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First NHS outcomes framework published

The first NHS outcomes framework has been unveiled, identifying 51 indicators to be used to judge the service.

The NHS Outcomes Framework 2011-12, published today by the Department of Health, says it will “set the direction of travel” for the government’s intended move to a “focus on outcomes”, rather than other forms of performance management.

There are 10 over-arching indicators and 31 “improvement area” indicators, divided between five domains of healthcare (see below).

Various health interest groups and representatives are understood to have pushed strongly for the inclusion of indicators in their area.

For 2011-12 no targets are set and, for many of the indicators, reliable information is not yet available. Some are provisional and earmarked to be replaced when a better measure is identified.

From 2012-13 an outcomes framework will be negotiated annually between the health secretary and NHS Commissioning Board, along with “levels of ambition” for improvement.

The document says these future target levels will be “ambitious yet feasible and affordable”. They will take into account how easily the NHS can affect their improvement, how long NHS change may take to impact the outcomes, “achievability and affordability as a whole” and “the variation and inequalities in heath outcome indicators”.

In future years, the framework states: “The NHS Commissioning Board will translate the national outcomes into outcomes and indicators that are meaningful at a local level in the commissioning outcomes framework, which it will use to hold GP commissioning consortia to account for their contribution to improving outcomes”.

The board will also produce commissioning guidance and work with the National Institute for Health and Clinical Excellence to produce standards for high quality care.

The document says the “duty to secure continuous quality improvement in the NHS”, which the government intends to place on commissioning consortia, “will ensure that quality runs throughout the whole system and, in practical terms, means that commissioners will be required to have regard to guidance produced by the board, including NICE Quality Standards”.

The framework’s overarching indicators include – under the domain of “enhancing quality of life for people with long-term conditions” – the health related quality of life for people with long term conditions.

This would be measured by adding the EQ-5D survey to GP Patient Survey questionnaires, and developing a new case-mix adjustment model. This information is already collected by the Health Survey for England, but is not currently published and there is a long delay on it being available, according to the framework.

Under the safety domain, overarching indicators include the number of severe safety incidents, and the number of “similar” safety incidents reported by a provider – reflecting ability to learn from previous incidents.

The Department of Health also today published a consultation on an outcomes framework for public health. It has different domains, but indiactors are expected to overlap with the NHS outcomes framework.

NHS Confederation acting chief executive Nigel Edwards said: “While, overall, targets have helped improve our health services, there is little doubt that the next step forward has to be a focus on outcomes. They have genuine potential to deliver better care for patients.

“At the same time, it is worth pointing out that targets are not dead. Measuring outcomes is extremely difficult and in especially complex cases a process target might be the only way of ensuring a treatment is being performed properly.

“It can take some time for improvements in care to show up through improved outcomes. There will therefore need to be some flexibility over how and when those delivering health services are paid for the outcomes they achieve.”

 

Indicators

Domain 1 - Preventing people from dying prematurely

Overarching indicators

1a. Mortality from causes considered amenable to healthcare (The commissioning board would be expected to focus on improving mortality in all the components of amenable mortality as well as the overall rate)

1b. Life expectancy at 75

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

1.2 Under 75 mortality rate from respiratory disease*

1.3 Under 75 mortality rate from liver disease*

1.4 Cancer survival

                i One and

                ii five year survival from colorectal cancer

                iii One and

                iv five year survival from breast cancer

                v One and

vi five year survival from lung cancer

Reducing premature death in people with serious mental illness

1.5 Under 75 mortality rate in people with serious mental illness*

Reducing deaths in babies and young children

1.6 i Infant mortality*

ii Perinatal mortality (including stillbirths)

 

Domain 2 - Enhancing quality of life for people with long-term conditions

Overarching indicator

2. Health related quality of life for people with long term conditions (EQ-5D)**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition***

Improving functional ability in people with long term conditions

2.2 Employment of people with long term conditions

Reducing time spent in hospital by people with long term conditions

2.3 i. Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

ii. Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Enhancing quality of life for carers

2.4 Health related quality of life for carers (EQ5D)**

Enhancing quality of life for people with mental illness

2.5 Employment of people with mental illness

 

Domain 3 - Helping people to recover from episodes of ill health or following injury

Overarching indicators

3a Emergency admissions for acute conditions that should not usually require hospital admission

3b Emergency readmissions within 28 days of discharge from hospital***

Improvement areas

Improving outcomes from planned procedures

3.1 Patient reported outcomes measures (PROMs) for elective procedures

Preventing lower respiratory tract infections (LRTIs) in children from becoming serious

3.2 Emergency admissions for children with LRTIs

Improving recovery from injuries and trauma

3.3 An indicator needs to be developed.

Improving recovery from stroke

3.4 An indicator needs to be developed.

Improving recovery from fragility fractures

3.5 The proportion of patients recovering to their previous levels of mobility/ walking ability at i 30 days and ii 120 days***

Helping older people to recover their independence after illness or injury

3.6 The proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into rehabilitation services***

 

Domain 4 - Ensuring that people have a positive experience of care

Overarching indicators

4a. Patient experience of primary care

4b. Patient experience of hospital care

Improvement areas

Improving people’s experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals’ responsiveness to personal needs

4.2 Responsiveness to inpatients’ personal needs

Improving people’s experience of accident and emergency services

4.3 Patient experience of A&E services

Improving access to primary care services

4.4 Access to i GP services and ii dental services

Improving women and their families’ experience of maternity services

4.5 Women’s experience of maternity services

Improving the experience of care for people at the end of their lives

4.6 An indicator needs to be developed based on the survey of bereaved carers.

Improving experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Improving children and young people’s experience of healthcare

4.8 An indicator needs to be developed.

 

Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Patient safety incident reporting

5b Severity of harm

5c Number of similar incidents

Improvement areas

Reducing the incidence of avoidable harm

5.1 Incidence of hospital related venous thromboembolism (VTE)

5.2 Incidence of healthcare associated infection (HCAI)

i MRSA

ii C difficile

5.3 Incidence of newly acquired category 3 and 4 pressure ulcers

5.4 Incidence of medication errors causing serious harm

Improving the safety of maternity services

5.5 Admission of full term babies to neonatal care

Delivering safe care to children in acute settings

5.6 Incidence of harm to children due to ‘failure to monitor

Indicators in italics are placeholders, pending development or identification of a suitable indicator

*Shared responsibility with Public Health England

** EQ-5D is a trademark of the EuroQol Group. Further details at www.euroqol.org

***Indicator also included in the Adult Social Care Outcomes Framework

Readers' comments (4)

  • 51 centrally dictated measures of quality - how very Stalinist.

    Anyone familiar with the measurement of quality will be familiar with lists like this. Bernard Crunp published a 'Better Metrics' list 10 years ago which was better than this.

    The point isn't that one list of quality indicators is better than another, or even that you can capture quality in 51 undicators (what a ridiculous thought that is).

    The point is how you use these things. How do you get these indicators (and others) to really drive quality improvement? Where is the social movement to deliver the change? How do you stop these being turned into targets?

    Would it be churlish to point our that CQUIN has already become a dismal numbers game far removed from the original lofty intentions?

    Unsuitable or offensive?

  • It is a great pity that the only dental outcome in the list of 51 is a perpetuation of the current useless access target that has done such harm in mis-shaping the commissioning of primary care dentistry towards meeting access numbers instead of meeting population needs. Sadly, frustration and stagnation will therefore continue for another year.

    Unsuitable or offensive?

  • Apart from some of the general categories that will embrace the patient's experience of mental health services; I am delighted by the inclusion of a specific measure at 4.7 on the performance of community mental health services based on the patient's experience.

    May I offer two thoughts? First, Heathwatch will require a specific arm for mental health - the CQC recently pointed up serious concerns in this area. Secondly, patients must be involved in 'operationalising' 4.7 to avoid another 'company' interpretation being developed by other stakeholders.

    This is likely to be my last post before Christmas, so may I wish everyone a Happy Christmas.

    Unsuitable or offensive?

  • Apart from some of the general categories that will embrace the patient's experience of mental health services; I am delighted by the inclusion of a specific measure at 4.7 on the performance of community mental health services based on the patient's experience.

    May I offer two thoughts? First, Heathwatch will require a specific arm for mental health - the CQC recently pointed up serious concerns in this area. Secondly, patients must be involved in 'operationalising' 4.7 to avoid another 'company' interpretation being developed by other stakeholders.

    This is likely to be my last post before Christmas, so may I wish everyone a Happy Christmas.

    Unsuitable or offensive?

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