The commissioning outcomes framework will help in measuring meaningful improvement in long term conditions, says NICE deputy chief executive Gillian Leng.
As the population ages, the number of people with long term conditions is also increasing, and many elderly patients have to cope with multiple morbidities.
Recommended management of specific long term conditions with comorbidities has been set out in a series of National Institute for Health and Clinical Excellence guidelines.
For example, NICE has set out best practice in identification, treatment and management of depression in adults who also have a chronic physical health problem. A long term physical health problem can both cause and exacerbate depression. Pain, functional impairment and disability associated with chronic physical health problems can greatly increase the risk of depression in people with physical illness. Depression can also exacerbate the pain and distress associated with physical illnesses and adversely affect outcomes, including shortening life expectancy.
Some of the more recent long term conditions covered by NICE guidelines are hip fracture, hypertension and self-harming, and further guidelines are planned to address common comorbidities and key service areas, such as optimisation of drug therapy and managing long term conditions.
In addition to clinical guidelines, NICE is developing a library of more than 170 quality standards that will each provide a set of statements defining high quality care. These statements will act as “sentinel markers” of high quality to drive improvement in care for patients, and will be used both by providers and commissioners. Chronic heart failure, chronic obstructive pulmonary disease, dementia and glaucoma are among topics published so far.
Quality standards will be aligned with the NHS outcomes framework, and their use will be encouraged through mechanisms such as the best practice tariff, commissioning for quality and innovation and the commissioning outcomes framework.
The commissioning outcomes framework will be set by the NHS Commissioning Board to become operational in April 2013. Indicators will form part of a wider accountability framework used by the board to hold clinical commissioning groups to account for quality improvement, when they take on their statutory responsibilities for commissioning from 2013‑14. Importantly, framework indicators will reflect areas that can meaningfully be measured at clinical commissioning group population level.
NICE has been asked to develop suggested indicators for the commissioning board to consider and, as part of this process, NICE is responsible for consulting on potential indicators. It will then publish a menu of framework indicators from which the board will choose the final indicators for inclusion in the 2013 framework.
The framework will consist of routinely measureable indicators based on the NHS outcomes framework, NICE quality standards and existing collections. Designed to help drive improvement in quality of healthcare and patient outcomes through better commissioning, commissioning outcomes framework indicators will apply in England only. In general, NICE commissioning outcomes framework indicators will measure healthcare processes that are linked to health outcomes and that can be influenced by CCGs as part of their commissioning activities. However, where possible, direct measurement of health outcomes by indicators will be included.
For example, a health outcome indicator could be “mortality rate within 30 days of hospital admission for stroke”. An example of an indicator where the process is linked to a health outcome is “time to thrombolysis”. It is likely that the majority of commissioning outcomes framework indicators will be of this type, ie linked to improved health outcomes.
In September 2011, the independent commissioning outcomes framework committee considered draft indicator statements based on quality standards for depression, COPD, dementia, diabetes, glaucoma, specialist neonatal care, stroke, venous thromboembolism prevention and chronic kidney disease.
Indicators were prioritised for further development, testing and consultation. NHS outcome framework indicators and other indicators were then added to this process. The commissioning outcomes framework committee then consider the results of this testing, before making the final menu available in summer 2012. The commissioning board’s final choice for the 2013 framework is expected to be published in autumn 2012.
The framework will provide information to patients and the public on the quality of healthcare provided by local CCGs by enabling health outcomes for major long term conditions and others, such as those listed above, to be measured. These health outcome measures will also allow the CCGs to benchmark their performance and identify priorities for improvement in commissioning care for their communities.