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					Quality indicators to support
commissioning of unscheduled
care
 June 2009
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business support to London‟s NHS.
Slide title

• First bullet
  – Second bullet
     • Third bullet
        – Fourth bullet
            » Fifth bullet
Guidance for PCTs on commissioning a new delivery model for unscheduled care in London was published in October 2008.
      This document forms part of a toolkit developed to support PCTs in commissioning the new delivery model and
                                    to promote a consistent approach across London.


                   Unscheduled care delivery model




         Unscheduled care is any unplanned contact with the NHS by a person requiring or seeking help, care or advice.
  It follows that such demand can occur at any time and that services must be available to meet this demand 24 hours a day.
                                 Unscheduled care includes urgent care and emergency care.                                    3
Identifying indicators of quality in unscheduled care

Foreword                                                               In recognising these complexities and attempting to balance the
                                                                       achievement of meaningful, comparable quality indicators against
In June 2008, High Quality Care For All (the NHS Next Stage            an overly burdensome requirement for the collection of data, a
Review Final Report) put quality at the heart of the NHS.              number of metrics are proposed here. These have been
Subsequent guidance on measuring for quality improvement               developed on clinical principles and include a number of common
outlines the importance of measuring three dimensions of care:         clinical scenarios which are either direct or surrogate indicators of
safety, effectiveness and a good patient experience.                   quality including, importantly, patient experience and outcomes.


There is a now a need to develop indicators which can                  There are many other conditions and metrics that could be used,
demonstrate that the required quality and desired health               but after consideration of a large number, those listed here are
outcomes are being achieved and improved. These indicators             considered to provide the most value when balanced against the
need to reflect not only volume throughput, which demonstrates         demand levied on everyday clinical life and the effort required to
the availability of care and performance of the system, but also       obtain them.
the quality of the clinical episodes that comprise that throughput
and the quality of the patient experience throughout the pathway       Dr Marilyn Plant, General Practitioner, Healthcare for London
of care including the health outcomes patients experience as a         Clinical Advisory Group (Project Clinical Director)
result of the care they receive.
                                                                       Professor Peter Hutton, Professor of Anaesthesia, Healthcare
Quality practice is difficult to measure (numerically or otherwise)    for London Clinical Advisory Group
and, as a result, valid and easily recorded quality measures are
rare in healthcare. Despite the difficulties in developing effective   Professor Sir George Alberti, National Director for Emergency
indicators, measuring quality and clinical outcomes is crucial to      Access
the current health agenda.

                                                                       Dr Andy Parfitt, Consultant in Emergency Medicine, Healthcare
Nowhere is this more necessary than in the management of               for London Clinical Advisory Group
unscheduled care. Users of these services are a heterogeneous
group, frequently from disadvantaged communities, who present
with a whole range of physical, mental health and social care          Clinical members of the Unscheduled Care Project Board
problems, without warning, to a variety of NHS entry points with
diverse service delivery models.

                                                                                                                                            4
Commissioning to improve quality in unscheduled care (1)

                                                                                                               Figure 1. Measuring quality at different points in the health system
 Commissioning is a key lever for driving improvements in quality.
 Following publication of guidance for PCTs on commissioning a
 new delivery model for unscheduled care in London (October                                                                              National            Life expectancy
 2008) this document gives guidance on outcome measures and                                                                                                  Inequalities
 quality indicators that can be used to support commissioning and
 implementation of the unscheduled care delivery model                                                                                                         Pan-London quality indicators

                                                                                                                                  PCTs                           Including World Class Commissioning
                                                                                                                                                                   indicators
 The delivery model guidance identified a strong case for change.
                                                                                                                                                                     Commissioning quality indicators
 Opportunities for improvement were grouped into five key themes:                                                                                                     within contracts (CQUIN)

                                                                                                                                                                        Quality Accounts
 1.More can be done to prevent people defaulting to the                                                               Providers
 unscheduled care system to have their needs met                                                                                                                               NHS Choices
 2.Access to care needs to improve and be more responsive to
 patients‟ needs and expectations                                                                              Clinical                                                           Clinical Quality Indicators
 3.The system needs to be less complex and easier to understand                                                 teams                                                              PROMS
                                                                                                                                                                                      Audit
 and navigate for patients and staff
 4.Standards and quality can be more consistent and improved
 across the spectrum of care in community and hospital services
 5.Improving the way the system works as a whole will improve care
 and patient experience and make better use of resources                                                       This guidance recognises these different roles and proposes
                                                                                                               measures for PCTs, providers and clinical teams with the
                                                                                                               expectation that commissioners will play an overarching role in
 The drive for change is more likely to be achieved if there are                                               encouraging and, where appropriate, incentivizing measurement
 consistent messages and consistency in approach across London.                                                as part of a wider evaluation framework.

 The London Commissioning for Quality Network1 has set out the                                                 Improving unscheduled care at a system level will involve complex
 context in which quality measurement and improvement should be                                                change. Learning and development cycles need to be an integral
 undertaken in London and an approach involving local freedom                                                  part of the change process and built in from the outset in order to
 and flexibility with support from regional and national levels. It has                                        understand whether the desired improvement goals are being
 defined the roles of organisations as part of the wider health                                                achieved and sustained as well as the pace and scale of
 system, illustrated in Figure1.                                                                               improvement.                                                      5
1 The Network was set up in October 2008 to support the joint work of PCTs in using commissioning as a lever
  for quality in London.. It works on behalf of the London Directors of Commissioning Group
Commissioning to improve quality in unscheduled care (2)

Commissioning approach                                                         Next steps – recommendations for moving forward

Successful implementation of the delivery model will require a                 The set of indicators proposed in this paper should be
coordinated commissioning approach across health and social                    implemented and tested to consider their merit individually and
care, covering primary, community, mental health, acute,                       collectively as indicators of quality improvement across the
ambulance and social services. This could be led at borough or                 unscheduled care system. This process would involve in depth
sector level; either option will require a very strong interface               consideration of how and what indicators work in practice in order to
between relevant borough and sector functions. The approach to                 refine the indicator set and inform future development. This would
quality improvement and learning needs to be built into this                   include developing and testing data collection instruments for
commissioning process. Following the establishment of sector                   indicators where these do not exist (or are not effective). This
acute commissioning units there is likely to be benefit in this                process could be carried out through a pilot project involving a
function being led at a sector level.                                          number of PCTs across London or focused in one sector

                                                                               In parallel, all PCTs should consider the indicators proposed and
How PCTs can evaluate change                                                   their use in the local context and select a minimum of 5-6 most
A variety of approaches can be employed:                                       relevant to local priorities for implementation; this will involve
                                                                               identifying necessary resources and allocating responsibilities to
1.The use of measures e.g. to measure what is important to                     support the process locally (at PCT and sector levels).
patients, to enable PCTs to understand how the whole system is
working. These can be supplemented with demographic data to                    PCTs should build these indicators into commissioning plans AND
build a richer picture. A recommendation from this work is to chose            report them to the new London Quality Observatory (LQO) within
sentinel indicators from the selection proposed.                               Commissioning Support for London (CSL).
2.Audit and case review – this could include a role for networks in
                                                                               The LQO should provide technical support to PCTs e.g. data
supporting audits across services/the system as well as audits in a
                                                                               analysis and feedback of results for indicators reported; this could
single service
                                                                               include benchmarking relevant indicators across PCTs to facilitate
3.Patient and professional experience of change – a range of                   local assessment and to inform development of standards.
methods can be used, including development of patient reported
outcome measures                                                               PCTs should consider what other support and expertise would be
4.Use of PDSA2 tools to support a cycle of learning and feeding                helpful in taking this work forward and whether this can be provided
outcomes into future development plans; working with clinical                  locally (e.g. through Public Health Departments, local partnership
networks with the aim of creating a self-generating quality                    arrangements). CSL and the SHA should consider what support and
improvement environment .                                                      expertise can be provided at a regional level e.g. expertise in    6
                                                                               developing PROMS, facilitating learning/sharing events across
2 e.g. The Institute of Healthcare Improvement PDSA tool http://www.ihi.org)   PCTs.
Proposed outcome measures and indicators to support implementation
and commissioning of the unscheduled care delivery model
The delivery model for unscheduled care in London (illustrated on    Approach to this work
page 2) is a tiered approach encompassing three broad responses      The measures and indicators proposed have been informed by a
to patients‟ unscheduled care needs: rapid/moderate, urgent and      process that included the following:
emergency. A key feature of this model is that, regardless of
location, services should function as a single system supported by
shared processes and infrastructure. The model is underpinned by
eight principles:

1.The approach to care should be shaped around patients‟ and
carers needs and expectations
2.Developments should aim to reduce inequalities in access and
improve choice, patient experience and outcomes – and these
should be continuously assessed                                                                           The approach
                                                                                                       involved a review of
3.Services should be delivered within a whole-systems model                                             relevant work and
4.Collaborative working arrangements, common protocols and                                                opinion from a
processes and consistent standards are essential features                                               variety of sources
5.Patients and carers should expect 24/7 consistent and rigorous
assessment of the urgency of their need and appropriate and
prompt response
6.The response should support patients and carers to access the
most appropriate service to meet their assessed need within a
suitable timeframe – and follow through to conclusion
7.Care should be delivered in community settings close to home
wherever possible – and at home wherever appropriate
8.Specialised care should be concentrated in fewer centres to
improve standards and outcomes                                       Pages 7-8 draw out some key points from areas examined
                                                                     through this process. Key findings and recommendations are
These principles alongside the five improvement goals set out on     summarised on pages 9 and 10.
page 4, set the framework for this work to identify outcome          Note 1: This involved reviewing: the outcome of interviews, focus groups and a workshop involving
measures and quality indicators that support implementation and      patients and the public in phase 1 of the unscheduled care project; responses to Consulting the
                                                                     Capital; relevant literature
commissioning of the unscheduled care delivery model.                Note 2: Not just a matter of time: A review of urgent and emergency services in England (September
                                                                     2008 Commission for Healthcare Audit and Inspection)                                                 7
Experience and outcomes important to patients and the public in
using unscheduled care services
Priorities for patients and the public have been identified by
drawing from a range of sources, including patient and public           Priorities for patients and the public
involvement in the unscheduled care project to date, and
triangulating views expressed. The main sources were:                   Cleanliness: Clean and well maintained facilities are important and
                                                                        patients seek assurance that good hygiene and cleanliness are also
                                                                        important issues for staff e.g. hand washing.
• Responses to the Consulting the Capital consultation from
  PPI groups, individuals and community groups representing             Communication: A particular concern for some people e.g. older
                                                                        people, people with a learning disability, hearing impaired, people whose
  patients and the public                                               first language is not English. Other issues include lack of information about
• Reports informing the consultation process                            services available and confusion over which service to use and service
  Consultation with Traditionally Under Represented’ Groups on the      names; telephone access not easy/not preferred by some groups;
                                                                        information continuity is important.
  Healthcare for London Proposals March 2008‟(Healthlink)
  Health Inequalities and Equality Impact Assessment of                 Dignity and respect: Patients want to receive personalised care and
  „Healthcare for London: Consulting the Capital‟ (London Health        be treated with dignity and respect; also linked to equality issues.
  Commission, March 2008)
                                                                        Equality: Patients want to be treated equally and without discrimination;
• Findings from patient focus groups interviewed for A study
                                                                        having equal access to services including access for vulnerable groups is
   of Unscheduled Care in 6 Primary Care Trusts (April 2008)            important (e.g. homeless, people with disability including learning disabled,
• Findings from an Unscheduled Care Project consultation                older people, people with mental health or alcohol and substance misuse
                                                                        problems, people with HIV, people whose first language is not English).
   event on emerging proposals on a delivery model for
   London (Healthlink July 2008)                                        GP Access: People report difficulty (real or perceived) in obtaining
• Relevant literature e.g. Patient Views of the Emergency and           appointments at short notice and want more convenient opening hours.
                                                                        Other issues include registration difficulties for homeless people and new
   Urgent Care System, O‟Cathain, A., Coleman, P. and Nicholl, J.,      migrants, difficulty in contacting services e.g. out of hours or negotiating
   ScHARR, 2007.                                                        the system and defaulting to emergency departments; also linked to
• Not just a matter of time: a review of urgent and emergency           equality issues.
   services in England (Commission for Healthcare Audit and             Transport: Convenience and accessibility of location (including
   Inspection September 2008 )                                          availability of public transport and parking – and cost of parking); mobility
                                                                        issues are also identified as a consideration.
These sources identified seven areas to be particularly important       Waiting times: Speed of response is important; waiting times to see a
priorities for patients and the public in their use and experience of   GP can be too long (general point of access ); waiting times to be seen
unscheduled care services. These are not presented in an order of       following arrival at services can be an issue – more communication to
priority.                                                               keep people informed is required.
                                                                                                                                                        8
Not just a matter of time: A review of urgent and emergency services
in England (September 2008, Healthcare Commission)
This review highlights the importance of good information on the                       Aspects of care that require better data to support
performance and use of services for commissioning and as an
enabler to effective relationships within networks.
                                                                                       integrated working:
                                                                                       Care pathways
The review found that all PCTs monitor performance against                             • Time taken to see a clinician/deliver pain medication/undertake a
national standards (e.g. response and waiting times) and look at                         diagnostic test/start treatment
                                                                                       • Handover of patients between services (for example, time taken to hand
trends in use of the main urgent and emergency care services.
                                                                                         over patients arriving at A&E by ambulance)
Other ways to measure the quality and outcomes of care were                            • Total use of services for different reasons (for example alcohol-related
observed to be more limited. The report draws attention to the                           demand, use related to mental health issues)
opportunity for commissioners and service providers to make better                     • „Whole pathway‟ time to deal with urgent needs (from time of initial
use of data both on the performance of individual services and on                        contact to time urgent need is resolved)
how well services are working together. This includes data on the                      • Access to medication
quality of local services and comparative benchmarking data                            • Number of patients referred/redirected between services
looking across services in different areas.                                            • Time to reach a specialist centre
                                                                                       • Sharing data electronically within and between services

The review reported finding limited data on how well resources are                     Quality of care
used by urgent and emergency care services. Where it does exist,                       • Results of clinical audits
this data shows significant variations. The review highlighted a                       • Patient safety incidents
requirement for better data on the cost, capacity, use and                             • Unplanned repeat attendances within a short timescale (for example,
                                                                                         one week)
outcomes of services.
                                                                                       Outcomes
While all PCTs have taken some action to try to build people‟s                         • Patients treated at home/dealt with by telephone advice
understanding of services, opportunities to identify when this work                    • Patients who do not complete their care (for example, who do not wait
                                                                                         for care in A&E or do not attend appointments at out-of-hours GP centres)
makes a real difference are often lost, as its impact is not
                                                                                       • Emergency attendances and admissions
evaluated. This reinforces the importance of ensuring an evaluative                    • Patients‟ views
approach is built into commissioning processes.                                        • Mortality/survival rates (adjusted to take account of differences in risk and
                                                                                         case mix)
The review placed significant emphasis on integration. Four of the
seven recommendations refer specifically to improving information                      Use of resources
collection and reporting and outcomes. The report identifies various                   • Activity/demand for services
aspects of care that require better data to support integrated                         • Deployment/configuration of services
working (see opposite)                                                                 • Spend
http://www.healthcarecommission.org.uk/_db/_documents/Not_just_a_matter_of_time_A_review_of_urgent_and_emergency_care_services_in_England_200810155901.pdf         9
Key findings from this work – a variety of measures are needed to gauge
quality improvements in unscheduled care; potential indicators exist
A range of measures are needed to understand the impact of              Relevant work in this area is in development e.g. the Medical Care
commissioning decisions in improving the quality of unscheduled         Research Unit, University of Sheffield, is examining indicators to
care. To be comprehensive this needs to include measures which          measure the performance of emergency and urgent care systems
demonstrate how services work together within a whole system to         as part of a Department of Health funded research programme.
provide consistent, coordinated and high quality care to patients as    The Unscheduled Care Project Commissioning Group has
well as indicators applicable to individual services. Increasingly,     expressed particular interest in this work.
there should be consistency in measures used across the system          http://www.shef.ac.uk/content/1/c6/05/91/14/Performance%20Indicators.pdf
to enable this.

This work suggests that what is important to patients in the way
they experience unscheduled care is not significantly different from          Many indicators of unscheduled care
people‟s expectations of other health services. Better navigation             quality and performance already exist
and speed of access tend to be more important in accessing
unscheduled care and situations requiring emergency and urgent                Around 130 different metrics, in use or in development,
care can be anxious and stressful times for patients and carers.              can be immediately located which relate to
                                                                              unscheduled care, drawing from the following sources:
Whilst there is a need for better data on the cost, capacity, use and
outcomes of services, a significant amount of data is already                 • NHS Institute Innovation & Improvement (Better care,
available that could be used to measure improvements in                         better value metrics)
unscheduled care and indicate performance of the unscheduled                  • NHS Improvement Agency
care system (see box opposite); most of the existing data focuses             • Healthcare Commission (Annual Health check, Better
on specific clinical or service areas, rather than the whole system,            Metrics, service reviews)
although some proxy indicators for the latter are available.                  • DH existing national targets (inc. 4 hr A&E target)
                                                                              • DH Vital Signs
                                                                              • National indicator set for local authorities and local
The aim should clearly be to measure what is important and not                  authority partnerships
just what can be measured. Some outcome measures will require                 • Local Area Agreements
new data collection processes to be put in place; the practicalities          • World Class Commissioning Outcomes
and any added burden of data collection needs to be weighed                   • Quality Outcomes Framework
against the benefit anticipated; however if the outcome and                   • National Audit Office
associated measure is considered an important one then the                    • Primary Care Foundation GP OOHs benchmarks
commissioning process should seek to ensure that mechanisms                   • PCT/Acute specific data measured e.g. HES
and, where necessary incentives, are put in place.
                                                                                                                                                   10
Recommendations – take a pragmatic approach using data already
available whilst developing a more robust way forward
Proposed approach                                                                  Involving patients and the public
Taking account of the findings from this work the unscheduled care                 The proposed measures encompass some but not all of the areas
project recommends a pragmatic approach initially, focusing on a                   that have been identified as particularly important by patients and
relatively small number of outcome measures and indicators that:                   the public for unscheduled care. These should be viewed as a
                                                                                   starting point, to be developed and built on.
 Include aspects of care important to patients and the public
 Include quality markers of clinical care and patient outcomes                    Patient reported outcomes measures (PROMs)
 Show how the delivery model is being implemented e.g. shifts in                  For unscheduled care, methods established by commissioners and
care to new settings, access to new pathways                                       service providers should embrace a whole system perspective as
 Have potential to signal improvements in the unscheduled care                    well as specific services and/or settings of care. Patients‟ and the
system i.e. integration, consistency                                               publics‟ use of different services and referrals between services
 Could be implemented relatively easily and therefore could start to              mean that they are likely to have the greatest insight into how well
be used quickly e.g. do not require significant new data collection                the unscheduled care system works as a whole – this is highlighted
                                                                                   as an important consideration. Ways of receiving feedback on
                                                                                   patient experience and effectiveness of care from a patient's
What should be measured?                                                           perspective will need to be determined locally e.g. measured
14 measures are proposed as initial indicators of progress towards                 through patient reported outcome measures (PROMs).
implementation of the unscheduled care delivery model. These are
described in pages 11-14 and mapped against the delivery model on          A variety of techniques can be used to explore patients‟ and the
page 16. Potential developmental measures are shown on page 17.            publics‟ views and experiences, however. Commissioners and
                                                                           providers are encouraged to examine and utilise different methods
These measures are recommended alongside the following (and there and to share and disseminate local work, particularly where the
may be some overlap):                                                      impact has been evaluated, to promote findings and to help raise
                                                                           the profile of involvement. A „Guide to Patient and Public
• National priorities and existing commitments, including vital signs, set
                                                                           Involvement in Urgent Care„ (link below)
out in the operating framework for 2009/10
                                                                           http://www.nhscentreforinvolvement.nhs.uk/index.cfm?Content=220 explores the
•The target agreed for 2009/10 with the LAS for ambulance turnaround
                                                                           range of techniques that are available. A further example of a tool
times under the Commissioning for Quality and Innovation (CQUIN)           is available at http://www.shef.ac.uk/content/1/c6/05/91/04/final%20report.pdf (section
payment framework                                                          4). A pan-London tool to assist in identifying key systems issues to
• Any other relevant measures being developed locally by PCTs              focus on could be developed for local adaptation. Pan-London work
                                                                           to support development of PROMs may also be helpful.
                                                                                                                                                              11
14 indicators of quality in unscheduled care are proposed as                                                                                                Indicators
                                                                                                                                                                1-3
an initial set; these include some measures of outcome
The table below summarises each proposed quality indicator, the rationale for proposing it, comments on a potential metric and notes
other relevant information. The indicators are categorised into three groups: outcome based indicators, process based indicators and
system based indicators. They are mapped against the delivery model on page 16 to show where they apply in the overall system.

 No.     What would be                   Rationale                                      Proposed                        NOTES
         included                                                                       metric(s)
Outcome based indicators (indicators/proxy indicators of practice likely to improve outcomes)
         Improvement in patient          Patients report aspects of their experience    Improvements reported           This could focus on specific issues (e.g.
  1      experience of the unscheduled   in using unscheduled care services that        through PROMs, patient          speed of access, receipt of information,
         care system                     fall short of their expectations and/or do     surveys or other technique      interactions with staff) or on overall
                                         not meet their needs                           applied                         experience or focus on specific
                                                                                                                        communities etc; the extent to which
                                                                                        Patterns of complaint and       patients and the public are involved at all
                                                                                        related processes               (this could be a bespoke metric)

         Effective management of acute   Asthma is still a significant cause of death   % of patients with this         Many possible metrics exist. The two
  2      asthma                          in young adults. Its effective management      condition whose oxygen          proposed in combination are suggested
                                         reduces morbidity and the need for             saturation level was            as key measures of good care.
                                         hospital admission.                            assessed on arrival (i.e.
                                                                                        %yes/%no)                       Time to first O2 measurement was
                                                                                                                        considered but considered onerous.
                                                                                        % of staff trained in British
                                                                                        Thoracic Society guidelines     Some stakeholders flagged assessment
                                                                                                                        on arrival of O2 saturation together with
                                                                                        See note on p14                 respiratory rate and peak flow as a more
                                                                                                                        comprehensive indicator. This could be
                                                                                                                        considered further following testing.

         Effective management of         Indicator of process and quality of care for   Time to pain management         Expectations about use of pain
  3      fractured neck of femur         older people.                                                                  management guidelines need to be
                                                                                        Time to operation               considered.
                                         Prompt treatment in the ED followed by                                         Submission of data to/use of the National
                                         early access to theatre followed by            Time to home                    Hip Fracture Database would provide
                                         rehabilitation increases likelihood of older                                   comparative data
                                         people maintaining independence,                                               The NHS Institute of Improvement and
                                         reduces discomfort and reduces risk of                                         Innovation has useful resources at
                                         complications.                                 See note on p14                 http://www.institute.nhs.uk/quality_and_value/high_volume_c
                                                                                                                        are/fractured_neck_of_femur_facts.html

                                         High volume HRG.
                                                                                                                                                                                12
                                                                                                                                                      Indicators
14 indicators of quality in unscheduled care are proposed as                                                                                              4-7
an initial set; these include some measures of outcome
 No.   What would be                     Rationale                                   Proposed                         NOTES
       included                                                                      metric(s)
 Outcome based indicators (cont’d)
       Effective management of pain      Reducing pain promptly and effectively,     Availability and adherence to    Link to indicator 1– explore whether any
  4                                      reduces adverse physiological responses     guidelines on assessment of      related work is taking place as part of
                                         and improves patient experience.            pain and receipt of              wider PROMs development.
                                                                                     appropriate analgesia.
                                                                                                                      Various tools and clinical practice
                                                                                     See note on p14                  guidelines are available. Further work
                                                                                                                      should determine if use of particular
                                                                                                                      guidelines should be advocated.

       Effectiveness of falls            This is a good indicator of the interface   % of people attending            Should be applied to all unscheduled
  5    assessment and prevention         and communications between hospital         unscheduled care services        care access points.
                                         and community services; focusing on         following a fall who are
                                         people who have already been assessed       appropriately assessed           Need to establish what good practice in
                                         has the potential to highlight issues                                        assessment looks like.
                                         relevant to preventative intervention.      % who have previously been
                                                                                     referred to a falls service.
                                                                                     See note on p14

 Process indicators (indicators of improvement in unscheduled care processes)
       Participation in audit (e.g. by   Routine participation in audit is a good    Annual review of audits          Could form part of commissioners and
  6    professional bodies College of    indicator of quality                        carried out, key findings and    provider review process.
       Emergency Medicine, RCGP                                                      action taken.                    Joint audits (e.g. hospital and community
       clinical audit toolkit for OOH                                                                                 based UCCs audits with ED) potential
       services and local audit                                                                                       indicator of collaboration/enabler to
       processes)                                                                                                     improve care pathways
       Time to clinical assessment by    Indicator of:                               % of walk-in attendances         20 minutes proposed to be consistent
  7    an appropriately skilled          • Speed of response                         who receive a clinical           with OOH service standard. Should apply
       professional in an urgent care    • Effectiveness of risk management          assessment within 20             to all direct access urgent care services
       setting.                          • Consistency of response in                minutes of arrival (15           i.e. hospital and community based urgent
                                           different settings IF the same            minutes for children)            care centres (including WiCs and MIUs)
                                           measure is applied                                                         and urgent care services in polyclinics.
                                                                                     Aim is 100% - benchmark          Standard for children consistent with
                                                                                     initially rather than set as a   intercollegiate guidance applied to UCCs
                                                                                     standard                         www.rcpch.ac.uk/doc.aspx?id_Resource=2621
                                                                                                                      Not proposed for GP practices.              13
                                                                                                                                             Indicators
14 indicators of quality in unscheduled care are proposed as                                                                                    8-11
an initial set; these include some measures of outcome
No.   What would be                      Rationale                               Proposed                           NOTES
      included                                                                   metric(s)
Process indicators (cont’d)
      How promptly definitive care       Indicator of speed of access and        % of walk-in attendances who       This would apply to all direct access
 8    (patient assessed, treated and     consistency of access across the        are seen (assessed, treated and    urgent care services i.e. hospital and
      discharged) is received in an      unscheduled care system IF applied to   discharged) within 60 minutes of   community based urgent care centres
      urgent care setting.               all walk-in urgent care services.       arrival                            (including polyclinics, WiCs and MIUs).
                                                                                                                    Not proposed for GP practices.

      Time taken to transfer patients    For UCCs at the front of EDs            Number and % of UCC                This measure is included in the UCC
 9    from an Urgent Care Centre to      measurement of the 4-hour wait starts   attendances referred to the ED     commissioning guidance and endorsed
      an adjoining ED when treatment     from the point of arrival at the UCC.   more than 60 minutes after         by the clinical reference group that
      in the ED is assessed to be        Any referral to the ED must be made     arrival.                           advised on development of that
      required.                          early enough to ensure timely access                                       guidance. We expect a clinical decision
                                         to appropriate care and case            All UCC referrals to the ED that   about treatment required to have been
                                         completion w/o breaching the            breach the 4 hour standard.        taken within a maximum of 60 minutes.
                                         standard.

      Time taken for a patient with an   The current response for patients       Access to assessment with 60       RCPsych standard is 30 minutes to
10    acute mental health problem        attending UCCs/emergency                minutes.                           assessment and 60 minutes for Section 12
      attending an UCC/ED to be seen     departments with mental health                                             assessment. MH project flags move towards
                                                                                                                    integration of psychiatric liaison and crisis
      by a psychiatric liaison team/     problems is acknowledged to be poor     Assessment of equality of access
                                                                                                                    teams and geographical variation, hence
      CRHT.                              and services are patchy. A short wait   to services.                       suggestion of focus on equality of access.
                                         would indicate both availability of                                        Project Commissioning Group suggested 60
                                         services and services working well                                         minutes overall standard.
                                         together.                                                                  This needs to be benchmarked rather than
                                                                                                                    being a target initially.

      The extent to which relevant       Information sharing is important for    % of attendances with a            Should apply to all unscheduled care
11    information is shared and how      care continuity .                       summary of the care episode        services.
      quickly this occurs.                                                       communicated to:                   UCC guidance includes proposed standard
                                                                                                                    for communication with GPs, also consistent
                                         Data collection and sharing processes   • a patients GP by 8.00am on the
                                                                                                                    with OOH standards.
                                         across the unscheduled care system      next working day                   Health visitor/school nurse standard included
                                         are acknowledged to be poor.            • Health visitor or school nurse   in UCC guidance.
                                                                                 within 2 working days              CMHT standard advised by HfL Mental Health
                                                                                 • a CMHTs within 2 working days    project
                                                                                 (for relevant patients)            May need to adopt a benchmarking approach
                                                                                 % of MDS sent in electronic form   rather than set a standard initially.
                                                                                 See note on p14                    Could develop a minimum data set/content
                                                                                                                    for summary information.
                                                                                                                                                               14
                                                                                                                                        Indicators
14 indicators of quality in unscheduled care are proposed as                                                                              12-14
an initial set; these include some measures of outcome
 No.   What would be                Rationale                                Proposed                            NOTES
       included                                                              metric(s)
 System indicators (indicators of development and greater integration across the unscheduled care system)
       999 callers conveyed to      Indicator of:                            % of all 999 calls not conveyed     Could be linked to initiatives to
 12    alternative (than ED)        • Whole system working                   to an ED                            incentivise new pathway development
       pathways (i.e. treated at    • Availability/shortage of alternative
       scene, conveyed to             pathways                               Increase in ambulance               Would need to be recorded and
       community settings)          • Shift in care setting/                 responses that result in treat at   reported by LAS (already being
                                      development of new pathways            scene                               considered)
                                    • Enhanced skills in LAS workforce
                                      and staff empowerment                  Number of alternative pathways      The expectation is that the %
                                                                             available to each LAS complex       conveyed to settings other that an
                                                                                                                 emergency department (ED) would
                                                                             See note below                      increase over time.

       Emergency admissions for     Indicator of :                           % of patients admitted with         Data already available
 13    ambulatory care sensitive    • Adherence to good practice             ambulatory care sensitive           Included within Better Care Better
       conditions (ASCs)            • Potential to use resources more        conditions                          Value work of NH Institute – can be
                                      effectively                                                                readily benchmarked.
                                    • Development of care closer to home/                                        NHS Information Centre ASC set
                                      new pathways                                                               proposed) – could measure some/all
                                    • How well the system works as a whole                                       of 19 ASCs in this set

       Patients re-admitted as      Indicator of :                           % of emergency re-admissions        Data already available
 14    emergencies within a short   • How well the system works as a whole   within 14 days of discharge         Included within Better Care Better
       period following discharge   • Potential to use resources more                                            Value work of NH Institute – can be
                                      effectively                            % of emergency re-admissions        readily benchmarked.
                                    • Community services/home support        within 28 days (for mental
                                      working /not working well              health admissions)
                                    • Discharge arrangements working / not
                                      working well


                                                                             Note
                                                                             • Method of extracting and reporting the
                                                                               metric and frequency not yet established
                                                                             • Need to determine whether this should be a
                                                                               specific standard or a benchmark?
                                                                                                                                                       15
Some of the indicators proposed need further refinement – e.g. in the
form developed by the London Commissioning for Quality Network
The Commissioning for Quality Network has considered the potential for using quality indicators at a strategic level across London. These
indicators are not meant to replace the quality indicators that PCTs have been developing as part of their commissioning process with
providers. Instead they are meant to shine a spotlight on a small number of quality issues that are key priorities for London and where
progress on the specific issues identified would act as a clear marker for wider changes in quality outcomes for patients across London. Ten
indicators have been developed; two summary examples are shown below.

The ten quality indicators include interim      States which major
quality indicators focussed on improvements                                  6. Improving the quality of the risk assessment and risk
                                                aspects of quality covered
to systems and process and data quality         by the Next Stage Review        management of people with severe mental illness
indicators developed to address areas           – Safe, Effective, and       Aspects of        Safe care – by reducing the risk of patient
where the quality of the data collected         Patient Experience - are     quality           safety incidents occurring
directly compromises the ability to assess      addressed by the indicator   addressed by      Effective care – by improving the support of
the quality of care and outcomes for patients                                indicator         people with severe mental illness through
                                                                                               effective risk assessment and risk management
  1. Patient experience of care when admitted to hospital                    Purpose of        To improve the quality and delivery of risk
  Aspects of       Patient experience – focusing on patients                 Indicator         assessment procedures for people with severe
  quality          interactions with professionals and on their                                mental illness so that the safety of patients, staff
  addressed by     experience of cleanliness of the health care                                and the public is improved and the care of
  indicator        settings they are admitted to.                                              people with severe mental illness addresses
  Purpose of       To improve the components of the patient                                    their needs
  Indicator        experience that patients rate weakest and                 Description of    All Mental Health Trusts to use agreed risk
                   improve the areas of care that get the lowest             the Indicator 4   assessment and risk management tools in the
                   patient experience ratings                                                  care of people with severe mental illness
  Description of   The improve the current patient experience                Nature of         Interim          Focus of      Mental Health
  the Indicator    scores for the areas of:                                  indicator         Quality          Indicator     Trusts and PCT
                   treating patients with dignity and respect                                 indicator                      Provider services
                   involvement in decisions about care                      Potential         Reduction in patient safety incidents involving
                   cleanliness                                              quality           people with a severe mental illness including:
                   for patients admitted to hospital as:                     outcome           Falls
                   impatient general admissions                             indicators        Self-harm
                   emergency psychiatric admissions (MH Trusts)                               Suicide
                   maternity cases                                                            Medicines management
  Nature of        Quality         Focus of         Secondary care                             Failure to recognise physical health problems
  indicator        indicator       Indicator        Acute and Mental                           Sexual Assault
                                                    Health Trusts                              Homicide


                                                                                                                                                  16
Proposed outcomes and indicators mapped to the unscheduled care
delivery model
                                   •   Improvement in patient experience
                                   •   Participation in audits (e.g. College of Emergency Medicine)
                                   •   Effective management of acute asthma
                                   •   Effective management of fractured neck of femur
                                   •   Effectiveness of falls assessment and prevention
                                   •   Effectiveness management of pain
                                   •   Time for a mental health patient to be seen by a PLT/CRHT
                                   •   Improvement in timely information sharing with GPs/others

                                   • Improvement in patient experience
                                   • 999 calls conveyed to alternative pathways
                                   • Participation in audits (e.g. OOH Quality Requirement)
                                   • Effectiveness of falls assessment and prevention
                                   • Effectiveness management of pain
                                   • Time to clinical assessment in urgent care services
                                   • Time for referral from UCC to ED where ED treatment is required
                                   • Time to definitive care in an urgent care service
                                   • Time for a mental health patient to be seen by a PLT/CRHT
                                   • Improvement in timely information sharing with GPs/others


                                   • Improvement in patient experience
                                   • Improvement in timely information sharing with GPs/others
                                   • Effectiveness of falls assessment and prevention
                                   • Effective management of pain
                                   • Participation in audit
                                   System/system wide indicators
                                   • Improvement in patient experience (across services)
                                   • Improvement in timely information sharing (with GPs, health visitors,
                                     school nurses and community mental health teams)
                                   • Variations in levels of emergency admissions for 19 ambulatory
                                     sensitive conditions (ASCs)
                                   • Patients re-admitted as emergencies following a previous admission



                                                                                                       17
Other potential outcome measures and quality indicators have been
identified and could be developed for future use
In considering outcome measures and quality indicators for unscheduled care, particularly for an unscheduled care system, a number of
other areas have been identified as important however potential indicators and/or the means of collecting and reporting them need further
consideration. These are identified below as “developmental” measures. Whilst they need further work, commissioners and providers may
wish to explore their merit. The list includes aspects of care important to integrated working identified in the Healthcare Commission report
Not just a matter of time: a review of urgent and emergency care services in England (see page 8).
  No.    Potential outcome indicators
   1     Outcome and impact of clinical audits, reviews of patient safety incidents etc.

   2     Extension of monitoring the impact of different pathways of care, including on patient experience e.g. patients treated at home/dealt with by telephone advice

   3     Development of more indicators of effective treatment for specific clinical scenarios (short-term focus or ongoing) e.g. management of the limping child

   4     Mortality/survival rates (adjusted to take account of attribution: difference in risk and case mix)

   5     Patients who do not complete their care (e.g. leave before treatment)

   6     Equality of access to quality services e.g. people with disability, mental health problems, homeless, age, sexual orientation

   7     Access to medication; compliance with national/local prescribing guidance

  No.    Potential process indicators
   8     Improvement in access to same day primary care (e.g. urgent GP slots, unscheduled primary care mental health liaison)

   9     Availability of information for patients, the public and staff (e.g. including streamlining processes/reducing complexity via single points of access/referral)
   10    Number of patients referred/redirected between services and effectiveness of handoffs

  No.    Potential system indicators
   11    Unplanned re-attendance/repeat attendance at unscheduled care access points within defined period (e.g. 3 or 7 days)

   12    Access to specialist advice (e.g. access for primary care providers), access to specialist care (e.g. time to reach centre), access to specialist teams e.g. older
         people‟s team/service
   13    Access to care plans across the unscheduled care system (or across key access points)

   14    Consistency of assessment across access points (health and social care)
   15    Sharing data electronically (gradual extension of measure across access points) and consistent use of NHS number, including across social care.

   16    Increase in availability of integrated out of hospital pathways/care packages (evidence of health and social care co-design/joint commissioning) and impact

   17    „Whole pathway‟ time to deal with urgent needs (from time of initial contact to time urgent need is resolved)
                                                                                                                                                                           18
   18    Total use of services for different reasons (for example alcohol-related demand, use related to mental health issues)
Where benchmarking is in use – potential resources (1)

This page summarises resources (and web-links where relevant) that could be used to support improvements in unscheduled care delivery
and inform commissioning. It is not exhaustive.
 DH Essence of Care Benchmarking categories                            NHS Benchmarking Club as at 2008 – website provides data analysis
                                                                       reports on various projects
 http://www.dh.gov.uk/en/Publichealth/Patientsafety/Clinicalgovernan
 ce/DH_082929                                                          http://www.nhsbenchmarking.nhs.uk/projects.asp
                                                                       Completed projects:
 • Communication
                                                                       PMS
 • Privacy & Dignity
                                                                       Older people
 • Records/ transfer of information                                    Community provision
 • Safety of clients with mental health needs                          Asthma, diabetes and CHD in primary care
 • Self-care and control of own health care                            Dental, Optometric, pharmaceutical
 • Everyone will be supported to make healthier choices for            Contribution to public health
 • themselves and others                                               Health Improvement programmes
 • People are confident that the care environment meets their          Health Authority costs/finance
   individual needs and preferences                                    PCG (primary care groups) Clinical Governance
                                                                       PCG Public Involvement
                                                                       PCG Performance
 NHS Institute - Productivity Metrics                                  HlmP performance
 http://www.productivity.nhs.uk/                                       Demand Management
 Accessed on line per SHA broken down into AHTs or PCTs or per
                                                                       Current projects:
 all Foundation trusts:                                                PCT provider functions
 Clinical categories – Acute Trusts/FTs:                               Shared services
 • Reducing length of stay                                             Older people – non-acute
 • Increasing day case surgery rates                                   10 High impact changes
 • Reducing pre-operative bed days                                     Diabetes
 • Reducing DNA                                                        Maternity
 • New to follow up                                                    Primary care indicators
 • Reducing emergency patient readmissions                             Prescribing
                                                                       Workforce
                                                                       Out of hours
 Clinical categories PCTs:
 • Managing variation in surgical thresholds                           Planned projects:
 • Managing variation in emergency admissions                          Primary Care Contracting - Benchmarking Medical Services (2009)
 • Managing variation in outpatient attendances                        11 WCC competencies
 • Managing variation in outpatient referrals
Where benchmarking is in use – potential resources (2)

Primary Care Foundation GP OOHs                                     Healthcare Commission
benchmarking standards project                                      Annual Healthcheck 2008/09
http://www.primarycarefoundation.co.uk/
(Reports back to PCTs and hospital trusts in March 2009)


The Information Centre provides information on line for the
following primary care categories which provide a
benchmark:
http://www.ic.nhs.uk/statistics-and-data-collections/primary-care

• Pharmacies
• Prescriptions
• General practice
• Dentistry
• Eye care

Examples of reports accessed from this site include:
The Quality and Outcomes 2007/08 Exception Report
A summary of public health indicators using electronic data from
primary care                                                        Benchmarking data from the review of urgent and emergency care in
Q research report on trends in consultation rates in General        England (CD issued in February 2009 to all PCTs, NHS Trusts, NHS
Practice 1995-2008                                                  Foundation Trusts and SHAs in England).
The Quality and Outcomes Framework2007/08
GP Practice Vacancies Survey 2008                                   College of Emergency Medicine
GP Survey 2007/08 http://www.gpps.ic.nhs.uk/results08/              http://www.collemergencymed.ac.uk/asp/subview2.asp?ID=196
                                                                    Clinical Standards for Emergency Departments (January 2008)

				
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