standards assessment – where metrics relevant to core standards are available from national data sources, they are included in the core standard screening dataset for the annual health check • improvement reviews – any improvement reviews covering metrics topics have included currently available metrics in their assessment tools (for example mental health, heart failure and diabetes) • developmental standards assessment – the Healthcare Commission extended the annual health check to include a pilot assessment of trusts’ progress against developmental standards in 2006/2007. This includes the indirect use of metrics in assessment of the clinical and cost effectiveness developmental standards (for stroke, heart disease, cancer and mental health). The aim is to include more metrics topics from 2007/2008 onwards as data sources become more readily available. As well as the benefits of metrics also being used by the Healthcare Commission, the other advantages of selecting from a menu of metrics include: • improving the clinical relevance of performance measures • helping to align local quality improvement initiatives with the performance regime • encouraging overlap between the measures required by different aspects of the performance regime • even in a more devolved NHS, allowing the possibility of benchmarking where local targets and other initiatives on the same topic are using the same data definitions • potentially providing some expert support to organisations in developing measurable local targets and quality indicators The aims of the project also included sharing the metrics with the Connecting for Health (CfH) programme, so that the process for development of electronic patient records could consider how easily such metrics could be measured routinely in the future.

How were the better metrics developed? This was a pragmatic project, intended for rapid dissemination within the NHS, rather than a formal academic exercise. However, the aim is developmental, with the opportunity to revise the metrics in response to comments and to evaluations of how Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

useful they are locally. Details of how to comment or otherwise contribute to the project are given at the end of this chapter. In brief, the process followed for the project was: • identification of a lead contributor from each SHA community • each of these contributors offered to link with one of the NCDs • these groups of two or three people were asked to propose a series of about 10 metrics that they believed would be more clinically relevant measures of performance in the area for which the NCD has responsibility. In identifying these measures the groups were asked to be cognizant of a series of criteria, which the NHS Top Team had suggested are the features of good clinical metrics for use in (see Appendix B) • each group determined its process, to include professional and public involvement in its work as it saw fit • a small advisory group, including academics with an interest in the measurement of clinical performance (see Appendix A for membership of the expert group), suggested some revisions to the proposed metrics, and refined the criteria. The current draft of the criteria is provided in Appendix B • since the first publication of the Better Metrics document, further extensive efforts have been made to publicise the metrics and to seek comments from professional and patient organisations • in summer of 2005, all metrics leads were asked to refresh their metrics in the light of comments received to date. For those topics being proposed for coverage in the Healthcare Commission performance assessment, leads were also asked to revisit which metrics might be obtainable from national data sources Importantly, the project did not constrain the groups to proposing only metrics where data is currently available to measure them. Although we expected some of the metrics to be currently measurable, so that the NHS could be immediately engaged with the project, the emphasis was on identifying what is important to measure. Where metrics have been proposed that are considered important but not currently measurable, the NCDs are looking at how they might be measured in future, including dialogue with CfH.

How the metrics are presented within this document The document is structured by NCDs’ areas of responsibility (with one or two additional sections from other areas, for example dentistry, where representatives at top team requested to be involved). This also explains why the metrics do not attempt to cover all clinical areas (i.e. where there is not a current NCD), and one of the longer term aims of the project is to include metrics for forthcoming National Service Frameworks (NSFs) and other areas keen to engage with the project. Following some brief introductory text about issues specific to the development of that section’s metrics, the metrics themselves are presented in a standard format. The format is intended to assist users of the metrics in identifying which might be useful for assessing progress against national targets; against specific NSF standards where relevant; and against the standards for better health.’ Where the metrics relate to an area covered by a high-level Public Service Agreement (PSA) target (i.e. a national target for 2005–2008, the document includes a cross-reference Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

to the technical note on the national requirements for monitoring the 2005/08 Planning Framework. This should help to clarify the potential uses of the metrics in addition to the national requirements. Information is also provided on data sources for measuring the metric, although, in many cases, further work is required on detailed data definitions and will be made available on this website as it progresses. The “data source” section of each metric is prefaced by a simple classification to assist users of the metrics as follows: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done) Although the initial brief for the project suggested about 10 metrics per area, the numbers of metrics provided do vary, but all have attempted to keep to a relatively small number of key measures.

What next? Although some consultation was carried out before publication of this document, we are very keen to receive comments. We would particularly like to improve the linkages with existing projects relevant to metrics. We aim to revise the document regularly, including after the publication of new national service frameworks. We are hoping to add metrics for renal services and ambulance services. There is also ongoing work with “Essence of care” to explore the potential for using it to derive metrics. Subsequently, we hope that this will continue to be a living document, revised regularly as required. We have also encouraged sites to get in touch if they are using the metrics, so we can share lessons and learn more about what is proving useful locally. Several of these ‘implementation sites’ already exist, details of which will be published on this website. A number of recent developments will have an impact on the Better Metrics project. These include: the Health and Social Care Bill’s establishment of the Care Quality Commission, a new regulator for health and adult social care in England, in April 2009; Lord Darzi’s continuing review of the NHS in England, with its vision of a clinically driven, patient-centred service; and other proposals, such as those in the Government’s White Paper on professional regulation (Trust, Assurance and Safety [2007] Cm 7013) and in the report of Sir John Tooke’s high-level group on clinical effectiveness to the Chief Medical Officer (October 2007). The Healthcare Commission intends to increase its focus on clinical quality in the annual health check for 2008/09 – for details see the consultation document to be published in mid-December 2007 on www.healthcarecommission.org.uk In November 2007 it held a joint workshop with the Academy of Medical Royal Colleges about improving the measurement of clinical quality. Materials from the event are available at www.healthcarecommission.org.uk The Commission will be working with the academy and clinical bodies from other disciplines to carry forward this initiative in 2008. Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

How do I comment, ask questions or get involved? If your comments are about the project in general, please contact: Paula Whitty Lead for the Better Metrics project e-mail: p.m.whitty@ncl.ac.uk If you wish to comment about a particular group of metrics, you will find contact details at the end of each section. We are very keen to hear from you, so please do let us know what you think.

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Glossary BHF BMI CfH CHD CPA CPN CVD DC DfES GMS GORs GYNAE HES HESPs HoNOS HSE IOGs LAs LDP LTNCs LUCADA MDTs MHMDS MI MINAP NatPACT NCASP NCDs NCPS nGMS NHS NSFs NICE NIMHE NPfIT NPSA PCTs PHOs PSA PPF QMAS QOF QRs RPHOs SHAs SMDTs VHIUs

British Heart Foundation body mass index Connecting for Health coronary heart disease Care Programme Approach community psychiatric nurse cardiovascular disease (regional) development centre(s) (of the National Institute for Mental Health in England (NIMHE)) Department for Education and Skills General Medical Services Government Office Regions gynaecological Hospital Episode Statistics Health and Education strategic partnerships Health of the Nation Outcome Scale Health Survey for England Improving Outcome Guidance local authorities Local Delivery Planning long-term neurological conditions national lung cancer audit project multidisciplinary teams Mental Health Minimum Data Set myocardial infarction national myocardial infarction audit project National Primary and Care Trust Development Programme National Clinical Audit Support Programme National Clinical Directors National Cancer Patient Survey new General Medical Services contract National Health Service National Service Frameworks National Institute for Clinical Excellence National Institute for Mental Health in England National Programme for Information Technology National Patient Safety Agency primary care trusts Public Health Observatories Public Service Agreement Priorities and Planning Framework Quality Management and Analysis system Quality and Outcomes Framework quality requirements Regional Public Health Observatories strategic health authorities specialist multidisciplinary teams very high intensity users

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List of metrics 1 Cancer 1.01

1.02 1.03 1.04 1.05

1.06

1.07

1.08

1.09

Percentage of eligible women aged 53 to 64 in a PCT population with an adequate breast screening test result in the last three years 2 a) Percentage of eligible women aged 25 to 49 in a PCT population with an adequate cervical screening test result in the last three years b) Percentage of eligible women aged 50 to 64 in a PCT population with an adequate cervical screening test result in the last five years Both metrics included in the refreshed metrics To be developed (early presentation of patients with symptoms) To be developed (initial assessment of patients with symptoms in primary care) Specialist teams are constituted as defined by the Manual for Cancer Services Proportion of new patients diagnosed with cancer whose care is discussed by a designated (multidisciplinary) team or designated specialist multidisciplinary team (SMDT) Percentage of acute trusts providing care for people with cancer using statistical process control (SPC) charts to monitor their survival data at one, two and five years by MDT for individual cancer groups Refreshed metrics: 1 Cancer mortality trends â&#x20AC;&#x201C; for breast, colorectal and lung cancer by PCT 2 One year mortality rates for lung, pancreas and oesophageal cancers by PCT Percentage of acute trusts providing care for people with cancer using statistical process control (SPC) charts to monitor their 30-day postoperative mortality rate for major surgery by MDT (examples are colorectal surgery, oesophageal surgery, head and neck surgery, and surgery for lung cancer) Refreshed metrics: 30-day post-operative mortality rate for major surgery by acute hospital (equivalent to one MDT) â&#x20AC;&#x201C; colorectal, oesophageal, gastric, pancreatic, head and neck, lung, ovarian and bladder cancers Prostate cancer: evidence that all possible management options have been discussed with patients Refreshed metrics: Urological cancer : surgeon specific volumes for radical cystectomies and radical prostatectomies (more than five) Breast cancer: evidence that all patients who are suitable are offered adequate information to be able to make an informed choice between mastectomy and breast conserving surgery Refreshed metrics: Breast cancer: i ratio between mastectomy and breast conserving surgery ii hospital volumes for breast cancer operations (including surgeonspecific volumes)

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1.10

Rectal cancer: proportion of patients operated on for rectal cancer with a permanent stoma formation Refreshed metrics: Colorectal cancer: i proportion of patients operated on for rectal cancer with a permanent stoma formation ii hospital volumes for colorectal surgery (including surgeon-specific volumes) iii participation rates in national colorectal cancer audit Refreshed metrics for upper GI cancer, lung cancer, and head and neck cancer: 1 Upper GI cancer: hospital volumes for gastric, oesophageal and pancreatic resections (including surgeon-specific volumes) 2 Lung cancer: i resection rates (by trust and PCT) ii participation rate in national lung cancer audit (LUCADA) 3 Head and neck cancer: participation rate in the National Head and Neck Audit 1.11 To be developed (palliative and end of life care) Refreshed metrics: 1 Deaths at home from all cancers (ICD10 C00-C97) percent (and 95% confidence intervals ), 2003, all ages 2 Percentage of GP practices which have implemented the Gold Standards Care Framework 1.12 Mean scores on the abbreviated National Cancer Patient Survey (NCPS) questionnaire (improvement on NCPS results (baseline 1999/2000)) 1.13 Mean scores on the abbreviated NCPS questionnaire (improvement on NCPS results (baseline 1999/2000)) 1.14 Mean scores on additional questions from the National Audit Office survey of patient experience 1.15 To be developed (coordination of care and cooperation across organisational boundaries) 2 Heart disease and stroke 2.01 The percentage of patients with hypertension who smoke whose notes contain a record that smoking cessation advice has been offered at least once. Also a refreshed metric Refreshed metrics: i GP recording of BMI status ii Patients with coronary heart disease, diabetes or stroke who also smoke â&#x20AC;&#x201C; offered smoking cessation advice 2.02 The percentage of patients with hypertension in whom the last blood pressure (measured in the last nine months) is 150/90 or less 2.03 The percentage of patients with hypertension who have a record of total cholesterol in the last 15 months 2.04 The percentage of patients with a stroke shown to be nonhaemorrhagic, or a history of TIA, who have a record that aspirin, and alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side effects are recorded). Also a refreshed metric

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2.05

2.06

2.07

2.08

2.09

The percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less. Also a refreshed metric The percentage of patients with a history of stroke or TIA whose last measured total cholesterol (measured in the last 15 months) is 5 mmol/l or less. Also a refreshed metric Refreshed metrics for stroke relating to diagnosis, acute clinical management and rehabilitation, and improving acute stroke care: 1 Diagnosis: the percentage of new patients with presumptive stroke (presenting after 1 April 2003) who have been referred for confirmation of diagnosis by CT or MRI scan 2 Acute clinical management and rehabilitation: Key 12 indicator score from the stroke audit 3 Improving acute stroke care: i the availability of stroke units set up to deliver thrombolysis to eligible patients, in accordance with the National Clinical Guidelines for Stroke ii the percentage of eligible patients receiving thrombolysis iii participation rates in the National Audit of Carotid Endarterectomy Deliver a 10% increase per year in the proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help. Also a refreshed metric Refreshed metrics: A new composite indicator of the performance of the system in relieving blockages to coronary arteries in eligible patients with AMI â&#x20AC;&#x201C; exact construction to be determined The percentage of patients with coronary heart disease who are currently treated with a beta-blocker (unless a contraindication or side effects are recorded). Also a refreshed metric Refreshed metrics: i Percentage of patients following myocardial infarction discharged on all three of the following drugs: aspirin, beta-blockers and statins ii Percentage of patients with CHD with a record in last 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contra-indicator or side effects are recorded) iii Percentage of patients with CHD in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less iv Percentage of patients with CHD whose last measured cholesterol (measured in last 15 months) is 5 mmol/l or less Whether all hospitals receiving patients with heart attack or other acute coronary syndromes have 24/7 availability to troponin-T testing Refreshed metrics: a Routine provision of troponin T or I tests for patients with acute coronary syndromes b Percentage of patients with ST- segment elevation for whom a troponin T or I test is recorded Refreshed metrics for the diagnosis and assessment of angina: Percentage of patients with newly diagnosed angina (after 1 April 2003) who are referred for exercise testing and/or specialist assessment

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2.10

The percentage of patients with a diagnosis of CHD and left ventricular dysfunction who are currently treated with ACE inhibitors (or A2 antagonists) Refreshed metrics for surgical management: i Observed/expected revascularisation (coronary artery bypass graft) and percutaneous coronary intervention [PCI]) rates ii Risk-adjusted mortality rates after first time CABG iii Readmission rates after pacemaker implantation Refreshed metrics for rehabilitation: i Participation rates in the BHF rehabilitation audit ii Percentage of patients following MI or revascularisation procedures who receive an appropriate rehabilitation programme iii Average patient anxiety and depression scores and health-related quality of life scores post-rehabilitation and mean changes scores from baseline to 12 weeks 2.11 The ratio of the number of registered patients with CHD to the expected number of patients with CHD (based on prevalence estimates adjusted for age, sex, deprivation and ethnicity) 3 Children and maternity The children and maternity metrics chapter is temporarily unavailable. This is while the chapter is being reviewed in light of new metrics under development for monitoring the National Service Framework. The revised chapter will be made available on this website as soon as possible. If you have any queries in the meantime, please contact Andy Mobbs at andy.mobbs@ic.nhs.uk or Elaine Edgar at elaine.edgar@dh.gsi.gov.uk 4 Diabetes 4.01 i Prevalence of overweight (BMI 25-30 kg/m.sq.) and obesity (BMI 30 kg/m.sq.) in the general adult population by age ii A multi-agency obesity strategy is in place with agreed local strategic partnership targets iii A multi-agency physical activity strategy is in place with agreed local strategic partnership 4.02 i Number of people diagnosed with diabetes compared to the predicted level of the total prevalence of all forms of diabetes diagnosed and undiagnosed ii Percentage of people diagnosed with diabetes in the last 12 months who have retinopathy at the time of diagnosis 4.03 Measurement of diabetic patient satisfaction in respect of ease of access, attention/interaction, respect for the individual, knowledge gained, empowerment and age/cultural appropriateness 4.04 i Percentage of patients with diabetes with a record of HbA1c within the last 15 months ii Percentage of patients with diabetes in whom the last HbA1c is 7.4% or less in the last 15 months. iii Percentage of patients with diabetes in whom the last HbA1c is 10% or less in the last 15 months

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4.05

4.06

4.07

4.08

4.09

4.10

4.11

Percentage of adults with diabetes with a record of cholesterol in the last 15 months ii Percentage of adults with diabetes in whom the last cholesterol measurement is 5 or less iii Percentage of adults with diabetes with a record of blood pressure in the last 15 months iv Percentage of adults with diabetes in whom the last blood pressure is 145/85 mm or less i Percentage of adults and children with diabetes with a record of testing for proteinuria or microalbuminuria ii Percentage of adults and children with diabetes with proteinuria or microalbuminuria who are treated with ACE inhibitors or A2 antagonists iii Percentage of patients with diabetes who have a record of retinal screening according to national standards in the previous 15 months iv Percentage of patients with diabetes diagnosed with sight-threatening retinopathy v Percentage of patients with diabetes who have undergone laser treatment for sight-threatening retinopathy i The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months ii The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months iii Percentage of patients with diabetes who have been assessed as being at increased risk of foot ulcers iv Percentage of patients with diabetes who have been assessed as being high risk of foot ulcers v Percentage of patients with diabetes having a foot care emergency or foot ulcers i The percentage of patients with diabetes in whom there is a record of smoking status in the previous 15 months except those who have never smoked where smoking status should be recorded once ii The percentage of patients with diabetes who smoke and whose notes contain a record that smoking cessation advice has been offered in the last 15 months i Percentage of diabetic patients who have been offered a structured education programme (with their families / carers where appropriate) within 12 months of diagnosis ii Percentage of diabetic patients who have received a structured education programme (with their families / carers where appropriate) within 12 months of diagnosis iii Percentage of pregnant diabetic women who have received prepregnancy counselling Percentage of all staff (specialist in diabetes and non-specialist) who come into contact with people with diabetes, and who have undergone a competency assessment and had opportunity for diabetes education and training Population adjusted ambulance call out rates to diabetic emergencies and diabetic A&E attendances and A&E attendances due to diabetic emergencies or complications

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4.12

Percentage of patients where completion of an explicit care plan at annual review included use of a joint decision making tool 4.13 Age adjusted excess length of stay (LOS) and LOS ratio in diabetes patients for key indicators condition (see below) compared to non-diabetic patients 5 Urgent care 5.01 Percentage of A&E departments which, for 80% of causes of admissions, have reached agreement on what the definitive intervention and optimal time to treatment is for each of these causes of admission 5.02 Duration of stay in assessment unit 5.03 Deliver a 10 percentage point increase per year in the proportion of people suffering from a heart attack who receive thrombolysis, or the decision to proceed with percutaneous coronary intervention (PCI), within 60 minutes of calling for professional help. 5.04 Percentage of acute trusts using statistical process control (SPC) charts to monitor their 30-day mortality post-MI 5.05 Proportion of patients treated in an acute stroke unit service 5.06 Time from first entry into the hospital to admission to the acute stroke unit 5.07 Percentage of patients presenting to A&E with a fall who are referred for a multidisciplinary falls assessment (provided by old age specialist teams) 5.08 Proportion of acute trusts with access to old age liaison psychiatry services 5.09 Proportion of people presenting with a mental health problem at A&E who receive a psychosocial assessment 5.10 Proportion of people referred to crisis assessment services who are assessed within four hours 5.11 Proportion of health communities with an effective local urgent and emergency network meeting regularly (at least every four weeks) 5.12 Proportion of out of hours consultations for which full data is provided to GP practices by 9am on the next working day 5.13 Proportion of telephone calls to the NHS Direct abandoned within 30 seconds 5.14 Scores from the A&E patient survey, i.e. for the five domains of: Access and waiting; Safe, high quality coordinated care; Better information, more choice; Building better relationships; Clean, friendly, comfortable place to be 6 Public health and inequalities â&#x20AC;&#x201C; see section for details 7 Long-term neurological conditions (LTNCs) 7.01 Proportion of people with a LTNC who have within the last 12 months: â&#x20AC;˘ had an integrated assessment/review assessment â&#x20AC;˘ received a personal care plan 7.02 Proportion of people with LTNCs with complex needs who have a named individual who acts as a coordinator of their care 7.03 Proportion of people with LTNCs who have received high quality information about their condition, its management, local services and how to access them, and wider social inclusion issues 7.04 Percentage of people who report a positive experience from their contact with services

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7.05

Proportion of people with LTNCs who receive specialist assessment, investigations and treatment within timescales designated in NICE guidelines (where they exist), and within the 18-week PSA target where NICE guidelines do not exist 7.06 Proportion of people with LTNCs on three or more drugs who have received a medicines review within the last 12 months 7.07 People with a neurosurgical or neurological emergency access as appropriate: a critical care within one hour of referral b neuroscience centre within six hours of referral c spinal cord injury centre within one day of referral d acute neurological team in local DGH within one day of referral 7.08 Wait times for individuals to access specialist neuro-rehabilitation inpatient facilities in line with national guidance 7.09 People with identified needs on the care plan for rehabilitation in the community receiving: a community neuro-rehabilitation (specialist team/generic team with neurological expertise) b vocational rehabilitation 7.10 People with identified needs on the care plan for equipment / adaptations receiving: a standard equipment within seven working days b bespoke items within 20 working days c adaptations to their property (including those funded by Direct Facility Grants) within the agreed timescale and no more than six months d repair/replacement of equipment no longer functioning properly within locally agreed timeframes 7.11 People with LTNCs with identified needs on the care plan for assistance / support with living independently are offered the option of direct payments and the necessary support to operate it 7.12 Percentage of people with a long-term neurological condition offered support to live in their own home as opposed to residential/nursing care 7.13 Percentage of carers of people with a long-term neurological condition who: • have received a carers assessment • receive support appropriate to their identified needs 7.14 a Percentage of people with a long-term neurological condition accessing palliative care services b Percentage of people with a long-term neurological condition who are terminally ill with evidence of good end of life care in line with NICE best practice guidance 8 Learning disabilities 8.01 Number of people with learning disabilities known to GP practice but not yet coded using a locally agreed and appropriate Read code 8.02 • Number of people with learning disabilities with or offered (which to be confirmed) a comprehensive health check prior to a Health Action Plan (per 10,000 of PCT general pop.) in last three years • Number of people with a health action plan (HAP) (per number offered) 8.03 Each PCT should have a system for identifying local health facilitators Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

8.04

Numbers of patients with learning disabilities who have been invited, in the past year, for a comprehensive health check if they have not visited the GP surgery in the last three years 8.05 • A system is in place within each PCT to review the treatment plans of patients in NHS funded hospital beds (in and out of district) at least annually by a qualified clinician • Percentage of people with learning disabilities who are in NHS hospital funded beds where duration of stay has exceed 12 months (per 10,000 of PCT general population) 8.06 Number of people with learning disabilities in out of area treatment provision who are assessed by an appropriately qualified specialist clinician as severely challenging or who have a mental health or forensic need 8.07 The PCT have a system and protocols in place to ensure that people with learning disability and mental health needs are able to swiftly access local mental health services 8.08 • How many people with learning disabilities have been screened for dysphagia in the last three years? • How many people have a plan for dysphagia in place that has been regularly reviewed? 8.09 Regular survey to ascertain how easy to understand information provided about their health and treatment was for patients with learning disability and their family carers 8.10 • Number of patients with learning disabilities on any patient forums • Number of people with a learning disability in health provision who are inpatients including long stay and campus provision who are receiving support from independent health advocacy services 8.11 Acute hospitals have a system in place to ensure patients with learning disabilities are identified and appropriate support provided 8.12 PCTs have a system in place to ensure access and take up rates are monitored by the PCT executive board quarterly for people with learning disabilities to check and promote equal access to benefits in mainstream services, NSFs and plans 9 Mental health Child and adolescent mental health 9.01 Service satisfaction with child and adolescent mental health services, from the perspective of young people and parents or guardians 9.02 Number of children and young people requiring mental healthcare admitted to adult psychiatric wards: measured for both under 16s and 16 and 17 year olds Refreshed metrics: The proportion of hospital occupied bed days on adult psychiatric wards by: i under 16s ii 16 or 17 year olds 9.03 Percentage of children discharged from psychiatric inpatient care subject to the Care Programme Approach (CPA) 9.04 Percentage of children transferred from CAMHS to adult mental healthcare who are subject to the CPA

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9.05

Percentage of children and young people who receive urgent care when required and a specialist mental health assessment within 24 hours or the next working day Adult mental health 9.06 The number/proportion of people who get access to psychological therapies assessment and to treatment within three months of referral (two measures) Refreshed metrics: i Counselling (the proportion of service users receiving wanted psychological therapies) ii The proportion of service users, provided by assertive outreach teams and community mental health teams, assessed and receiving psychological therapies as recommended by NICE guideline on schizophrenia 9.07 The number/proportion of people who are referred with a provisional diagnosis of psychosis who get access to specialist assessment from a member of the mental health team within two weeks Refreshed metrics: Availability of assertive outreach, crisis resolution, early intervention in psychosis services, model fidelity and persons served and the availability of community development, graduate, gateway, carer support, support time and recovery workers 9.08 The proportion of people who get access to crisis assessment within four hours of referral Refreshed metrics: Mental health service users’ survey: Crisis care 9.09 The number/proportion of people on enhanced CPA in work, education or training Refreshed metrics: i Employment status of people with recorded mental health issues ii Mental health service users’ survey (support in community, the proportion of service users receiving help with accommodation, work and benefits) 9.10 The number/proportion of people with a mental health problem presenting at A&E who receive a psychosocial assessment 9.11 Service user satisfaction with inpatient service, broken down by ethnicity Refreshed metrics: Mental health service users’ survey – questions relating to involvement in care planning, choice, waiting times, access to useful information and quality of relationships between service users and professionals 9.12 Service user satisfaction with assertive outreach, broken down by ethnicity Refreshed metrics: 1 Mental health service users’ survey – questions relating to involvement in care planning, choice, waiting times, access to useful information and quality of relationships between service users and professionals 2 Mental health service users’ survey – cancelled appointments, continuity of healthcare professionals 9.13 The death rate by age group for people with severe and enduring mental illness compared to the average population (adjusted for demographic factors) Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Refreshed metrics: 1 Extent to which services are collecting data to routinely measure outcomes 2 The proportion of service users with severe long-term mental health problems who have had a physical health review in line with recommended good practice in the last 15 months 3 The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status 9.14 The number of people referred locally to a service who are admitted in an emergency and admitted out of area because of lack of facilities 9.15 The number/proportion of people on enhanced CPA getting follow up (by phone or face-to-face) within seven days of discharge from hospital. Also a refreshed metric. Refreshed metrics: Proportion of service users who received a CPA review within one month of discharge from hospital 9.16 The number of carers who have had a carerâ&#x20AC;&#x2122;s assessment in relation to the total number of people on enhanced Care Programme Approach who have a relevant carer for whom an assessment could be performed Refreshed metrics: Percentage of people recorded as having a carer 9.17 The proportion of people on enhanced CPA who are waiting for suitable accommodation (having had their needs identified) for more than a month Refreshed metrics: Proportion of people on enhanced CPA with recorded social work involvement Refreshed metrics were also developed for: Implementation of NICE guidelines: 1 The proportion of service users of assertive outreach teams and community mental health teams who are on medication regimes that meet the recommendations as set out in the National Institute for Health and Clinical Excellence guideline for schizophrenia 2 Rates of prescribing for antipsychotics and selective serotonin reuptake inhibitor (SSRI) antidepressants Other: 1 Emergency bed days 2 Proportion of patients registered with a GP 3 Compliance with the Mental Health Act and Mental Health Act Code of Practice 4 Section 31 Health Act 1999 notifications Older peopleâ&#x20AC;&#x2122;s mental health 9.18 The proportion of people eligible for anti-dementia drugs that are receiving them, within NICE guidance 9.19 The proportion of people admitted to mental health wards from the community who have had a multi-disciplinary team community assessment Refreshed metrics: 1 Availability of components of mental health services for older people 2 (Specifically) the availability of an A&E liaison service for older people

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10 Older people 10.01 Proportion of people aged 75 and above who have had a contact and overview assessment in the last year, or an update, and have received a personal care plan 10.02 Population percentage of assessed older people whose carers have received a carer’s assessment 10.03 Proportion of older people admitted to long-term care (residential/nursing home/intensive home care) who have received comprehensive level of assessment prior to admission 10.04 Population percentage of older people on four or more drugs who have had a medicines review in one year 10.05 Proportion of older people (75+) with more than one fall in the last 12 months on risk register and reviewed by falls service 10.06 Proportion of deceased older people with evidence of good end of life care prior to death (one of preferred place of care, Liverpool Care Pathway, Gold Standards Care or equivalent) 10.07 Population level of independence in activities of daily living by age bands 65 to 74, 75 to 84, 85 plus 10.08 Excess winter death rates by local geographic clusters 11 Improving patient experience – see section for details 12 Primary care 12.1 General primary care – see section for details 12.2 Primary care nursing 12.2.1 Percentage of patients registered with GP practice with diagnosis of leg ulceration appropriately assessed by a nurse competent to do so 12.2.2 Percentage of patients registered with GP practice population who are at risk – i.e. have considerably impaired mobility – who have been screened and assessed 12.2.3 Percentage of PCT nurses (including GP employed and PCT employed) using Essence of care in at least two dimensions 12.3 Primary care dental services 12.3.1 Percentage of PCT’s population who have been able to access NHS dentistry within a specific period of time 12.3.2 Percentage of workforce plans judged satisfactory and appropriate by SHA 12.3.3 Evidence of PCT validation of nhs.uk database every four weeks 12.3.4 Patients are provided with appropriate information to enable them to choose the most appropriate care 12.3.5 Percentage of reports received by PCT which are categorised as satisfactory each year 12.3.6 Percentage of dental practices by PCT with quality assurance policies in accordance with PCT clinical governance 12.3.7 Percentage of dental practices visited at three-yearly intervals by PCT or agent 12.3.8 Number of annual complaints by practice and by PCT 12.3.9 Out of hours services provided by PCT in days per week and hours per day during both weekdays and weekends 12.3.10 Has the PCT an appropriate portfolio of OH needs assessment validated by the SHA? (yes/no)

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12.3.11

PCT has included oral health within its LDP and has developed an action plan for improving oral health developed with local stakeholders 13 Research & development 13.01 The amount awarded over the last three years to the organisation or to an academic partner organisation (where the researchers are based in the organisation) by the external funding body to carry out the noncommercial R&D and which utilises NHS R&D Support Funding, where the organisation is the main base for the principal investigator or coapplicant for the grant 13.02 The total number of research publications printed in peer-reviewed journals in the previous three years. Publications may be cited once per programme and can be included under only one programme in an organisation. A named author must be based in that organisation Refreshed metrics: Externally funded peer reviewed research activity: a Total number of projects b Number which involve working with clinical research networks c Number which involve working with industry d Number of patients recruited into studies e Proportion of activity by disease/condition including public health 13.03 The amount allocated over the last three years to the NHS organisation 13.04 Average time and range of time taken from: • receipt of protocol and request for authorisation to • confirmation of acceptance/rejection Partners’ satisfaction with the local research governance process Refreshed metrics: a Time interval between application for permission for research to proceed, and the granting of permission b Satisfaction with the efficiency of governance procedures through a survey of researchers and the funders of research (focussing on permissions for research) Refreshed metrics also developed for: Appraisal and use of evidence – Policy and procedures in place which ensure use of research evidence in the decision-making process governing the introduction of new technologies/new procedures Patient focus – Policy and procedures in place governing the involvement of patients and the public in research, which will include: procedures for ensuring that patients are aware of research in the organisation, providing opportunities to take part in research, providing feedback of results to participants in studies

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Cancer

National Clinical Director: Professor Mike Richards Incidence, survival and mortality figures for cancer have been available from cancer registries for many years. However, taken alone these figures provide relatively little information on the quality of cancer services at a local or national level. Until a few years ago few measures were available to enable assessment of individual aspects of cancer service delivery, with the noteworthy exception of cancer screening services (www.cancerscreening.nhs.uk).

What information is needed to assess quality of cancer care? In order to assess progress on cancer, information is needed on: • prevention – the prevalence of risk factors (e.g. smoking) and the effectiveness of preventive measures such as stop smoking services • early detection – the extent/impact of any delays by patients in seeking medical advice and of delays in onward referral from primary to secondary care. Late diagnosis has been a major contributor to the poor survival rates in England in comparison with Europe • hospital waits – the interval between referral and treatment • service provision – the extent to which services for diagnosis, treatment and care are in line with best practice, as defined by Improving Outcomes guidance • treatment – the extent to which patients are offered and/or receive optimal treatments appropriate to their condition • end of life care – the extent to which patients' preferences for care at the end of life are met and the quality of care provided • patients' experience of care – patient’s ratings of their experience of care in relation, for example, to being treated with dignity and respect; being empowered to make informed choices, pain and symptom management and psychological, social and spiritual care

Current initiatives and progress The NHS Cancer Plan (2000) set out a comprehensive strategy for tackling cancer in England encompassing prevention, screening, early diagnosis, treatment and care. The Improving Outcomes guidance on specific cancer areas (such as breast; colorectal; lung; gynaecological cancers; etc.) and on supportive and palliative care, supplements this broad framework. The guidance programme is managed by NICE and each document is, in effect, a mini National Service Framework. Detailed measures have been developed to assess progress on implementing of the NICE Improving Outcomes guidance. A national peer review appraisal programme has been established to monitor progress on implementation using these measures, which largely relate to the structure and process of service delivery. Good progress has been made collecting information on patients' experience of care. The National Cancer Patient Survey (2002) included items on dignity and respect, trust and confidence in doctors and nurses, information and communication, access to care and pain management. Over 65,000 patients completed the survey (a 74% Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

response rate), demonstrating patients’ willingness to provide information on aspects of care. The National Audit Office has used a modified version of that survey instrument to assess progress. Items from this survey instrument may also be useful for assessing local profiles. (The findings are published at www.nao.org.uk/pn/04-05/0405288.htm.) The collection of case-mix adjusted data is critical to evaluating different quality aspects of cancer care delivery. Information on the extent (stage) of disease is of particular importance. Good progress has been made on the development of a national cancer dataset, which defines the items needed for comparative analysis. A National Clinical Audit Support Programme (NCASP), managed by the Healthcare Commission, will facilitate the collection, analysis and interpretation of comparative data for different cancers. Projects related to lung, bowel and head and neck cancers are currently being rolled out. An audit has also been commissioned for oesophagogastric cancers.

Aim of the Better Metrics cancer measures The aim of the metrics set out in this chapter is to complement existing data sources (such as cancer registries, cancer waiting times database) and ongoing initiatives described above. The metrics deliberately focus on output or outcome measures, rather than on structure and process (which are well covered by Cancer Peer Review already). The intention is that they should be useful to local health economies who wish to set local targets in addition to existing national targets. Further work is needed to define metrics for some of the topic areas listed in the introduction. Nonetheless, it was felt appropriate to include topics that are not yet possible to measure easily – to demonstrate their importance. Suggestions for metrics would be warmly welcomed. The metrics are set out in three parts: • first – themes that are relevant to specific aspects of the care pathway • second – themes that are relevant to the whole care pathway • third – a small number of metrics related to individual cancer types

Relationship between the metrics and monitoring of national targets As explained in the introduction section, the metrics are offered as examples of good practice for local consideration. It is therefore important to place them in context of the data SHAs and PCTs will be required to collect as part of monitoring national targets for 2005–2008. In particular, we have tried not to reproduce the national data requirements within the metrics.

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For cancer, the national monitoring data will be: 3 •

PSA03a: Cancer mortality rates (see also the inequalities element of this target) Mortality rate from cancer in people younger than 75 per 100,000 population (Directly age standardised)

•

PSA03b: Cancer – implementation of the NICE Improving Outcomes Guidance (IOGs) Progress on implementing the improving outcomes series of guidance for cancer, demonstrated by the number of designated, specialist multidisciplinary teams in place for different tumour groups

•

PSA03c: Bowel cancer screening (returning plans to Department of Health deferred, see below) Percentage of the 50 to 70 year old adult population screened for bowel cancer (data line definitions to be developed)

See also the health inequalities section for detail on Spearhead Groups, where greater progress will be expected to try to meet the inequalities element of the cancer target. As a reduction in smoking rates is one of the most important interventions to reduce the incidences of and mortality rates from cancer, the national data requirements for monitoring smoking rates are also reproduced here (and explains why no metrics for smoking reduction are included in this section). •

PSA08a: Smoking quitters at four weeks attending NHS Stop Smoking Services Number of four-week, smoking quitters who attended NHS Stop Smoking Services per 100,000 population

•

PSA08b: Smoking status amongst the population aged 15 to 75 years Smoking status among status among people aged 15 to 75 years, as recorded in GP records

Other metrics within the document that may be of interest to readers of the cancer section are in the section on health inequalities. Promoting dignity in the acute hospital: development of national standards for care of the dying as part of a continuous quality improvement programme (with reference to metric 1.11 below) Over 50% of people in England die in acute hospitals. In promoting dignity and care in acute hospitals, a key element must be the care of the dying. The NICE Supportive and Palliative Care Strategy Key Recommendation 14 states: “In all locations, the particular needs of patients who are dying of cancer should be identified and 3

addressed. The Liverpool Care Pathway for the Dying Patient (LCP) provides one mechanism for achieving this. 4 The LCP is part of a continuous quality improvement programme that includes an audit of organisations that have implemented the LCP. This has been piloted within the Merseyside and Cheshire Cancer Network. The institute is currently working with the SHA in Manchester on a benchmark programme. Over the past eight years the LCP has been disseminated throughout all care settings and 60% of acute hospital trusts in England are currently involved in its implementation. The University of Liverpool-based Marie Curie Palliative Care Institute leads the dissemination of the framework. In 2006/2007, a joint initiative between the Marie Curie Palliative Care Institute, the Department of Health End of Life Initiative and the Royal College of Physicians Outcomes Unit will undertake a national audit including hospitals currently using the LCP. From this work, it is possible to envisage the development of standards for care of the dying against which acute hospital trusts could be assessed. Outlined below are 10 potential standards that could be piloted and implemented nationally: 1 the hospital has an identified specialist palliative care team 2 the hospital collects, collates and reports annually on the demographics of dying patients 3 there is a framework for care of the dying 4 within the framework for care of the dying the Liverpool Care Pathway (LCP) goals are identifiable, in association with NICE guidance 5 percentage of deaths in the hospital using the framework for care of the dying (such as the LCP), is recorded, including location of death in hospital and demographic data 6 care of the dying is discussed annually at trust board level 7 the hospital participates in a continuous quality improvement programme incorporating the National Audit for Care of the Dying 8 the trust monitors its performance against a national scoring system 9 there is a current service improvement plan for improving care of the dying within the trust 10 care of the dying is a key element of performance management for hospital trusts at board level

Metrics refresh 2005/2006 In summer 2005, the Healthcare Commission asked the National Cancer Action Team to refresh their metrics, specifically to try to identify metrics available from national data sources. This was to facilitate use of the metrics by the Healthcare Commission when assessing trustsâ&#x20AC;&#x2122; progress against developmental standards. However, the refreshed metrics should be seen as an adjunct to the original metrics not as a replacement. The aspiration to try to find a way to measure those metrics that are currently unavailable still stands.

National Institute for Clinical Excellence Guidance on Cancer Services â&#x20AC;&#x201C; Improving Supportive and Palliative care for Adults with Cancer â&#x20AC;&#x201C; The Manual, page 11, NICE March 2004. Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Here we provide a description of the process followed to produce the refreshed metrics. The refreshed metrics are provided with their original metrics in the proposed metrics section below, and are italicised for clarity.

Process A process was established during summer 2005 to refresh the metrics with each of the NCDs, during which existing Healthcare Commission performance indicators and those generated from pilot improvement reviews were also reviewed for inclusion in the set. In particular, where the original metrics were not available from existing national datasets, we asked for any available proxy indicators to be identified that were available from national data where possible. NCDs were asked to look specifically at whether their metrics adequately cover relevant NICE guidelines. As in the original project, NCDs were asked to involve patients and professionals, and consult patient and professional organisations in this process. The refreshed metrics provided here are those included in the Healthcare Commissionâ&#x20AC;&#x2122;s 2006 consultation document on developmental standards. The constraint of existing national data sources has limited the indicators available, particularly for trying to identify indicators related to NICE guidance. (Most of the audit criteria within NICE guidelines require a local audit to provide the data. NICE are now exploring whether they will be able to supplement the audit criteria they already provide by proposing indicators to monitor the implementation of their guidance.) A wide range of specific cancer service performance measures is already included in the LDP assessment process. These include cancer waiting times, IOG implementation Action Plans, and milestones and some smoking cessation and screening uptake data for PCTs. A comprehensive programme of cancer peer review is in progress that will enable a broad-based analysis of progress in implementing a range of national (Department of Health and NICE) guidance on cancer services. It is intended that a comprehensive and up-to-date assessment of all acute trusts (and networks) based on peer review visits and validated self assessment will be provided for the 2006/2007 Healthcare Commission assessment. There has been consistent comment and advice from clinical sources that both of the above indicators should be complemented by clinical indicators that give a more direct assessment of the performance of the delivery of clinical cancer care closer to the patient level. In terms of process for developing the refreshed metrics, Professor Mark Baker, Medical Director of the Yorkshire Cancer Network and Clinical Advisor to the Department of Health undertook a further brainstorm on potential metrics. The National Cancer Action Team then took a shortlist to the National Cancer Lead Clinicians Group, in the context of a background paper from Professor Baker and the original cancer metrics. The refreshed metrics included here have been amended to take into account their comments. Overall, the clinicians were pleased that there would be a focus on these metrics but also raised issues such as clinical Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

interpretation. They would want to contribute to this more fully as the metrics are refined. Both they and the National Cancer Action Team are keen to better understand the follow-up process for outlier organisations by the Healthcare Commission. This process did not include direct consultation with patients but the refreshed metrics all relate to issues raised in NICE Improving Outcomes Guidance for Cancer, for which there has been extensive consultation on the principles involved with clinical and patient stakeholders. If you have any queries, comments or suggestions related to the cancer metrics, please e-mail them to: Teresa Moss at Teresa.Moss@gstt.nhs.uk

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Cancer The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done) Themes relating to specific aspects of the care pathway 1.01 Theme: Screening of healthy adults Objective: To ensure that all eligible patients are offered appropriate invitations and access to national cancer screening programmes, which meet agreed standards for quality, safety, and timeliness Description of metric: 1 Percentage of eligible women aged 53 to 64 in a PCT population with an adequate breast screening test result in the last three years 2 a) Percentage of eligible women aged 25 to 49 in a PCT population with an adequate cervical screening test result in the last three years b) Percentage of eligible women aged 50 to 64 in a PCT population with an adequate cervical screening test result in the last five years Rationale/evidence base: Based on NHS breast and cervical cancer screening programmes (www.cancerscreening.nhs.uk) NHS Cancer Plan, chapter 3 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing mortality from cancer) Standards for better health domain: Seventh domain: Public health (core standards C23) CURRENTLY AVAILABLE: Data source: KC53 and KC63 % Unit of analysis: Process Structure/process/outcome: Notes: Defined by National Screening Programme. Could also use the trust-based breast screening uptake statistics as metrics (KC62), although uptake is a less useful metric than coverage as coverage includes a wider range of influences, such as the correct setting up and running of the programme (see www.cancerscreening.nhs.uk). Both metrics included in the refreshed metrics

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1.02 Theme: Early presentation of patients with symptoms Objective: To improve public knowledge and awareness of symptoms that may indicate the presence of cancer and encouraging patients to seek early clinical advice in primary care Description of metric: To be developed Rationale/evidence base: NSF standard(s) where applicable: High level PSA target: Standards for better health domain: CURRENTLY UNAVAILABLE (see notes) Data source: Unit of analysis: Structure/process/outcome: Notes: Possible data sources for this would be: 1 ask cancer patients how long they had had symptoms before presentation (survey) 2 monitoring stage of cancer at diagnosis 3 monitoring one-year survival rates for patients with newly diagnosed cancer by resident population

1.03 Theme: Initial assessment of patients with symptoms in primary care Objective: 1 To ensure that patients presenting to their GP with symptoms that could be due to cancer are appropriately identified and that further investigation and/or specialist referral are undertaken without delay 2 To ensure that patients with a very low risk of having cancer are appropriately reassured within primary care and are either discharged or monitored appropriately Description of metric: To be developed Rationale/evidence base: NSF standard(s) where applicable: High level PSA target: Standards for better health domain: CURRENTLY UNAVAILABLE (see notes) Data source: Unit of analysis: Structure/process/outcome: Notes: The cancer waits database now provides reports showing performance by PCT on a managed population basis. These reports are for the two-week wait, 31-day performance and 62-day performance. On a PCT managed population basis the following metrics could be produced: 1 number of two week wait referrals per 1,000 population 2 proportion of two week referrals subsequently diagnosed with a new cancer and treated under the NHS 3 proportion of all cancer patients treated who are referred through the two-week wait

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1.04 Theme: Hospital assessment, diagnosis and treatment planning Objective: To ensure that appropriately trained specialists make recommendations on treatment and care for patients with cancer based on best current practice Description of metric: Specialist teams are constituted as defined by the Manual for Cancer Services Rationale/evidence base: NHS Cancer Plan chapter 6 NICE Improving Outcomes Guidance (for all sites) “The care of all patients should be reviewed by NSF standard(s) where applicable: a specialist team” (Cancer Plan, chapter 6) Priority I: Improve the health of the population High level PSA target: (reducing cancer mortality) Standards for better health domain: Second domain: clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: • teams as defined by the Manual for Cancer Services • assessment of teams by peer review • National Clinical Audit – discussion by teams As defined by national peer review appraisal Unit of analysis: programme Structure, process Structure/process/outcome: Notes:

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1.05 Theme: Effective and appropriate care Objective: To ensure that patients have access to optimal diagnostic care and treatments for their condition Description of metric: Proportion of new patients diagnosed with cancer whose care is discussed by a designated (multidisciplinary) team or designated specialist multidisciplinary team (SMDT) Rationale/evidence base: NHS Cancer Plan; NICE Improving Outcomes guidance (all sites) NHS Cancer Plan, chapter 6 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing cancer mortality) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: Number of new patients diagnosed with cancer per provider trust is from cancer registry data CURRENTLY POSSIBLE: The number of new patients whose care is discussed by a MDT/SMDT is if team coordinators keep a list of all patients discussed (see notes) Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: The national cancer dataset contains a field for whether a patientâ&#x20AC;&#x2122;s care has been discussed by a MDT. Improvements in completion of this field would allow this metric to be measured more routinely. Caution should be exercised as numerator and denominator are from different sources

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1.06 Theme: Effective and appropriate care Objective: To promote the continuous quality improvement of diagnostic and treatment services for people with cancer Description of metric: Percentage of acute trusts providing care for people with cancer using statistical process control (SPC) charts to monitor their survival data at one, two and five years by MDT for individual cancer groups Rationale/evidence base: NHS Cancer Plan NHS Cancer Plan, chapter 6 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing cancer mortality) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Cancer registry; Hospital Episode Statistics (HES) data (NB data would have to be prepared by either cancer registries or Public Health Observatories (PHOs), so would not be done for individual trusts) Percentage Unit of analysis: Process, outcome Structure/process/outcome: Notes: Controlling for case mix may be required for interpretation of these metrics. Stage at diagnosis may have a large impact on survival. Survival data by trust are a problem where there is a lot of flux dependent on the treatment option. The noise is much less in the circumstances addressed by 1.07. Within trusts, specialist multidisciplinary teams (MDTs) may choose to examine the charts for individual surgeons Refreshed metrics: Metrics: Cancer mortality trends â&#x20AC;&#x201C; for breast, colorectal and lung cancer by PCT Data source: ONS Notes: Need reasonably long periods of time at PCT level. The noise on these indicators may be too high at PCT level to make these useful or fair indicators Metrics: One year mortality rates for lung, pancreas and oesophageal cancers by PCT Data source: ONS Notes: Issues: problems with confidence intervals here but they are only two to three years in arrears. The questions they pose include public awareness of key symptoms, speed of diagnosis, ambition of treatment etc. The cancers selected here are those with a generally poor prognosis and/or those with high operative attrition rates. One-year mortality rates for breast or colorectal cancer not included, as they would not tell us much about the quality of care

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1.07 Theme: Effective and appropriate care Objective: To promote the continuous quality improvement of diagnostic and treatment services for people with cancer Description of metric: Percentage of acute trusts providing care for people with cancer using statistical process control (SPC) charts to monitor their 30-day post-operative mortality rate for major surgery by MDT (examples are colorectal surgery, oesophageal surgery, head and neck surgery, and surgery for lung cancer) Rationale/evidence base: NHS Cancer Plan NHS Cancer Plan, chapter 6 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing cancer mortality) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Cancer registry data CURRENTLY POSSIBLE: HES data records linkage for post-discharge mortality is via PHOs, however most PHOs are not doing this linkage themselves yet. This linkage should be available on all HES data once it is linked with ONS deaths in near future. Also, as for 1.06, it would need to be prepared for all trusts in PHO’s catchment area Percentage Unit of analysis: Process, outcome Structure/process/outcome: Notes: Controlling for case mix may be required for interpretation of these metrics. Stage at diagnosis may have a large impact on survival. Within trusts, specialist MDTs may choose to examine the charts for individual surgeons Refreshed metrics: Metrics: 30-day post-operative mortality rate for major surgery by acute hospital (equivalent to one MDT) – colorectal, oesophageal, gastric, pancreatic, head and neck, lung, ovarian and bladder cancers Data source: HES data Notes: Issues: case mix, including emergency and elective. As adequate case mix adjustment is not possible using HES data, this metric may be deferred until comprehensively available from the relevant national audits. Additional note: there may be more than one MDT in a merged trust – National Cancer Team can identify any discrepancies here from waiting times returns

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1.08 – 1.10: Effective and appropriate care for individual cancer sites. NICE Improving Outcomes Guidance is available for a number of cancer sites (www.nice.org.uk) and examples of metrics for three of these areas are given here. These are examples of metrics for the care of people with prostate cancer, breast cancer and rectal cancer and are provided here as exemplars of what could be done locally for each of the cancers where Improving Outcomes Guidance is available. Refreshed metrics are also provided for upper GI cancer, lung cancer and head and neck cancer. 1.08 Theme: Effective and appropriate care Objective: Prostate cancer: To ensure that patients have access to optimal treatments for their condition Description of metric: Prostate cancer: evidence that all possible management options have been discussed with patients* Rationale/evidence base: NICE Improving Outcomes guidance – urological cancers, page 65 NHS Cancer Plan, chapter 6 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing cancer mortality) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Local audits (records review) for evidence of discussion of management options CURRENTLY AVAILABLE: Cancer registry data for the total number of patients diagnosed with prostate cancer (note: there may be delays in registration process) As available from records review; % of total Unit of analysis: number of new cases Process Structure/process/outcome: Notes: *There are two key groups here: newly diagnosed early prostate cancer (where the issue is the type of interventions offered) and invasive prostate cancer (where the main issue is about the use (and type) of androgen suppression). One option would be to use the ‘proportion of cases receiving radical treatment who have radical surgery’ as a marker of balanced decision-making. “Currently possible” only, through local audit Refreshed metrics: Metrics: Urological cancer: surgeon specific volumes for radical cystectomies and radical prostatectomies (more than five) Data source: HES data Notes: Issues: sorting out locums and consultants that are new in the post

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1.09 Theme: Effective and appropriate care Objective: Breast cancer: To ensure that patients have access to optimal treatments for their condition Description of metric: Breast cancer: evidence that all patients who are suitable are offered adequate information to be able to make an informed choice between mastectomy and breast conserving surgery Rationale/evidence base: NICE Improving Outcomes guidance – breast cancer NHS Cancer Plan, chapter 6 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing cancer mortality) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Local audits (records review) for evidence of information provided and discussed CURRENTLY AVAILABLE*: Cancer registry data for the total number of patients diagnosed with breast cancer As available from records review; % of total Unit of analysis: number of new cases Process Structure/process/outcome: Notes: *A possibly useful proxy indicator for local commissioners and providers might be HES (or commissioner’s own CDS data) and cancer registry data on the proportion of patients receiving mastectomy and local excision (cancer registry by stage) Refreshed metrics: Metrics: Breast cancer: i ratio between mastectomy and breast conserving surgery ii hospital volumes for breast cancer operations (including surgeon-specific volumes) Data source: i HES/registry data on proportion of women receiving mastectomy and local excision ii HES data Notes: i age [analyse under 75s separately]; case mix – review data from screen-detected patients [check national availability from screening services] compared to whole population under 75 ii looking to identify hospitals where surgeons are operating on less than 50 cases per year (issues: sorting out locums and consultants new into post for surgeons specific volumes)

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1.10 Theme: Effective and appropriate care Objective: Rectal cancer: To ensure that patients have access to optimal treatments for their condition Description of metric: Rectal cancer: proportion of patients operated on for rectal cancer with a permanent stoma formation Rationale/evidence base: NICE Improving Outcomes guidance â&#x20AC;&#x201C; colorectal cancer NHS Cancer Plan, chapter 6 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing cancer mortality). Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: HES data or cancer registry data for permanent stoma formation procedures, HES data or cancer registry data for the total number of patients operated on for rectal cancer (note: HES and cancer registry may give different results; HES should be quicker) Proportion or % Unit of analysis: Process Structure/process/outcome: Notes: There is wide variation in the proportion of patients who end up with a permanent colostomy following total mesorectal excision Refreshed metrics: Metrics: Colorectal cancer: i proportion of patients operated on for rectal cancer with a permanent stoma formation ii hospital volumes for colorectal surgery (including surgeon-specific volumes) iii participation rates in national colorectal cancer audit Data source: i HES data or cancer registry data for permanent stoma formation procedures, HES data or cancer registry data for the total number of patients operated on for rectal cancer ii HES data iii national colorectal cancer audit Notes: i HES and cancer registry may give different results HES should be quicker. Issues: accuracy of coding. Abdomino-perineal resection/abdominal resection) ii looking for surgeons carrying out less than 20 colorectal resections with curative intent per annum. Issues: sorting out locums and consultants new into post for surgeons specific volumes iii need to define participation rate â&#x20AC;&#x201C; completeness of data should also be assessed

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Refreshed metrics for upper GI cancer, lung cancer, and head and neck cancer Metrics: Upper GI cancer: hospital volumes for gastric, oesophageal and pancreatic resections (including surgeon-specific volumes) Data source: HES data Notes: Issues: sorting out locums and consultants new into post for surgeons specific volumes Metrics: Lung cancer: i resection rates (by trust and PCT) ii participation rate in national lung cancer audit (LUCADA) Data source: i Requires linkage of HES and cancer registry data, or data from LUCADA ii LUCADA Notes: i LUCADA data preferred so that rates can be case mix adjusted. However, this indicator is also denominator-dependent: variations in the definition of the denominator, and the completeness of collecting it locally may change the apparent rate without any real evidence of underperformance. This may well explain some of the international variation in this measure. Other useful indicators of access to care include: the proportion of patients with non-small cell lung cancer who receive first line chemotherapy (or chemoradiation) Metrics: Head and neck cancer: participation rate in the National Head and Neck Audit Data source: National Head and Neck Audit Notes: Need to define participation rates â&#x20AC;&#x201C; completeness of data should also be assessed

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1.11 Theme: Palliative and end of life care Objective: To ensure that patients with advanced incurable cancer and their families/carers have access to high quality palliative care in the community hospitals and/or in hospices and that their preference for place of care is respected whenever possible Description of metric: To be developed (see notes) Rationale/evidence base: NICE Supportive and Palliative Care Guidance NHS Cancer Plan, chapter 7 NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus Fifth domain: Accessible and responsive care CURRENTLY UNAVAILABLE (see notes) Data source: Unit of analysis: Structure, process Structure/process/outcome: Notes: Possible candidates for metrics are: ‘% of patients who have had a discussion on their preferred place of death’; ‘% of patients dying in their preferred place of death’; ‘% of GP practices which have implemented the Gold Standards Care framework’. Possible data sources: audits in primary care. For example, some services have added ‘preferred place of care’ to their “Integrated Care Pathway for the dying” on the initial assessment sheets. See also background section above for developments in this field. While this metric is under development, readers could consider using the Department of Health compendium indicator “DEATHS AT HOME FROM ALL CANCERS (ICD10 C00C97) PERCENT (AND 95% CONFIDENCE INTERVALS ), 2001-02 POOLED, ALL AGES”, which is available for primary care organisations (Compendium of Clinical and Health Indicators 2003 / Clinical and Health Outcomes Knowledge Base (www.nchod.nhs.uk)). Note that this indicator could be confounded by a range of factors (for example, rural compared to urban areas). This Department of Health compendium indicator is one of the refreshed metrics Refreshed metrics: Metrics: Percentage of GP practices which have implemented the Gold Standards Care Framework Data source: SHA baseline reviews – updates to this may need to be bespoke in future

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Themes relevant to the whole of the cancer pathway 1.12 Theme: Patient dignity and respect; empowerment and choice Objective: To ensure that all patients are treated with dignity and respect by all healthcare professionals; and that the public and patients receive the information they need in a way that is acceptable to them Description of metric: Mean scores on the abbreviated National Cancer Patient Survey (NCPS) questionnaire (improvement on NCPS results (baseline 1999/2000)) Rationale/evidence base: Patient/user experience is a national priority NHS Cancer Plan, chapter 7 NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus (developmental standards D8) CURRENTLY POSSIBLE: Data source: See Appendix C for abbreviated questionnaire Obtained from surveys (local and/or national) Mean scores; mean change in scores Unit of analysis: Outcome Structure/process/outcome: Notes: Unclear at present when the next National Cancer Patients Survey will be undertaken (however, for trust-level results, will need to undertake survey locally). Work is ongoing to produce a user-friendly version of the questionnaire which could be used for local surveys. For all surveys, ensure demographic questions are included to allow analysis of results by postcode

1.13 Theme: Pain and symptom management Objective: To ensure that all patients are offered optimal control for pain and other symptoms at all stages in the care pathway Description of metric: Mean scores on the abbreviated NCPS questionnaire (improvement on NCPS results (baseline 1999/2000)) Rationale/evidence base: Patient/user experience is a national priority NHS Cancer Plan, chapter 7 and NICE NSF standard(s) where applicable: Supportive and Palliative Care Guidance Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus (developmental standards D8) CURRENTLY POSSIBLE: Data source: See Appendix C for abbreviated questionnaire Obtained from surveys (local and/or national) Mean scores; mean change in scores Unit of analysis: Outcome Structure/process/outcome: Notes: Unclear at present when the next National Cancer Patients Survey will be undertaken. Work is ongoing to produce a user-friendly version of the questionnaire which could be used for local surveys. For all surveys, ensure demographic questions are included to allow analysis of results by postcode

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1.14 Theme: Psychological, Social and Spiritual Support Objective: To ensure all patients have their needs for psychological, social and spiritual support identified and appropriately acted upon at all stages in the care pathway Description of metric: Mean scores on additional questions from the National Audit Office survey of patient experience Rationale/evidence base: Patient/user experience is a national priority NHS Cancer Plan, chapter 7 NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus (developmental standards D8) CURRENTLY UNAVAILABLE: Data source: Local surveys incorporating these additional questions Mean scores Unit of analysis: Outcome Structure/process/outcome: Notes: Although survey instrument not yet available, the aim is to include these additional questions in the â&#x20AC;&#x2DC;user friendlyâ&#x20AC;&#x2122; instrument referred to earlier. The National Audit Office has agreed to provide copies of the questions they have used and these will be reviewed for their suitability for this purpose. Local services may also wish to consider the suitability of the many cancer-specific quality of life measurement tools that are available

1.15 Theme: Coordination of care and cooperation across organisational boundaries Objective: To ensure that all patients experience seamless care within an individual healthcare organisation and across any organisational boundaries, throughout their care pathway Description of metric: To be developed Rationale/evidence base: Patient/user experience is a national priority NSF standard(s) where applicable: NHS Cancer Plan Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus (developmental standards D10) Fifth domain: Accessible and responsive care (developmental standard D11 ( c ), (d) ) CURRENTLY UNAVAILABLE (see notes) Data source: Unit of analysis: Structure, process Structure/process/outcome: Notes: Needs new patient survey questions

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Heart disease and stroke

National Clinical Director: Dr Roger Boyle

Background and context The national NHS targets for the financial years 2005/2006 to 2007/2008 (based on the PSA between the Treasury and the Department of Health) include the following target for cardiovascular (CVD) mortality: substantially reduce mortality rates by 2010 (from the Our Healthier Nation baseline, 1995-97) from heart disease and stroke and related diseases by at least 40% in people under 75, with a 40% reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole. The text within National Standards, Local Action supporting this target suggests that PCTs, in partnership with LAs, NHS and other local organisations, will need to focus on the following “key current challenges” for reducing mortality from heart disease: …the NHS interventions which will result in the largest reductions in deaths from heart disease and stroke by 2010 are management of hypertension, high cholesterol, and diabetes in primary care, both for people with established disease and those at high risk. Positive effects will also be achieved by reductions in smoking and in “call to needle time” for thrombolysis. The National Services Frameworks for coronary heart disease, diabetes, older people and children provide models of care to support achievement of reduced mortality. More detailed guidance from the Department of Health on how this target will be performance managed centrally, establishes these data requirements for central performance monitoring: •

PSA01a: Cardiovascular disease mortality Mortality rate from heart disease and stroke and related diseases in people aged under 75 per 100,000 directly age standardised population

•

PSA01b: Practice-based registers Percentage of GP practices with PCT validated registers of patients without symptoms of cardiovascular disease with an absolute risk of CHD events greater than 30% over the next 10 years

•

PSA01c: Blood pressure Percentage of patients with CHD whose last blood pressure reading (measured within the last 15 months) is 150/90 or less

•

PSA01d: Cholesterol levels Percentage of patients with CHD whose last measured cholesterol (measured within the last 15 months) is 5 mmol/l or less

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See also the health inequalities section for more detail on Spearhead Groups, where greater progress will be expected to try to meet the inequalities element of the CVD target. As reducing smoking rates is also a key intervention for preventing the onset of CVD and reducing CVD mortality, see also the LDP monitoring requirements for smoking, which are provided in the introduction to the cancer section of this document. Similarly, as reducing obesity is an important element of preventing CVD, the national monitoring requirements for monitoring obesity are reproduced here: •

PSA10a: Childhood obesity [returning plans to Department of Health deferred until baseline is established in 2005/2006] Prevalence of obesity among children aged 5 to 10 years (to be developed, subject to agreement with the Department of Education and Skills (DfES))

•

PSA10b: Broader strategy on obesity: obesity status amongst the GP registered population aged 15 to 75 years Obesity status among people aged 15 to 75 years, as recorded in GP records

As these central monitoring requirements are the minimum metrics for heart disease and stroke that will need to be measured locally, they are not reproduced in the proposed metrics below. Clearly, the general targets within the other three broad national priority areas (access to services, long-term conditions and patient/user experience) are also relevant for people with heart disease and stroke.

The local target setting process and framework As described in the introductory chapter, the new performance regime envisages that there will be headroom to set local targets. The proposed metrics are intended to be considered as additional areas where local targets could be set; or guides for local quality improvement initiatives. In common with other areas of the document, the Healthcare Commission is also using them where possible as criteria for assessment of compliance with national standards. The metrics are intended to cover a broader range of issues relevant to people with heart disease and stroke (for example, affecting symptoms and quality of life) and not only reduction in mortality. Ideally they could have been chosen more formally using a number of criteria such as health impact and/or cost effectiveness, e.g. quality-adjusted years of life saved) or potential to reduce health inequalities, but this would require the development of a clearer overall framework for the metrics project than has been developed to date. This section should be read in conjunction with the diabetes, urgent care, older people’s and health inequalities sections, which all contain relevant metrics for heart disease and stroke.

Metrics refresh 2005/2006 In summer 2005, the Healthcare Commission asked the Department of Health heart disease and stroke teams to refresh their metrics, specifically to try to identify metrics available from national data sources. This was to facilitate use of the metrics by the Healthcare Commission when assessing trusts’ progress against developmental Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

standards assessment. However, the refreshed metrics should be seen as an adjunct to the original metrics, not as a replacement. The aspiration to try to find a way to measure those metrics that are currently unavailable still stands. Here we provide a description of the process followed to produce the refreshed metrics. The refreshed metrics are provided alongside their original metrics in the proposed metrics section below, and are italicised for clarity.

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Heart disease and stroke The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done) These metrics may need updating in the light of Quality and Outcomes Framework (QOF) 2006. However, at the time of writing, while the headline changes are available (for example, new indicators for atrial fibrillation), the detail is still awaited.

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2.01 Theme: Preventing heart disease and stroke in high risk patients Objective: To reduce the incidence of heart disease and stroke Description of metric: The percentage of patients with hypertension who smoke whose notes contain a record that smoking cessation advice has been offered at least once Rationale/evidence base: 2003–2006 Priorities and Planning Framework (PPF) target: “in primary care, update practice-based-registers so that patients with CHD and diabetes continue to receive appropriate advice and treatment in line with NSF standards and by March 2006, ensure practice-based registers and systematic treatment regimes, including appropriate advice on diet, physical activity and smoking, also cover the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a BMI greater than 30” Coronary Heart Disease (CHD) NSF: standards 1, NSF standard(s) where 2 and 4: applicable: 1 The NHS and partner organisations should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease 2 The NHS and partner organisations should contribute to a reduction in the prevalence of smoking in the local population 4 General practitioners and primary healthcare teams should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke and tackling the underlying determinants of ill health and health inequalities by reducing adult smoking rates to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less) Seventh domain: Public health Standards for better health domain: CURRENTLY AVAILABLE: New General Medical Data source: Services Contract (nGMS) (BP3) Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: There is an opportunity to make more use of practice-level records of smoking status, overweight (BMI greater than 27) and obesity (BMI greater than 30) in high-risk patients. Potential data sources being checked out include CHD/vascular risk registers, nGMS, and PRIMIS. Also a refreshed metric Refreshed metrics: Metrics: i GP recording of BMI status ii Patients with coronary heart disease, diabetes or stroke who also smoke – offered smoking cessation advice Data source: Healthcare Commission (measured through national targets, constructions to be confirmed) Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

2.02 Theme: Preventing heart disease and stroke in high risk patients Objective: To reduce the incidence of heart disease and stroke Description of metric: The percentage of patients with hypertension in whom the last blood pressure (measured in the last nine months) is 150/90 or less Rationale/evidence base: 2003–2006 PPF target: “in primary care, update practicebased-registers so that patients with CHD and diabetes continue to receive appropriate advice and treatment in line with NSF standards and by March 2006, ensure practicebased registers and systematic treatment regimes, including appropriate advice on diet, physical activity and smoking, also cover the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a BMI greater than 30” CHD NSF: standard 4: NSF standard(s) where applicable: 4 General practitioners and primary healthcare teams should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: nGMS (BP5) Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes:

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2.03 Theme: Preventing heart disease and stroke in high risk patients Objective: To reduce the incidence of heart disease and stroke Description of metric: The percentage of patients with hypertension who have a record of total cholesterol in the last 15 months Rationale/evidence base: 2003–2006 PPF target: “in primary care, update practicebased-registers so that patients with CHD and diabetes continue to receive appropriate advice and treatment in line with NSF standards and by March 2006, ensure practicebased registers and systematic treatment regimes, including appropriate advice on diet, physical activity and smoking, also cover the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a BMI greater than 30” CHD NSF: standard 4: NSF standard(s) where applicable: 4 General practitioners and primary healthcare teams should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks Priority I: Improve the health of the population High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Can be extracted from GP data* Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: *Not nGMS; as although this can theoretically be extracted from GP data, it may be difficult to obtain

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2.04 Theme: Stroke or transient ischaemic attacks Objective: To reduce the incidence of first and recurrent strokes Description of metric: The percentage of patients with a stroke shown to be nonhaemorrhagic, or a history of TIA, who have a record that aspirin, and alternative antiplatelet therapy, or an anti-coagulant is being taken (unless a contraindication or side effects are recorded) Rationale/evidence base: Older People’s NSF The CHD NSF does not specifically mention NSF standard(s) where applicable: stroke. However the Older Peoples’ NSF states that every health system should, “review current arrangements, in primary care and elsewhere to identify those at greatest risk of stroke, and to intervene actively to reduce these risks; and agree local priorities to improve the rates of identification and effective intervention in stroke” Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: nGMS (STROKE 9). Percentage Unit of analysis: Process Structure/process/outcome: Notes: Also a refreshed metric

2.05 Theme: Strokes and transient ischaemic attacks Objective: To reduce the incidence of first and recurrent strokes Description of metric: The percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less Rationale/evidence base: Older People’s NSF See metric 2.04 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: nGMS (STROKE 6) Percentage Unit of analysis: Process Structure/process/outcome: Notes: Also a refreshed metric

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2.06 Theme: Strokes and transient ischaemic attacks Objective: To reduce the incidence of first and recurrent strokes Description of metric: The percentage of patients with a history of stroke or TIA whose last measured total cholesterol (measured in the last 15 months) is 5 mmol/l or less Rationale/evidence base: Older Peopleâ&#x20AC;&#x2122;s NSF See metric 2.04 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: nGMS (STROKE 8) Percentage Unit of analysis: Outcome Structure/process/outcome: Notes: Also a refreshed metric

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For stroke, refreshed metrics were also developed related to: â&#x20AC;˘ diagnosis â&#x20AC;˘ acute clinical management and rehabilitation â&#x20AC;˘ improving acute stroke care As follows: Metrics: Diagnosis: the percentage of new patients with presumptive stroke (presenting after 1 April 2003) who have been referred for confirmation of diagnosis by CT or MRI scan Data source: Quality management and analysis system (QMAS) STROKE 2 Metrics: Acute clinical management and rehabilitation: Key 12 indicator score from the stroke audit Data source: Royal College of Physicians (RCP) stroke audit Notes: While the key 12 indicator score includes rehabilitation indicators, these are based on too few cases to be looked at separately from the overall score. The key 12 indicators from the stroke audit are: i patients treated in a stroke unit ii patients treated for >50% stay in a stroke unit iii screening for swallowing disorders < 24 hours after admission iv emergency brain scan within 24 hours of stroke v aspirin by 48 hours of stroke vi physiotherapist assessment within 72 hours of admission vii OT assessment within seven days of admission viii patient weighed during admission ix patient's mood assessed by discharge x patient on antithrombotic therapy by discharge xi rehabilitation goals agreed by multidisciplinary team xii home visit performed before discharge Metrics: Improving acute stroke care: i the availability of stroke units set up to deliver thrombolysis to eligible patients, in accordance with the National Clinical Guidelines for Stroke ii the percentage of eligible patients receiving thrombolysis iii participation rates in the National Audit of Carotid Endarterectomy Data source: i and ii RCP stroke audit iii National Carotid Endarterectomy audit Notes: i and ii The first is clearly a precursor to the second indicator. Rates of eligible patients receiving thrombolysis are running currently at 1% from the audit, whereas it is about 10% in European centres iii This is a new audit, running from December 2005

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2.07 Theme: Heart attack and other acute coronary syndromes Objective: To continue the reduction in mortality following heart attack Description of metric: Deliver a 10% increase per year in the proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help Rationale/evidence base: 2003–2006 PPF target which is still relevant CHD NSF: standard 6: People thought to be NSF standard(s) where applicable: suffering from a heart attack should be assessed professionally and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE for acute trusts: Data source: From MINAP* (see notes) Percentage Unit of analysis: Process Structure/process/outcome: Notes: For the current Healthcare Commission star ratings, this has had to be revised to ‘door to needle’ time due to data collection difficulties for ambulance trusts in particular. However, ‘call to needle’ time remains the aspiration so this formulation has been retained in this draft * MINAP currently shows the proportion of people receiving treatment within 60 minutes of calling for help ('call to needle' times) attributed to hospitals. Commissioners do not have access to MINAP but they would be able to obtain aggregated information at hospital level from their SHAs. Also trusts would have details of their own hospitals' performance benchmarked against a national average. MINAP does not currently attribute call times to ambulance trusts but the MINAP database is being developed to enable ambulance trusts to access their own pre-hospital data including call time. It is hoped to roll this out to trusts from December 2004. Also a refreshed metric (existing Healthcare Commission national targets monitoring indicator) Refreshed metrics: Metrics: A new composite indicator of the performance of the system in relieving blockages to coronary arteries in eligible patients with AMI – exact construction to be determined Data source: MINAP Notes: The existing targets indicator probably only has a further life of 12 months as, over time, we will also need to consider the impact of primary angioplasty rates. Thrombolysis rates are likely to decrease where primary angioplasty rates increase. The key time to measure for the latter is 'call to balloon'. We will need to construct a new indicator that ensures the whole system is still working effectively for eligible patients

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2.08 Theme: Preventing CHD mortality in established CHD Objective: To reduce CHD mortality Description of metric: The percentage of patients with coronary heart disease who are currently treated with a beta-blocker (unless a contraindication or side effects are recorded) Rationale/evidence base: CHD NSF CHD NSF standard â&#x20AC;&#x201C; by April 2002, improving NSF standard(s) where applicable: the use of effective medicines after heart attack (especially use of aspirin, beta-blockers and statins) so that 80-90% of people discharged from hospital following a heart attack will be prescribed these drugs Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENLY AVAILABLE: Data source: nGMS (CHD 10) Percentage Unit of analysis: Process Structure/process/outcome: Notes: Also a refreshed metric Refreshed metrics: Metrics: i Percentage of patients following myocardial infarction discharged on all three of the following drugs: aspirin, beta-blockers and statins ii Percentage of patients with CHD with a record in last 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindicator or side effects are recorded) iii Percentage of patients with CHD in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less iv Percentage of patients with CHD whose last measured cholesterol (measured in last 15 months) is 5 mmol/l or less Data source: ( i MINAP ii QMAS CHD 9 iii QMAS CHD 6 iv QMAS CHD 8 Notes: i This data has been collected by MINAP since its inception. Rates of prescription of these drugs individually have increased markedly since then, and are now high. However, this composite indicator for all three drugs is new iv NICE will shortly be publishing a HTA on statins. Indicators on cholesterol levels/statin use may need updating following this publication

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2.09 Theme: Heart attack and other acute coronary syndromes Objective: To improve the diagnosis of heart attacks Description of metric: Whether all hospitals receiving patients with heart attack or other acute coronary syndromes have 24/7 availability to troponin-T testing Rationale/evidence base: New metric. Enables the NHS to apply consistently the new definition of MI(1), and to make the diagnosis more accurately (in the case of non-ST elevation MI) and rapidly No exact match within the CHD NSF NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Direct question to relevant hospital trusts Yes/no Unit of analysis: Structure Structure/process/outcome: Notes: (1) The Joint European Society of Cardiology/American College of Cardiology Committee. Myocardial infarction redefined â&#x20AC;&#x201C; a consensus document of the joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction. Eur Heart J 2000; 21:150-13 Refreshed metrics: Metrics: a Routine provision of troponin T or I tests for patients with acute coronary syndromes b Percentage of patients with ST- segment elevation for whom a troponin T or I test is recorded Data source: a RCP survey of access to facilities (data will be available in spring 2006) b MINAP for a continuous patient-based indicator Notes: The findings from the one-off survey due in spring 2006 [metric (a) will determine whether there is a need to monitor metric (b)]. Ideally, we would monitor the use of troponin T/I testing in acute coronary syndromes rather than just ST-segment elevation. To open up discussions about options for data collection for acute coronary syndromes. Other indicators we should consider for acute coronary syndromes include the use of angiography (where there are significant inequalities within E&W and with Europe) and the place of admission/hospital stay (CCU versus non-CCU, under the care of cardiologist, etc.) Refreshed metrics were also identified related to the diagnosis and assessment of angina: Metrics: Percentage of patients with newly diagnosed angina (after 1 April 2003) who are referred for exercise testing and/or specialist assessment Data source: QMAS CHD 2

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2.10 Theme: Heart failure/Left ventricular dysfunction Objective: To improve survival and the quality of life of people with heart failure/LVD Description of metric: The percentage of patients with a diagnosis of CHD* and left ventricular dysfunction who are currently treated with ACE inhibitors (or A2 antagonists) Rationale/evidence base: NICE guidance on management of chronic heart failure in adults in primary and secondary care: all patients with heart failure due to left ventricular systolic dysfunction should be considered for treatment with an ACE inhibitor. Complements 2003–2006 PPF target: improve the management of patients with heart failure in line with the NICE Clinical Guideline due in 2003, and set local targets for the consequent reduction in patients admitted to hospital with a diagnosis of heart failure CHD NSF: standard 11: Doctors should NSF standard(s) where applicable: arrange for people with suspected heart failure to be offered appropriate investigations e.g. electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely both to relieve their symptoms and reduce their risk of death should be offered Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease and stroke) Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: nGMS (LVD3) Percentage Unit of analysis: Process Structure/process/outcome: Notes: *nGMS wording has been used for this metric but may be an area for refinement in the next QOF. The Healthcare Commission’s recently launched improvement review for heart failure also includes indicators on treatment with beta blockers and anticoagulants. These will require bespoke data collection (i.e. “currently possible”) Refreshed metrics were also identified for surgical management as follows: Metrics: i Observed/expected revascularisation (coronary artery bypass graft) and percutaneous coronary intervention [PCI]) rates ii Risk-adjusted mortality rates after first time CABG iii Readmission rates after pacemaker implantation Data source: i HES ii Adult cardiac surgery audit iii HES Notes: i Model for O/E needs to include all the key factors (age, deprivation, etc.) ii Adult cardiac surgery audit data required for case mix adjustment

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Refreshed metrics were also identified for rehabilitation as follows: Metrics: i Participation rates in the BHF rehabilitation audit ii Percentage of patients following MI or revascularisation procedures who receive an appropriate rehabilitation programme iii Average patient anxiety and depression scores and health-related quality of life scores post-rehabilitation and mean changes scores from baseline to 12 weeks Data source: British Heart Foundation (BHF) rehabilitation audit Notes: i This new rehabilitation audit is currently being rolled out and recruitment of sites is increasing rapidly. However, full data is unlikely in 2007/2008 (see below). This audit will address a wider group of patients than AMI and will include patients requiring rehabilitation post-cardiac surgery or other primary intervention ii This data will be available for all trusts from a supplementary survey run by the rehabilitation audit from 2006/2007 iii This data will not be available for all rehabilitation programmes in 2006/2007

2.11 Theme: Health inequalities Objective: Reducing inequalities in the management of established CHD* Description of metric: The ratio of the number of registered patients with CHD to the expected number of patients with CHD (based on prevalence estimates adjusted for age, sex, deprivation and ethnicity) Rationale/evidence base: See PSA target. Also, pilot projects in parts of the country demonstrating increases in registered patients in more deprived areas after feedback of this type of data See PSA target NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (substantially reduce mortality rates by 2010, from heart disease and stroke and related conditions by at least 40% in people under 75, with at least a 40% reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a whole) Standards for better health domain: Seventh domain: Public health CURRENTLY UNAVAILABLE: Data source: Number of registered patients with CHD can be generated from nGMS data; models for generating the expected number of patients with CHD are not yet available (see notes) Ratio Unit of analysis: Process Structure/process/outcome: Notes: Several approaches to generating prevalence estimates are possible including: local prevalence surveys; from the national database of nGMS data (QMAS); synthetic estimation from national prevalence surveys (e.g. from the Health Survey for England (HSE), models for which are in progress). *Although it would be desirable to extend this metric to cover stroke and vascular risk factors, the first step will be to develop models for established CHD Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Children and maternity

National Clinical Director: Dr Sheila Shribman The children and maternity metrics chapter is temporarily unavailable. This is while the chapter is being reviewed in light of new metrics under development for monitoring the National Service Framework. The revised chapter will be made available on this website as soon as possible. If you have any queries in the meantime, please contact Andy Mobbs at andy.mobbs@ic.nhs.uk or Elaine Edgar at elaine.edgar@dh.gsi.gov.uk.

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Diabetes

National Clinical Director: Dr Sue Roberts

Introduction These metrics were originally produced in 2004. However, in the light of changes in data sources and reporting elsewhere, some small changes have been made which the original production group has validated. The metrics are designed to provide a broad indication of the quality of health services and systems dealing with diabetes. They refer to data already available to SHAs and PCTs from existing monitoring and reporting activity. The metrics have been designed to be valid and relevant indicators that: • are a starting point for further investigation and not an exhaustive test of performance • are produced by the representatives of people who will work to them • will reflect both patient and clinician priorities • will be available to inform the development of new national and local performance measures • would measure areas deemed important to care and not simply those easy to collect and measure The project group producing the indicators included individuals with a variety of expertise and backgrounds including researchers, academics, clinicians, patients and practitioners and representatives of primary, secondary and intermediate care organisations. They were either drawn from the East of England or the Midlands or had previous experience of working on quality assessment in diabetes. The broadbased nature of the original production group, and the subsequent rigorous testing, verified the extent to which the required data could be accessed and whether the indicators, in practice, could report on those aspects of activity and outcomes intended. The indicators have already seen use as an informal self-assessment tool for systems wanting to evaluate the quality of their services and as a reference for the design of national standards. Other applications have aimed to apply a selection of the measures to answer a specific local audit question or to benchmark a specific problem. More recently, their value in determining standards and priorities within commissioning activity has also been recognised, and they are recommended as the main reference data set for commissioning in diabetes (see www.yhpho.org.uk/diabetes_commissioning.aspx). Therefore, whether your need is for whole systems quality evaluation, strategic analysis or as a commissioning tool, I recommend them to you and hope that these indicators will assist us in providing the best possible services to people with diabetes and those at risk of it. Sue Roberts National Clinical Director, Diabetes NSF

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Relationship between the metrics and monitoring of national targets As explained in the introductory section, the metrics are offered as examples of good practice for consideration locally. It is therefore important to place them in context of the data SHAs and PCTs will be required to collect as part of monitoring national targets for 2005â&#x20AC;&#x201C;2008. In particular, we have tried not to reproduce the national data requirements within the metrics. The national targets on long-term conditions, cardiovascular mortality and obesity are particularly relevant for diabetes. Data requirements for monitoring cardiovascular mortality and obesity are reproduced in the cardiovascular disease section of this document. Contact name: Alex Findlay (alex.findlay@diabetes.nhs.uk)

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Diabetes The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done)

4.01 Theme: Overweight and obesity prevalence and strategies Objective: To measure existence and effectiveness of anti-obesity / physical activity strategies Description of metric: i Prevalence of overweight (BMI 25-30 kg/m.sq.) and obesity (BMI 30 kg/m.sq.) in the general adult population by age ii A multi-agency obesity strategy is in place with agreed local strategic partnership targets iii A multi-agency physical activity strategy is in place with agreed local strategic partnership Rationale/evidence base: See NSF Diabetes NSF: standard 1 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: Standards for better health domain: Seventh domain: Public health i CURRENTLY AVAILABLE: Data source: HSE at SHA level (and synthetic estimation from this to PCT-level) ii and iii CURRENTLY POSSIBLE: Local audit NB. The new QOF indicator, OB1 states, “The practice can produce a register of patients aged 16 and over with a BMI greater than or equal to 30 in the previous 15 months” Percentage Unit of analysis: i Outcome Structure/process/outcome: ii Process Notes: See introduction to cardiovascular disease section for information on the national target for obesity and required monitoring data

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4.02 Theme: Effective identification Objective: To gauge the effectiveness of services to identify and diagnose diabetes in their patient population and how early in the disease process diagnoses are made Description of metric: i Number of people diagnosed with diabetes compared to the predicted level of the total prevalence of all forms of diabetes diagnosed and undiagnosed(1) ii Percentage of people diagnosed with diabetes in the last 12 months who have retinopathy at the time of diagnosis Rationale/evidence base: See NSF Standard 1 NSF standard(s) where applicable: Priority III: Access to services High level PSA target: Standards for better health domain: Seventh domain: Public health (developmental standard D13) / Clinical and cost effectiveness (developmental standard D2) CURRENTLY POSSIBLE: Data source: i Can be extracted from GP data (QOF DM1 requires registers and numbers can be extracted from these)(1) ii Diabetic retinopathy screening (DRS) services Recent change: The new QOF indicators for 2006/2007 replace DM1 with DM19 which states, â&#x20AC;&#x153;The practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has Type 1 or Type 2 diabetes.â&#x20AC;? This enables a register to collect information on people registered with diabetes according to type of their diabetes Percentage Unit of analysis: Outcome Structure/process/outcome: Notes: (1) Using the model of age, sex and ethnic group predicted diagnosed diabetes available through Yorkshire and Humber Public Health Observatory (see www.yhpho.org.uk). Guidance on using this metric in relation to ethnic minority communities will be available within the next 12 to 18 months. Guidance relating to screening and diagnosis for diabetes as part of a vascular programme will be available shortly

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4.03 Theme: Patient experience and engagement Objective: To evaluate the quality of services from the patient perspective Description of metric: Measurement of diabetic patient satisfaction in respect of ease of access, attention/interaction, respect for the individual, knowledge gained, empowerment and age/cultural appropriateness Rationale/evidence base: See NSF Standards 3, 5, 6 NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Patient focus, clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: Healthcare Commission User Satisfaction Tool. Individual sections may be used separately for focused evaluation* To be determined Unit of analysis: Process, outcome Structure/process/outcome: Notes: * Available from Healthcare Commission: summer 2007

4.04 Theme: HbA1c (1) Objective: To indicate the effectiveness of current clinical management of diabetes (glycaemia) Description of metric: i Percentage of patients with diabetes with a record of HbA1c within the last 15 months ii Percentage of patients with diabetes in whom the last HbA1c is 7.4% or less in the last 15 months. iii Percentage of patients with diabetes in whom the last HbA1c is 10% or less in the last 15 months Rationale/evidence base: See NSF Standard 4 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: National Diabetes Audit. Following this yearâ&#x20AC;&#x2122;s changes to the QOF, the relevant indicators are DM5, DM20 and DM7 Percentage Unit of analysis: Outcome, process Structure/process/outcome: Notes: (1) Glycosylated Haemoglobin A1c â&#x20AC;&#x201C; a measure of blood glucose

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4.05 Theme: Macrovascular risk Objective: To indicate the effectiveness of clinical management of diabetes in reducing vascular risk Description of metric: i Percentage of adults with diabetes with a record of cholesterol in the last 15 months ii Percentage of adults with diabetes in whom the last cholesterol measurement is 5 or less iii Percentage of adults with diabetes with a record of blood pressure in the last 15 months (1) iv Percentage of adults with diabetes in whom the last blood pressure is 145/85 mm or less (1) Rationale/evidence base: See NSF Standard 4 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: QOF – Cholesterol – DM16, DM17 Blood Pressure – (DM11 and DM12) Percentage Unit of analysis: Outcome, process Structure/process/outcome: Notes: (1) Target BP may be subject to update in the light of changes in acknowledged best practice

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4.06 Theme: Micro-vascular complications Objective: To indicate the effectiveness of long-term clinical management of diabetes and of long-term complications Description of metric: i Percentage of adults and children with diabetes with a record of testing for proteinuria or microalbuminuria ii Percentage of adults and children with diabetes with proteinuria or microalbuminuria who are treated with ACE inhibitors or A2 antagonists iii Percentage of patients with diabetes who have a record of retinal screening according to national standards in the previous 15 months iv Percentage of patients with diabetes diagnosed with sight-threatening retinopathy v Percentage of patients with diabetes who have undergone laser treatment for sightthreatening retinopathy Rationale/evidence base: See NSF Standard 4 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: i and ii â&#x20AC;&#x201C; QOF (DM13 and DM15) iii, iv and v â&#x20AC;&#x201C; diabetic retinopathy screening services Percentage Unit of analysis: Process, outcome Structure/process/outcome: Notes:

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4.07 Theme: Foot ulceration Objective: To indicate the effectiveness of long-term clinical management of diabetes and of long-term complications Description of metric: i The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months ii The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months iii Percentage of patients with diabetes who have been assessed as being at increased risk of foot ulcers(1) iv Percentage of patients with diabetes who have been assessed as being high risk of foot ulcers(1) v Percentage of patients with diabetes having a foot care emergency or foot ulcers(1) Rationale/evidence base: See NSF Standard 4 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY AVAILABLE: Data source: QOF DM9 and DM 10 iii, iv and v CURRENTLY POSSIBLE (Referral rates and/or local audit). Percentage Unit of analysis: i, ii, ii and iv process; v outcome and process Structure/process/outcome: Notes: (1) As determined in the NICE guidance â&#x20AC;&#x153;Prevention and management of foot problemsâ&#x20AC;? 4.08 Theme: Smoking Objective: To gauge the effectiveness of services in promoting healthy life styles Description of metric: i The percentage of patients with diabetes in whom there is a record of smoking status in the previous 15 months except those who have never smoked where smoking status should be recorded once ii The percentage of patients with diabetes who smoke and whose notes contain a record that smoking cessation advice has been offered in the last 15 months Rationale/evidence base: See NSF Standard 4 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority I: Improve the health of the population Standards for better health domain: Second domain: Clinical and cost effectiveness First domain: Safety CURRENTLY POSSIBLE: Data source: local audit (ii) QOF subset 1 and 2 Percentage Unit of analysis: Process Structure/process/outcome: Notes:

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4.09 Theme: Patient education and empowerment Objective: To gauge the effectiveness of services in promoting healthy life styles and in promoting the capacity of patients to self manage their diabetes Description of metric: i Percentage of diabetic patients who have been offered a structured education programme (1) (with their families / carers where appropriate) within 12 months of diagnosis ii Percentage of diabetic patients who have received a structured education programme (1) (with their families / carers where appropriate) within 12 months of diagnosis iii Percentage of pregnant diabetic women who have received pre-pregnancy counselling Rationale/evidence base: See NSF Standards 3, 5 and 6 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Fourth domain: Patient focus Second domain: Clinical and cost effectiveness First domain: Safety CURRENTLY AVAILABLE: Data source: National diabetes audit (NDA) Percentage Unit of analysis: Process Structure/process/outcome: Notes: (1) Criteria by which a structured education programme should be judged to meet NICE guidelines is available on the NDST website at www.diabetes.nhs.uk/workareas/patient-education

4.10 Theme: Staff education Objective: Description of metric: Percentage of all staff (specialist in diabetes and non-specialist) who come into contact with people with diabetes, and who have undergone a competency assessment and had opportunity for diabetes education and training Rationale/evidence base: See NSF Standards 7, 8, 5, and 6 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Third domain: Governance CURRENTLY UNAVAILABLE (unless local Data source: training needs analysis is available) Percentage Unit of analysis: Process Structure/process/outcome: Notes:

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4.11 Theme: Diabetic emergencies Objective: To gauge the effectiveness of services in the clinical management of diabetes and in promoting the capacity of patients to self manage their diabetes Description of metric: Population adjusted ambulance call out rates to diabetic emergencies and diabetic A&E attendances and A&E attendances due to diabetic emergencies or complications Rationale/evidence base: See NSF Standard 7 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Ambulance services Simple descriptive statistics Unit of analysis: Outcome Structure/process/outcome: Notes:

4.12 Theme: Annual review / care planning Objective: To indicate the extent to which patients are actively involved in planning and prioritising their own care Description of metric: Percentage of patients where completion of an explicit care plan at annual review included use of a joint decision making tool Rationale/evidence base: See NSF Standard 3, 5 and 6 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Fourth domain: Patient focus (developmental standards D10) CURRENTLY UNAVAILABLE Data source: Percentage of all diabetes patients Unit of analysis: Process Structure/process/outcome: Notes:

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4.13 Theme: Length of stay Objective: To gauge the effectiveness of secondary care services to manage the diabetes of patients while they are in their care for other treatments Description of metric: Age adjusted excess length of stay (LOS) and LOS ratio in diabetes patients for key indicators condition (see below) compared to non-diabetic patients Rationale/evidence base: See NSF Standard 8 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness First domain: Safety CURRENTLY AVAILABLE: Data source: Secondary Care (HES)(1) Simple descriptive data Unit of analysis: Outcome Structure/process/outcome: Notes: Key indicators condition (Emergency) myocardial infarction, fractured neck of femur Key indicators condition (Elective) hysterectomy, cholecystectomy, hip replacement, bypass grafting (Elective) (1) If used for benchmarking with other trusts, important to ensure calculated the same way (e.g. whether trim points are used) and same summary measures used for comparison (e.g. mean or median)

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Urgent care

National Clinical Directors: Professor Sir George Alberti and Dr David ColinThomé These are mainly proposals for metrics as indicators of continuous improvement, with the aim of improving upon them over successive planning cycles. In each case, the intent is to move towards metrics of patient experience across their whole pathway, rather than for selected portions. For this reason, the metrics go beyond provision of care in Accident and Emergency (A&E) departments to aspects of urgent care as a whole. With reference to A&E, we would also direct towards the standards document produced by the British Association for Accident and Emergency Medicine’s Clinical Effectiveness Committee (January 2004; available via e-mail from: BAEM1@compuserve.com) as a useful source for constructing metrics. We have received some feedback from A&E consultants suggesting more metrics that we hope to address in future. 5 As with all of the other areas within this document, the proposed urgent care metrics should be considered within the context of the mandatory requirements to meet national targets. The metrics are not intended to duplicate these mandatory requirements but rather to suggest measures that could be useful for local target setting or quality improvement activities. For urgent care, the relevant national target is one of the Existing commitments to be maintained listed within Appendix 1 of National Standards, Local Action which can be found at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida nce/DH_4086057. The target states, “Reduce to four hours the maximum wait in A&E from arrival to admission, transfer and discharge,” which is a commitment due to be achieved before March 2005 (at 100%, with 98% being the minimum performance level). Several metrics within this section are reproduced from other sections of the series, notably, cardiovascular disease, mental health and older people. Contact name: Professor Sir George Alberti (e-mail: george.alberti@dh.gsi.gov.uk)

It would also be useful to examine some disease specific metrics for common conditions. Examples for trauma care could include trauma mortality, time to surgery for extradural, or laparotomy. Examples for medical conditions could include compliance with best evidence/treatment guidelines such as the administration of aspirin/clopidogral and heparin for acute coronary syndromes or time to initiate antibiotics for pneumonia. Examples for minors could be time to definitive procedure such as to reduce a fracture or relocate a joint.

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Urgent care The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done)

5.01 Theme: A&E waiting times Objective: To improve A&E waiting times up to completion of the definitive intervention Description of metric: Percentage of A&E departments which, for 80% of causes of admissions, have reached agreement on what the definitive intervention and optimal time to treatment is for each of these causes of admission Rationale/evidence base: A&E waiting times were a 2003–2006 PPF target and need to be maintained. This metric attempts to build on these NSF standard(s) where applicable: Priority III: Access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: Yes/no question to A&E clinical directors/heads of department (i.e. new data collection) Yes/no Unit of analysis: Process Structure/process/outcome: Notes:

5.02 Theme: A&E waiting times Objective: To promote appropriate use of assessment units Description of metric: Duration of stay in assessment unit Rationale/evidence base: Assessment units should be used to confirm/make a diagnosis and initiate treatment – and to determine the need for a longer stay in hospital. They have been shown to shorten total stay in hospital (North Manchester experience). Best practice suggests that a time limit of 24 hrs in an assessment unit is appropriate NSF standard(s) where applicable: Priority III: Access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: By local audit (see notes) Times Unit of analysis: Process Structure/process/outcome: Notes: New data requirements if it is to be routinely measured – ultimately from electronic patient record for A&E patients? Would need clear data definitions. Could be ‘gaming’ if used for performance management – recommended for use as a local quality improvement indicator Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

5.03 Theme: Myocardial infarction (MI) Objective: To continue the reductions in mortality from MI Description of metric: Deliver a 10 percentage point increase per year in the proportion of people suffering from a heart attack who receive thrombolysis, or the decision to proceed with percutaneous coronary intervention (PCI), within 60 minutes of calling for professional help. Rationale/evidence base: See equivalent CHD metric (3.07) See equivalent CHD metric NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: (reducing mortality from heart disease) Standards for better health domain: Seventh domain: Public health See equivalent CHD metric (3.07) Data source: See equivalent CHD metric Unit of analysis: Process Structure/process/outcome: Notes: The logistics of arranging urgent PCI are such that target times are difficult to define at present. The outcome of the National Infarct Angioplasty Project funded by the DH will not be known until late 2008 at the earliest. Trusts that in 2006/2007 maintain or exceed the percentage they achieved in 2005/2006 will be considered to have achieved the target providing they also achieve greater than or equal to 38%.

5.04 Theme: Myocardial infarction (MI) Objective: To promote the continuous quality improvement of acute services for people with MI Description of metric: Percentage of acute trusts using statistical process control (SPC) charts to monitor their 30-day mortality post-MI Rationale/evidence base: SPC charts are increasingly being recognised as a better way of monitoring outcomes than charts of rates with confidence limits. Controlling for case-mix remains an issue for SPC charts however NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness Seventh domain: Public health CURRENTLY POSSIBLE: Data source: Direct question to trusts; data for constructing the charts from MINAP audit Percentage Unit of analysis: Process (for an outcome) Structure/process/outcome: Notes:

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5.05 Theme: Stroke Objective: To improve patient outcomes following a stroke Description of metric: Proportion of patients treated in an acute stroke unit service Rationale/evidence base: Substantial RCT evidence that outcomes are improved by treatment in an acute stroke unit Older people’s NSF, standard 5 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness Seventh domain: Public health CURRENTLY AVAILABLE: Data source: RCP stroke audit Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: Preliminary indicator would be proportion of acute trusts that have a specialist stroke service (yes/no). Data from RCP stroke audit

5.06 Theme: Stroke Objective: To improve the timeliness of specialist stroke care Description of metric: Time from first entry into the hospital to admission to the acute stroke unit Rationale/evidence base: To try to remove the ‘perverse incentive’ of reducing waiting time for admission, but while not necessarily being admitted to an acute stroke unit Older People’s NSF, standard 5 NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: By local audit only (see notes) Unit of analysis: Structure/process/outcome: Notes: I.e. to include time spent waiting in the Emergency Department. New data requirements if this is to be measured routinely: could potentially be collected through electronic patient records, once introduced. Would need clear data definitions. Could be ‘gaming’ if used for performance management (for example, through what is defined as an “acute stroke unit”) – recommended for use as a local quality improvement indicator 5.07 Theme: Falls Objective: To reduce the incidence of falls in older people Description of metric: Percentage of patients presenting to A&E with a fall who are referred for a multidisciplinary falls assessment (provided by old age specialist teams) Rationale/evidence base: See NSF Older People’s NSF, standard 6 NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: By local audit Percentage Unit of analysis: Process Structure/process/outcome: Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

Notes: Also see older peopleâ&#x20AC;&#x2122;s section for related metrics

5.08 Theme: Mental health emergencies Objective: To improve the management of older people with mental health problems who present at A&E Description of metric: Proportion of acute trusts with access to old age liaison psychiatry services Rationale/evidence base: 30% of emergency admissions of older people involve a mental health problem NSF standard(s) where applicable: Priority III: Access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: Yes/no question to acute trusts (i.e. new data collection) Yes/no Unit of analysis: Structure Structure/process/outcome: Notes:

5.09 Theme: Mental health emergencies Objective: Description of metric: Proportion of people presenting with a mental health problem at A&E who receive a psychosocial assessment* Rationale/evidence base: NSF standard(s) where applicable: High level PSA target: Standards for better health domain: Data source: Unit of analysis: Structure/process/outcome: Notes: *Relevant measure from the mental health metrics. See mental health metrics (9.10) for details

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5.10 Theme: Mental health emergencies Objective: Description of metric: Proportion of people referred to crisis assessment services who are assessed within four hours* Rationale/evidence base: NSF standard(s) where applicable: High level PSA target: Standards for better health domain: Data source: Unit of analysis: Structure/process/outcome: Notes: *Relevant measure from the mental health metrics. See mental health metrics (9.08) for details

5.11 Theme: Out of hours primary care Objective: To ensure provision of whole system integrated care Description of metric: Proportion of health communities with an effective local urgent and emergency network meeting regularly (at least every four weeks) Rationale/evidence base: Smooth, seamless care NSF standard(s) where applicable: Priority III: Access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: Yes/no acute trusts (i.e. new data collection) Yes/no Unit of analysis: Structure Structure/process/outcome: Notes: Define health community as based on acute trust catchment areas

5.12 Theme: Out of hours primary care Objective: To maximise the effectiveness of the interface between NHS Direct and routine primary care Description of metric: Proportion of out of hours consultations for which full data is provided to GP practices by 9am on the next working day Rationale/evidence base: NHS Direct routine monitoring data NSF standard(s) where applicable: Priority IV: Access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care. CURRENTLY AVAILABLE: Data source: NHS Direct routine monitoring data Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: Selected from the Carson review report

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5.13 Theme: Out of hours primary care Objective: To improve the patient experience of NHS Direct Description of metric: Proportion of telephone calls to the NHS Direct abandoned within 30 seconds Rationale/evidence base: NHS Direct routine monitoring data NSF standard(s) where applicable: Priority IV: Access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY AVAILABLE: Data source: NHS Direct routine monitoring data Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: Selected from the Carson review report

5.14 Theme: Patient experience in A&E departments Objective: To improve patient experience in A&E departments Description of metric: Scores from the A&E patient survey, i.e. for the five domains of: Access and waiting; Safe, high quality coordinated care; Better information, more choice; Building better relationships; Clean, friendly, comfortable place to be* Rationale/evidence base: Patient experience survey scores for A&E are lower than for other NHS settings. The aim would be for continuous improvement in these scores NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus CURRENTLY AVAILABLE: Data source: A&E national patients survey (Healthcare Commission). Could be repeated locally using the same questionnaire* Mean scores; mean change scores (from Unit of analysis: baseline to follow up surveys) Outcome Structure/process/outcome: Notes: * For details, see section on patient experience

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Public health and health inequalities

Health Inequalities Unit, Department of Health Readers should note that public health issues are addressed throughout this document, including several references to the Department of Health’s Public Service Agreement Priority I – Health of the population targets. Further work will be undertaken during the implementation of the Public Health Information and Intelligence Strategy to agree the specific metrics that support the monitoring and performance management of public health and health inequalities. This chapter focuses on the good work done so far on health inequalities. Visit the health inequalities website at www.dh.gov.uk/healthinequalities for further information on inequalities, including Tackling Health Inequalities – A Programme for Action, Health Equity Audit, and PSA targets (including details of the ‘spearhead group’).

Public Service Agreement targets on inequalities The Department of Health’s PSA target contains a suite of targets on health inequalities under Priority I – Health of the population. These aim to narrow the inequalities gaps in infant mortality across social classes and in life expectancy, cancer and cardiovascular disease mortality across geographical areas. In addition, there is a PSA target to address smoking in routine and manual social groups. The high priority of health inequalities is reflected in National Standards, Local Action and Local Delivery Planning guidance.

Local target setting for inequalities Health inequalities and pockets of disadvantage exist in all areas, so all health communities should look to narrow these inequalities as an integral part of setting local targets, skewing activity towards the disadvantaged areas and groups which will tend to have highest needs. Achievement of the infant mortality aspect of the PSA target and the smoking in manual groups target calls for a focus on routine and manual groups in all areas. The geographically based PSA targets mean there is a need for faster progress on a larger scale in the areas with the worst health and deprivation indicators (the Spearhead Group of areas) compared to the national average. The Spearhead Group of areas will be published on the health inequalities website. National Standards, Local Action identified the need to address local service gaps and deliver equity (supported by use of Health Equity Audit) as key principles of local target setting for all. The Health Poverty Index provides summary key information on differences in health and health outcomes between various geographical areas and groups, allowing differences to be monitored over time. The index’s website www.hpi.org.uk presents information in easily accessible formats such as spider charts, bar charts and tables, which PCTs may find useful in setting local priorities and targets for local health communities and their partners.

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What are the priorities for action to reduce health inequalities? Tackling Health Inequalities – A Programme for Action sets out a comprehensive programme across a range of policies and services. The aim is to show what needs to be done to meet the 2010 national health inequalities target on life expectancy (by geographical area) and infant mortality (by social class) as well as the things that need to be set in train now to ensure we are not causing a perpetuation of health inequalities into the future. Many of these will rely on strong and effective partnership working with local authorities and other key partners. Specifically, it sets out the key NHS interventions that will achieve the targets, achievement of both being underpinned by good availability of high quality primary care.

Life expectancy • •

• •

reducing smoking in manual social groups (e.g. through extended cessation services, complementary tobacco education campaigns and other supporting interventions) prevention and effective management of other risk factors in primary care (e.g. through early identification and intervention on poor diet, obesity and hypertension through lifestyle and therapeutic interventions including use of statins, anti-obesity drugs and anti-hypertensives according to need) targeting over-50s where the greatest short-term impact on life expectancy will be made, including through flu vaccination working proactively with partners on issues affecting life expectancy

Infant mortality • • • • • • • •

reducing smoking in pregnancy, also focusing on paternal smoking improving nutrition in women of childbearing age reducing teenage pregnancy increasing breastfeeding initiation and duration rates providing effective antenatal care (including screening and immunisation) and promoting early antenatal booking improving the quality of midwifery, obstetric and neonatal services effective education about ways to promote health, e.g. immunisation, etc. provision of high quality family support (e.g. through health visitors), including particular efforts to address risk factors for Sudden Infant Death – parental smoking, sleeping position and adverse social circumstances

To support the achievement of the target, all of these activities should ensure that the greater needs of families in lower socio-economic groups are being met. In the PSA targets and National Standards, Local Action, it is recognised that health inequalities is a cross-cutting issue within the NHS as well as outside it. Inequalities are therefore embedded within the metrics to reduce cancer, cardiovascular disease (CVD) and infant mortality, and to reduce the prevalence of smoking. Within local target setting, these metrics should be used to ensure faster progress in disadvantaged groups and areas.

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Health inequalities The proposed NHS metrics Metrics to track the NHS’s contribution to reducing health inequalities are weighted towards the key interventions that are known to affect CVD, cancer, and infant mortality, though locally there may be other inequalities issues to be addressed. Locally, PCTs and local authorities should use these to track progress and estimate trajectories that will contribute to the goal. The Health Inequalities Unit’s suggested metrics, drawn from the metrics in this document, are: •

cancer: cancer screening coverage in disadvantaged areas and the Spearhead Group; measurable change in questionnaire ratings of screening benefits and reduction in fatalism 6 , audits undertaken in primary and/or secondary care of appropriateness of referrals and of time between first GP attendance and onward referral

•

cardiovascular disease: in disadvantaged areas and the Spearhead Group, percentage of the PCT population with a BMI>30; the percentage of patients over 50, excluding those with diabetes, for whom a complete absolute risk score can be calculated, using data recorded in the last 15 months (if lipid ratios are unavailable, using the local mean ratio does not result in large errors); the prevalence of overweight (BMI 25-30 kg/m.sq.) and obesity (BMI>30 kg/m.sq.) in the general adult population by age

•

diabetes: in disadvantaged areas and the Spearhead Group of PCTs, the number of people diagnosed with diabetes compared to predicted levels (reduce any inequalities in detection between the PCT mean and practices in disadvantaged areas or with large ethnic minority populations) i percentage of adults with diabetes with a record of HbA1c within the last 15 months ii the percentage of adults with diabetes in whom the last HbA1c is 7.4% or less in the last 15 months iii percentage of adults with diabetes in whom the last HbA1c is 10% or less in the last 15 months iv percentage of patients with diabetes who smoke and whose notes contain a record that smoking cessation advice has been offered in the last 15 months v the percentage of people diagnosed with diabetes in the last 12 months who have retinopathy at the time of diagnosis

•

oral health: reduce the difference in children’s DMF scores at 5 and 12 years between PCTs with high scores and the national mean

•

child health: child health inequalities indicators include the PSA target (reduce health inequalities by 10% by 2010 as measured by infant mortality and life expectancy at birth), and also the proxy measures of smoking in pregnancy, breastfeeding initiation, percentage of low birth-weight births, and

Rationale/evidence base: there is evidence that lower SES groups rate the benefits of cancer screening lower, the barriers to screening higher, and are both more fearful and more fatalistic about cancer, Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

maternal nutrition (uptake of Healthy Start), and immunisation for diphtheria, pertussis, measles, mumps and rubella. These are specified in the child health section In addition a local basket of indicators has been developed to track progress on reducing inequalities in public services across a range of inequalities dimensions. Local health communities can draw on this to identify local measures both for NHS organisations and also to support local priority and target setting with partners. The measures in the basket of indicators are provided in Appendix D. Further information on the purpose and use of the indicators is to be found on the London Public Health Observatory website at www.lho.org.uk/HEALTH_INEQUALITIES/Basket_Of_Indicators/BasketOfIndicators. aspx. Key contacts for any comments are: Health Inequalities Maggie Rae â&#x20AC;&#x201C; e-mail: maggie.rae@dh.gsi.gov.uk Public Health George Leahy â&#x20AC;&#x201C; e-mail: george.leahy@dh.gsi.gov.uk

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Long-term neurological conditions

National Clinical Directors: Professor Ian Philp and Kathryn Hudson The NSF for long-term conditions was published in March 2005. While its underlying principles can be applied to all long-term conditions, it focuses on long-term neurological conditions in its 11 evidence-based quality requirements (QRs). This neurological focus is reflected in the metrics that have been developed to support local health and social care practitioners and commissioners in their consideration of the local implementation of the NSF. Person-centred care supported by effective integrated health and social care working underpins the delivery of the NSF. The metrics draw on information from both health and social services, and try to use data that is currently available where possible to reduce the burden of data collection. It would have been easy to defer collection of data until the advent of the electronic patient record, which will make more accurate data available to support the metrics, however we were keen that services should start to consider how they measured up against the QRs, establish baselines and identify areas for improvement. In addition, there was the feeling from practitioners that they did not want to delay this process, and that with advance warning they would be willing to collect data prospectively for audit purposes. The 14 clinical indicators closely reflect the content of the 11 QRs, and many are based on performance indicators suggested by the NSF External Reference Group during development of the NSF. They are principally process indicators at the current time. Further work will be needed at local and national level to develop appropriate minimum datasets and outcome measures that will facilitate audit and provide more detailed evaluation of the quality of care provided. Members of the multi-professional National Neurological Advisory Panel were consulted on the draft metrics, and their comments have been incorporated, however comments from other interested practitioners are welcomed. Please send comments to: Beverley Hopcutt, Clinical Adviser (NSF for Longterm Conditions), Department of Health, 8E30, Quarry House, Quarry Hill, Leeds, LS2 7UE or e-mail: beverley.hopcutt@dh.gsi.gov.uk

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Long-term neurological conditions (LTNCs) The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done)

7.01 Theme: Integrated care planning Objective: To ensure that people with LTNCs have an integrated multi-agency assessment and receive a person-centred care plan Description of metric: Proportion of people with a LTNC who have within the last 12 months: • had an integrated assessment/review assessment • received a personal care plan Rationale/evidence base: Long-term conditions NSF – QR1 1 NSF quality requirement: Priority II: Improve health outcomes for people High level PSA target: with long-term conditions Standards for better health domain: Fourth domain: Patient focus Second domain: Clinical and cost effectiveness Third domain: Governance PCT and LA and/or specific services, e.g. Setting: community neuro-rehabilitation team, inpatient rehabilitation facility CURRENTLY POSSIBLE: Data source: Audit of patient records within specific services CURRENTLY UNAVAILABLE: Minimum dataset for LTNCs from Patient Information Spine Secondary Uses Percentage Unit of analysis: Process Structure/process/outcome: Notes: The features of an integrated multi-agency assessment is described in QR1. The aim is for the proportion to increase by at least 10% year on year from the current baseline to achieve 100% by 2015. Services might build on local implementation of the Older People’s Single Assessment Process to develop an equivalent system for use with people with LTNCs

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7.02 Theme: Better coordination of care Objective: To ensure that people with LTNCs who have complex needs receive wellcoordinated care Description of metric: Proportion of people with LTNCs with complex needs who have a named individual who acts as a coordinator of their care Rationale/evidence base: Long-term conditions NSF 1 NSF quality requirement: Priority II: Improve health outcomes for people High level PSA target: with long-term conditions Standards for better health domain: Fourth domain: Patient focus Second domain: Clinical and cost effectiveness Third domain: Governance Population with complex needs/by PCT and/or Setting: specific service, e.g. community neurorehabilitation team, inpatient rehab facility CURRENTLY POSSIBLE: Data source: Service audit of patient records CURRENTLY UNAVAILABLE: Minimum dataset for LTNCs from Patient Information Spine Secondary Uses Percentage Unit of analysis: Process Structure/process/outcome: Notes: The aim is for the proportion to increase by at least 10% year on year from the current baseline to achieve 100% by 2015. Definition of people with complex needs: people with needs in three or more domains of the integrated assessment and/or three or more needs in one domain, e.g. mobility, sensory, behavioural, communication, cognitive-psychological, emotional, social, work and leisure

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7.03 Theme: Better provision of information to people with LTNCs Objective: To ensure that people with LTNCs receive appropriate information Description of metric: Proportion of people with LTNCs who have received high quality information about their condition, its management, local services and how to access them, and wider social inclusion issues Rationale/evidence base: Long-term conditions NSF 1 NSF quality requirement: Priority II: Improve health outcomes for people High level PSA target: with long-term conditions Priority IV: Improve the patient and user experience Standards for better health domain: Fourth domain: Patient focus By PCT and LA and/or specific services, e.g. Setting: community neuro-rehabilitation team, inpatient rehabilitation facility CURRENTLY POSSIBLE: Data source: Service user audit via questionnaire; percentage of follow-ups that are self-referrals to service CURRENTLY UNAVAILABLE: Minimum dataset For LTNCs from Patient Information Spine Secondary Uses Percentage service users satisfied with Unit of analysis: information received; self-referrals as % of total referrals for follow-up/review Process Structure/process/outcome: Notes: Plan for a phased increase from the current baseline for information provision so that 100% is achieved by 2015. Services will need to agree at a local level what is an acceptable % of self-referral to reaccess services for a follow-up review. Requests may be made by the individual or by their family/carer

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7.04 Theme: Experience of services Objective: To improve people with LTNCs experience of services Description of metric: Percentage of people who report a positive experience from their contact with services Rationale/evidence base: Long-term conditions NSF All QRs NSF quality requirement: Priority IV: Improve the patient and user High level PSA target: experience Standards for better health domain: Fourth domain: Patient focus Within specific services, e.g. community neuroSetting: rehabilitation team, inpatient rehab facility or at key points on the pathway e.g. admission to hospital with a non-neurological problem CURRENTLY POSSIBLE: Data source: Service user audit via questionnaire Percentage Unit of analysis: Process Structure/process/outcome: Notes: Establish the current baseline and then plan a phased increase until 100% in 2015. In Better Metrics, there is a specific section on metrics for patient experience (Section 11). This draws heavily on the content of Healthcare Commission national surveys and identifies a number of questions that could be used to construct a local questionnaire. While this section is very subjective, it tries to capture some of the person-centredness that the NSF aspires to. For people with LTNCs who have severe communication and/or cognitive problems and who are unable to use standard questionnaires, the BSRM can supply information on alternative approaches

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7.05 Theme: Prompt recognition of symptoms, diagnosis and treatment Objective: To ensure that individuals suspected of having a neurological condition receive within maximum of 18 weeks: i referral from GP to a specialist with neurological expertise ii access to diagnostic services iii initial treatment Description of metric: Proportion of people with LTNCs who receive specialist assessment, investigations and treatment within timescales designated in NICE guidelines (where they exist), and within the 18-week PSA target where NICE guidelines do not exist Rationale/evidence base: Long-term conditions NSF 2 NSF quality requirement: Priority III: Improve access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care Second domain: Clinical and cost effectiveness Third domain: Governance Neurological conditions/by PCT and Setting: Neuroscience Centre waiting more than NICE recommended time/18 weeks from GP referral to treatment CURRENTLY AVAILABLE: Data source: Neuroscience Centre and DGH neurology outpatient waiting times (currently available) Diagnostic services waiting times (radiology for MRI/CT scans, neurophysiology) CURRENTLY POSSIBLE: Audit of wait times for tertiary and local specialist neuro services, e.g. neuro-rehab teams, GPwSIs, specialist nurses and AHPs, IV steroids for MS, spasticity management CURRENTLY UNAVAILABLE: Total time from referral to treatment from Patient Information Spine Secondary Uses broken down into neurological conditions Percentage Unit of analysis: Process Structure/process/outcome: Notes: NICE guidance timeframes currently apply â&#x20AC;&#x201C; epilepsy: two weeks for specialist assessment following first seizure; MS: six weeks from referral to seeing neurologist, six weeks for investigations to be completed. For all other conditions, the maximum 18week wait has to be met by 2008

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7.06 Theme: Improved care Objective: To ensure that people with LTNCs on three or more drugs have an annual medicines review Description of metric: Proportion of people with LTNCs on three or more drugs who have received a medicines review within the last 12 months Rationale/evidence base: Long-term conditions NSF, Management of Medicines: a resource to support implementation of the wider aspects of medicines management for the NSFs for diabetes, renal services and long-term conditions 1, 2 NSF quality requirement: Priority III: Improve health outcomes for people High level PSA target: with long-term conditions Standards for better health domain: Fifth domain: Accessible and responsive care Second domain: Clinical and cost effectiveness Third domain: Governance PCT and LA and/or specific services, e.g. Setting: community neuro-rehabilitation team CURRENTLY POSSIBLE: Data source: Audit of patient records within specific services CURRENTLY UNAVAILABLE: minimum dataset for LTNCs from Patient Information Spine Secondary Uses Percentage Unit of analysis: Process Structure/process/outcome: Notes: May be possible to extrapolate from data collected for QOF section on medication review

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7.07 Theme: Access to specialist acute services Objective: To ensure that individuals who develop a neurosurgical or neurological emergency have rapid access to the appropriate specialist acute services and facilities Description of metric: People with a neurosurgical or neurological emergency access as appropriate: a critical care within one hour of referral b neuroscience centre within six hours of referral c spinal cord injury centre within one day of referral d acute neurological team in local DGH within one day of referral Rationale/evidence base: Long-term conditions NSF, NICE guidelines 3 NSF quality requirement: Priority III: Improve access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care Second domain: Clinical and cost effectiveness Secondary and tertiary care Setting: CURRENTLY AVAILABLE/POSSIBLE: Data source: Critical Care, Neuroscience Centre and Spinal Injury Centre transfer times for people with LTNCs, acute neurological team assessment (may be collected for payment by results in near future) CURRENTLY UNAVAILABLE: Total time from referral to transfer to facility from Patient Information Spine Secondary Uses broken down into neurological conditions Percentage of people with LTNCs referred who Unit of analysis: access service/facility within the recommended timeframe Process Structure/process/outcome: Notes: Data will be available for critical care but data for people with LTNCs will have to be extracted from the total. Discussion with service providers indicates that they would be able to collect this data prospectively if notified

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7.08 Theme: Access to specialist rehabilitation services Objective: To ensure that individuals with a long-term neurological condition achieve the best possible outcomes through access to appropriate rehabilitation Description of metric: Wait times for individuals to access specialist neurorehabilitation inpatient facilities in line with national guidance Rationale/evidence base: Long-term conditions NSF â&#x20AC;&#x201C; BSRM Guidelines on rehabilitation following acquired brain injury, NICE MS Guidelines 4 NSF quality requirement: Priority II: Improve health outcomes for people High level PSA target: with long-term conditions III. Improve access to services Standards for better health domain: Fifth domain: Accessible and responsive care Second domain: Clinical and cost effectiveness Secondary and tertiary care Setting: CURRENTLY AVAILABLE/POSSIBLE: Data source: Specialist inpatient neuro-rehabilitation facility wait times for people with LTNCs CURRENTLY UNAVAILABLE: Total time from referral to admission to facility from care plan via Patient Information Spine Secondary Uses broken down into neurological conditions Percentage of people with LTNCs referred for Unit of analysis: specialist rehabilitation are seen for assessment within five working days of receipt of referral and if accepted and ready for transfer, access service/facility within two weeks Process Structure/process/outcome: Notes: The aim is for the proportion to increase by at least 10% year on year from the current baseline, to achieve 100% by 2015. Discussion with service providers indicates that they would be able to collect this data prospectively if notified

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7.09 Theme: Access to specialist rehabilitation services in the community Objective: To enable and support individuals with a long-term neurological condition to lead a full life in the community through access to: â&#x20AC;˘ rehabilitation including community neuro-rehabilitation â&#x20AC;˘ vocational rehabilitation Description of metric: People with identified needs on the care plan for rehabilitation in the community receiving: a community neuro-rehabilitation (specialist team/generic team with neurological expertise) b vocational rehabilitation Rationale/evidence base: Long-term conditions NSF, BSRM/RCP guidelines on rehabilitation following acquired brain injury, DWP/RCP inter-agency guidelines on vocational rehabilitation 5, 6 NSF quality requirement: Priority III: Improve health outcomes for people High level PSA target: with long-term conditions Standards for better health domain: Second domain: Clinical and cost effectiveness Third domain: Governance Fifth domain: Accessible and responsive care Community Setting: CURRENTLY POSSIBLE: Data source: Service audit of patient records CURRENTLY UNAVAILABLE: Minimum dataset for LTNCs from care plan via Patient Information Spine Secondary Uses Percentage of people with LTNCs with Unit of analysis: identified needs on care plan who are in receipt of appropriate specialist services to meet those needs Percentage of people with LTNCs referred for community neuro-rehabilitation seen within four weeks, and vocational rehab within four weeks Process Structure/process/outcome: Notes: DWP may collect data about vocational rehab from which it may be possible to extract neuro-specific information but this will not identify the unmet need, only how many are currently in receipt of services. The specialist, multidisciplinary, neuro-rehabilitation team staffed by a variety of professionals with neuro expertise, may exist as a separate team or as part of a larger rehabilitation team with a broader remit. The aim is for the proportion to increase by at least 10% year on year from the current baseline to achieve 100% by 2015. Discussion with service providers indicates that they would be able to collect waiting time data prospectively if notified

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7.10 Theme: Provision of equipment and adaptations Objective: To provide timely appropriate equipment and adaptations to individuals with a long-term neurological condition Description of metric: People with identified needs on the care plan for equipment / adaptations receiving: a standard equipment within seven working days b bespoke items within 20 working days c adaptations to their property (including those funded by Direct Facility Grants) within the agreed timescale and no more than six months d repair/replacement of equipment no longer functioning properly within locally agreed timeframes Rationale/evidence base: Long-term conditions NSF, ICES Guidelines 7 NSF quality requirement: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Second domain: Clinical and cost effectiveness Fourth domain: Patient focus Fifth domain: Accessible and responsive care Community, with Integrated Community Setting: Equipment Services (ICES) playing a key role CURRENTLY POSSIBLE: Data source: Data from referral, assessment and packages of care (RAP) returns for adult physical and sensory disability services CURRENTLY UNAVAILABLE: Minimum dataset for LTNCs from care plan via Patient Information Spine Secondary Uses Proportion of people with LTNCs who receive Unit of analysis: equipment/adaptations within the statutory / identified timeframe Proportion of people with LTNCs who receive repair/replacement of essential equipment within the locally agreed timeframe Outcome Structure/process/outcome: Notes: The aim is for the proportion to increase by at least 10% year on year from the current baseline to achieve 100% by 2015

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7.11 Theme: Providing personal care and support Objective: To give individuals with a long-term neurological condition maximum choice about living independently at home through the offer of direct payments Description of metric: People with LTNCs with identified needs on the care plan for assistance / support with living independently are offered the option of direct payments and the necessary support to operate it Rationale/evidence base: Long-term conditions NSF 8 NSF quality requirement: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Second domain: Clinical and cost effectiveness Third domain: Governance Fourth domain: Patient focus Community, working with LA direct payment Setting: schemes CURRENTLY POSSIBLE: Data source: Data from referral, assessment and packages of care (RAP) returns for adult physical and sensory disability services CURRENTLY UNAVAILABLE: Offer of direct payment from minimum dataset for LTNCs from care plan via Patient Information Spine Secondary Uses Expressed as a proportion of total number of Unit of analysis: adults under 65 with a LTNC in receipt of care Outcome Structure/process/outcome: Notes: The aim is for the proportion of those in receipt of direct payments to increase by 1% year on year from the current baseline. Once data collection can support this, the offer of direct payment will be measured and will be expected to increase in increments greater than 1%

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7.12 Theme: Providing personal care and support Objective: To give individuals with a long-term neurological condition maximum choice about remaining/returning to their own home Description of metric: Percentage of people with a long-term neurological condition offered support to live in their own home as opposed to residential/nursing care Rationale/evidence base: Long-term conditions NSF 8 NSF quality requirement: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Second domain: Clinical and cost effectiveness Third domain: Governance Fourth domain: Patient focus Community working with Social Services and Setting: Housing CURRENTLY POSSIBLE: Data source: Data from referral, assessment and packages of care (RAP) returns for adult physical and sensory disability services Numbers of patients with LTNCs who are supported to live in their own home expressed as a proportion of all in receipt of this support, i.e. also including those in residential/nursing CURRENTLY UNAVAILABLE: Home care dataset from care plan via Patient Information Spine Secondary Uses Expressed as a proportion of total number of Unit of analysis: adults with a LTNC in receipt of care Outcome Structure/process/outcome: Notes: The aim is to increase the proportion of those receiving support to live at home by 1% year on year from the current baseline. Once data collection can support this, the offer of choice to people with LTNCs to live at home, with support, will be measured and will be expected to increase in increments of more than 1%

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7.13 Theme: Supporting family and carers Objective: To improve support for families and carers Description of metric: Percentage of carers of people with a long-term neurological condition who: • have received a carers assessment • receive support appropriate to their identified needs Rationale/evidence base: Long-term conditions NSF 10 NSF quality requirement: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness Fourth domain: Patient focus All settings Setting: CURRENTLY POSSIBLE: Data source: Data from referral, assessment and packages of care (RAP) returns for adult physical and sensory disability services Percentage of carers of people with LTNCs who have received a carer’s assessment from case note audit CURRENTLY UNAVAILABLE: Minimum dataset for LTNCs from care plan via Patient Information Spine Secondary Uses Percentage Unit of analysis: Process and outcome Structure/process/outcome: Notes: The aim is to increase the proportion of carers of people with LTNCs who are offered a carers’ assessment and are in receipt of support by 5% year on year from the current baseline: people who provide a carer service/support. Once data collection can support this, the offer of a carer’s assessment to carers of people with LTNCs, and the provision of support appropriate to their needs will be measured and will be expected to increase in increments of 5%

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7.14 Theme: Palliative care Objective: To improve end of life care for people with LTNCs Description of metric: a Percentage of people with a long-term neurological condition accessing palliative care services b Percentage of people with a long-term neurological condition who are terminally ill with evidence of good end of life care in line with NICE best practice guidance Rationale/evidence base: Long-term conditions NSF, Gold Standards Framework, Liverpool Care Pathway for the Dying, Preferred Place of Care 9 NSF quality requirement: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness Fourth domain: Patient focus Fifth domain: Accessible and responsive care a Community, working with specialised Setting: palliative care services b All care settings a CURRENTLY POSSIBLE: Data source: Numbers of people with LTNCs accessing palliative care services expressed as a percentage of overall numbers accessing palliative care services via local service audit of referrals b CURRENTLY POSSIBLE: Local service audit of care plan for evidence of end of life care in line with best practice expressed as a percentage of total people with LTNCs at the end of life CURRENTLY UNAVAILABLE: Both sets of information would be accessible in the future using the minimum dataset for LTNCs from care plan via Patient Information Spine Secondary Uses Percentage Unit of analysis: Process Structure/process/outcome: Notes: The aim is for the proportion to increase by (a) 1% and (b) 5% year on year from the current baseline

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Learning disabilities

National Director of Implementation, Valuing People: Rob Grieg The document â&#x20AC;&#x2DC;All Means Allâ&#x20AC;&#x2122; provides the source and/or rationale for many of the metrics provided in this section and is available at www.doh.gov.uk/vpst. Contact name: Debra Moore (e-mail: debra.moore@csip.org.uk)

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Learning disabilities – the proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done)

8.01 Theme: Equity and access Objective: All GP Practices have a system for identifying patients who have a learning disability Description of metric: Number of people with learning disabilities known to GP practice but not yet coded using a locally agreed and appropriate Read code Rationale/evidence base: The identification and registration of patients with learning disabilities in GP practices is a target of the White Paper – Valuing People (Department of Health 2001) (6:14) Identification will enable appropriate support to enable patients to access the full range of primary care provision and the monitoring of access to a range of routine health screening opportunities such as cervical and breast screening programmes NSF standard(s) where applicable: Priority II: Long-term conditions High level PSA target: Standards for better health domain: Seventh domain: Public health Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE Data source: Number Unit of analysis: Process Structure/process/outcome: Notes:

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8.02 Theme: Health facilitation – equity and access Objective: All patients with learning disabilities have a health action plan that has been initiated or checked by a primary care professional and is based on a comprehensive health check Description of metric: • Number of people with learning disabilities with or offered (which to be confirmed) a comprehensive health check prior to a Health Action Plan (per 10,000 of PCT general pop.) in last three years • Number of people with a health action plan (HAP) (per number offered) Rationale/evidence base: The requirement to offer Health Action Plans and Health Facilitation is a requirement of the White Paper – Valuing People (Department of Health 2001) (6:15) people with learning disabilities have a higher prevalence than other population groups of some illnesses and may have undiagnosed and untreated conditions. The need to self-refer to a GP can be a barrier for many people with learning disability NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Fourth domain: Patient focus Fifth domain: Accessible and responsive care Third domain: Governance CURRENTLY POSSIBLE: Data source: Local audit; or, if metric 8.01 were in place, from GP data* Number per 10,000 of PCT general pop or per Unit of analysis: number offered Process Structure/process/outcome: Notes: *Unlikely that 8.01 in place for all practices

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8.03 Theme: Health Facilitation – equity and access Objective: PCT’s have a system in place to identify 1:1 health facilitators / navigators to primary care for people with learning disabilities and their families Description of metric: Each PCT should have a system for identifying local health facilitators Rationale/evidence base: The requirement to offer Health Action Plans and Health Facilitation is a requirement of the White Paper – Valuing People (Department of Health 2001) (6:15) people with learning disabilities have a higher prevalence than other population groups of some illnesses and may have undiagnosed and untreated conditions. The need to self-refer to a GP can be a barrier for many people with learning disability NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Fourth domain: Patient focus Fifth domain: Accessible and responsive care Third domain: Governance CURRENTLY POSSIBLE: Data source: “Yes/no" question to PCTs (i.e. new data collection) Yes/no Unit of analysis: Process Structure/process/outcome: Notes:

8.04 Theme: Equity and access Objective: All GPs have a system for ensuring that patients with learning disabilities are invited to attend for health screening if they have not visited the surgery in the last three years Description of metric: Numbers of patients with learning disabilities who have been invited, in the past year, for a comprehensive health check if they have not visited the GP surgery in the last three years Rationale/evidence base: Research has demonstrated that many people with learning disabilities have a range of undiagnosed and untreated health problems – improvement, expansion, reform: ensuring that ‘all means all’ (Department of Health 2003; see www.doh.gov.uk/vpst) NSF standard(s) where applicable: Priority I : Improving the health of the High level PSA target: population Standards for better health domain: Seventh domain: Public health Third domain: Governance Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: Question to PCTs (i.e. new data collection) Number Unit of analysis: Outcome Structure/process/outcome: Notes:

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8.05 Theme: Inpatient care provision Objective: All PCTs have a system for reviewing NHS funded hospital beds (in and out of district) where the duration of stay exceeds 12 months Description of metric: • A system is in place within each PCT to review the treatment plans of patients in NHS funded hospital beds (in and out of district) at least annually by a qualified clinician • Percentage of people with learning disabilities who are in NHS hospital funded beds where duration of stay has exceed 12 months (per 10,000 of PCT general population) Rationale/evidence base: Need to encourage an increase in core spending on local community based services and reduce reliance on hospitalisation and bed based services – Valuing People (Department of Health 2001) (6:26) NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Second domain: Clinical and cost effectiveness Third domain: Governance Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE Data source: Yes/no and number per 10,000 of PCT general Unit of analysis: population Structure Structure/process/outcome: Notes: 8.06 Theme: Local services Objective: Reduction in the number of people in out of area treatment provision – who are described as severely challenging or who have a mental health or forensic need Description of metric: Number of people with learning disabilities in out of area treatment provision who are assessed by an appropriately qualified specialist clinician as severely challenging or who have a mental health or forensic need Rationale/evidence base: Need to encourage commissioners to develop a range of local services and community support such as assessment and treatment, assertive outreach, etc. Valuing People (Department of Health 2001) (6:26) NSF standard(s) where applicable: Priority IV: Patient experience High level PSA target: Priority III: Access to services Standards for better health domain: Second domain: Clinical and cost effectiveness Third domain: Governance CURRENTLY POSSIBLE: Data source: PCTs should know number of people in out of area provision; denominator from local authority learning disability register Numbers Unit of analysis: Structure, process Structure/process/outcome: Notes:

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8.07 Theme: Equity and access Objective: An agreed system and protocols are in place that enable people with learning disability and mental health needs to swiftly access local mental health services Description of metric: The PCT have a system and protocols in place to ensure that people with learning disability and mental health needs are able to swiftly access local mental health services Rationale/evidence base: The prevalence of mental health needs in people with learning disability is high. White Paper – Valuing People states that people with learning disabilities and mental health needs are able to access general psychiatric services wherever possible – Valuing People (Department of Health 2001) (6:23) Need to ensure people with learning disabilities benefit from the standards within the Mental Health NSF Mental health NSF NSF standard(s) where applicable: Priority III: Access to services High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: “Yes/no”question to PCTs (i.e. new data collection) Yes/no Unit of analysis: Structure Structure/process/outcome: Notes:

8.08 Theme: Safety Objective: A system is in place to ensure that patients at risk of dysphagia are screened and assessed to determine vulnerability and that a care plan is in place and reviewed regularly Description of metric: • How many people with learning disabilities have been screened for dysphagia in the last three years? • How many people have a plan for dysphagia in place that has been regularly reviewed? Rationale/evidence base: NPSA report (2004) identified that people with learning disabilities are at high risk of dysphagia – this can lead to respiratory tract infections which are a leading cause of death in people with learning disabilities NSF standard(s) where applicable: Priority I: Improve the health of the population High level PSA target: Standards for better health domain: First domain: Safety CURRENTLY POSSIBLE: Data source: Questions to PCTs (i.e. new data collection) Numbers Unit of analysis: Structure Structure/process/outcome: Notes:

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8.09 Theme: Patient experience and engagement Objective: Patients with learning disabilities and their families will be offered easy to understand information about their health Description of metric: Regular survey to ascertain how easy to understand information provided about their health and treatment was for patients with learning disability and their family carers Rationale/evidence base: NPSA report (2004) identified this as one of the top five priority areas – in particular risks around information about prescriptions. Also key area raised in the choice consultation NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: First domain: Patient safety Fourth domain: Patient focus CURRENTLY UNAVAILABLE: Data source: Tool needs to be developed Mean scores; mean change scores from a Unit of analysis: baseline survey Outcome Structure/process/outcome: Notes:

8.10 Theme: Patient experience and engagement Objective: Increased strength of the voice of people with learning disabilities and their families through membership of patient forums, advocacy and annual surveys Description of metric: • Number of patients with learning disabilities on any patient forums • Number of people with a learning disability in health provision who are inpatients including long stay and campus provision who are receiving support from independent health advocacy services Rationale/evidence base: To work on strategies to eliminate discriminatory practice and negative patient experiences NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus CURRENTLY POSSIBLE: Data source: (Bullets 1 and 2) Direct questions to PCTs and specialist mental health and learning disability trusts (i.e. new data collection); see notes for bullet 3* Number Unit of analysis: Process Structure/process/outcome: Notes: *Unsure whether Healthcare Commission surveys would clearly identify learning disabilities or encourage them to participate, e.g. written in accessible way and in a range of formats with support to complete if needed, etc.

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8.11 Theme: Equity and access Objective: To ensure people with learning disabilities are appropriately supported during acute care Description of metric: Acute hospitals have a system in place to ensure patients with learning disabilities are identified and appropriate support provided Rationale/evidence base: NPSA (2004) – identified that patients with learning disability are more vulnerable in acute hospital settings due to additional and complex needs NSF standard(s) where applicable: Priority III: Access High level PSA target: Standards for better health domain: Third domain: Governance Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: Direct “yes/no” question to acute trusts (i.e. new data collection) Yes/no Unit of analysis: Structure Structure/process/outcome: Notes:

8.12 Theme: Equity and access Objective: To ensure that a system is in place to ensure patients with learning disabilities benefit from the local implementation and progress on the targets within the NSFs, CHD, Cancer Plan, etc. Description of metric: PCTs have a system in place to ensure access and take up rates are monitored by the PCT executive board quarterly for people with learning disabilities to check and promote equal access to benefits in mainstream services, NSFs and plans Rationale/evidence base: Valuing People (Department of Health 2001) (6:22) states that all NSFs and National Cancer Plan apply equally to people with learning disability and that they should benefit from all these initiatives People with learning disabilities are at increased risk of particular conditions such as coronary heart disease and certain cancers Relevant to coronary heart disease and cancer NSF standard(s) where applicable: NSFs Priority III: Access High level PSA target: Standards for better health domain: Seventh domain: Public health Third domain: Governance Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: Direct (“yes/no”) question to PCTs (i.e. new data collection) Yes/no Unit of analysis: Structure Structure/process/outcome: Notes:

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Mental health

National Clinical Director: Professor Louis Appleby Section author: Deputy National Clinical Director – Dr Hugh Griffiths

Summary This section sets out the proposed measures covering child, adolescent, adult and older people’s mental health; the context and key issues for their implementation, and consideration of next steps.

Context Mental health is in the mainstream of health and social care reform. During the last seven years, the care services have made important progress to the extent that a message of reforming the NHS alone presents an incomplete picture for local communities. Improving service quality requires a strategic approach with currency across the NHS, LAs and voluntary sector, to make it as easy as possible for these agencies to provide joined up services and support. The building blocks of such a strategic approach should include: • sharing a strong vision and leadership for delivering service quality through collaboration • working with the Healthcare Commission as lead regulator on improving data quality • proactively addressing barriers to partnership working, which needs to include developing common systems, process, language and lines of accountability that will facilitate partnership working and address cultural boundaries between statutory and voluntary agencies • communicating clear messages about the purpose of data collection nationally and promoting appropriate information sharing locally • ensuring adequate funding and effort is channelled into developing information infrastructures including hardware and software through Connecting for Health (the National Programme for IT) and in engaging practitioners, service users, managers, commissioners, etc., at a local level

Localised implementation support structure linking to performance management In National Institute for Mental Health in England (NIMHE), mental health already has a localised implementation support structure in place (as do other initiatives within the Care Services Improvement Partnership). Eight development centres (DC) each give sufficient economies of scale to offer meaningful support for local communities to help them implement evidence based practice, meet policy targets and encourage innovation. Across the country, over 10 national programmes prioritise shared projects and learning on core themes. DCs have important links to SHAs in their patch, connecting performance development to performance management, which is supported by a SHA/SSI national network meeting once every two months. Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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We plan to take forward this work, connecting staff working in mental health for different age groups and supporting them with NIMHE’s information and knowledge management programme.

Building on foundations in mental health outcomes development There are examples of positive local practice in mental health. There is also an Outcomes Implementation Group with a remit to implement the findings of the Reference Group Report from 2004 and to develop networks of practice in routine outcome measurement. In child mental health, the CAMHS Outcome Research Consortium (CORC) has brought together 36 member services that have agreed common measures and protocol and have committed to sharing their data for joint analysis. The consortium’s work is ongoing and increasing numbers of child services are planning to join. The report from the Reference Group set out key recommendations arising from the pilot sites and allied initiatives and was published in 2004. In the report, Peter Fonagy and colleagues set out that: “Collecting outcomes data alone has limited value, it is only when it is interpreted and translated into positive changes in practice that it will yield improvements in the quality of services. Skills in interpreting outcomes data have to evolve locally and require the active involvement and goodwill of all responsible for collecting and interpreting outcomes data within each local trust. Implementation of outcomes measurement should therefore follow a developmental path. Further, successful implementation requires a balance between setting minimal national standards while allowing sufficient flexibility to encourage local innovation and initiative.” The key recommendations of the report were as follows: 1 A clear policy statement from the National Director for Mental Health on the requirements for, and use to which mental health outcomes data will be put. 2

Integration of outcomes measurement within the national IT investment in electronic record systems with the development of the National Care Records Service (NCRS).

Introduction of outcomes measures should begin with the most tried and tested measures – the clinician-rated morbidity measures. The suite of Health of the Nation Outcome Scale (HoNOS) measures could provide a developmental anchor, setting the minimum domains to be covered for the relevant population. Some trusts have adopted or developed more detailed morbidity measures and such innovation should be encouraged. Trusts would have the option of adopting different measures for morbidity, generating a HoNOS equivalent score where appropriate. Introduction of outcomes measures should include the most tried and tested measures, the clinician-rated morbidity measures. For adult mental health, the suite of HoNOS measures could provide a developmental anchor setting the minimum domains to be covered for the relevant population. Some trusts have adopted or developed more detailed morbidity measures and such innovation

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should be encouraged. Trusts would have the option of adopting different measures for morbidity, where appropriate generating a HoNOS equivalent score. 4

The development by mental health trusts and other provider organisations of mental health services of an implementation plan for routine outcome measurement. This implementation plan must take into account: • the integration of outcome measures with existing care processes and IT systems • a phased introduction within trusts taking into account local IT infrastructure, capacity and resources • adequate resourcing of outcome measurement

Although there is much positive experience to be built on from the pilot studies and associated work, some significant limitations to existing outcome measures were identified. The three principal concerns are: •

the lack of measures that fully represent the experience of people from black and minority ethnic groups. The needs and experience of black and minority groups of mental health services must be an early priority within the implementation plan

•

for all service users and carers, the lack of acceptable service user and carer measures of quality of life and satisfaction, was identified within the pilot programmes. A key development focus for outcome measures should be on developing more acceptable versions of these measures

•

many trusts lack effective systems to promote feedback, interpretation and understanding of outcome measurement, and without these any national or local programme is unlikely to be effective. Therefore a key priority for the programme is to establish trust clinical governance mechanisms to aggregate and analyse the data. This is so that outcome measurement can fully contribute to the understanding of the nature of the care provided and its general improvement

Outcome measures We believe that principles underpinning mental health outcome measures should take into account the following: • combine a range of core measures and improvement or developmental measures • reflect different perspectives, notably of service users and clinicians • cover themes of morbidity, mortality, quality of life and service satisfaction, originally set out by the National Director for Mental Health when work on outcomes began • seek to highlight the importance of connecting measures on mental health for services supporting people of all ages • embrace whole life issues, which in turn reflect the contribution of different service providers (e.g. primary and secondary care, as well as health, social care, education) and statutory/voluntary sectors • measures should be time limited and subject to review Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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Proposed metrics Discussions between those working across mental health policy development and implementation led to agreement that it is most appropriate for different age groups to have specific measures suiting their individual needs. Local communities will be best placed to implement outcome measures if: • they have a manageable total number • the metrics are measurable in practice (even if not currently collected) • informatics support and development improves • the metrics make sense to the service user and clinician • we are explicit and selective about what and how data is aggregated into a national picture or for benchmarking purposes • we are clear about how this work relates to other data collection exercises already being undertaken by the Department of Health and the Healthcare Commission • and, rather than allowing only validated metrics, there are guiding principles for local communities to implement localised ways of measurement This work will be taken forward under Louis Appleby’s sponsorship, involving Hugh Griffiths (chair of national group), and will continue to engage with NIMHE’s development centres at a regional level and other appropriate initiatives to support local practice development.

Relationship between the metrics and monitoring of national targets As explained in the introductory section, the metrics are offered as examples of good practice for local consideration. Therefore, it is important to place them in context of the data SHAs and PCTs will be required to collect as part of monitoring national targets for 2005–2008. In particular, we have tried not to reproduce the national data requirements within the metrics. For mental health, a key national target is reducing suicide mortality. The national data requirements for monitoring this target will be: 7 •

PSA05a: Suicide rates Mortality rate from suicide and undetermined injury per 100,000 directly age standardised population

•

PSA05b: CPA seven-day follow-up Percentage of people on enhanced CPA receiving follow up (by phone or face to face) within seven days of discharge from hospital

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Interventions that will help deliver this suicide target are described in the National Suicide Prevention Strategy 8 and the National Service Framework for Mental Health 9 . Unemployment and social isolation are important risk factors for deteriorating mental health and suicide. Information on how to help people with mental health problems gain and retain work, and improve community engagement, is set out in the report on mental health by the Governmentâ&#x20AC;&#x2122;s Social Exclusion Unit. Particular attention needs to be paid to the needs of those from black and ethnic minority communities (see metrics 9.11 and 9.12) and other groups that may be hard to reach. Contact name: Simon Pearson (e-mail: Simon.Pearson@dh.gsi.gov.uk)

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui dance/DH_4009474 9

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Mental health

The proposed metrics In summer 2005, we asked Dr Griffiths and colleagues to refresh their metrics, specifically to try to identify metrics available from national data sources. This was to facilitate use of the metrics by the Healthcare Commission when assessing trusts’ progress against developmental standards. However, due to the identification of data problems with some of the original metrics, a full consultative process for the refresh was postponed. A rapid process to derive indicators for the Healthcare Commission was lead by the mental health team at the Healthcare Commission in consultation with Dr Griffiths and others. The refreshed metrics derived from this process are provided with the original metrics, italicised for clarity. However, these refreshed metrics should be seen as an adjunct to the original metrics and not as a replacement. The aspiration to try to find a way to measure those metrics that are currently unavailable still stands. As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done)

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Child and adolescent mental health 9.01 Theme: Patient experience Objective: To maximise young people and their parents’ (or guardians’) satisfaction with child and adolescent mental health services Description of metric: Service satisfaction with child and adolescent mental health services, from the perspective of young people and parents or guardians Rationale/evidence base: Patient/user experience is a national priority National Service Framework for children, NSF standard(s) where applicable: young people and maternity services – standard 3: “Children and young people and families receive high quality services which are coordinated around their individual and family needs and take account of their views” Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: patient focus: developmental standards, D8 CURRENTLY POSSIBLE: Data source: Relevant Healthcare Commission patient experience survey tool See Healthcare Commission guidance Unit of analysis: Outcome Structure/process/outcome: Notes: This is actually the former CHI’s CAMHS patient experience survey tool. Discussions are currently ongoing to allow the tool and survey instructions to be handed over to CORC. Trusts would need to produce a list of recent or current patients as a sampling frame for their local surveys. Questions in survey tool may need to vary according to whether opinions are obtained from inpatients or outpatients

9.02 Theme: Access to age appropriate services Objective: Children and young people requiring mental healthcare are no longer admitted to adult psychiatric wards but receive care in appropriate inpatient settings Description of metric: Number of children and young people requiring mental healthcare admitted to adult psychiatric wards: measured for both under 16s and 16 and 17 year olds Rationale/evidence base: Due to the insufficient number of adolescent beds, some young people are being cared for inappropriately in adult psychiatric beds National Service Framework for Children, NSF standard(s) where applicable: Young People and Maternity Services – standards 3, 9: “The Mental Health and Psychological Wellbeing of Children and Young People” (see specifically sections 9.7 – 9.12 of standard 9). Also for 16-17 year olds, see National Service Framework for Mental Health (quoted on p32 of standard 9) National priority area: access to services (no High level PSA target: specific national target) Standards for better health domain: Accessible and responsive care – core standards: C19

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CURRENTLY POSSIBLE: Direct question to trust chief executive(s) (see notes) Number Unit of analysis: Process Structure/process/outcome: Notes: Expressed as a number (with no denominator) as regarded as a breach indicator. Assumes that there is local monitoring so that all trust chief executives have access to this information (particularly the under 16s). May also need to ask clinicians for their judgement of appropriateness of placement for 16 and 17 year olds. Data source:

However, it is advised that this metric is not used as a local target for measuring the performance of individual providers, but rather is seen as an indicator that includes the performance of commissioning. While the aim is to reduce the number of admissions of under 16 year olds to adult psychiatric care to nil, this will not happen until the necessary number of beds or alternative facilities are commissioned. If the focus is on measuring the performance of an individual provider trust then a perverse incentive may be created by the attempt to prevent necessary admissions to adult psychiatric care with no alternatives being provided. Over the lifetime of the Children's NSF the aim is for CAMHS to develop the capacity to look after all 16 and 17 year olds, with some flexibility and choice according to need and the views of the young person. There are two currently available proxy indicators that could also be used here: • “number of hospital occupied bed-days on adult psychiatric wards by under 16s” • “number of hospital occupied bed-days on adult psychiatric wards by 16 or 17 year olds” Both of these are available from Local Delivery Planning Returns (LDPR). See refreshed metric below Refreshed metrics: Metrics: The proportion of hospital occupied bed days on adult psychiatric wards by: i under 16s ii 16 or 17 year olds Data source: Mental Health Act Commission, Count me in Census

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9.03 Theme: Discharge and aftercare Objective: All children discharged from psychiatric inpatient care are subject to the Care Programme Approach (CPA) Description of metric: Percentage of children discharged from psychiatric inpatient care subject to the CPA Rationale/evidence base: National Service Framework for children, NSF standard(s) where applicable: young people and maternity services – standard 9 : “The Mental Health and Psychological Wellbeing of Children and Young People” (see specifically sections 9.13 – 9.14 of standard 9) High level PSA target: Standards for better health domain: Accessible and responsive care: developmental standards D11 CURRENTLY POSSIBLE: Data source: By local audit only (but see notes) Percentage Unit of analysis: Process Structure/process/outcome: Notes: CAMHS not using MHMDS. This will be difficult if current data collection systems are used, as admission frequently happens to units distant from the local service that should be providing the CPA or in the independent sector. Direct linkage will therefore not be possible. Could be identified by HES, though this will not cover independent sector providers and the sources available through the Regional Public Health Observatories (RPHOs) is about 18 months out-of-date when it appears. Need to investigate when the National Programme for Information Technology (NPfIT) spine will produce an effective discharge list. The local electronic CPA records will not cover those who are missed because their records have not been transferred to the local CPA system from their admitting unit. There are also discussions ongoing about what might be possible to collect from LDPRs

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9.04 Theme: Transition to adult services Objective: All children transferred from CAMHS to adult mental healthcare are subject to the CPA Description of metric: Percentage of children transferred from CAMHS to adult mental healthcare who are subject to the CPA Rationale/evidence base: See NSF standards National Service Framework for children, NSF standard(s) where applicable: young people and maternity services standard 4 (see section 6); standard 9 (see 7.3 to 7.5) High level PSA target: Standards for better health domain: Accessible and responsive care – developmental standards D11 CURRENTLY POSSIBLE: Data source: Transfers into adult services via MHMDS* Percentage Unit of analysis: Process Structure/process/outcome: Notes: *Currently, low rates of completion of CPA fields on MHMDS but improvement in this expected quarter on quarter. However transfers out of CAMHS would need to be identified by local audit. A desirable indicator would look at what happens to all young people ‘graduating’ from CAMHS

9.05 Theme: Emergency access to services Objective: Children and young people are able to receive urgent care when required and a specialist mental health assessment within 24 hours or the next working day Description of metric: Percentage of children and young people who receive urgent care when required* and a specialist mental health assessment within 24 hours or the next working day Rationale/evidence base: See NSF standards National Service Framework for Children, NSF standard(s) where applicable: Young People and Maternity Services standards 4, 9 (see specifically 6.8 to 6.11 of standard 9) National priority area: access to services (no High level PSA target: specific national target) Standards for better health domain: Accessible and responsive care – core standard C19 CURRENTLY UNAVAILABLE: Data source: But could be partially addressed by local audit (see notes) Percentage Unit of analysis: Process Structure/process/outcome: Notes: Local audit is unlikely to be able to capture all this data, as it is difficult to identify those people who try to get help but do not reach services. Audit of all those referred for urgent assessment could be undertaken. The CAMHS service mapping gives some indication of trusts able to offer this service – a proxy structure indicator is available from the mapping on the 24 hour availability of urgent access services for children and young people and whether these services are provided by CAMHS specialists

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Adult mental health (Note: There was an original intention to include a metric on hospital medication errors in the adult mental health metrics. However, this was removed after advice that it was unsuitable for use as a local target due to the anonymisation of data submitted to the NPSA.) 9.06 Theme: Access to appropriate services Objective: Improving access to psychological therapies when required Description of metric: The number/proportion of people who get access to psychological therapies assessment and to treatment within three months of referral (two measures) Rationale/evidence base: See NSF standards National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standard 2, 3 National priority area: Access to services High level PSA target: (national target applies only to acute elective hospital care “but PCTs are encouraged to agree local plans to reduce waiting for other types of treatment”) Standards for better health domain: Accessible and responsive care: developmental standard D11 CURRENTLY POSSIBLE: Data source: Local audit (see notes) Number and proportion (or percentage) Unit of analysis: Structure Structure/process/outcome: Notes: In previous versions of the metrics, it was stated that this data would be available through LDPRs. However, this was not finally agreed. This needs to be a high priority for inclusion in LDPRs in future. This data is not collected by adult service mapping Refreshed metrics: Metrics: i Counselling (the proportion of service users receiving wanted psychological therapies) ii The proportion of service users, provided by assertive outreach teams and community mental health teams, assessed and receiving psychological therapies as recommended by NICE guideline on schizophrenia Data source: i Healthcare Commission, Mental health service users’ survey ii Healthcare Commission, Mental Health service users’ survey

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9.07 Theme: Access to appropriate services Objective: Improve the timeliness of specialist assessment for people with psychosis Description of metric: The number/proportion of people who are referred with a provisional diagnosis of psychosis who get access to specialist assessment from a member of the mental health team within two weeks Rationale/evidence base: See NSF standards National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standard 4 National priority area: Access to services High level PSA target: (national target applies only to acute elective hospital care “but PCTs are encouraged to agree local plans to reduce waiting for other types of treatment”) Standards for better health domain: Accessible and responsive care: developmental standard D11 CURRENTLY POSSIBLE: Data source: Local audit (see notes) Number and proportion (or percentage) Unit of analysis: Process Structure/process/outcome: Notes: In previous versions of the metrics, it was stated that this data would be available through LDPRs. However, this was not finally agreed. This needs to be a high priority for inclusion in LDPRs in future. More work is awaited on data definitions and data collection systems. Adult service mapping does not collect this data and, unfortunately, waiting times for EI services are not collected through the LDPR and won’t be in the short term Refreshed metrics: Metrics: Availability of assertive outreach, crisis resolution, early intervention in psychosis services, model fidelity and persons served and the availability of community development, graduate, gateway, carer support, support time and recovery workers Data source: Adult Mental Health Service Mapping, Durham University

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9.08 Theme: Emergency access to services Objective: Improve the timeliness of crisis assessment Description of metric: The proportion of people who get access to crisis assessment within four hours of referral Rationale/evidence base: See NSF standards National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standards 3, 4 High level PSA target: Standards for better health domain: Accessible and responsive care: core standard C19 CURRENTLY POSSIBLE: Data source: Local audit Proportion (or percentage) Unit of analysis: Process Structure/process/outcome: Notes: This could be developed through a special minimum dataset for crisis teams. This would require resource input, but it should be achievable as there is a developing community of crisis teams Refreshed metrics: Metrics: Mental health service usersâ&#x20AC;&#x2122; survey â&#x20AC;&#x201C; crisis care Data source: Healthcare Commission

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9.09 Theme: Reducing inequalities, social exclusion and stigma Objective: Promote the employment of people with severe and enduring mental health problems Description of metric: The number/proportion of people on enhanced CPA in work, education or training Rationale/evidence base: See NSF standards National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standards 1 and 4 Improve the health of the population: reducing High level PSA target: mortality from suicide (see supporting text 1(iv)) Standards for better health domain: Public health: developmental standard D13 Clinical and cost effectiveness: developmental standard D2 CURRENTLY AVAILABLE: Data source: MHMDS* (partially only – see notes) Number and proportion (or percentage) Unit of analysis: Outcome Structure/process/outcome: Notes: *See earlier comments about MHMDS. This data is currently only partially available in MHMDS (for sheltered work programmes only), and depends on the completeness of data from the CPA records that are currently not very complete. Discussion is now ongoing to amend the coding for this item to include employment, education and training options. The key problem then will be identifying which patients would appropriately be in work, education or training. May also be a population measure available for PCT/LSP use, i.e. “unemployment rate in people with mental health problems” derived from the Labour Force Survey. (Also a refreshed metric – see below) Refreshed metrics: Metrics: i Employment status of people with recorded mental health issues ii Mental health service users’ survey (support in community, the proportion of service users receiving help with accommodation, work and benefits) Data source: i Labour Force Survey ii Healthcare Commission, Mental health service users’ survey

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9.10 Theme: Emergency access to services Objective: Improve the appropriateness of assessment of people with mental health problems presenting at A&E Description of metric: The number/proportion of people with a mental health problem* presenting at A&E who receive a psychosocial assessment Rationale/evidence base: See NSF standards National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standards 3 and 4 Priority I: Improve the health of the population High level PSA target: (reducing mortality from suicide) Standards for better health domain: Accessible and responsive care: core standard C19 CURRENTLY POSSIBLE: Data source: LDPR* (see notes) Number and proportion (or percentage) Unit of analysis: Process Structure/process/outcome: Notes: *To include people presenting with deliberate self-harm. In previous versions of the metrics, it was stated that this data would be available through LDPRs. However, this was not finally agreed. This needs to be a high priority for inclusion in LDPRs in future. More work is awaited on data definitions and data collection systems. Adult service mapping does not collect this data, although proxy structure indicators are available on which A&E departments have some sort of service. The benchmarking tool from the Department of Health’s guidance “Improving the management of patients with mental ill health in care settings” (published 3 September 2004) may also be useful in this context

9.11 Theme: Patient/user experience Objective: To maximise service users’ satisfaction with inpatient mental health services Description of metric: Service user satisfaction with inpatient service, broken down by ethnicity Rationale/evidence base: Patient/user experience is a national priority National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standard 5 Patient/user experience High level PSA target: Standards for better health domain: Patient focus: developmental standards, D8 CURRENTLY UNAVAILABLE: Data source: Work is currently underway through the Mental Health Outcomes Implementation Group to identify and agree suitable measures of service user satisfaction To be determined Unit of analysis: Outcome Structure/process/outcome: Notes: Refreshed metrics: Metrics: Mental health service users’ survey – questions relating to involvement in care planning, choice, waiting times, access to useful information and quality of relationships between service users and professionals Data source: Healthcare Commission, Mental health service users’ survey Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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9.12 Theme: Patient/user experience Objective: To maximise service users’ satisfaction with assertive outreach services Description of metric: Service user satisfaction with assertive outreach, broken down by ethnicity Rationale/evidence base: Patient/user experience is a national priority National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standards 4 and 5 Patient/user experience High level PSA target: Standards for better health domain: Patient focus: developmental standards, D8 CURRENTLY UNAVAILABLE: Data source: Work is currently underway through the Mental Health Outcomes Implementation Group to identify and agree suitable measures of service user satisfaction To be determined Unit of analysis: Outcome Structure/process/outcome: Notes: Refreshed metrics: Metrics: 1 Mental health service users’ survey – questions relating to involvement in care planning, choice, waiting times, access to useful information and quality of relationships between service users and professionals 2 Mental health service users’ survey – cancelled appointments, continuity of healthcare professionals Data source: Healthcare Commission, Mental health service users’ survey

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9.13 Theme: Health outcomes Objective: To reduce the inequalities in mortality rates for people with severe and enduring mental illness Description of metric: The death rate by age group for people with severe and enduring mental illness compared to the average population (adjusted for demographic factors) Rationale/evidence base: Mortality rates for people with severe and enduring mental illness are known to be higher than the general population, even when adjusted for demographic factors National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standards 1, 4, and 7 Priority I: Improve the health of the population High level PSA target: (no specific national target) Standards for better health domain: Public health: developmental standards D13 CURRENTLY UNAVAILABLE: Data source: Requires prospective flagging of people recorded on the MHMDS as on enhanced CPA within ONS, for linkage with death certificate data. Identified as a future task for Department of Health/ONS Standardised mortality ratio Unit of analysis: Outcome Structure/process/outcome: Notes: Not currently in the scope for the MHMDS work programme. This should be identified as a high priority for inclusion in the work programme Refreshed metrics: Metrics: 1 Extent to which services are collecting data to routinely measure outcomes 2 The proportion of service users with severe long-term mental health problems who have had a physical health review in line with recommended good practice in the last 15 months 3 The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status Data source: 1 Information Centre, Mental Health Minimum Data Set 2 Quality and Outcomes Framework 3 Information Centre, Mental Health Minimum Data Set (MH9)

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9.14 Theme: Emergency access to services Objective: To improve provision of inpatient services as locally as possible to service users’ place of residence Description of metric: The number of people referred locally to a service who are admitted in an emergency and admitted out of area because of lack of facilities Rationale/evidence base: See NSF standards National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standards 4 and 5 High level PSA target: Standards for better health domain: Accessible and responsive care: core standard C19 CURRENTLY AVAILABLE: Data source: HES (see notes*) Number Unit of analysis: Structure Structure/process/outcome: Notes: Breach indicator. *In order to better interpret the data, the agreed catchment area of NHS trusts needs to be mapped, although this might not be straightforward (many trusts have beds at more than one site which are not considered appropriate substitutes, and many sites have catchment areas which include specific anomalies).Ref: Glover G, Bindman J . Out of area hospitalisations – the view from routine statistics. Psychiatric Bulletin, 25: 376-8, 2001

9.15 Theme: Suicide prevention Objective: To reduce the incidence of suicide in a high-risk group Description of metric: The number/proportion of people on enhanced CPA getting follow up (by phone or face-to-face) within seven days of discharge from hospital Rationale/evidence base: See NSF standard; also “Safer Services” checklist National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standard 7 Priority I: Improve the health of the population High level PSA target: – substantially reduce mortality rates by 2010 from suicide and undetermined injury by at least 20% Standards for better health domain: Public health CURRENTLY AVAILABLE: Data source: MHMDS* Number and proportion (or percentage) Unit of analysis: Process Structure/process/outcome: Notes: *See earlier comments about completeness of MHMDS. Also MHMDS data does not currently include phone contact. Discussion currently ongoing about whether coding for the MHMDS should be amended to include phone contact. Also a refreshed metric (data source: Healthcare Commission, national targets) Refreshed metrics (in addition to 9.15, which is also a refreshed metric [see above]): Metrics: Proportion of service users who received a CPA review within one month of discharge from hospital Data source: Information Centre, Mental Health Minimum Data Set

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9.16 Theme: Responding to the needs of carers Objective: To improve carers’ health, psychological wellbeing and their ability to continue with their caring responsibilities Description of metric: The number of carers who have had a carer’s assessment in relation to the total number of people on enhanced Care Programme Approach who have a relevant carer for whom an assessment could be performed Rationale/evidence base: See NSF standard National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standard 6 No specific target High level PSA target: Standards for better health domain: Patient focus: developmental standards D9 CURRENTLY POSSIBLE: Data source: Local electronic CPA records (where available) or local audit (see notes) Proportion/percentage Unit of analysis: Process Structure/process/outcome: Notes: If this is included in local electronic CPA records, it could easily be added to the MHDMS. There could be an anomaly in this metric that people don’t record carers they don’t assess, unless the presence or absence of carers is a required field in the record. Discussions are ongoing about including such a field in the MHMDS. In which case, given the likely anomaly, it may be as useful to use “percentage of people recorded as having a carer” as an indicator. The latter is a refreshed metric: Information Centre, Mental Health Minimum Data Set (proportion of people recorded as having a carer)

9.17 Theme: Appropriate accommodation for people with severe and enduring mental health problems Objective: To improve the provision of (and timeliness of provision of) suitable accommodation for people with severe and enduring mental health problems Description of metric: The proportion of people on enhanced CPA who are waiting for suitable accommodation (having had their needs identified) for more than a month Rationale/evidence base: See NSF standards National Service Framework for Mental Health: NSF standard(s) where applicable: relates to standards 4 and 5 No specific target High level PSA target: Standards for better health domain: Public health: developmental standards D13 CURRENTLY POSSIBLE: Data source: Local audit (see notes) Proportion/percentage Unit of analysis: Process Structure/process/outcome: Notes: A more limited version of this should be produced in the MHMDS Refreshed metrics: Metrics: Proportion of people on enhanced CPA with recorded social work involvement Data source: Information Centre, Mental health Minimum Data Set

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Refreshed metrics were also developed for adult mental health as follows: Metrics: Implementation of NICE guidelines: 1 The proportion of service users of assertive outreach teams and community mental health teams who are on medication regimes that meet the recommendations as set out in the National Institute for Health and Clinical Excellence guideline for schizophrenia 2 Rates of prescribing for antipsychotics and selective serotonin reuptake inhibitor (SSRI) antidepressants Data source: 1 Healthcare Commission, Community Mental Health Services Improvement review 2 Prescribing Analysis and Cost Tabulation (ePACT) Metrics: Other: 1 Emergency bed days 2 Proportion of patients registered with a GP 3 Compliance with the Mental Health Act and Mental Health Act Code of Practice 4 Section 31 Health Act 1999 notifications Data source: 1 Healthcare Commission, national targets 2 Information Centre, Mental Health Minimum Data Set 3 Mental Health Act Commission 4 Department of Health

Older people's mental health Readers should also see the adult mental health metrics (metrics 9.06, 9.07. 9.10, 9.11, 9.12, 9.13 are directly relevant; most of the others have relevant objectives but the specific metric would not apply); and the older peopleâ&#x20AC;&#x2122;s metrics (all of which will apply to older people with mental illness). General note on data sources: Older peopleâ&#x20AC;&#x2122;s mental health service mapping is now supported and from 2004 the Durham website will be able to provide data on caseloads, referrals, attendances, occupied bed days, staffing, etc. (www.dur.ac.uk/mental.health). However this will only apply if services complete the mapping fully, otherwise Department of Health/Healthcare Commission data requirements only will be collected.

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9.18 Theme: Appropriateness of treatment for people with dementia Objective: To increase the prescription of anti-dementia drugs for eligible people Description of metric: The proportion of people eligible for anti-dementia drugs that are receiving them, within NICE guidance. (Metric to be reviewed when NICE produces its revised guidance) Rationale/evidence base: www.nice.org.uk/pdf/ALZHEIMER_full_guidance.pdf National Service Framework for Older People: NSF standard(s) where applicable: standard 7 Priority IV: Patient/user experience â&#x20AC;&#x201C; support High level PSA target: for older people to live in their own homes. Also priority II: Supporting people with longterm conditions Standards for better health domain: Clinical and cost effectiveness: core standard C5 CURRENTLY POSSIBLE: Data source: a Number of people receiving anti-dementia drugs from: mental health trust pharmacy records; audit of shared care protocols with primary care; local audit b Information on appropriateness of prescribing from local audit (including MMSE scores) c Number of people in a PCT population eligible for anti-dementia drugs â&#x20AC;&#x201C; synthetic estimation from best estimates of dementia prevalence by MMSE score (see notes) or audit in primary care to identify those people not referred to specialist services Proportion/percentage Unit of analysis: Process Structure/process/outcome: Notes: This should be a population or PCT indicator, which requires some estimate of the number of people in a population with dementia meeting the NICE criteria for prescription of anti-dementia drugs. Medical Research Council Cognitive Function and Ageing Study (1998) Cognitive Function and dementia in six areas of England and Wales: the distribution of MMSE and the prevalence of GMS organicity level in the MRC CFA Study. Psychological Medicine 28: 319- 335. (www.cfas.ac.uk) In the longer term, as OPMHS are in the MHMDS, numerator could be identified via MHMDS. However because of overlap with the Single assessment process (SAP), all the CPA derived items are frequently lacking. Drug details are only very limited in their completion in the MHMDS because pharmacy systems are still not usually patient linked in hospitals. NPfIT is the route by which this might get addressed

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9.19 Theme: Appropriateness of assessment Objective: To improve the appropriateness of admission of older people to inpatient mental health services Description of metric: The proportion of people admitted to mental health wards from the community who have had a multi-disciplinary team community assessment Rationale/evidence base: To avoid remediable problems being missed which could have prevented admission to hospital Older Peopleâ&#x20AC;&#x2122;s NSF standard 7 NSF standard(s) where applicable: No specific target High level PSA target: Standards for better health domain: Accessible and responsive care: developmental standards D11(d) CURRENTLY POSSIBLE: Data source: Local audit (see notes) Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: Data not available from the MHMDS Refreshed metrics: Metrics: 1 Availability of components of mental health services for older people 2 (Specifically) the availability of an A&E liaison service for older people Data source: Older peopleâ&#x20AC;&#x2122;s mental health service mapping, Durham University

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Older people

National Clinical Director: Professor Ian Philp It is now generally acknowledged that the needs of older people should be central to the development and organisation of health and social care services. This has been made explicit within the NSF for Older People – a 10-year programme of action aimed at developing high quality, integrated health and social care services for older people. However, many other programmes of work are highly relevant to the needs of older people and this is reflected in several sections of the Better Metrics project. For example, coronary heart disease and stroke, urgent care, diabetes, mental health, patient experience and primary care – all are highly pertinent to older people. This is partly a direct implication of rising condition prevalence rates with increasing age that necessitate that older people are a majority user of such services, but also because, if these services are sympathetic to the often complex needs of older people, all other service users will benefit. In healthcare settings, particularly in secondary and tertiary care, there is a pervasive tendency to view all older people as infirm, frail and to have chronic health problems. However, this group, although the largest consumers of health and social care, are not representative of the older population as a whole. The large majority of older people are healthy, active and socially engaged. Indeed, older people had a major influence in the content of the NSF and wished it to reflect their own priority of maintaining independence. Hence two metrics have been incorporated that aim to examine population health and wellbeing, and thereby act as a stimulus to keep our health and social services mindful of the key ambition of older people – to maintain their active and independent lifestyles. It is now well recognised that older people can have several conditions of varying severity such that it can be complex to unravel and identify the critical components and form a personalised intervention plan. The process of doing so is called assessment and has been central to good practice since the inception of special services for older people. There is reliable evidence that the process is effective in improving the outcomes for older people, with the proviso that the assessment process is closely linked to appropriate interventions. However, we have abundant evidence that assessment is not always well done or well coordinated between professionals or agencies. For this reason the second theme in the better metrics project in respect of older people is “Better assessment and care”. There is no doubt that our continuing drive to improve the consistency and quality of assessment for older people at all levels and services within health and social care will translate into large improvements in health experience and outcomes for this major population group in our society. The draft metrics were discussed with some interested clinicians around the country but we are taking the opportunity of this publication to invite wider comments. Please send comments to Professor Young, whose contact details are provided at the end of this introduction.

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Relationship between the metrics and monitoring of national targets As explained in the introductory section, the metrics are offered as examples of good practice for consideration locally. It is important, therefore, to be place them in context of the data SHAs and PCTs will be required to collect as part of monitoring national targets for 2005â&#x20AC;&#x201C;2008. In particular, we have tried not to reproduce the likely national data requirements within the metrics. For older people, clearly most of the national targets are relevant. Data requirements for monitoring targets in each of the national priority areas are reproduced in the relevant sections of this document. The patient/user experience target also specifically mentions the experience of older people. The national monitoring requirements for this target will be: 10 â&#x20AC;˘

PSA18a: Increase the proportion of older people being supported to live in their own home, and increase the proportion of those supported to live intensively to live at home [SHAs are not required to submit plan data to the Department of Health]

Part 1 The number of care managed clients aged 65 and over receiving services to help them live at home expressed as a rate per 1,000 population measures the support provided to care managed clients. Part 2 The number of people supported intensively to live at home as a proportion of the total being supported by social services intensively at home or in residential care. Contact name: Professor John Young, Department of Elderly Care, Extension Block, St Luke's Hospital, Little Horton Lane, Bradford BD5 0NA, e-mail: John.Young@bradfordhospitals.nhs.uk

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10 Older people The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done) 10.01 Theme: Better assessment and care Objective: To promote unified multi-agency assessment Description of metric: Proportion of people aged 75 and above who have had a contact and overview assessment in the last year, or an update, and have received a personal care plan Rationale/evidence base: Older People’s NSF Older People’s NSF, standard 2 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Fourth domain: Patient focus CURRENTLY POSSIBLE: Data source: Single assessment process (SAP) records (by local audit currently)* Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: The aim is for the proportion to increase from 30% in 2005 to 50% in 2006 and 70% in 2007 and thereafter * National Programme for IT (NPFIT) have an ‘early action team’ on the SAP, with the aim of expediting electronic SAP records

10.02 Theme: Better assessment and care Objective: To improve support for carers Description of metric: Population percentage of assessed older people whose carers have received a carer’s assessment* Rationale/evidence base: Older People’s NSF Older People’s NSF, standard 2 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Priority IV: Patient/user experience Standards for better health domain: Fourth domain: Patient focus CURRENTLY POSSIBLE: Data source: Single assessment process (SAP) records (local audit currently)** Percentage Unit of analysis: Process Structure/process/outcome: Notes: *Recommended to be at least 25% of 10.01 ** National Programme for IT (NPFIT) have an ‘early action team’ on the SAP, with the aim of expediting electronic SAP records Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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10.03 Theme: Better assessment and care Objective: To avoid overlooking remediable medical, mental health and social issues prior to admission to long-term care Description of metric: Proportion of older people admitted to long-term care (residential/nursing home/intensive home care) who have received comprehensive level of assessment prior to admission* Rationale/evidence base: Older People’s NSF Older People’s NSF, standard 2 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY POSSIBLE: Data source: Local audit Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: Recommended to be 100%

10.04 Theme: Better assessment and care Objective: 1 To reduce falls 2 To improve the appropriateness of medication Description of metric: Population percentage of older people on four or more drugs who have had a medicines review in one year* Rationale/evidence base: Older People’s NSF Older People’s NSF (1) standard 6 (2) NSF standard(s) where applicable: medicines appendix Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Not in nGMS** but could be extracted from GP data (may be difficult) Percentage Unit of analysis: Process Structure/process/outcome: Notes: *Recommended to be 100% **The relevant indicator from the QOF is "A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medications." There is no age specification and this only refers to repeat medications. Also, as this is in the organisational domain of the QOF, it is an indicator that only requires a yes/no answer. The practice will have had to have done some form of search of its records to determine whether it has met the indicator, and have this evidence available for the PCT to justify its achievement – but whether this can be broken down to cover older adults will depend on how the practice has done it

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10.05 Theme: Better assessment and care Objective: To reduce the frequency of falls in older people Description of metric: Proportion of older people (75+) with more than one fall in the last 12 months on risk register and reviewed by falls service* Rationale/evidence base: Older People’s NSF Older People’s NSF, standard 6 NSF standard(s) where applicable: Priority II: Supporting people with long-term High level PSA target: conditions Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Number of people assessed from the Falls Service; number of people on practice risk registers could be extracted from GP data (not in nGMS so extraction may be difficult) Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: *The aim would be for a 100% level of assessment

10.06 Theme: Better assessment and care Objective: To improve end of life care for older people, particularly those with noncancer terminal conditions Description of metric: Proportion of deceased older people with evidence of good end of life care prior to death (one of preferred place of care, Liverpool Care Pathway, Gold Standards Care or equivalent)* Rationale/evidence base: To promote similar standards of end of life care as for terminal cancer for people with other chronic conditions in their terminal phase NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care CURRENTLY UNAVAILABLE: Data source: Needs further work. The metric could be narrowed to the “proportion of deceased older people with chronic heart failure and chronic respiratory disease with evidence of good end of life care” and assessed by local audit in primary care Proportion or percentage Unit of analysis: Process Structure/process/outcome: Notes: * Aim for 100% of people with cancer and with chronic heart failure and chronic respiratory disease. See cancer metrics for metric on palliative care for people with cancer

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10.07 Theme: Population health and wellbeing Objective: To promote the ability to live independently Description of metric: Population level of independence in activities of daily living by age bands 65 to 74, 75 to 84, 85 plus Rationale/evidence base: National priority (see high level PSA target) Older People’s NSF, standard 8 NSF standard(s) where applicable: Priority IV: Patient/user experience – “Improve High level PSA target: the quality of life and independence of vulnerable older people by supporting them to live in their own homes where possible by: • increasing the proportion of older people being supported to live in their own home by 1% annually in 2007 and 2008; and • increasing by 2008 the proportion of those supported intensively to live at home to 34% of the total of those being supported at home or in residential care” Standards for better health domain: Fourth domain: Patient focus CURRENTLY POSSIBLE: Data source: Local surveys using Activities of Daily Living (ADL) questionnaire. (It would be possible to review SAP records, but this would limit the sample to only those in contact with services) ADL scores/Change in ADL scores over time Unit of analysis: Outcome Structure/process/outcome: Notes:

10.08 Theme: Population health and wellbeing Objective: To reduce excess winter death rates Description of metric: Excess winter death rates by local geographic clusters Rationale/evidence base: UK known to have higher excess winter death rates than many comparable and colder developed countries Older People’s NSF, standard 8 (particularly flu NSF standard(s) where applicable: vaccination) Priority I: Improving the health of the High level PSA target: population Standards for better health domain: Seventh domain: Public health CURRENTLY AVAILABLE: Data source: ONS mortality data Rates Unit of analysis: Outcome Structure/process/outcome: Notes: High uptake of flu vaccination is a key intervention here. Also an important metric for Local Strategic Partnerships as the other relevant interventions (e.g. adequacy of heating and housing, ref: Wilkinson P. Author’s reply. BMJ 2004; 329: 977) are within the local authority’s remit

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Improving patient experience

Department of Health and the Healthcare Commission

Improving the patient experience One of the main aims of the Better Metrics project is to engage clinicians in the performance improvement agenda through the use of more clinically relevant measures of performance. Clearly, patients’ experience of services is of vital importance to practitioners, highlighting the key role for patient experience metrics within this project. Within this context, the National Patient Survey Programme provides highly robust metrics of performance. While trusts and PCTS will need to use a variety of research tools to capture patients’ perspectives and experiences of the quality of local service planning and delivery, the programme provides a valuable evidence base for constructing a more fully rounded view of performance – both in its own right, and especially when used in conjunction with conventional operational/administrative measures. With this in mind, this section briefly describes the National Patient Survey Programme. The Healthcare Commission has overall responsibility for the day-to-day management of the national survey programme 11 12 , while trusts are responsible for organising and funding the surveys at a local level (according to standard guidance), and submitting their final data to the Healthcare Commission (via one of the sector-specific patient survey coordinating centres). The surveys are settingbased, and are conducted among recent users, allowing for the collection of detailed information about different aspects of their care and treatment. The survey programme is one of the largest in existence. As the tables overleaf show, 18 surveys have been conducted since 2001, across seven different settings, and well over one million patients have taken part in them. Three further surveys are scheduled to be conducted in 2007/2008. The tables in Appendix E present technical and reference details for all surveys conducted to date.

The results and full details of all national patient surveys conducted to date are available on the Healthcare Commission website, via the following link: www.healthcarecommission.org.uk/nationalfindings/surveys/patientsurveys.cfm

The Healthcare Commission is also responsible for running a number of patient surveys outside the “national patient survey”. These are National Service Framework (NSF) related surveys and they are conducted at a national level among clinically distinct groups of patients, with the aim of exploring patients’ experience of their journey across the entire care pathway. To date, this programme includes surveys conducted among patients who have experience of chronic heart disease (2004), strokes (2004 and 2005), and diabetes (2006/2007). Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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Survey results are used in a variety of ways, including, for example: • NHS trusts – to track their own performance over time, benchmark their results against similar organisations, inform local improvement activities (including Local Delivery Plans) and monitor the impact of these activities on the patient experience. Strategic Health Authorities (SHAs) also use results to monitor performance of trusts within their geographical area •

Healthcare Commission – results feed into the annual health check for all NHS organisations, via the new national targets, and standards based assessments. 13 Results are also widely used in relevant service reviews 14 and investigations 15

•

Department of Health – results are used to measure progress against a national Public Service Agreement target. 16 The PSA defines the patient experience in terms of five domains or dimensions, the development of which has been informed and validated by extensive social research among service users. The dimensions are as follows: • access and waiting • safe, high quality coordinated care • building closer relationships • better information, more choice • clean, friendly and comfortable place to be

Further details are available on the Healthcare Commission website, via the following link: http://annualhealthcheckratings.healthcarecommission.org.uk/annualhealthcheckratings.cfm 14 For example, service reviews of adult community mental health services and maternity services. Further details on each, respectively, are available on the Healthcare Commission website, via the following links: www.healthcarecommission.org.uk/serviceproviderinformation/reviewsandinspections/improvementreviews/adultcommunitymentalheal thservices.cfm www.healthcarecommission.org.uk/serviceproviderinformation/reviewsandinspections/acutehospitalportfolio/maternityservicesreview.cfm 15 Further details are available on the Healthcare Commission website, via the following link: www.healthcarecommission.org.uk/yourlocalhealthservices/investigationreports.cfm 16 PSA 7: “To secure sustained national improvements in the patient experience by 2008, as measured by independently validated surveys, ensuring that individuals are fully involved in decisions about their healthcare, including choice of provider.” Full technical details on the PSA are available on the Department of Health website, via the following link: www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/NationalsurveyofNHSpatients Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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National Patient Survey Programme: 2001/2002 â&#x20AC;&#x201C; 2007/2008 Year Survey 2001/02 Adult inpatients 2002/03 Outpatient services Emergency services PCT residents registered with a GP 2003/04 Adult inpatients PCT residents registered with a GP Young patients (day case and inpatient) Users of mental health services (CPA) Users of ambulance (urgent/emergency) services 2004/05 Outpatient services Emergency services PCT residents registered with a GP Users of mental health services (CPA) 2005/06 Adult inpatients Users of mental health services (CPA) PCT residents 17 registered with a GP 2006/07 Adult inpatients Users of mental health services (CPA) 2007/08 Adult inpatients PCT residents registered with a GP Users of mental health services (CPA) Users of maternity services

Number of trusts or PCTs 176 171 155 304 169 303 150 81 31 169 153 303 81 169 79 NA5 167 69

Number of useable responses 95,280 90,552 59,155 123,833 88,308 122,113 62,277 27,398 12,282 84,280 55,339 116,939 26,555 80,793 19,494 10,003 80, 694 Results to be published in September 2007

To be confirmed

Results from the surveys are analysed and presented in a number of ways â&#x20AC;&#x201C; for example, as percentage results, scores for each individual survey question, or aggregated scores for each of the five patient experience dimensions. These are presented for each trust, type of trust and the national average. The table overleaf summarises each of the different outputs from the survey programme. 17

Please note that this survey is different to PCT surveys that have been conducted in recent years. Although the same methodology and survey instrument was used, it has been commissioned by the Department of Health and is designed to provide national level data only (to enable performance against the PSA target to be monitored). Results are available on the Department of Health website via the following address: www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/NationalsurveyofNHSpatients/GPsurvey1999-2002 Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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Presentation of survey results Results for individual survey questions The Healthcare Commission publishes the following documents (please note that the tables in Appendix E present a website address where each of these outputs can be found): • local benchmark reports – a separate report for each trust, presenting their results on a subset of questions (all questions that can be scored), and how they compare to other trusts • Excel spreadsheets presenting results for all survey questions for all trusts participating in each survey. National level results are included, along with aggregated scores for each type of trust (except for the PCT surveys, which are grouped by Strategic Health Authority) 18 • national report – a report summarising the key findings from each survey – results presented are based on nationally aggregated data only Materials for each survey (including the full data set) are also deposited with the UK Data Archive (UKDA) 19 . Results for aggregated survey questions The Healthcare Commission also calculates aggregated scores for each of the five dimensions (based on a small subset of scored survey questions). The results of this analysis are used in two complementary ways: • performance assessment: in rating the performance of each trust, the Healthcare Commission construct performance indicators using a subset of survey questions – scores are calculated for each of the five patient experience dimensions, and from 2006 are now aggregated to form the “experience of patients” indicator. (For further details, please go to the website address given in footnote 3) • patient experience PSA target: the metrics used for measuring progress against the patient experience PSA are the same as that used by the Healthcare Commission for performance assessment. (For further details on the PSA methodology, please go to the website address given in footnote 6). The relative contribution of each NHS organisation towards the national target is presented in PEXIS, an improvement tool developed by the Department of Health (see footnote 10 for further details) 18

Please note that these results are not standardised to take into account differences in the populations surveyed, so are not intended to be used for comparisons between trusts. 19

UKDA is a service provider for the Economic and Social Data Service (ESDS), based at the University of Essex. All relevant survey materials are submitted to the archive including anonymised datasets, variable lists, questionnaires, descriptions of survey methodology, and national key findings reports. www.data-archive.ac.uk Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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Taken together, this means that organisations are able to monitor their own performance over time, as well as compare how well they do in relation to other organisations or the national ‘average’ – and this can be done at a question or patient experience dimension level. All of these datasets are valuable, and should be used by trusts in monitoring performance and planning/evaluating their improvement activities. To support the NHS in understanding survey data and to make it easier for them to monitor their performance, the Department of Health has developed a visually simple display tool – the Patient Experience Information System (PEXIS) – which was launched as part of UNIFY in March 2005, and made available to the NHS. PEXIS brings survey data together with other patient-focused performance data in an easy to use ‘traffic light’ system 20. PEXIS currently presents data for survey questions that are used in the construction of performance indicators by the Healthcare Commission; this is exactly the same set of questions used to measure progress against the patient experience PSA target. (The full list of these questions is set out on the following pages.) In time, this will be expanded to include other data sets that are used to measure performance against healthcare standards. Department of Health contacts Jason Cox (jason.cox@dh.gsi.gov.uk)

Healthcare Commission contacts Karen Hallt (karen.hallt@healthcarecommission.org.uk)

Mary Simpson (mary.simpson@dh.gsi.gov.uk)

Ian Seccombe (ian.seccombe@healthcarecommission.org.uk)

PEXIS/UNIFY is available at the website address given below. If you have not used UNIFY before, then you will need to log on first. This can be done by clicking on “sign on” at the top of the screen, followed by “request a UNIFY account”. If you have any questions about PEXIS/UNIFY, then please contact the help desk on 0113 254 5278, or by e-mail: unify@dh.gsi.gov.uk. nww.unify.dh.nhs.uk/unify/interface/homepage.aspx Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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The following pages present, survey by survey, the subset of core questions from the National Patient Survey Programme that are used by the Healthcare Commission and the Department of Health to construct measures of performance. Adult inpatient survey Access and waiting Was your admission date changed by the hospital? [Waiting list only] How do you feel about the length of time you were on the waiting list before your admission to hospital? [Waiting list only] Did you feel that you had to wait a long time to get to your room or ward or bed? [All] Safe, high quality, coordinated care Sometimes in a hospital, a member of staff will say one thing and another will say something quite different. Did this happen to you? [All] On the day you left hospital, was your discharge delayed for any reason? + What was the main reason for the delay? [All/All delayed] Did a member of staff tell you about any danger signals you should watch for after you went home? [All] Better information, more choice Were you involved as much as you wanted to be in decisions made about your care and treatment? [All] Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand? [All given medication] Did a member of staff tell you about medication side effects to watch for when you went home? [All given new medication and wanting an explanation] Building closer relationships When you had important questions to ask a doctor, did you get answers that you could understand? [All wanting and explanation] Did doctors talk in front of you as if you werenâ&#x20AC;&#x2122;t there? [All] When you had important questions to ask a nurse, did you get answers that you could understand? [All wanting an explanation] Did nurses talk in front of you as if you werenâ&#x20AC;&#x2122;t there? [All] Clean, comfortable, friendly place to be Were you ever bothered by noise at night from other patients? + Were you ever bothered by noise at night from hospital staff? [All] In your opinion, how clean was the hospital room or ward that you were in? [All] How would you rate the hospital food? [All who had food] Were you given enough privacy when being examined or treated? [All] Overall, did you feel you were treated with respect and dignity while you were in hospital? [All] Do you think hospital staff did everything they could to help to control your pain? [All who were in pain]

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2001/02

2003/04

2005/06

2006/07

Q9 Q7

Q7 Q4

Q16 Q14

Q13 Q12

Q11

Q17

Q14

Q28

Q23

Q33

Q35

Q40

Q35-Q36

Q52-Q53

Q54-Q55

Q43

Q40

Q58

Q60

Q29 Q41

Q24 Q38

Q34 Q55

Q36 Q57

Q42

Q39

Q56

Q58

Q21

Q16

Q24

Q26

Q23 Q25

Q18 Q19

Q26 Q28

Q28 Q30

Q27

Q21

Q30

Q32

Q15

Q11-12

Q19-Q20

Q20-21

Q16 Q18 Q33 Q46 Q39

Q13 Q15 Q29 Q43 Q34

Q21 Q23 Q38 Q62 Q43

Q22 Q24 Q41 Q64 Q45

PCT survey

2002/03

Access and waiting The last time you saw a doctor from your GP surgery did you have to wait for an appointment? [All seen by someone/Dr at surgery in last year] How long after your appointment time did you have to wait to be seen? [All visiting surgery in last year] In the last 12 months, have you ever been put off going to you GP surgery/health centre because the opening times are inconvenient? [All] Safe, high quality, coordinated care Did you have confidence and trust in the doctor? [All seen by someone/Dr at surgery in last year] When you first saw the person you were referred to, did he/she seem to have all the necessary information about you and your condition or treatment? [All who have been referred in last year] In the last 12 months, have you seen at your GP surgery to check how you are getting on with this medicine? [All taking medication for longer than a year] Better information, more choice Were you involved as much as you wanted to be in decisions about your care and treatment? [All seen by someone/Dr at surgery in last year] Were you given enough information about the purpose of the medicine(s)? [All prescribed new medication] Were you given enough information about any side effects the medicine might have? [All prescribed new medication] Building closer relationships If you had questions to ask the doctor, did you get answers that you could understand? [All seen by someone/Dr at surgery in last year] Were you given enough time to discuss your health or medical problem with the doctor? [All seen by someone/Dr at surgery in last year] Clean, comfortable, friendly place to be Did someone tell you how long you would have to wait? [All visiting surgery in last year] In your opinion, how clean is the surgery/health centre? [All] Did the doctor treat you with respect and dignity? [All seen by someone/Dr at surgery in last year] When you arrived at the surgery, how would you rate the courtesy of the receptionist? [All visiting surgery in last year]

2005/06 21

2003/04

2004/05

QA3

QA2

QB4 QG5

QB4 QH2

Q8 Q36

Q8 Q45

QA9 QD3

QC6 QF3

Q16 Q27

Q16 Q32

QE7

QD7

Q24

QA11

QC4

Q13

QE3

QD3

Q20

QE4

QD4

Q21

QA13

QC8

Q15

Q14

QA7

QC3

Q12

QB5 QG1 QA12

QB5 QH1 QC7

Q9 Q34 Q17

Q9 Q43 Q17

QB2

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Outpatient survey Access and waiting How long after the stated appointment time did the appointment start? [All] Overall, from the time you were first told you needed an appointment to the time you went to the Outpatients Department, how long did you wait for an appointment? [All] Safe, high quality, coordinated care Sometimes in a hospital or clinic, a member of staff will say one thing and another will say something quite different. Did this happen to you? [All] Did a member of staff tell you about what danger signals regarding your illness or treatment to watch for after you went home? [All] Did you have confidence and trust in the doctor examining and treating you? [All who saw doctor] Did you have confidence and trust in him/her? [All who saw other healthcare professional] Did the doctor seem aware of your medical history? [All who saw doctor] Better information, more choice Were you involved as much as you wanted to be in decisions about your care and treatment? [All] Did a member of staff explain the purpose of the medications you were to take at home in a way you could understand? [All prescribed new medication] Did a member of staff tell you about medication side effects to watch for? [All prescribed new medication] While you were in the Outpatients Department, how much information about your condition or treatment was given to you? [All] Before any treatment, did a member of staff explain any risks and/or benefits in a way you could understand? [All who had treatment] Building closer relationships If you had important questions to ask the doctor, did you get answers that you could understand? [All who saw doctor] If you had important questions to ask him/her, did you get answers that you could understand? [All who saw other healthcare professional] Did doctors and/or other staff talk in front of you as if you werenâ&#x20AC;&#x2122;t there? [All] Did you have enough time to discuss your health or medical problem with the doctor? [All who saw doctor] Did the doctor listen to what you had to say? [All who saw doctor] Clean, comfortable, friendly place to be In your opinion, how clean was the Outpatients Department? [All] Were you told how long you would have to wait for the appointment to start? [All waiting longer than 15 minutes] Overall, did you feel you were treated with respect and dignity while you were in the Outpatients Department? [All]

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2002/03

2004/05

QB1 QA1

Q5 Q1

QF5

Q27

QH5

Q44

QD8 QE4 QD9

Q17 Q22 Q18

QF6 QH3

Q28 Q41

QH4 QF4

Q42 Q24

QG7

Q38

QD7 QE3

Q16 Q21

QF3 QD2 QD5

Q23 Q12 Q15

QC1 QB2 QJ2

Q9 Q6 Q48

A&E survey

2002/03

Access and waiting From the time you first arrived at the Emergency Department, how long did you wait before being examined by a doctor or nurse practitioner? [All] Overall, how long did your visit to the Emergency Department last? [All] How long did you wait before you spoke to a nurse of doctor? [All] Safe, high quality, coordinated care Sometimes in a hospital, a member of staff will say one thing and another will say something quite different. Did this happen to you in the Emergency Department? [All] Did a member of staff tell you about what danger signals regarding your illness or treatment to watch for after you went home? [All] Did you have confidence and trust in the doctors and nurses examining and treating you? [All] Better information, more choice Were you involved as much as you wanted to be in decisions about your care and treatment? [All] Did a member of staff explain the purpose of the medications you were to take at home in a way you could understand? [All who were prescribed new medication] Did a member of staff tell you about medication side effects to watch for? [All who were prescribed new medication] While you were in the Emergency Department, how much information about your condition or treatment was given to you? [All] Building closer relationships Did doctors or nurses talk in front of you as if you werenâ&#x20AC;&#x2122;t there? [All] Did you have enough time to discuss your health or medical problem with the doctor or nurse? [All] While you were in the Emergency Department, did a doctor or nurse explain your condition and treatment in a way you could understand? [All] Did doctors and nurses listen to what you had to say? [All] If you had any anxieties or fears about your condition or treatment, did a doctor or nurse discuss them with you? [All] Clean, comfortable, friendly place to be In your opinion, how clean was the Emergency Department? [All] Were you given enough privacy when being examined or treated? [All] Overall, did you feel you were treated with respect and dignity while you were in the Emergency Department? [All] Do you think hospital staff did everything they could to help control your pain? [All]

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2004/05

QB4

QB6 QB1

Q7 Q3

QD6

Q19

QH6

Q38

QC6

Q12

QD7 QH4

Q20 Q35

QH5 QD3

Q36 Q15

QC8 QC1 QC2

Q14 Q8 Q9

QC3 QC5

Q10 Q11

QG1 QD5 QJ1 QF5

Q29 Q17 Q41 Q28

Mental health survey 22 Access and waiting Can you contact your Care Coordinator if you have a problem? In the last 12 months have you had any talking therapy (e.g. counselling) from NHS Mental Health Services? Safe, high quality, coordinated care Did you have trust and confidence in the psychiatrist you saw? The last two times you had an appointment with a psychiatrist was it with the same psychiatrist both times or with two different psychiatrists? Did you have trust and confidence in the CPN? Do you have the number of someone in Mental Health Services that you can call out of office hours? Better information, more choice Do you have enough say in decisions about your care and treatment? In the last 12 months have you received any information about local support groups for mental health service users? Has your diagnosis been discussed with you? Were the purposes of the medications explained to you? Were you told about possible side effects of the medications? Building closer relationships Did the psychiatrist listen carefully to you? Did the psychiatrist treat you with respect and dignity? Did the CPN listen carefully to you?

2003/04

2004/05

2005/06

2006/07

QE10 QD1

Q29 Q24

Q27 Q23

QB3 QB6

Q5 Q9

QB9 QG1

Q12 Q44

Q12 Q42

QJ2 QF7

Q52 Q43

Q52 Q38

QJ3 QC4 QC5

Q53 Q22 Q23

Q53 Q21 Q22

QB2 QB4 QB8

Q4 Q6 Q11

Please note that, since the mental health services surveys are not setting-based, questions are not used to construct scores for the â&#x20AC;&#x153;clean, friendly and comfortable place to beâ&#x20AC;? domain.

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Primary care

National Clinical Director: Dr David Colin-Thomé

12.1 General primary care Background to the Quality and Outcomes Framework The QOF was developed and introduced as part of the negotiations surrounding the new GMS contract for GP practices. It was published in spring 2003 and implemented by GPs from April 2004. Although originally developed as part of the GMS contract, it can also be used by PMS, PCTMS (medical services provided directly by the PCT) and APMS (medical services provided by alternative providers such as commercial companies) contractors. The contract was reviewed in 2005/2006 for implementation in April 2006 under recommendations made in the original contract. NHS Employers started a review process in 2005, engaging an expert panel led by the University of Birmingham. The panel received submissions for changes to existing or new indicators in the summer 2005 and assessed the evidence before feeding their reports into the negotiating process. NHS Employers and GPC agreed to release 138 points for new indicators for 2006/2007 to be used mainly in clinical areas. A further 28 points have been reallocated to existing indicators where data suggested the potential for further improvement. The QOF is a set of indicators that rewards practices for the quality of care they provide. It does not replace payments for actually performing that care (these are included in the practice’s global sum and any MPIG payment). Each indicator has a given number of points attached to it, and the practice scores a certain number of points depending on their performance. Each point scored translates into an average payment of £77.50 in 2004/2005 and £124.50 for 2005/2006 onwards. The payment is adjusted upwards if the practice records above average prevalence of disease, or has a high list size, and downward if the opposite is the case. The negotiators of the new GMS contract agreed the following principles relating to the QOF: • indicators should, where possible, be based on the best available evidence • the number of indicators for each clinical condition should be kept to the minimum number compatible with an accurate assessment of care • data should not be collected purely for audit purposes • only data useful in patient care should be collected • data should not be collected twice In addition, for the 2006/2007 contract (www.nhsemployers.org/primary), it was agreed between NHS Employers and GPC that they are committed to ensuring a contract that: • is better for patients • is fair to the profession • represents good value for money These principles were applied to the construction of the indicators. This means some areas and outcomes were not included, because it was impossible to construct an appropriate indicator.

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The 2006/2007 QOF comprises 135 indicators and 1000 points. It is split into four areas or domains: clinical, organisational, patient experience and additional services. There is also a bonus payment: for holistic care, which is a payment based on the achievement in the clinical domain (see www.nhsemployers.org/primary to view the full QOF). The clinical domain is the largest section of the QOF, forming just over half of the QOFâ&#x20AC;&#x2122;s content (80 indicators, 655 points). A greater focus has been secured in the revised framework for 2006/2007 on clinical areas so as to obtain a more direct impact on health outcomes for patients. Inclusion of new areas was made possible through releasing 138 points from the existing QOF. The clinical domain rewards high quality clinical practice and covers the following 19 indicator groups: coronary heart disease, heart failure (formerly left ventricular dysfunction), stroke (including transient ischaemic attacks), hypertension, diabetes, chronic obstructive pulmonary disease, epilepsy, hypothyroidism, cancer, palliative care, mental health, asthma, dementia, depression, chronic kidney disease, atrial fibrillation, obesity, learning disabilities and smoking. The authors of the QOF chose the disease areas according to the following reasons: i where responsibility for ongoing management rests primarily with the GP and the primary care team ii where there is good evidence for the health benefits likely to result from improved primary care iii whether a national accepted clinical guideline existed iv where the disease is a priority across the UK The organisational domain rewards good organisational and HR practice. It covers five areas: records and information about patients, patient communication, education and training, practice management and medicines management. It is based extensively on the Royal College of General Practitionersâ&#x20AC;&#x2122; Quality Practice Award. For 2006/2007, the organisational domain consists of 188 points spread over 43 indicators. The patient experience domain covers two areas: length of consultation and patient surveys Two patient surveys are accredited for use: the General Practice Assessment Questionnaire (GPAQ) and the Improving Practice Questionnaire (IPQ). Finally, the additional service domain covers four of the new GMS contractâ&#x20AC;&#x2122;s additional services: cervical screening, child health surveillance, maternity services and contraceptive services. The negotiating parties agreed and recognised that the QOF is a living thing, which will be subject to a process of change and improvement over time as part of the negotiation process. It is expected that changes will be negotiated with reference to those elements of the QOF where science and evidence has moved on, or which are no longer necessary, or where the workload has been shown to have changed; and in the context of the value for money agreement described above. Equally, the negotiating parties agreed that for the ongoing success of the QOF, it should have a reasonable degree of stability, be evidence based, be able to be supported by information management and technology software and be governed by an agreed process of evidence review and refinement. Contact name: Tracy Owen (Tracy.Owen@dh.gsi.gov.uk) Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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General primary care The proposed metrics Description of metric: Improvement in a PCT’s aggregated scores (overall, by domain or by sections within the domains) on the QOF. The asthma, COPD and epilepsy section scores from the clinical domain are suggested as an initial priority as these conditions are not covered elsewhere in the metrics. The patient experience domain is also highlighted as an area where metrics could be constructed.

12.2 Primary care nursing The proposed metrics Many nurses are contributing to delivering the Quality and Outcomes Framework and their work is captured alongside that of other colleagues. These indicators of quality have been selected because they comprise, almost exclusively, nursing care. They also have a good evidence base and lend themselves to measurement relatively easily. Contact name: Maureen Morgan (e-mail: Maureen.Morgan@dh.gsi.gov.uk) As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done)

12.2.1 Theme: Care for people with ulceration of the leg Objective: All patients presenting with ulceration of the leg are assessed, including the use of a Doppler, by a nurse who is competent to do so, and all findings are recorded Description of metric: Percentage of patients registered with GP practice with diagnosis of leg ulceration appropriately assessed by a nurse competent to do so Rationale/evidence base: NICE Guidance (www.nice.org.uk/pdf/clinicalguidelinepressuresoreguidancenice.pdf) NSF standard(s) where applicable: High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness CURRENTLY POSSIBLE: Data source: Local audit of patient nursing record – care plan Percentage Unit of analysis: Process Structure/process/outcome: Notes: Equipment to be available with sufficient nurses trained in its use; nurses carry out procedure when patient presents with ulceration, record findings, initiate treatment, refer to vascular service as appropriate; patients receive appropriate treatment and healing rates are improved

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12.2.2 Theme: Prevent pressure sores in people at high risk Objective: All at risk patients are screened and assessed to determine level of vulnerability for pressure sores. Findings are recorded and reassessment is considered continuously Description of metric: Percentage of patients registered with GP practice population who are at risk – i.e. have considerably impaired mobility – who have been screened and assessed Rationale/evidence base: NICE Guidance (www.nice.org.uk/pdf/clinicalguidelinepressuresoreguidancenice.pdf) NSF standard(s) where applicable: High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness CURENTLY POSSIBLE: Data source: Local audit – Nursing records and care plans Percentage Unit of analysis: Process Structure/process/outcome: Notes: Patients with impaired mobility are referred to district nurse team, an assessment method is defined and agreed, nurses are trained in assessment, pressure relieving equipment is available; assessments are carried out as part of initial contact and episodically, treatment implemented, progress is recorded, patients general health, including nutrition, is assessed and recorded and action initiated as required; patients suffer fewer pressure and healing rates are improved for those that do

12.2.3 Theme: Essence of care Objective: The national nursing care benchmarking system, Essence of care, is being used in at least two of the eight dimensions and plans are in place for further extension Description of metric: Percentage of PCT nurses (including GP employed and PCT employed) using Essence of care in at least two dimensions Rationale/evidence base: Essence of care NSF standard(s) where applicable: High level PSA target: Standards for better health domain: Second domain: Clinical and cost effectiveness Fourth domain: Patient focus CURRENTLY POSSIBLE: Data source: PCT local audit – evidence of nursing activity Percentage Unit of analysis: Process Structure/process/outcome: Notes: A project lead is identified and training is available for staff; staff are encouraged to become proficient in using bench-marking techniques, nurses are given time for undertaking the work, records are kept at PCT level on the standards teams taking forward; each nurse team defines the area to work on and facilitation is given to begin the process; the quality of care in the area chosen is improved according to the Essence of care standard

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12.3 Primary care dental services Chief Dental Officer: Barry Cockcroft The following metrics have been developed to assist dental practices and PCTs in evaluating and improving NHS primary care dental services. New contractual arrangements for NHS dentists working in general dental practice were introduced in April 2006, the biggest change in dentistry for 50 years. PCTs now have the resources to commission the dental services that are needed to meet all reasonable health needs of their population. Local commissioning will benefit patients by improving access, improving oral health inequalities and the new contractual arrangements will improve the working lives of the dental team. A small team from the office of the Chief Dental Officer in the Department of Health, strategic health authorities and the Dental Reference Service developed the metrics. In addition, the British Dental Association has had an opportunity of commenting on the metrics and their comments have been taken into consideration. In developing the metrics, the team drew first on the PCT Competency Framework for dentistry developed by National Primary and Care Trust Development Programme (NatPaCT) (www.primarycarecontracting.nhs.uk/89.php) together with existing service requirements. There are no new data sources required and all the objective information for measurement should be readily available, and in many cases, may already be in use. The dental metrics cover three of the four National Priority Areas (PSAs) and all seven of the Core and Development Standards Domains as outlined in the Health and Social Care Standards and Planning Framework 2005/2006 – 2007/2008. Contact name: Tony Jenner (e-mail: tony.jenner@dh.gsi.gov.uk)

Primary care dental services The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done)

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12.3.1 Theme: Maintaining access to NHS dentistry Objective: To ensure that the public has access to appropriate and locally available dental services Description of metric: Percentage of PCTâ&#x20AC;&#x2122;s population who have been able to access NHS dentistry within a specific period of time (see note below) Rationale/evidence base: Key objective for dentistry: Maintaining access to NHS dentistry NSF standard(s) where applicable: Priority III: Access to services* High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care (C18, D11c) CURRENTLY AVAILABLE: Data source: Information will be provided by the BSA Percentage Unit of analysis: Process Structure/process/outcome: Notes: * This metric relates to the general issue of access but not directly to the PSA target. The period of time has currently to be confirmed but it is likely to relate closely to the NICE guidance on recommended recall intervals for dentistry

12.3.2 Theme: Workforce in Primary Dental Care Objective: PCTs have detailed plans about the size and development requirements for the whole dental workforce in their areas Description of metric: Percentage of workforce plans judged satisfactory and appropriate by SHA Rationale/evidence base: Key objective for dentistry: Maintaining the dental workforce NSF standard(s) where applicable: Priority III: Access to services* High level PSA target: Standards for better health domain: Fifth domain: Accessible and responsive care (C18) CURRENTLY AVAILABLE: Data source: PCT workforce returns to SHAs Percentage Unit of analysis: Structure Structure/process/outcome: Notes: NHS Dentistry â&#x20AC;&#x201C; Delivering the Change detailed how the dental workforce in England is to be expanded. PCTs should have a clear indication of their future dental workforce requirements. * This metric relates to the general issue of access but not directly to the PSA target

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12.3.3 Theme: Accurate information for patients Objective: To ensure that patients have access to accurate and accessible information to support choice of a dental service that meets their needs Description of metric: Evidence of PCT validation of nhs.uk database every four weeks Rationale/evidence base: Key objective for dentistry: Providing accurate information for patients, relatives and other healthcare professionals NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus (C16, D9) CURRENTLY AVAILABLE: Data source: nhs.uk/dental practices N/A Unit of analysis: Process Structure/process/outcome: Notes: PCTs need to regularly gather information about the services practices provide and practice acceptance policies and should update the nhs.uk database which is an a source of information for the public and NHS Direct

12.3.4 Theme: Information for patients about treatment choices Objective: Patients are provided with appropriate information to enable them to choose the most appropriate care Description of metric: Patients are provided with appropriate information to enable them to choose the most appropriate care Rationale/evidence base: Key objective for dentistry: Providing information for patients about treatment choices NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus (C16,D9) CURRENTLY AVAILABLE: Data source: Practices â&#x20AC;&#x201C; NHS patient treatment plan (currently DC 17) Percentage Unit of analysis: Process Structure/process/outcome: Notes: The Dental Reference Service will assess standards in record keeping on their practice visits. Following a full examination, dental practices should be providing full explanations about available and appropriate care and treatment and whether this is NHS or private. Patients should be provided with a written estimate of costs (Form FP17DC) for all Band 2 and 3 courses of treatment and where private treatment is to be provided or whenever a patient asks for one

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12.3.5 Theme: Quality of clinical care in NHS dentistry Objective: Monitoring the quality of dental care being provided for patients Description of metric: Percentage of reports received by PCT which are categorised as satisfactory each year Rationale/evidence base: Key objective for dentistry: Ensuring high quality of clinical care in NHS dentistry NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Third domain: Governance Second domain: Clinical and cost effectiveness (C5,8, D2,3,4,7) CURRENTLY AVAILABLE: Data source: Dental Reference Service reports to PCT about each dental practice Percentage Unit of analysis: Process, outcome Structure/process/outcome: Notes: Dental practices will review the quality of care provided as part of their on-going governance arrangements. The Dental Reference Service will alert dentists and PCTs to potential quality issues

12.3.6 Theme: Patient safety Objective: Dental practices have appropriate policies to protect patient and staff safety Description of metric: Percentage of dental practices by PCT with quality assurance policies in accordance with PCT clinical governance Rationale/evidence base: Key objectives for dentistry: Ensuring patient and staff safety NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: First domain: Safety Second domain : Governance (C4,7, D1,3,4) CURRENTLY AVAILABLE: Data source: Dental practice quality assurance policies Percentage Unit of analysis: Structure, process Structure/process/outcome: Notes: As part of PCT clinical governance arrangements, dental practices should have quality assurance policies in place. This information will be obtained through practice visits from the PCT or its agents

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12.3.7 Theme: Visits and inspections of dental practices Objective: All surgery premises should be visited as a minimum on a three-yearly basis by a suitable body able to assess and report on their compliance with current legislation and best practice Description of metric: Percentage of dental practices visited at three-yearly intervals by PCT or agent Rationale/evidence base: Key objective for dentistry: Ensuring dental practices are inspected on a regular basis NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Sixth domain: Care environment and amenities Third domain: Governance (C7, 20, 21, D12) CURRENTLY AVAILABLE: Data source: PCT governance records Percentage Unit of analysis: Process Structure/process/outcome: Notes: There is a standard protocol for practice visits agreed between the BDA, the Department of Health and the Healthcare Commission

12.3.8 Theme: Patient feedback Objective: Patients should have the opportunity of feeding back their views on the dental services they have received to practices, the NHS and the Healthcare Commission and the General Dental Council Description of metric: Number of annual complaints by practice and by PCT Rationale/evidence base: Key objective for dentistry: Supporting patient feedback on dental services NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Fourth domain: Patient focus (C14, D8) CURRENTLY AVAILABLE: Data source: National requirement for complaints return from dental practices to PCTs Number Unit of analysis: Process Structure/process/outcome: Notes: Schedule 3, Part 6 No 52 of the contract regulations requires the contractor to inform the PCT of the number of complaints received at such time as the PCT requires. PCTs should assess the complaints and feedback from patients and advise patients of processes for the prompt handling of these

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12.3.9 Theme: Access to out of hours (OOH) dental services Objective: PCTs have made appropriate and adequate provision for OOH dental care Description of metric: OOH services provided by PCT in days per week and hours per day during both weekdays and weekends Rationale/evidence base: Key objective for dentistry: Appropriate access to out of hours dental care NSF standard(s) where applicable: Priority IV: Patient/user experience High level PSA target: Standards for better health domain: Accessible and responsive care (C19) CURRENTLY AVAILABLE: Data source: PCT Days per week and hours per day Unit of analysis: Structure Structure/process/outcome: Notes: PCTs have the responsibility for providing a dental OOH service 12.3.10 Theme: Assessing oral health needs Objective: PCTs should assess local oral health needs by commissioning appropriate surveys of their adult and child populations and provide a portfolio of oral health needs assessment for their localities Description of metric: Has the PCT an appropriate portfolio of OH needs assessment validated by the SHA? (yes/no) Rationale/evidence base: Key objective for dentistry: Assessing oral health needs NSF standard(s) where applicable: Priority I: Improve health of the population High level PSA target: Standards for better health domain: Seventh domain: Public health (D13a) CURRENTLY AVAILABLE: Data source: PCT Yes/no Unit of analysis: Process Structure/process/outcome: Notes: PCTs have a statutory responsibility to assess oral health needs and provide services to meet those needs. Note also link to Public Health 12.3.11 Theme: Reducing oral health inequalities Objective: PCTs should aim to improve poor oral health and reduce inequalities by implementing effective health improvement programmes Description of metric: PCT has included oral health within its LDP and has developed an action plan for improving oral health developed with local stakeholders Rationale/evidence base: Key objective for dentistry: Reducing oral health inequalities NSF standard(s) where applicable: Priority I: Improve the health for the population High level PSA target: Standards for better health domain: Seventh domain: Public health (C22, 23, D13) CURRENTLY AVAILABLE: Data source: PCTs Yes/no Unit of analysis: Process Structure/process/outcome: Notes: The Governmentâ&#x20AC;&#x2122;s Oral Health Plan for England Choosing Better Oral Health pointed out that although oral health is improving, there are inequalities between regions and within localities. PCTs should ensure that these inequalities are addressed through appropriate preventive programmes Better Metrics version 8. Published at www.healthcarecommission.org.uk November 2007

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Research & development

National Director of Research and Development: Professor Sally Davies These metrics are offered to support local assessment of NHS research activity. They do not measure whether research is being conducted to an acceptable standard of governance. Research governance is one of the core standards set out in Standards for Better Health (Department of Health, 2004). The Healthcare Commission will be responsible for an assessment framework including reviews and inspections of NHS service providers and others providing healthcare for which NHS bodies and service providers have responsibility. It will include tools for selfassessment of research governance. The initial metrics below are proposed for local assessment of two aspects of performance: • scale and productivity of research groupings in which NHS bodies are partners • efficiency in dealing with requests for permission to conduct studies involving people to whom the NHS has a duty The metrics for scale and productivity are based on information that NHS recipients of R&D funding have reported to the Department of Health for the last five years. It is best not to use these measures separately. Not all NHS bodies have the same level of engagement in research. When assessing whether an organisation is making an effective contribution, it is helpful to consider which of these categories apply to the organisation. It should be one or more of them: • a user of research evidence – should have capacity to apply evidence to decisions on adopting innovation or changed practice • a competent collaborator – should have capacity to conduct studies confidently under others’ leadership • a research centre – should have capacity to give expert support to lead investigators and their collaborators in designing studies This affects the way indicators are used. For example, most research benefits from collaboration. We need effective collaborators as much as effective leaders of research. It would be counter-productive to set a local target just for grant income. That could encourage investigators in NHS bodies to spend their time applying for grants, and divert them from collaborating with national studies, including the large studies that generate the evidence for NICE guidance. We therefore recommend using these metrics together to compare research activity between similar research groupings and similar research programmes or topic areas. The ratios of publications to grants, of publications to NHS R&D Funding, and of grants to NHS R&D Funding give a profile of research activity. They are a starting point for discussions which should include other factors affecting the value of research effort. This may lead to action to improve performance across a health community, or in particular research topic areas or settings.

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We suggest checking for any weakness or imbalance in the following areas. Action to correct it should be planned with the relevant clinical research networks. • • • • •

Is the total amount of externally funded peer reviewed research activity appropriate to this organisation, or to the health economy? What proportion of it involves working with clinical research networks? What proportion involves working with industry? How many patients take part in studies? (Do all the patients who might be willing to take part in research have the opportunity?) Is there an appropriate balance of research activity, for example by disease area – including public health research?

Time taken for permission is a useful internal measure of efficient research management. Particularly good or poor performance is also likely to be evidence of effectiveness in collaboration among NHS bodies, universities and industry. The aim is to strengthen and streamline these collaborative processes in order to facilitate high quality research: see the national health research strategy document Best Research for Best Health (Department of Health, January 2006). Therefore, other evidence is likely to be useful, such as surveys providing feedback from external users of management processes. We shall propose further metrics after development and testing. The following issues will be considered: • involvement in clinical trials (possible focus on underserved themes where the new UK Clinical Research Collaboration will build networks, and on health technology assessment supporting NICE guidance) • research capacity development • human resources applied to research, research management and governance • sponsorship • patient focus (policy and procedures on patient and public involvement in research, to include: procedures for ensuring that patients are aware of research in the organisation, providing opportunities to take part in research, providing feedback of results to participants in studies) Your views are invited about these and other measures. How useful would they be? How reliable would the information be? Is the right information readily available? Contact names: For metrics 13.01 to 13.03, contact Catherine Johns (e-mail: catherine.johns@dh.gsi.gov.uk) For metric 13.04, contact Marc Taylor (e-mail: marc.taylor@dh.gsi.gov.uk)

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Research & development The proposed metrics As explained in the main introduction, the “data source” section is prefaced with the following classification: • data is currently available (routinely collected or equivalent) • data is currently possible (the tools are either available or possible through records review or other audit) • data is currently unavailable (may require new tool development or an aspiration that this will be done) As in the chapters on stroke, heart disease, cancer and mental health, refreshed metrics (proposed for use as supporting data within 2006/2007 developmental standards assessment by the Healthcare Commission) are provided with their parent metrics and italicised for clarity.

13.01 Theme: Research activity supported (and reviewed) by grant givers Objective: To measure the scale and quality of funding for research in programmes, organisations, groups or health economies Description of metric: The amount awarded over the last three years to the organisation or to an academic partner organisation (where the researchers are based in the organisation) by the external funding body to carry out the non-commercial R&D and which utilises NHS R&D Support Funding, where the organisation is the main base for the principal investigator or co-applicant for the grant Rationale/evidence base: Grants are a widely accepted measure of research quality. They usually imply the proposals were quality assured by independent scientific and ethical review NSF standard(s) where applicable: High level PSA target: Standards for better health domain: CURRENTLY AVAILABLE: Data source: Department of Health RDD. Recipients of NHS R&D Funding have reported this measure annually to Department of Health for the last five years £,000 Unit of analysis: One axis of a composite measure of scale, Structure/process/outcome: quality and productivity Notes: It can be misleading to put weight on this measure in isolation. Some grant funders are more highly regarded than others. Grants come from a wide range of government-backed, charity and industry research funders. Some NHS bodies hold grants. Much NHS research activity is associated with grants held in a university. In that case, the researchers named on the application are likely to have NHS honorary contracts. Some kinds of research are more expensive than others. The size of the grant may not have much relationship with the NHS research activity. The value of grants per year may fluctuate widely. It is more informative to use a rolling average, to use this measure together with 13.02 and 13.03, and to take them together as a scorecard for research activity

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13.02 Theme: Research activity leading to publication Objective: To measure the productivity of research in programmes, organisations, groups or health economies Description of metric: The total number of research publications printed in peerreviewed journals in the previous three years. Publications may be cited once per programme and can be included under only one programme in an organisation. A named author must be based in that organisation Rationale/evidence base: Publication in peer review journals is a widely accepted quality measure, as well as one means of dissemination NSF standard(s) where applicable: High level PSA target: Standards for better health domain: CURRENTLY AVAILABLE: Data source: Department of Health RDD. Recipients of NHS R&D Funding have reported this measure annually to the Department of Health for the last five years Number of publications linked to an Unit of analysis: organisation (for use as a ratio: for example, publications per ÂŁm grants, or per 100 research active staff) See introduction and notes. One axis of a Structure/process/outcome: composite measure of scale and quality Notes: The rate of publication is not the same in all kinds of research. Not all research leads to publications every year. It is better to use a rolling average. Absolute numbers of publications are uninformative. It is more informative to measure publications per ÂŁ1,000 of grant funding and/or of NHS R&D funding, and to compare that with organisations or research groupings that have a comparable research portfolio. Used across a health economy there is a likelihood of some double counting because of coauthorship. It may therefore be hard to attribute precise numbers of publications to NHS organisations. This is only one measure of research output. There is a tendency for journals to favour positive findings. The aim is to make all results, positive or negative, accessible by various means so that systematic review and new research take account of research already completed. There are independent sources of evidence about citation, and systematic reviews provide assessments of quality and impact. However, these are not organisation-based. It would be unreasonable to expect organisations to self-assess quality using them. For the last five years, recipients of NHS R&D Funding have also reported "research outcomes that have health and social care impacts" Refreshed metrics: Metrics: Externally funded peer reviewed research activity: a Total number of projects b Number which involve working with clinical research networks c Number which involve working with industry d Number of patients recruited into studies e Proportion of activity by disease/condition including public health Data source: Department of Health Research and development directorate

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13.03 Theme: NHS R&D funding Objective: To map NHS R&D funding attracted by research in programmes, organisations, groups or health economies Description of metric: The amount allocated over the last three years to the NHS organisation Rationale/evidence base: Department of Health allocates funds annually to over 200 NHS recipients NSF standard(s) where applicable: High level PSA target: Standards for better health domain: CURRENTLY AVAILABLE: Data source: Department of Health RDD £,000 Unit of analysis: One axis of composite measures of scale, Structure/process/outcome: quality and productivity Notes: It can be misleading to put weight on this measure in isolation. The funds allocated partly reflect historical declarations of the NHS resources applied in support of research. Subsequent allocations have increasingly reflected: • evidence of external grants • evidence of coherent and productive NHS research programmes, whether or not supported by grants • allowance for research management and governance systems This measure is not expected to track other measures such as grants or publications precisely. Some kinds of research draw on NHS resources much more than others. It is more informative to use this measure together with 13.01 and 13.02, as the basis for a local research map or scorecard. Comparing ratios of NHS R&D funding to grants, publications or other measures across different organisations may expose issues such as value for money, or inadequate NHS support for productive research teams, for example

13.04 Theme: Permission for research Objective: To begin high quality research without undue delay. See notes Description of metric: Average time and range of time taken from: • receipt of protocol and request for authorisation to • confirmation of acceptance/rejection Partners’ satisfaction with the local research governance process Rationale/evidence base: Anecdotal evidence of health and social care organisations applying inappropriate processes and/or inadequate resources to requests for permission to conduct externally funded research, Complaints of excessive delay, and of the organisations second-guessing scientific, ethical and regulatory review processes for which other stakeholders have primary responsibility. Department of Health issued supplementary guidance in 2004 to help health and social care organisations simplify their approval process when others have the lead responsibilities NSF standard(s) where applicable: High level PSA target: Standards for better health domain: C12: research governance

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Data source:

Unit of analysis:

CURRENTLY POSSIBLE: Local records, no national data. (May be difficulties in extracting from local records however, health and social care organisations begin to collect and review performance information internally in 2005/2006. From 2006/2007, PCTs and SHAs can then benchmark performance issues and address causes of delay with other stakeholders through Health and Education Strategic Partnerships (HESPs) and, if necessary, national mechanisms.) Surveys of user satisfaction, including reasons for dissatisfaction and delay Days per request (average and range) Surveys of user satisfaction, including reasons for dissatisfaction and delay

Structure/process/outcome: Notes: This is one of a number of possible measures of efficient research management and governance. Evidence of excessive delay will call for investigation of underlying causes. It might prompt local action to improve processes, structures or staffing. It could also be a sign of poor practice in organisations seeking permission, or inadequate communication. The aim is for health and social care organisations to be good partners to those requesting permission for well-prepared, safe research, and to rely on reasonable assurances from them. When a health or social care organisation is in the lead as the main research employer, main funder or sponsor, it is expected to take the time it needs to be satisfied with the design of a study and all the arrangements to conduct it. Ethics committees normally complete ethical review within 60 days. It is reasonable to expect a decision on a well-evidenced request for permission within 60 days Refreshed metrics: Metrics: a Time interval between application for permission for research to proceed, and the granting of permission b Satisfaction with the efficiency of governance procedures through a survey of researchers and the funders of research (focussing on permissions for research) Data source: Department of Health Research and development directorate Additional refreshed metrics were also developed, as follows: Metrics: Appraisal and use of evidence â&#x20AC;&#x201C; Policy and procedures in place which ensure use of research evidence in the decision-making process governing the introduction of new technologies/new procedures Data source: Department of Health Research and development directorate Metrics: Patient focus â&#x20AC;&#x201C; Policy and procedures in place governing the involvement of patients and the public in research, which will include: procedures for ensuring that patients are aware of research in the organisation, providing opportunities to take part in research, providing feedback of results to participants in studies Data source: Department of Health Research and development directorate

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Appendix A â&#x20AC;&#x201C; Membership of the expert advisory group The following acted as a technical advisory group to this process, but the final product remains the responsibility of Paula Whitty and the authors of the individual sections within the Better Metrics document. Meryl Deane, GP, Portsmouth City PCT, and clinical advisor, Healthcare Commission David Pencheon, Director, Eastern Regional Public Health Observatory Mohammed A. Mohammed, Department of Public Health and Epidemiology, University of Birmingham Martin McKee, Professor of European Public Health, London School of Hygiene and Tropical Medicine Veena Raleigh, Lead, Statistics and Database Analysis Team, Healthcare Commission (joined project in November 2004) Michael Soljak, Health Inequalities Unit, Department of Health (joined project in November 2004) Richard Thomson, Professor of Epidemiology and Public Health, University of Newcastle, and Director of Epidemiology and Research, National Patient Safety Agency

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Appendix B – Features of a good measure Features of a good measure: • aligned to the overall aims of improvement •

is supported by a strong evidential link to the aims/outcome of improvement

•

is consistent with other measures linked to the aims of improvement

•

can be measured in a timely way

•

can be directly influenced by the organisation whose performance is being managed

•

has comparators – either to itself (trends) or externally (benchmarks)

•

is part of a suite of measures which, taken together, reflect on a reasonable proportion of the work of the service concerned

•

ideally, the measure would relate to a critical point in a system or pathway and function as a marker for that system or pathway

•

does not result in perverse incentives

•

the effort of data collection does not outweigh the benefits of using the measure

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Appendix C – Shortened questionnaire for the National Cancer Patient Survey (NCPS) Extracted from Alison Prescott’s proposals for a shortened questionnaire for the NCPS Qn no.

Question

Your hospital visit A1 Confirmation of date of hospital admission A2 Insufficient doctors on duty A3 Insufficient nurses on duty Your first hospital treatment B1 Date of first appointment cancelled/postponed by hospital B5 No confidence and trust in hospital doctors B6 No confidence and trust in hospital nurses B7 Not treated with respect and dignity B19 Doctor didn’t discuss purpose of treatment with patient B21 Patient was not asked to sign a consent form B24 In pain or discomfort during first hospital visit for treatment Leaving hospital C1 Doctors did not spend enough time informing patient on aftercare C2 Patient not given printed information on care after discharge Finding out what was wrong with you D1 Date first noticed signs or symptoms of condition D2 Whether visited GP about condition before attending hospital D3 Waited too long for first appointment with hospital doctor D9 Whether told of condition during/before/after hospital appointment D10 Patient was not told of condition in person at first appointment D15 Time spent on explaining condition to doctor on first visit Outpatient appointments E1 Outpatient appointment at any hospital in the last two years E2 Date of most recent outpatient appointment E4 Recent outpatient appointment was cancelled/postponed by hospital E6 Waiting time to see doctor E7 Time spent by doctors with patient E8 Not enough time spent by doctors with patient E9 No confidence and trust in outpatient doctor E11 Lack of privacy when discussing condition/treatment E13 Not treated with respect and dignity as an outpatient Note: General questions about the respondent should be included in addition to the above questions.

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Appendix D – Selection from “Local basket of indicators to track progress on reducing inequalities in public services across a range of inequalities dimensions” (See www.lho.org.uk/HEALTH_INEQUALITIES/Basket_Of_Indicators/BasketOfIndica tors.aspx for full details)

1 Employment, poverty and deprivation Theme: Addressing the underlying determinants of health No Indicator definition 1.1

Those unemployed (ILO definition) as a % of the economically active population in the area

1.2

The proportion of unemployed people claiming benefits who have been out of work for more than a year

1.3

The proportion of people of working age in employment

1.4

The proportion of young people (18-24 year olds) in full time education or employment

1.5

The percentage increase or decrease in the number of local jobs

1.6

Percentage of residents claiming council tax benefit

1.7

1.8

The percentage of population of working age who are claiming key benefits (JSA, IB, Severe Disablement Allowance, Disability Living Allowance) Index of multiple deprivation (full index)

1.9

Affordable housing (house price/earnings affordability ratio)

1.10 Proportion of children under 16 living in “low income households” (Child Poverty Index)

2 Housing and homelessness Theme: Addressing the underlying determinants of health No Indicator definition 2.1 2.2

Number of homeless families with children living in temporary accommodation Number of unfit homes per 1,000 dwellings (or proportion living in non-decent housing)

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3 Education Theme: Addressing the underlying determinants of health No Indicator definition 3.1

Percentage of 11 year olds achieving the expected Level 4 or above in Maths and English Key Stage 2

3.2

% of 14 year olds at or above level 5 standard of literacy numeracy science and ICT Key Stage 3

3.3

% of unauthorised half days missed from secondary/primary schools

3.4

% of 15 year old in schools maintained by the local authority gaining five or more GCSEs at A*-C

3.5

Number of enrolments on all adult education courses provided and secured by the local authority per 1,000 adult population

4 Crime Theme: Engaging communities and individuals No Indicator definition 4.1

Number of robberies recorded per 1,000 population

4.2

Vehicle crimes recorded per 1,000 population

4.3

Violent offences recorded per 1,000 population

4.4

Domestic burglaries recorded per 1,000 households

5 Pollution and the physical environment Theme: Addressing the underlying determinants of health No Indicator definition 5.1

Air pollution a Number of days per year when air pollution is “moderate” or “higher” for PM10 b Annual average nitrogen dioxide concentration c For rural sites, number of days per year when air pollution is moderate” or “higher” for ozone

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6 Community development Theme: Engaging communities and individuals No Indicator definition 6.1

Number of recorded racial incidents per 100,000 population (applies to all in authority's services including schools and to employment by the authority)

7 Lifestyle including diet, smoking and physical activity Theme: Addressing the underlying determinants of health No Indicator definition 7.1

Proportion of people who have set a quit date and remain quit at four weeks

7.2

Proportion of women continuing to smoke throughout pregnancy (those who smoke at delivery as a proportion of total maternities)

8 Access to local health and other services Theme: Preventing illness and providing effective treatment and care No Indicator definition 8.1

Number of primary care professionals per 100,000 population

8.2

Percentage of patients able to be offered an appointment to see a GP within two working days

8.3

Percentage of patients able to be offered an appointment to see a Primary Care Professional within one working day

8.4

Proportion of patients admitted, transferred or discharged from A&E within four hours Proportion of patients on waiting list that have been waiting more than six months for treatment Proportion of patients on waiting list that have been waiting more than three months for treatment Number of primary care trust commissioned non-elective general and acute admissions per 100,000 population (age and sex standardised)

8.5 8.6 8.7 8.8

% of drug users successfully completing treatment program

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9 Accidents and injury Theme: Preventing illness and providing effective treatment and care No Indicator definition 9.1

Percentage of primary school pupils aged five and over receiving road safety advice during the year

9.2

9.3

The number of nursery and primary pupils aged five and over in local education authority schools which have an adopted school travel plan, as a percentage of the total number of nursery and primary pupils aged five and over in local education authority schools Number of pedestrian casualties per 100,000 population

9.4

Number of road traffic casualties per 1,000 resident population

9.5

Directly age-standardised hospital episode rates for serious accidental injury requiring a stay exceeding three days per 100,000 population Number of people killed or seriously injured in RTAs per 100,000 population Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) for accidents

9.6 9.7

10 Mental health Theme: Preventing illness and providing effective treatment and care No Indicator definition 10.1 Age standardised hospital episode rates for neuroses per 100,000 population 10.2 Age-standardised hospital episode rates for schizophrenia per 100,000 population 10.3 Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) from suicide and undetermined injury

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11 Maternal, infant and child health Theme: Supporting families, mothers and children No Indicator definition 11.1 Number of conceptions to girls under 18 per 1,000 population aged 15-17 11.2 Proportion of total births with a birthweight less than 2500 grams 11.3 Infant mortality rate (three year rate) 11.4 Percentage of teenage mothers participating in education and obtaining qualification at NVQ Level 1 or above 11.5 The number of childcare places available per 1,000 population 11.6 Number of Sure Start local programmes 11.7 Percentage of children registered during the year on the Child Protection Register who had been previously registered 11.8 Percentage of children with active dental decay 11.9 % of children reaching their second birthday who were vaccinated against MMR

12 Older people Theme: Preventing illness and providing effective treatment and care No Indicator definition 12.1 % uptake of influenza immunisation in people aged over 65 12.2 Admissions to hospital of people aged 75 or over due to hypothermia or injury caused by a fall per 1,000 head of population aged 75 and over 12.3 Number of households receiving intensive home help/care as a percentage of all adults and older people in residential and nursing care and households receiving intensive home help/care 12.4 Proportion of assessments of older people completed by social services within two weeks 12.5 Number of carers receiving a formal break from caring 12.6 Older people aged 65 or over helped to live at home (per 1,000 â&#x20AC;&#x201C; 65s or over)

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13 Tackling the major killers Theme: Preventing illness and providing effective treatment and care No Indicator definition 13.1

Proportion of women aged 65-70 who have been successfully screened for breast cancer (performance indicator is aged 53-64)

13.2

Tuberculosis notification rate per 100,000 population (directly standardised rates) Proportion of those treated waiting more than three months for revascularisation Proportion of those treated waiting more than three months for angiography Proportion of cancer patients waiting more than one month between diagnosis and treatment Number of emergency admissions of children aged under 16 with lower respiratory infections, per 100,000 resident children (age sex standardised) Emergency admissions to hospital for people of all ages per 1,000 people Proportion of people admitted for stroke, admitted to a hospital with a specialised stroke service

13.3 13.4 13.5 13.6

13.7 13.8 13.9

Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) from circulatory disease for those aged under 75 13.10 Age-standardised mortality rate (direct standardised mortality rate per 100,000 population) from cancer for those aged under 75 13.11 Age-standardised mortality rate from lung cancer for those aged under 75 13.12 Life expectancy at birth

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Appendix E – Details of national patient experience surveys to date 2001/2002 – 2002/2003 National Patient Survey Programme 2001/2002 2002/2003 Technical details and Adult inpatient deliverable Primary care DH CHI 23 Commissioning organisation Baseline Baseline Survey type 176 acute and specialist 304 primary care trusts Participating trusts trusts providing inpatient and care trusts care for adults responsible for primary care services People registered with a People eligible to take People over 18 years who had an overnight GP part stay (excluding psychiatric and maternity patients) Total sample size Total number of useable responses Overall response rate Response rate – range Website link for publications

Outpatients CHI

A&E CHI

Baseline 171 acute trusts who run outpatient clinics for adults

Baseline 155 trusts who run a main emergency department

Adults attending an outpatient clinic (excluding psychiatric and maternity patients)

Adults attending the department (excluding minor injuries units and medical or surgical admissions)

95,280

250,000 + 123,833

143,000 + 90,552

133,000 + 59,155

64% 47% – 86%

49% 26% – 65%%

63% 23% – 76%

46% 26% – 61%

http://www.healthcarecom mission.org.uk/NationalFin dings/Surveys.cfm

Please note that the Commission for Health Improvement was replaced by the Healthcare Commission in 2004.

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2003/2004 National Patient Survey Programme 2003/2004 Technical details and Adult inpatient deliverable Primary care CHAI CHAI Commissioning organisation Repeat Repeat Survey type 169 acute and 303 primary care Participating trusts specialist trusts trusts and care providing inpatient trusts responsible care for adults for primary care services People registered People eligible to take People over 16 years who had an with a GP part overnight stay (excluding psychiatric and maternity patients) Total sample size Total number of useable responses Overall response rate Response rate – range Website link for publications

Mental health services CHAI

Ambulance trusts CHAI

Young patients CHAI

Baseline 81 mental health trust and PCTs responsible for mental health services People of working age using mental health services (as part of a care approach programme)

Baseline 31 ambulance trusts

Baseline 150 acute and specialist trusts

Patients using urgent or emergency ambulance services

143,222 88,308

249,538 122,113

67,179 27,398

26,336 12,282

Patients aged 0– 17 years treated as inpatients or day cases (maternity and psychiatry patients were excluded) 125,827 62,277

63% 47% – 83%

49% 22% – 64%%

42% 32% – 54%

51% 39% – 56%

50% 32% – 64%

http://www.healthcare commission.org.uk/Na tionalFindings/Survey s.cfm

http://www.healthc arecommission.org .uk/NationalFinding s/Surveys.cfm

http://www.healthcare commission.org.uk/Na tionalFindings/Survey s.cfm

http://www.healthc arecommission.org .uk/NationalFinding s/Surveys.cfm

http://www.healthcar ecommission.org.uk/ NationalFindings/Sur veys.cfm

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2004/2005 National Patient Survey Programme 2004/2005 Technical details and deliverable A&E CHAI Commissioning organisation Baseline Survey type 153 trusts who run a Participating trusts main emergency department People eligible to take part

Total sample size Total number of useable responses Overall response rate Response rate – range Website link for publications

Outpatients CHAI

Primary care CHAI

Mental health services CHAI

Baseline 169 acute trusts who run outpatient clinics for adults

Repeat 303 primary care trusts and care trusts responsible for primary care services People registered with a GP

Adults attending the department (excluding minor injuries units and medical or surgical admissions) 129,948 55,339

143,596 84,280

257,505 116,939

Baseline 81 mental health trust and PCTs responsible for mental health services People of working age using mental health services (as part of a care approach programme) 66,948 25,555

44% 26% – 59%

59% 38% – 78%

47% 23% – 61%

41% 29% – 51%

www.healthcarecommissio n.org.uk/NationalFindings/ Surveys.cfm

Adults attending an outpatient clinic (excluding psychiatric and maternity patients)

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