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Hertfordshire
Commissioning for better health in Hertfordshire
Annual report of the Director of Public Health for Hertfordshire 2012 Executive summary
Contents • Foreword
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• Preface
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• Introduction
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• Commissioning Outcomes Framework (COF)
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• Shared responsibility and multi-agency working
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• Priorities for Hertfordshire CCGs
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• Acknowledgements
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Foreword
We are pleased to welcome the 2012 annual public health report which this year measures the health of the population of Hertfordshire against the recently published NHS Outcomes Framework. The NHS Outcomes Framework is part of the changing landscape of the NHS in England that is emerging as April 2013 draws nearer. The NHS Outcomes Framework will form part of the Commissioning Outcomes Framework, which for Clinical Commissioning Groups (CCGs), will be used to monitor their performance and effectiveness in commissioning to improve patient care and health outcomes. CCGs will need to work with local authorities, the mental health trust, the acute and community hospital trusts, and others, to bring about change to improve the general health of the population. The headlines in this report will prompt for some indicators more detailed local investigation, for some immediate local action, and some issues will be best addressed through the next round of commissioning arrangements. The report brings discussion of the NHS Outcomes Framework into a wider arena, but also makes reference to a number of other sources of valid and reliable local health information. It is the start of a process that will unfold further in the years to come. Dr Jane Halpin Chief Executive, NHS Hertfordshire Dr Mike Edwards Medical Director, NHS Hertfordshire Dr Tony Kostick Chair, East and North Herts Clinical Commissioning Group Dr Nicholas Small Chair, Herts Valleys Clinical Commissioning Group Ken Spooner Chair, Red House Clinical Commissioning Group
Executive summary
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Preface
The purpose of this report is to describe the health of the population of Hertfordshire living in the areas covered by the organisations taking on responsibility for commissioning services. The NHS is currently engaged in the most far-reaching and complex reorganisation since it began in 1948. It will be a new area of endeavour for many of those who will be involved in commissioning healthcare. The learning curve will be steep and there will be a number of ways in which the new commissioning bodies will be held to account. Organisations will be rewarded for sound financial management, and improvements in existing and new measures of patient and population outcome. The NHS Outcomes Framework (NHSOF) is a framework of indicators first published in 20101, each indicator is designed to measure an aspect of clinical effectiveness, patient experience or patient safety, grouped into five domains. A revised version of 60 indicators was published in December 20112. Many of the indicators in this Framework are still under development but the data that are currently available are presented in this report. The data are presented at CCG level where this is possible. This provides a baseline assessment of current performance to allow the early identification of local priorities. The Commissioning Outcomes Framework that will be used to hold CCGs to account is under development by the Department of Health3, but it is known that it will include indicators from the NHS outcomes framework4. In turn, CCGs can use the Outcomes Frameworks to seek assurance of the quality, safety and effectiveness of all services offered to the populations for which they are responsible. This summary paper describes the different outcomes frameworks by which the health of the population will be measured and identifies priority areas for immediate action. The main report measures the current health of the population of Hertfordshire against all indicators of the NHS Outcomes Framework for which data, or proxy data are available.
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www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_123138.pdf 2 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf 3 www.nice.org.uk/media/2F5/CF/NICECOFIndicatorConsultationDocument.pdf 4 www.nice.org.uk/aboutnice/cof/cof.jsp
Executive summary
Introduction
In 2010 the Government published Equity and Excellence: Liberating the NHS. Legislation currently going through the House of Lords will result in Clinical Commissioning Groups commissioning services for their patients and the creation of a public health service working directly with the county council. In Hertfordshire, the population is aligned through practices to clinical commissioning groups covering either West Hertfordshire (Herts Valleys CCG) or East and North Hertfordshire (East and North Herts CCG), and the Radlett area (the Red House CCG). A few Royston practices may join the Cambridgeshire and Peterborough CCG. Hertfordshire Primary Care Trust will cease to exist from April 2013. By the following year all hospitals will be fully independent Foundation Trusts. An NHS Commissioning Board (NHS CB) will be held accountable through the NHS Outcomes Framework as shown in Figure 1. In turn this Board will hold commissioning groups accountable through the Commissioning Outcomes Framework. Figure 1 The quality improvement system in the NHS - influences and accountability for clinical commissioning groups Duty of quality
Domain 2 Enhancing quality of life for people with long-term conditions
Domain 3 Helping people to recover from episodes of ill health or following injury
Domain 4 Ensuring that people have a positive experience of care
Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm
Duty of quality
Duty of quality
Domain 1 Preventing people from dying prematurely
Duty of quality
Executive summary
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Commissioning Outcomes Framework (COF)
The COF will be used by the NHS CB to monitor the improvements in the quality and outcome of patient care that can be linked with more effective commissioning of health care . 5
The COF will be publicly available and used by the NHS CB to hold CCGs to account. The COF will include: • indicators from the NHSOF that are meaningful at local level for the CCGs; • indicators derived from NICE quality standards; • indicators related to financial performance; • a measure of the contribution of the CCG to the joint health and wellbeing strategy; • fulfilment of statutory duties related to patient and public involvement. The National Institute for Health and Clinical Excellence (NICE) is currently developing a series of quality standards which will be reflected in the COF. In March 2011, NICE published quality standards on stroke, dementia, venous thromboembolism prevention, specialist neonatal care, chronic kidney disease, depression in adults, diabetes in adults and glaucoma. In total, NICE will be producing 150 Quality Standards within the clinical areas specified on their website over the next ten years. Indicators in these areas will be available to be used in the COF in 2013. There is a current consultation on indicators derived from these quality standards. In autumn of this year the National Commissioning Board will choose which indicators will be used in the COF in 2013. The COF will decide the quality premium bonuses to be given to the CCGs on the basis of improvement in indicators measured by the COF. Although the NHSCB has responsibility for commissioning primary care there is ongoing discussion on the part CCGs will have in their responsibility for commissioning primary care. The indicators are intended to be used for accountability, as a focus for improving the quality of care and as a catalyst for minimising inequalities in outcomes.
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www.commissioningboard.nhs.uk/2011/11/29/cof/
Executive summary
Shared responsibility and multi-agency working The NHSOF is the measure by which the NHS will be judged. All organisations working within the NHS will have to contribute. The five broad outcomes in the Outcomes Framework are: • preventing people from dying prematurely; • enhancing quality of life for people with long-term conditions; • helping people to recover from episodes of ill health or following injury; • ensuring that people have a positive experience of care; • treating and caring for people in a safe environment and protecting them from avoidable harm. Recognition of the many different factors determining health, not all of which are within the control of the health service, and joined up working with other commissioning bodies is encouraged by the sharing of indicators from the NHS outcomes framework with the Adult Social Care Framework6 and the Public Health Framework7 (figure 2). These, together with the Hertfordshire Joint Strategic Needs Assessment8 will underpin the strategy of the emerging Hertfordshire Health and Wellbeing Board. Figure 2: The three overlapping frameworks for the NHS, public health and adult social care services9
Further information on the local picture can be found in the JSNA www.hertslis.org/partners/jsna/ and in the 2011 local health profiles www.apho.org.uk/default.aspx?RID=49802 and the Atlas of Variation www.rightcare.nhs.uk/index.php/atlas/atlas-of-variation-2011/
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www.dh.gov.uk/health/2011/11/the-adult-social-care-outcomes-framework-handbook-of-definitions/ www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358 8 www.hertslis.org/partners/jsna/current 9 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_123138.pdf 7
Executive summary
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Priorities for Hertfordshire CCGs, as identified through the NHS Outcomes Framework DOMAIN 1 Preventing people from dying prematurely People living in Hertfordshire are generally more affluent10 and healthier than the national average but some health outcomes could be improved, and within Hertfordshire, inequalities persist. Watford and Stevenage • Have the highest death rates from causes considered amenable to health care11 in Hertfordshire. • Have the highest rates of mortality before age 75 from cardiovascular and respiratory disease. • have the highest rates of mortality attributable to smoking in Hertfordshire. • Are the only Local Authority areas in Hertfordshire to have a higher prevalence of smoking than the regional average. Suggested action: Agree targets to improve smoking cessation and health checks. Work with the Stop Smoking team www.smokefreehertfordshire.nhs.uk and partner agencies, the respiratory networks, and the Heart and Stroke Network www.bhhsnetwork.nhs.uk/Home.aspx
Cancer survival • Improvements in survival from colorectal cancer seen nationally have not been mirrored in Hertfordshire. • Intensive efforts co-ordinated by the Mount Vernon Cancer Network have resulted in improvements in one-year lung cancer survival over the last 4 years of 8% (24% to 32%). Suggested action: Support the Mount Vernon Cancer Network in its work to unpick the reasons for lower survival and agree the set of actions necessary for improvement www.mountvernoncancernetwork.nhs.uk
10 www.apho.org.uk/default.aspx?QN=HP_COMPARISON_RAGS_2011 ONS consulted on a proposed list of causes considered amenable to healthcare in February 2011 and is currently undertaking work to update the list. This is expected to be complete by spring 2012. ONS’s proposed amenable causes are listed in the consultation document here www.ons.gov.uk/ons/about-ons/consultations/closed-consultations/2011/definitions-of-avoidable-mortality/index.html 11
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Executive summary
DOMAIN 2 Enhancing the quality of life for people with long term conditions • People in Hertfordshire with long term conditions feel less supported in managing their condition compared with people in England as a whole. • There is a wide variation (although not statistically significant) among practices in the proportion of people feeling supported to manage their long term conditions. Suggested action: Audit recent service improvements in COPD and diabetes pathways to ensure these are delivering as intended. www.pathwaysforhealth.org/application/render08.asp?reference=C33FFD097D9C4 B4C9DEEB277EC7BF75F The NHS Midlands and East resources can be found at: www.eoe.nhs.uk/ltc The final indicator will be adjusted for case-mix (method to be confirmed). This may reduce the observed current variation among practices and facilitate identification of outliers.
DOMAIN 3 Helping people to recover from episodes of ill health or following injury • Hertfordshire has generally low emergency admission rates for conditions usually managed in primary care, but within Hertfordshire, Watford and Stevenage have the highest rates. • Less patient-reported health gain after knee replacement compared with the England average, but this difference is not statistically significant. • Lower proportion of Hertfordshire patients still at home at 91 days after hospital discharge compared with England. Suggested action: Continue to implement the intermediate care policy to provide care where patients live, and to prevent emergency admissions; continue to work with local acute Trusts and social services to understand and reduce readmission rates through audit, and pilot and evaluation of approaches indicated by external evidence; continue to monitor variations in admission rates by practice and focus where re-admissions are high; continue to roll-out the Falls Liaison service, with evaluation to ensure delivery as planned. Commissioners should continue to work closely with NHS providers, care homes and adult care services to develop fully integrated services that will support early and effective discharge. Supporting multi-agency working to a common goal such as this will be the core business of the Health and Wellbeing board.
Executive summary
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DOMAIN 4 Ensuring that people have a positive experience of care • Patients in a number of practices across Hertfordshire report low satisfaction scores. • Patient experience in both Hertfordshire hospital trusts is worse than the national average for inpatients, outpatients, and accident and emergency. • Hertfordshire hospital trusts score poorly on patient experience of maternity care. Suggested action: These measures need to be triangulated with other measures of satisfaction to understand the reasons and identify the actions required for improvement. Support the work of the Primary Care Team in improving patient experience by identifying and working with practices which have low scores. Ensure quality remains a top priority for Boards. Existing systems currently obligate regular reporting through the PCT structures and the quality review team has a rolling programme of site visits. Issues of patient experience can be addressed through contract meetings.
DOMAIN 5 Treating and caring for people in safe environment and protecting them from avoidable harm • Trusts in Hertfordshire report more safety incidents than the average acute trust, but the lower number of incidents where the degree of harm is ‘severe; or ‘death’ suggests this is explained by more complete reporting. • Much progress has been made locally and nationally in reducing healthcare associated infections (HCAI). The focus has now shifted from the acute to the community and primary care settings. • Since the beginning of 2011, there has been an increased focus on reducing pressure ulcers, with grade 3 and 4 being reported through the serious incident process. Since January 2012, prevalence data have been collected monthly and will be available for benchmarking later in 2012. Suggested action: monitor current trends in HCAI infection closely for assurance that recent steps introduced to reduce community-associated HCAI infections are having the intended result. Support the multi-agency approach of the East of England in use of the NHS Safety Thermometer www.ic.nhs.uk/services/nhs-safety-thermometer in the commissioning of community services.
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Executive summary
Acknowledgements
This report reflects the collective efforts of the following people. Hilary Angwin
Keir Mann
Jeni Beard*
Laura Maynard-Smith*
Sue Beck
Linda Mercy
Denise Boardman
Raj Nagaraj
Joel Bonnet
Gordon Pownall
Ian Brown*
Umair Rathore
Kate Chand
Kevin Ritchie-O’Dell*
Holly Christensen*
Louise Savory*
Tracey Cooper
Louise Smith*
Richard Garlick*
Jessica Stokes*
Barbara Gill
Miranda Sutters*
Sara Godward*
Robin Trevillion
Gill Goodlad
Nicky Williams
Raymond Jankowski
Peter Wright
Rachel Joyce
*Editorial team
For further information, please call, write or email: Hertfordshire NHS Charter House Parkway Welwyn Garden City AL8 6JL Telephone: 01707 369688 Website: www.hertfordshire.nhs.uk Email: enquiries@hertfordshire.nhs.uk