How to develop and implement a Balanced Scorecard to tackle … · 2010-03-05 · AdvANTAgeS ANd CHAlleNgeS oF developINg ANd ImplemeNTINg A BAlANCed SCoreCArd For HeAlTH INequAlITIeS

Health Inequalities National Support Team

Enhanced Support Programme

How to develop and implement a Balanced Scorecard to tackle health inequalities

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DH INFORMATION READER BOX

Policy EstatesHR/Workforce CommissioningManagement IM&TPlanning/Performance FinanceClinical Social Care/Partnership Working

Document purpose Best Practice Guidance

Gateway reference 13768

Title How to Develop and Implement a Balanced Scorecard to Support Primary Care Development

Author Jane Leaman

Publication date 05 Mar 2010

Target audience PCT CEs, NHS Trust CEs, Care Trusts CEs, Foundation Trust CEs, Directors of PH, Local Authority CEs

Circulation list SHA CEs, Medical Directors, Directors of Nursing, Directors of Adult SSs, PCT PEC Chairs, PCT Chairs, NHS Trust Board Chairs, Special HA CEs, Directors of HR, Directors of Finance, Allied Health Professionals, GPs, Communications Leads, Emergency Care Leads, Directors of Children’s SSs, Voluntary Organisations/NDPBs

Description One in a series of “How to” guides published as part of the Redoubling efforts to achieve the 2010 National Health Inequalities Life Expectancy Target resource pack

Cross ref Systematically Addressing Health Inequalities

Superseded docs N/A

Action required N/A

Timing N/A

Contact details Health Inequalities National Support TeamNational Support Team (NSTs) Wellington House 133-155 Waterloo Road London SE1 8UG 0207 972 3377 www.dh.gov.uk/hinst

For recipient’s use

HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities

Systematic and scaled interventions by frontline services

(B)

Partnership, vision and strategy,

leadership and engagement (A)

Personal health

Community health

Population health

Systematic community

engagement (C)

Frontline service engagement with the community (D)

Population focus Optimal population outcome

Challenge to providers

10. Supported selfmanagement

9. Responsive services

7. Expressed demand

8. Equitable resourcing

6. Known population

needs

1. Known intervention

efficacy

13. Networks, leadership and coordination

5. Engaging the public

4. Accessibility

2. Local service effectiveness

3. Costeffectiveness

12. Balanced service portfolio

11. Adequate service volumes

Bentley C (2007). Systematically Addressing Health Inequalities, Health Inequalities National Support Team.

Foreword TheHealthInequalitiesNationalSupportTeam(HINST)haschosentoprioritisethe developmentandimplementationofaBalancedScorecardasoneofits‘Howto’guides forthefollowingreasons:

• Inconsistentqualityofprimarycarewilldeliverinequitableoutcomes.Inorderto addressthisandhaveanimpactatpopulationlevel,approachestodevelopment willneedtobesystematicandsustainable,andmustaddressclinicalandmanagerial systemsandcompetencies.

• Specificallywithinthe‘Christmastree’diagnostic,itparticularlyaddressesthe followingcomponents:

– localserviceeffectiveness(2)

– engagingthepublic(5)

– knownpopulationhealth(6)

– responsiveservices(9).

• ActioninthisareaofworkwillhelptocontributetotheQualityandProductivity Challengebyprovidingamechanismtodevelopsystematicallythequalityand productivityofprimarycare.

• Successfuladoptionofprocessessimilartothoseoutlinedherewoulddemonstrate gooduseofthefollowingWorldClassCommissioningcompetencies:

– primarycaretrusts(PCTs)aslocalleadersoftheNHS(1)

– patientandpublicengagement(3)

– collaborationwithclinicians(4)

– stimulatesthemarket(7)

– performancemanagement(10).

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CoNTexT Theaimofthis‘Howto’guideistoproduceasimpletooltohelpSpearheadareasto developwaysinwhichtomeasurethequalityandcapacityofprimarycareanddeliver the2010PublicServiceAgreementtargettoreducehealthinequalities.Itdoesnot providenewguidancebutwilldrawonthefindings/learningfromareaswherethese toolsarebeingused,andcomplementsPrimary Care & Community Services: Improving quality in primary care,particularlyfocusingontwoofthesevenidentifiedelements: measuringqualityandpublishingqualityinformation.1

ThisguidehasbuiltontheNHSPrimaryCareCommissioning(NHSPCC)paperQuality Development Methodology Using a Balanced Scorecard.2Itusesexamplesofandlessons fromanumberofPCTswhoareatdifferentstagesintheirdevelopmentofaScorecard. However,whiletheseareasprovideexamplesforthisguide,localissuesofqualitymaynot beofthesameorderofmagnitudeorinexactlythesamedevelopmentalareas;therefore alocallyrelevantandlocallyownedScorecardprocessshouldyieldthegreatestbenefit.

Allresidentsneedaccesstoeffectiveprimarymedicalcare,particularlyinrelation tothemajorcontributorstoearlydeath.Thesearecardiovasculardisease,cancer andrespiratorydisease,andallareespeciallyrelevantintermsofaddressinghealth inequalities.Therefore,inordertoachievethe2010PSAtarget,HINSTregardsrapid developmentofthequalityofthissectorascritical.ImplementationofaBalanced Scorecardcanimprovebothspecifichealthinequalityindicatorstargetsandthequalityof generalpracticemorewidely,whichshouldhaveapositiveimpactonhealthoutcomes.

APCThasalegalresponsibilityforensuringdeliveryofprimarymedicalcaretothewhole residentpopulation.Indischargingthisresponsibility,thePCTcanexpecttoinvesttime, expertiseandotherresourcestosecureimprovedqualityandproductivity,andincreased costeffectivenessofcare.Strategically,theBalancedScorecardcanthereforesupportthe deliveryofthePCT’squalityandproductivityagendaforthelocalpopulation.Theapproach alsodemonstratesthatthecommissionersareworkingtoachievehighlevelsofWorld ClassCommissioningassuranceandcanusetheevolvingproductasassuranceevidence.

High Quality Care for All3reinforcestheNHSNextStageReviewvisionofanNHS inwhichqualityistheorganisingprinciple.Thiswillhelptoensurethatimproved qualityandinnovationcanberealised.ItsgoalisforeveryproviderofNHSservices tosystematicallymeasure,analyseandimprovequality.Tosupportthis,service commissionerswillneedtodeveloptheirownqualityframeworks,combiningrelevant indicatorsdefinednationallywiththoseappropriatetolocalcircumstances.

MostPCTshavenowbeguntodevelopBalancedScorecards,themethodologyof whichhasbeenevolvingoverthelastcoupleofyears.BalancedScorecardsareseen byPCTsasfundamentalto‘mappingthebaseline’inordertoensurethatprimarycare iscontributingtohealthoutcomeswithinacommunity,andtoinformcommissioning decisions.4However,thisapproachisnotconsistentacrossallPCTs,andforsomethis maybetimeforreview,asallarebeingcalledtoevidencequalityandproductivityinall areasofcommissioning.Theguide,itishoped,willalsohelpPCTstoreviewthepurpose

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oftheirBalancedScorecardsrelevanttotheircurrentrequirements,withregardtohealth inequalitiesandtheirprocessesofimplementation.

TheBalancedScorecardwillalsosupporttheCareQualityCommission’splanned registrationofgeneralpracticesfrom2012;andtheGeneralMedicalCouncil’s revalidationprocessofGPs.Ideally,thereshouldbetheaimofhavingthisonedataset formanyuses.

Atwhateverstageofitsdevelopment,inthoseareaswhosecommunitiesexperiencea highlevelofhealthinequality,theBalancedScorecardshouldbesetwithinthecontext ofaprimarycareimprovementplanorprimaryandcommunitycarestrategywhich aimstoaddresshealthinequalitiesandimprovelifeexpectancyintheshortterm.NHS Next Stage Review: Our vision for primary and community care(www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085937) statesthatallPCTsshouldhaveaprimaryandcommunitycarestrategy,whichincludes theprimarycareimprovementplan.

Todothis,indicatorsshouldfocusondemonstrating,forexample:

• thatthenumbersofpeopleonprimaryregistersandthepredictedprevalenceofa particulardiseasematch(throughcasefinding)

• thatQualityOutcomesFramework(QOF)indicatorsaremetorexceededforchronic diseasemanagement

• thatexceptionandexclusionreportingisataminimum

• thelevelofhealthserviceaccessofparticularcommunitieswhoarelikelytoexperience ahigherlevelofhealthinequalitiesthantheaverageforthepopulation.

ExamplesofspecificindicatorsaresetoutinAppendix4.

ABalancedScorecardforprimarycareisacollectionofdatafromallgeneral practicesinaPCTarea,acrossarangeoflocallyrelevantmetrics.Thiswillenablethe managementofperformanceandtheidentificationofbothdevelopmentalsupport needsandgapsinserviceprovision.

AdvANTAgeS ANd CHAlleNgeS oF developINg ANd ImplemeNTINg A BAlANCed SCoreCArd ForHeAlTH INequAlITIeS

Local leadership and ownership

PCTleadershipandexecutiveaccountabilityforimprovingqualityinprimarycare, togetherwitheffectiveclinicalleadershipandownership,iscrucialforthesuccessful implementationofaBalancedScorecard.ThisguideispremisedonthefactthatthePCT hasclearcommitmenttoimprovingqualityinprimarycareandthatithasexpressedthat aBalancedScorecardapproachisthebestapproachtomeasured,sustainablequality improvement.Ithasbeenidentifiedthatallsuccessfulprogrammestoimproveprimary

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http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085937



carequalitythatuseaBalancedScorecardhavefullBoardsign-upandengagement.The Scorecardshouldcomplementotherknowledgemanagementtools,whichthemselves canpopulatefurtheriterationsoftheScorecard;forexample,thePrimaryCare CommissioningSupport(PCCS)applicationpublishedbytheDepartmentofHealth(DH) tosupportPCTsinassessingpractice-leveldata,togetherwiththeNHSPCCqualityand productivitycalculatorwhichlooksatcomparativePCTperformance.

PCTscouldalsoconsiderinvolvingtheirequalityanddiversityleadstoexplorehowthis toolcanbelocalised,incorporatingotherequalitydimensions,nationalequalityguidance andlocalequalitypolicies.

Clarity of purpose

PCTSneedtobeclearofthepurposeofhavingaBalancedScorecard.Examplesacross thecountryhavebeenasadevelopmental,performancemanagementorcommissioning tool,or(ideally)allthree.Morerecently,followingtheintroductionofWorldClass Commissioning,anumberofPCTshaveusedaBalancedScorecardto‘stimulatethe market’,usingitasawayofensuringadequateserviceprovisioninalocalcommunity andachieveagreedhealthoutcomesdescribedinthebestpracticeguidance.NHS NorthamptonshireusedaBalancedScorecardtosupporttheproductionofan excellentprimarycaremarketmanagementstrategy.Itcanbeusedtodetermine keycommissioningprioritiesandinformthewiderprimaryandcommunitycare commissioningstrategy.

examples of purpose from pCTs

Transparentlyassessthequalityofgeneralpracticeonanannualbasis,andspeedup therateofimprovement.(NHSTowerHamlets,2007)

Addresslocalissuesandlocalneed,addressinghealthinequalities,particularlyinrelation toaccesstoprimarycareservicesandpublichealth.(NHSTowerHamlets,2009)

Provideafocusforsupportingthedevelopmentofprimarycareratherthan performancemanagement.(NHSKnowsley,2009)

Paintapictureofthepracticeandthecontextitisworkingin.Thematchingof deprivationanddemographicdatatopublichealthindicatorsprovidesausefulcontext forperformanceandprovidesaninsightintounderstandingwhatinterventionsmaybe appropriate.(DoncasterPCT,2009)

However,thereisanationalmovetofocusontheperformanceofprimarycarethrough thismethodology,ratherthanusingitonlyasadevelopmentaltool.Thisisdescribed inthebestpracticeguidancePrimary Care and Community Services: Improving GP services.5ThispublicationdescribeshowthePCTscan‘mapthebaseline’tobegina processofmonitoringpracticeperformanceinanumberofareasandsupporteffective commissioningofprimarycare.

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Thismaychangeovertime,dependingonthecircumstancesofprimarycare.For example,TowerHamletschangedtheScorecardfromadevelopmentaltooltoa performance/commissioningtoolin2008/09–tostrengthencommissioning,allowing practicestoearnautonomyandimprovethequalityofservicedeliveryandredesign.

Whatevertheultimategoal,aBalancedScorecardcanalsofulfilarangeof supplementaryfunctions,including:

• topromotegoodquality,andsupportimprovementinefficiencyandeffectiveness

• todetectfallingperformanceearlyenoughtopreventadverseconsequences

• toidentifyappropriatecapacitytodeliveroutcomes

• toidentifyareaswherethereisneedforserviceredesign

• toprovidecommissioningdata/information(forcommissioningprimarycareand integratedservices)

• toreassurepatientsintermsofthequalityofserviceandpublishedinformation, enablingpatientstomakerobustchoicesaboutwhichprimarycareservicestheywish toaccess

• todemonstratethevalueofprimarycare–makingitsroleandimpactvisible

• todemonstratethatprimarycareis‘fitforpurpose’

• tounpickandimprovethequalityofdata,whichcanreassurepracticesthattheyhave theappropriatelevelsofinvestment

• tosupportthedevelopmentofaneffective,local,contractualperformanceframework wherepersonalmedicalservices(PMS)andalternativeprovidersofmedicalservices (APMS)contractsareinplace.

The process for implementation in itself is useful in identifying where there is a need to improve quality.

example of practice

CoventryPCTincludedpracticeresourceandpopulationneed(age,percentageof SouthAsianethnicorigin–derivedfromNamPehchansurnameanalysis–andpractice indicesofmultipledeprivation(IMD)score)inadditiontoperformancemeasures.This wasespeciallyusefulbecauseithighlightedresourceinequityandshowedthat‘good’ performancecouldbeachievedfordeprivedpopulations.

Knowledge management, data quality and data reporting

Thisisoftenabigissue.Therecanbedifferentresultsfromdifferentdatasources,for exampleinmeasuringcervicalscreeninguptakeusingthequalitymanagementand analysissystem(QMAS)orusingpublichealthsubmissionstoDH.Asaprinciple,as muchdataaspossibleshouldbesourcedusingthepracticelistofpatients;wheredata isactuallyaprojectionorderivedfromasecondarysourceitmaybemoreopento challenge,lessreproducibleandthereforeseenaslessreliable.Training,particularlyin goodcoding,mayberequiredtoimprovedataquality.

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Thereareotheremergingtools,suchasthequalityandproductivitychallenge(QPC) calculatordevelopedbyNHSPCC,andthePCCSapplicationdevelopedbytheDH,both ofwhichaimtosupportcommissionersintheeffectiveuseofinformationgainedfrom existingprimarycaredatatosupportqualityandproductivity.Therehaspreviouslybeen acultureinsomeareaswithinprimarycareofnotsharinginformation,butwiththe emergenceofmoreeffectivetoolsandthedevelopmentoftheNHSChoiceswebsite, PCTsarebeginningtobeabletoapplyknowledgemanagementmuchmoreeffectively.

Ownershipandbetterunderstandingofdatabypractices,throughaprocessof verificationofdata-useandanagreementaboutwhichdatasourcesareused,willalso helpinthesharingofdata.

Tosupportthesharingofdata,theBritishMedicalAssociation(BMA)6adviseseffective co-operationbetweenpracticesandthePCT:

Much of the information that PCTs will seek to compile in the balanced scorecards is already in the public domain. However, there are some indicators which are not part of the routine contract data collected by PCTs, which practices will not wish to pass on, such as the access and capacity indicators.

However, paragraph 77(1) of Schedule 6 to the GMS [generalmedicalservices] regulations and paragraph 73(1) of Schedule 5 to the PMS regulations stipulate that practices must provide information reasonably required by the PCT. Moreover, the Freedom of Information Act 2000 states that all primary medical service providers are subject to requests of this Act, should they be made. It is therefore unfeasible for a practice to withhold this information from a PCT that requests it. Instead, GPs should proactively and collectively engage with PCTs, supported by their LMC [localmedical council], to influence the local use of such information and to mitigate against potentially adverse consequences of its publication.

TheScorecardcanalsoserveasaneffectivequalityaccreditationscheme,allowingfor standardisedcomparisonsbetweenpractices,e.g.benchmarking.Seethe‘Howto’guide, ‘How to develop a Taxonomy of General Medical Practices to support and encourage performance development’.

Clinical engagement

Clinicalengagementiscrucialforthesuccessfulimplementationofthiscommissioning tool.TheBMA6statesthatitisessentialthatLMCsandpracticesengagewithPCTs andtheBMAthroughoutthedevelopmentandimplementationprocess.Itneedsto beseenasacollaborativeapproach,anditisvitalthatconstructiverelationshipsare sought.“Practices should be working with PCTs, so that problems[inperformance] are identified and addressed at an early stage.”Clinicalleadershipfromwithinthe PCTisalsocrucialtosuccess(forexample,inNHSKnowsleythemedialdirector leadstheagenda),asisengagementwithlocalclinicalleadersattheearlystagesof implementation.

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examples of practice

TowerHamletsPCThasajointLMC/PCTimplementationgrouptocompileindicators andtoworkontheaspectsoftheScorecard.FinalreportsaresenttotheLMCfor ratification.

NHSCoventryaskedGPstobeinvolvedintheweightingscoreforthebanding scheme,whichproducedaveryconstructivedebate.

NHSSuffolkhasworkedveryhardtodeveloptransparentandconstructive relationshipswiththeirLMCthroughsix-weeklynegotiationmeetingswithPCT seniormanagers.Informalpre-meetingssupportthis.Thesemeetingsalsoprovidean opportunitytodiscussthewidercontextwithinwhichthePCTisworking,forexample theirfinancialposition.ThePCTkeepstheLMCinformedaboutpoorperforming practice,andtheLMChashelpedsupportthepracticeandfacilitateimprovement.

InNHSMedway,aqualitydevelopmentframeworkhasbeendevelopedwiththe supportofKentLMC,whorecognisedthatPCTswouldberequiredtoproducea ‘mappingthebaseline’toolandadvisedpracticesaccordinglyintheirnewsletter.

NHSKnowsleyusesitsCommunitiesofPracticeGroups8toagreeitsBalancedScorecard.

NHSHaringeyworkswithitspractice-basedcommissioninggroups.

GPsareoftenconcernedabouttheirratingoneachindicator–inparticularwhen comparedwithpeers.Thereforesharingresultsbetweenclinicianscanbeapowerful motivator.


NHSSuffolkproducesmonthly‘performancepacks’foritsGPs,whichallowpractices toseehowtheyareperformingcomparedtopeersandagainstnational,regionaland localtargets.Thishasbeenseentoimproveperformance.

NHSStokefoundthatmostpracticeswerekeentoimprovewhenshowntheir performanceagainsttheirpeers.Theuseof‘leaguetables’wasamorepowerful motivatorthanmoney.

Public engagement

TheNHSandotherhealthcarebodiesarerequiredtoensurethatpublicengagement isattheheartofservicedelivery.ABalancedScorecardwouldprovidethepublicwitha

8 MembersoftheCommunityofPracticeGroupsaredrawnfromGPsandnursesinprimarycare,cliniciansinsecondaryand communitycare,workersinpublichealth,medicinesmanagement,informationgovernance,education,intelligenceand commissioning,andmembersofthepublic.Inadditiontothecoremembership,individualcliniciansandotherinterestedparties willjointhecommunityonanadhocbasis.TheCommunityPracticeprovidesaforumforclinicaldialogueanddebate;responds toquestionsorissuesidentifiedbycommissioners,cliniciansandotherswithaninterestinthequalityofclinicalcare;utilisesdata toidentifygapsinpatientcareanddiseasemanagement;providesclinicaladviceandsupporttoinformthecommissioningprocess; supportspracticesindeliveringservicesinprimarycare;developsanddisseminatesguidance,pathwaysandtreatmentprotocols; identifiesandshareseffectivepractice;providessupportforclinicalaudit;developspatienteducation;anddevelopsprofessional educationandhorizonscanningfornewdevelopments.

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clearunderstandingofwhatisbeingmeasuredandthecontextwithinwhichapracticeis operating.Inordertoreinforcepublicaccountabilityforquality,High Quality Care for All3 committedallhealthcareproviderstoproducequalityaccounts.Thesewillprovideeasily accessibleinformationaboutthequalityofservicestopatients.Itisexpectedthatproviders ofmedicalanddentalcarewillberequiredtopublishqualityaccountsbetween2011and 2012.TheinformationproducedthroughBalancedScorecardscouldinformtheseaccounts.

Itisalsoimportantaspartoftheprocessofdevelopment,thatpracticesengagewith theirpatientstodiscusstheirexpectationsandaspirations.Thiswouldenhancethe choiceagendaforthepatient,helppracticesunderstandthebestmeansofdelivering care,improveaccessandresponsivenessandsupportthedeliveryofcareclosertohome. ThiscouldalsobenefitpracticesbyimprovingtheirGPsurveyscores.

ManyPCTsareintheprocessofconsideringwhethertopublishpracticeperformance information.Asprimarycareperformancemanagementanddevelopmentisnotalways wellunderstood,itisimportantthataPCTseekstoensurethatthepublicunderstand whataBalancedScorecardissaying,asitcanbemisrepresentedinthemedia,which couldleadtolossofpublicconfidence.ItisalsocrucialthataPCTboardisfully supportiveofpublishingtheresultssothatitispreparedforanypublic/mediafeedback, andcanthereforemanageitsreputationascommissionersofhealthservices.(Seestep9, ‘Decidehowtousetheresults’.)

How To develop A BAlANCed SCoreCArd Step 1: DevelopaclearvisionatthePCTofwhatconstitutesgoodperformance, acceptableperformanceandwhatconstitutesunacceptableperformanceinprimary medicalcare,withinastrategicvisionforlocalhealthcare.Thisneedstobeledwithclear executiveaccountability.

Thevisionshouldbesimpleandfunctional,notstructural.Itshouldbeaboutthings thatareimportanttopatients,commissionersandserviceproviders,including,but notexclusively:

• improvingthehealthofthepopulationandprotectingthem(e.g.vaccinationprogrammes)

• corporateambitionaroundhealthinequalities

• accessandresponsiveness

• premisesandprimarycareestate

• convenience

• safety

• quality

• productivityandcapacity

• compliancewithregulationsandregulators

• localissuesandconcerns

• patientandpublicengagement.

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NHSSuffolkBoardhadaveryclearmandateforthedevelopmentoftheirgeneral practiceperformanceframeworkinsupportingequalitiesofinvestmentandcare throughlocalcontracting.

NHSNorthamptonshirealsohasaclearvisionforqualityimprovementanddevelopment.

TowerHamlets,in2007,afterdiscussionandagreementwiththeLMC,agreedwith thePCTexecutiveboardtheperformancemanagementofallGPcontractsusingthe BalancedScorecard.Thisensuredthattherewasunifiedunderstandingthroughout seniormanagementandavoidedanypotentialconfusionofdivisionsappearinginthe statedapproach.

Step 2:Developthevisionintoaclearandagreedstrategyforprimarycare,within whichthereisunderstandingof:

• whatthehealthneedsofthepopulationanddesiredoutcomesare

• whatisacceptableordesirableactivityinaprimarycaresetting

• theplaceofperformanceimprovementandroleoftheBalancedScorecard

• performancemanagement

• competition

• collaboration

• howchoiceanddevelopmentfitwithintheoverallstrategy

• whattoolsandtechniqueswillbedeployed.


TheTowerHamletsstrategyisbroadlydefinedundertheirImprovingHealthandWell-beingStrategy2006–2016.7

Step 3:Agreemeasurableindicators(theseneedtobereferencedagainstthose recommendedbytheorganisationsthatdeveloptheindicatorssuchastheRoyal CollegeofGeneralPractice,theNHSClinicalGovernanceSupportTeamorCareQuality Commission)andfollowthequalitystandardssetbyNICEwhichunderpinthevision.8

ThevisionofqualityandperformanceisthefoundationofwhatthePCTmightwantto measurethroughasetofindicatorswhich:

• describegoodpractice

• areagreedlocallyasafairwayofmeasuringpractice

• aimtosupportqualityimprovementandtoidentifylesseffectiveperformance

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• canbebandedintogood,acceptableandunacceptablelocallydeterminedlevelsofcare

• demonstrateproductivityandvalueformoneyofservicestosupporttheQPC.

Theindicatorsandlocallydeterminedlevelsofcaremustbe:

• simple

• nottoogreatinnumber

• clearlydescribed

• basedoneverydaypractice

• measurable.


NHSHaringeyfounditbeneficialtoseparatetheinformationitcollectsintothe followingthreelevels:

• alargedatabasewhichisusedforannualcontractmonitoring

• amorefocusedBalancedScorecard

• informationforeachpractice.

Tosupporttheretrievalofthisdata,NHSHaringeyhasdevelopedaMIQuESTquery forminordertoextracttheinformationrequired.

TowerHamletsstructuresitsBalancedScorecardintothreesections:

• Section1–contractualcompliance

• Section2–keyindicators

• Section3–developmentalindicators.

Anationalindicatorsetiscurrentlybeingproposedto‘mapthebaseline’(seeAppendix1). Developmentofnewindicatorscanbehighlytechnical,anditisoftenbesttouse indicatorsdescribedelsewhere,toavoidproblemswithrecording,reliabilityand reproducibility.

Step 4:Introduceaprocessofchangemanagement,tochange‘heartsandminds’. TheapproachmustbebackedupbyPCTinvestmentinseniorstafftimeforprimarycare commissioningandcontractmanagement,includingastrongprogrammeofvisitsto eachpractice.Thisresourcecommitmentmustnotbeunderestimated.

ExamplesofmembersofaPCTteaminclude:

• prescribingadvisers

• primarycarefinancelead(itisessentialtoincludethis–NHSSuffolkwassupportedby thefullfinanceteam,acrucialcontributortotheoverallprogrammeofperformance management)

• medicaldirector

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• estatesmanager

• primarycarecommissioninglead

• controlofinfection

• QOFindicatorslead

• clinicalgovernancelead

• layassessor

• adminsupport.

How To ImplemeNT A BAlANCed SCoreCArd Step 5: Developaclearsupportprogramme.

Primary Care & Community Services: Improving quality in primary care9statesthatthe standardpositionforPCTsshouldbethattheywillassistGPpracticesinimprovingtheir services:“Direct support should be explicitly linked to the overall approach to managing performance… and PCTs should clearly define the circumstances in which they will provide support.”

SupportthatPCTscouldconsideroffering,whenrequired,includes:

• providingPCTstaffwithspecialistskillstoworkdirectlywithpractices

• sharingexamplesofbestpracticefromotherpractices

• theestablishmentoflocallearningnetworksacrosspractices

• brokeringsupportforpracticesfromsupportagencies.

ThereforethePCTneedstoprovide:

• aclearsystemofrobustcontractualmanagement

• expertinformationmanagementandanalyticalsupport

• trainedassessorswhocanrecommendandimplementsupporttopracticesandprovide educationalpackagesforleading-edgeandtrailing-edgepractices

• supportarrangementsforpracticesindifficulty

• facilitationandnegotiationskills

• primary-care-specificfinancialskills.

Inaddition,thePCTneedstohavepoliciesandasupportframeworkinplacefor education,developmentandperformanceimprovement.Thesewouldbeimplemented assoonaspossiblewhenperformancefallsshortofexpectationsandlocallydetermined levelsofcare.



NHSSuffolkfundsapracticemanagerconsultantfromanestablishedpooloflocal practicemanagerswhowillworkalongsideaprimarycarecommissioningmanager andthepracticemanagerfromafailingpracticetosupportimprovementsidentified inanagreedremedialactionplan(priortoaBreachofContractnotice).NHSSuffolk alsofundsGPmentorstoprovideconfidentialsupportandcustomerservicetraining packagesforreceptionists.

However,ifpracticescontinuallydeliverpoororunresponsiveservicestopatients,PCTs mayusethefollowingformalcontractleversoncelegaladvicehasbeensought:

• decommissioningenhancedoradditionalservices

• issuingremedialorbreachnotices

• terminatingcontracts.

examples of use of remedial action

TowerHamletshasdevelopedaContractReviewProcessthatislinkedtothenumber ofredscoresapracticehasbeengiven.Practicesarerequiredtoproduceactionplans oneachareaofunderperformanceandarevisitedquarterlyforreview.Failureto achieveintheseareascanformpartofaremedialnotice.

NHSSuffolkagreesaSpecificMeasurableAchievableRealisticTimescaled(SMART) remedialactionplanwithpracticespriortoapossibleBreachofContractnotice.

Step 6:ConsidersettingupaClinicalGovernanceGroup(CGG)asasubcommittee ofthePCT(reviewingenablesclearleadershipfromtheboard)inordertodevelopthe agendaforqualityanddelivery.Withappropriatemembershipandtermsofreference theClinicalGovernanceGroupcanfacilitatethedevelopmentanddeliveryofthe Scorecard.

Thegroupitselfneedsto:

• includeandbesupportedbyseniormanagersandclinicalchampions

• bemulti-disciplinaryincludingPCT–commissioners,publichealth,finance,clinical governance,pharmacyandIT–andlocalclinicians’andLMCrepresentation

• useauthorityasasubcommitteeofthePCT(andthereforealsohaveaccountability)

• beabletorequestinformationfrompublichealthpracticesorelsewhereinthePCT

• besupportedbyanalyticcapacity

• havethepowertorecommendactiontothePCTboard

• reassessindicators

• reviewprocess

• introducenewindicatorsandagreetodropoldones.

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TowerHamletsPCThasajointLMC/PCTimplementationgrouptoworkupindicators andotheraspectsoftheScorecard.

NHSKnowsleyhassetupCommunitiesofPracticeGroups(seefootnotepage7) whichprovideanoverviewofaclinicalareaandareinstrumentalinsupportingthe implementationoftheBalancedScorecard(seealso‘Clinicalengagement’onpage6).

Thecontextandtherelationshipwithprimarycareandtheclarityofexpectationsis reallyimportantforanyofthistowork.

Step 7:Developaclearstrategyandtimetableforadministration,thedevelopment ofaScorecardandformanagingtheresults.TheDepartmentofHealth4hassetoutan illustrativetimeline(seeAppendix2)foraperformancecycle.TheBMAstatesthatit “would not expect this process to have an unreasonable impact on GPs’ time”.6PCTs areencouragedtoensurethatthereissufficientcommissionercapacitycommittedtothe developmentandimplementationoftheBalancedScorecard.

Step 8:undertakepreliminarydiscussionsonindicatordevelopments.

Theseneedtoincludethefollowing:

• adecisioninprincipleontheareasforindicatordevelopment

• anexaminationofotherscorecardsagainstthefollowingcriteria:

– relevancetothePCT

– existingexperienceofotherPCTs

– easeofimplementation

• acomparisonoftheindicatorswantedwithanassessmentofhowavailablethe informationis.TheDHPCCSapplicationmaybeausefultoolforthis13

• acomparisonoftheareaswithnationalandlocalstrategicpriorities

• areviewofhowmeasurementmightcontributetounderstandingandfulfillingthe PCTstrategicobjectives

• areviewofsecondaryusesofthedata,forplanningandcommissioningaswellas servicedevelopmentandimprovement–NHSPCCQualityandProductivityChallenge Calculatorcanhelpsupportthisprocess.

Contractualcompliancecanberigorouslycheckedbuttheneedforpracticestoverify thattheymeetcontractual,specifiedlevelsofcarerequiresthedevelopmentofmore guidance/audittools.

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PCTsshouldensurecontractual,specifiedlevelsofcare(suchasforopeningtimes)are beingupheldfullybeforeincludingmoreadvancedindicators(basedonthecontract)in theScorecard.

The following are examples of how contractual obligations are dealt with:

TowerHamletsincludesthisinpartAofitsScorecardasaselfassessmentthatis verifiedbypractices.Randomindicatorsarecheckedforcomplianceatcontract reviewmeetings.

NHSSuffolkusesscorecardmethodologytodevelopaperformanceframeworkto supportthemanagementofitslocalPMScontracts.

Step 9:DecidehowtousetheresultsfromtheScorecard.

Thisshouldbedonebothatanindividualpracticelevelandenmassetoinformprimary caredevelopment.

ConsiderbenchmarkinginformationacrosstootherlocalpracticesoracrossotherPCT areas(refertothe‘Howto’guide,‘How to develop a Taxonomy of General Medical Practices to support and encourage performance development’).

ThefollowingtablesetsoutwaysBalancedScorecardscanbeusedandhighlightsissues forconsiderationiftheyareusedintheseways.

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Howtouse theresults

Considerations Examplesofpractice

Banding ABalancedScorecardscores NHSHaringeydetermineslevelof scheme practicesonlyonbroad

categories.Thebandsarethe foundationofinvestmentsand sanctions.

performancelocallyfordifferent priorities,withspecificlevels expectedbypoorlyperforming practices.

NHSStokesetsinitiallowerlevels ofcareforpoorlyperforming practices.

NHSNorthamptonshirehas producedascoringsystemwhich allowsbothasnapshotofapractice’s overalllevelandalsogroupsof metrics.Itdemonstratesmovement withinthatleveleveniftheoverall levelhasnotchanged.Thetrust alsohastwo-yeartrenddata.

Support for Performingpracticeswillwish AchievementinTowerHamlets delivery totakepartbutalsoexpect

toreceivedevelopment support;practicesneeding developmentmaynotsee themerit,especiallyifthey scorebadly.Goodsupportand developmentmechanismsto achieveimprovedlevelsofcare needtobeseenasincentives forthisgroup.

leadsto‘earnedautonomy’which meansalightertouchbythePCT.

InStoke,practiceshadtomeet anumberofprerequisitesbefore beingabletojoinadevelopment programme.Thisincludesaset ofexemplarylevelsofcareover andabovetheQOFindicators requirementsasameansof achievingbestpossible,rather thanaverage,practice.Funding hasbeenallocatedtosupport theprogramme,whichincludesa supportprogrammeforpractices.

Sanctions Remedialactionmaybe TowerHamletshasclearsanctions against poor requiredforcontractual, andusestheBalancedScorecardin performance specifiedlevelsofcare;

theBalancedScorecard schemeshouldneatlyfitinto performancemanagement.

newservicecontractspecifications. Theserequirepracticestomeet BalancedScorecardrequirements beforetheyareabletocontractfor newservices.

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Howtouse theresults

Considerations Examplesofpractice

Publication Thisdependsonconfidence NHSWestminsterpublishes80%of of results intheresults,thequalityof

thedataandconfidencein practices,althoughnoneof thedatashouldbepatient specificornotinsomeway inthepublicdomainalready. Itisthewayitistreatedthat makesthedifference.The publicalsoneedtounderstand thecontextwithinwhichthe practiceisoperatinginorderto fullyappreciatetheoutcomes oftheScorecard.

Severallevelsofpublication arepossible,forexampleas anaggregatedresulttothe PCTboardandpractices,or asseparatepracticeresultsto thePCTboardandown-results toeachpractice.Ingeneral, publicationmightbelimitedin thefirstyearofthescheme. BalancedScorecardsmaybe usefultofulfiltherequirement forpracticestodevelopquality accountsbytheCareQuality Commissionin2012.14

itsScorecardresultstohelppatients makedecisionsonwheretoaccess primarycareservices. Seeitswebsite: www.westminster-pct.nhs.ukand followthe‘FindaGP’link.

NHSWestminsterusedits communicationsandpatientand publicinvolvement(PPi)leadsto ensurethecommentaryonthe comparatorsisuserfriendly.There isalsoafeedbacksectiononthe websiteforuserstoinformof improvements.

Investment Dependingonresults,thePCT NHSNorthamptonshireusesthe for change mightfindthatthereneedsto

beinvestmentacrosstheboard (ieinotherservicesaswell asGPpractices)in,for example,access,childhood immunisations,improving thepatientexperience andprescribing,aswellas investmentinpracticesthat requiredevelopment.

BalancedScorecardasawayof understandingandstimulatingthe marketinordertoidentifyareasfor furtherinvestment.

BalancedScorecardsareused inNHSSuffolktoreviewand renegotiatePMScontracts.

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http://www.westminster-pct.nhs.uk


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Step 10:DecideontheinfrastructuretostandardiseoperationsoftheScorecardsystem.

Administration Thescorecardapproachdemandsgoodcommunicationand timetabling,timelyresponsesandclearaccountability.

Data Collectionshouldbeelectronicwherepossible,usingexisting channels,e.g.QMAS,butwithconsiderationofnoveldata extractsasintheQOFAssessorToolkit.

Documents Detailing,forexample,oflocalaudits,shouldbemanaged electronicallywherepossible,usingstandardtemplates.

Analysis The‘translation’intoscoresshouldbeagreedandautomated wherepossible.Itiscrucialthattheinformationisproducedwithacleardescriptionofmeaningandcontext.

Step 11:Decideonaframeworkfortheobjectivemeasuresandindicators.

Itisimportanttoensuretheframeworkemploystherightindicators.

Appendix1providesthesuggestednationalindicatorset,andAppendix3providesexamplesofthedomainsusedbyasampleofPCTs.

Step 12:Decidewhentoreporttheoutcomesandwhen/iftodiscussthefindingswith boardmembers.

Thisisprobablyonlyoncethedevelopmentteamisconfidentintheshapeofthepolicy, intheScorecarditselfandhasagreedtheoutcomesthattheteamwantstosee.

Step 13:DevelopacollaborativeapproachwiththeLMCandlocalclinicians.

Whentheelementsofthepolicyandtheshapeoftheframeworkareclear,itneeds tobesharedwiththeProfessionalExecutiveCommittee(PEC)andtheLMCassoon aspossible.

DevelopingagoodrelationshipwithLMCissightedbyallareaswithaneffective BalancedScorecardascrucialtotakingthisworkforward.Togainsupport, commissionersneedtobeabletodescribethebenefitsforpatients,butmore importantlythebenefitsforpracticesandthesupportavailabletoimprovepractice performance.ThemeetingswiththeLMCarelikelytobeaprinciplednegotiation–one whereyouhaverealisticbutstretchingobjectivesandclearbottomlines.

TheBMAadvocatesthatLMCsneedtomakecontactwithPCTsonbehalfoftheir practicesassoonasthePCTbeginstoundertaketheBalancedScorecarddevelopment. ThiswillenabletheLMCtoadviseonhowthecollecteddatawillbeused,toensurethat indicatorsareexpressedwithclearreferencetothecontextinwhichthecareisprovided, andthattheyarerobustandbalanced.


Step 14:Takestock.

Step9canbeverytime-consuming.Itisnotasinglemeeting.Frameworkdevelopment, ietheearliersteps,shouldproceedinparallel.

Step 15:DevelopajointimplementationgroupwiththeLMC.

Thisisrecommendedonanongoingbasistoensureconsultationoneachstageof developmentandreview.


TowerHamletshasajointLMC/PCTimplementationgrouptoworkonindicatorsand otheraspectsoftheScorecard.FinalreportsaresenttotheLMCforratification.

Thisgroupwouldbevaluableinagreeingwhenresultswillbepublishedinthepublic domain.Beforethishappens,practicescouldbesentalettershowingtheirresults comparedwithothers.

Step 16:PresentatapublicsessionofthePCTboard.

Thiswillensureabsolutesignupandonwardcommitment.

Step 17: Organisealauncheventwiththepurposeofengagingpartners,including localauthorityofficersandoverviewandscrutinycommitteemembers,forexample.

Thiswillprovidefurtherdemonstrationofcommitment.Detailofferedattheevent shouldincludefirmdatesforeachstageandtheconsequencesforpracticesandthe PCTifXorYhappens.

Step 18:Runtheprocess.

Theremustbecontinuousmonitoringandreviewoftheprocesswithswiftresponses fromtheprojectteam/owner.Theteamshouldbepreparedtoactatanytimeifvery poorordangerousperformanceshowsunexpectedly.Theimplementationgroupwillbe invaluableintakingthisstepforward.

Step 19:Actontheyear-endresultsandactionplan.

ThebroadoutlineoftheBalancedScorecardwillalreadyhavebeenagreedwiththe boardandLMC.

Theactionplanneedstobeagreedoverallandwitheachpractice.

Thereshouldbeanopportunitytocelebratesuccess.

Step 20:Reviewandchangetheframeworkonanannualbasis,ifrequired.

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19

AppeNdIx 1: mAppINg THe BASelINe (TAkeN From prImAry CAre & CommuNITy ServICeS: ImprovINggp ServICeS5)

National indicator set

Capacity,including:

• numberofGPandnurseconsultationsper1,000weightedpopulation

• lengthandqualityofallprimarycareconsultations

• averagepatientlistsizeperGPpractice

• numberofwhole-timeequivalentGPsandotherclinicalstaff(e.g.practicenurse, nursepractitioner,healthcareassistant)per1,000weightedpopulation.

Quality,mappedacrossthreeareas:

• organisationalquality(includingsafety)

– practiceaccreditation

– premises

• effectiveness

– achievementintheclinicaldomainoftheQOFindicators

– exceptionratesandcomparisonsbetweenreportedprevalenceandexpected prevalenceoflong-termconditions

– localdata,e.g.prescribing,referralsandclinicalgovernance

• patientexperience:GPs,practicenurses,receptionstaff,communicationssystems, parking,qualityofpremises,etc,combinedtomakeuptheoverallexperience. PCTsmayusethenewGPpatientsurvey,orotherformsofpatientfeedbackoran analysisofcomplaintsreceivedtomeasurethis.

Access and responsiveness,asdescribedbythespecificDHguideonthisissue, tobepublishedsoon.Measurementswillinclude:

• patientsatisfactionwithaccess

• practiceopeninghoursforclinicalappointments

• disabilityaccess

• consultationlanguages

• choiceofmaleandfemaleGPs

• uptakeofextendedopeninghours

• useofpremiumratetelephonenumber

• attendanceatA&Eorwalk-incentresasaproportionoflistsize.


Patient choice,includingchoiceofhospital,choiceofpracticeandpersonalised careplanning.

Value for money,includingGMSandPMSspendperhead,referraland prescribingdata.

Premises,includingcompliancewithnationalstandards.10

Demand,including:

• emergencyreferrals/spellsper1,000weightedpopulation

• A&Eactivityper1,000weightedpopulation

• activitywithinout-of-hourssettings,particularlyforroutineorplannedcare

• BetterCare,BetterValueindicatorsforambulatorycaresensitiveemergency admissions

• BetterCare,BetterValueindicatoronsurgicalthresholds

• BetterCare,BetterValueindicatoronout-patientreferrals.

Enhanced services,includingaccessanduptakeoftheseservices.

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AppeNdIx 2: exAmple TImeTABle When What Outcome

Jan–Feb Negotiateobjectivesanddevelopment planforthenextyear,ensuringthatthere isanappropriateblendofqualitativeand quantitativeobjectives.Agreeanycontract variations.ObjectiveslinkedtoPCT’s strategy,suchasincentivestotacklehigh priorityareaslikecoronaryheartdisease,will becommontoallproviders.Otherswillbe specifictoindividualpractices(e.g.extend openinghoursfromXtoY,orincrease patientsatisfactionbyX%).

Draftagreementfor eachpractice.

By Mar 31 Signoffagreement/contractvariationswith eachpractice.

Writtenplan/contract variation,signedby bothparties.

May Formal,senior-levelaccountabilityreview witheverypractice,assessingperformance overprevious12months.

Ensurethatanybalancingpayments/claw-backsrelatingtothepreviousyearare agreed.

Annuallettertopractice, tobesharedatPCT publicboardmeeting. Thiscouldinclude anoverall‘traffic light’assessmentof performance.

Practicetoreceive clearstatementof performance.

July PublishQ1keyperformancemetricsfor eachpractice.

Datapublishedon PCTwebsite.

Oct Formalmid-yearreviewwitheverypractice. PublishQ2keyperformancemetrics.

Letteroutliningmain pointsofreviewmeeting. Datapublishedon PCTwebsite.

Nov–Dec Reviewofperformanceframework andmetrics.

Revisedframework(if appropriate)published.

Jan PublishQ3keyperformancemetrics. Datapublishedon PCTwebsite.

April PublishQ4keyperformancemetrics. Datapublishedon PCTwebsite.

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AppeNdIx 3: exAmpleS oF THe dIFFereNT domAINS uSed By prImAry CAre TruSTS (pCTS) Doncaster PCT

Clinicalperformance

Safety

Organisationalprocesses

Quality

NHS Knowsley

Listsize/GPwhole-timeequivalent

Lifeexpectancy

GPaccess

PartnershipsinHealth

Clinicalquality

Expectedprevalence

unplannedcare

Education

PatientandPublicInvolvement

Coventry PCT

Activities

Diseaseandneed

Administrativeprocesses

Prescribing

Teamwork,training,employment

Additionalpossibilities:

Numbersremovedfromlistandwhy

Systemtoalertout-of-hoursservicetopatientsdyingathome

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23

NHS Haringey

Existingcommitment

Nationalrequirements:

Waitingtimes

Hospitalacquiredinfections

Nationalpriorities:

Allageallcausemortality

Cardiovasculardiseasemortality

Cancermortality

Suicideandundeterminedinjury

Smoking

Obesity

Immunisation

Breatfeeding

Childrenandadolescentmentalhealthservices

Chlamydiascreening

Accesstodrugmisuseservices

Self-reportedexperienceofNHS

NHSstaffsatisfaction

Primarydentalservices

Tower Hamlets PCT

Section A – Contractual and statutory requirements and compliance

Contractualcompliance

Businesscontinuityplanning

Healthcarecommissionstandards

ResponsetoCentalAlertingSystemalerts

Section B – Key indicators

Patientsabletogetanappointmentwithin48hoursiftheywish

Cervicalscreening

Childhoodimmunisations

Pre-schoolboosters

Pneumococcalimmunisationforover-65s


Section C – Developmental/quality indicators

Access:

Rangeofenhancedservices

Patientprofilinglocalenhancedservices–ethnicityrecording

Patientprofilinglocalenhancedservices–languagerecording

patient experience:

CompositeIpsos/MORIscore

public health:

Influenzaimmunisationsforover-65s

Breastscreening

Bodymassindexrecording–aged16yearsandoverinprevious15months

prescribing

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25

AppeNdIx 4: SpeCIFIC meTrICS THAT provIde A HeAlTH INequAlITy perSpeCTIve ABalancedScorecardisagenericscorecardbalancingdifferentmetricsanddomainsfora practice,butthesewouldbetheonesparticularlyofinterestforaddressinghealthinequalities:

Capacity and accessibility

• Numberofface-to-faceGPappointmentsperyearperpatient

• Numberoftrainednurseappointmentsperyearperpatient

• Extendedhoursoffered(outsidecorehours)

• Patientexperience–usingpatientsurveys

• Disabilityaccess

• Consultationlanguages

• Culturalsensitivities

• uptakeofenhancedservicestomapavailabilityanduptakebypopulationto ensureaccessibility

Prescribing

• useofstatins

• RatioofACEinhibitorstoangiotensin-IIantagonists>75%(excludingcombination products)

Public health targets

• Percentagesachievedforcervicalscreening,childhoodimmunisations,breastscreening

• Fluvaccineuptake

• Coronaryheartdisease,cancerandinfantmortality

• Allageallcauseandlifeexpectancylevel(maleandfemale)

Value for money

• Valueformoneyprescribingindicators–prescribingcostsversusoutcomesfor diabetes;hypertensionmanagement;status

• urgentandelectivereferralsper1,000weightpopulationcomparedacrosspractice SuperOutputAreas(SOAs)


Quality and Outcomes Framework indicators

• Prevalence–actualidentifiedagainstpredicted

• Exceptionreporting–reasonswhy

• WorkbeingdonetotreatthoseabovetheQOFindicatorstarget

• Diabetes–HbA1cachievement

• Cardiovasculardiseasemanagement–bloodpressurecontrol,treatmentand distribution

• Chronicpulmonaryobstructivediseasemanagement

• Cancerreferrals–earlydiagnosis,urgentversusnon-urgent,two-weekreferrals (anddiagnosisratio)

Local targets

• Smokingcessation–effectiveness

Local context

• IndicesofMultipleDeprivationscore(IMD)

• Demographics:populationagedover75years

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27

reFereNCeS 1 DH(2009)Primary Care & Community Services: Improving quality in primary care,

DH,www.dh.gov.uk/prod_consum_dh/groups/dh.../dh_106575.pdf 2 NHSPrimaryCareContracting(2008)Quality Development Methodology Using a

Balanced Scorecard,commissioningpaperPCC/C/QDM/WB/0508,www.pcc.nhs.uk 3 DH(2008)High Quality Care For All: NHS Next Stage Review final report,DH,

www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_085825

4 DH(2009)Primary Care & Community Services: Improving GP services,DH, www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_093830

5 DH(2009)Primary Care & Community Services: Improving GP services,DH, www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_093830

6 BritishMedicalAssociation(2009),Focus on the Department of Health’s ‘Improving GP Services’ Guidance,GPCguidanceforLMCsandGPs(Englandonly),BMA, www.bma.org.uk/images/focusimproveGPservices_tcm41-189138.pdf

7 www.towerhamlets.nhs.uk/publications/corporate-publications/?entryid4=29504&q= 0%c2%acimproving+health+and+well-being%c2%ac

8 www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp 9 DH(2009)Primary Care & Community Services: Improving quality in primary care,

DH,www.dh.gov.uk/prod_consum_dh/groups/dh.../dh_106575.pdf 10www.nhsestates.gov.uk/primary_care/index.asp

http://www.dh.gov.uk/prod_consum_dh/groups/dh.../dh_106575.pdf

http://www.pcc.nhs.uk




http://www.bma.org.uk/images/focusimproveGPservices_tcm41-189138.pdf

http://www.towerhamlets.nhs.uk/publications/corporate-publications/?entryid4=29504&q=0%c2%acimproving+health+and+well-being%c2%ac

http://www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp

http://www.dh.gov.uk/prod_consum_dh/groups/dh.../dh_106575.pdf

http://www.nhsestates.gov.uk/primary_care/index.asp


AuTHor ANd ACkNowledgemeNTS Written by:

JaneLeaman,AssociateDeliveryManager HealthInequalitiesNationalSupportTeam [email protected]

Acknowledgements:

editing Board BevNorton,HealthInequalitiesLead,NHSPrimaryCareCommissioning

PhilipLeech,PrimaryCareLeads,NHSPrimaryCareCommissioning

RebeccaThornton,AssociateDirector,NHSPrimaryCareCommissioning

Contributors AndrewRidley,DeputyChiefExecutive,TowerHamletsPCT

DrChrisMimnagh,MedicalDirector,NHSKnowsley

DavidHill,Acting,GPCommissioningManagerforNorthWestlocality, CommissioningManagerforCommunityHealthServices,TowerHamletsPCT

HeatherMarsh,DeputyDirectorofPrimaryCare,NHSDoncaster

Jo-AnnSheldon,GPCommissioningManager,TowerHamletsPCT

KristianSmith,HeadofContractingandPerformance,NHSNorthamptonshire

MabliJones,AssociateDirector,PrimaryCareCommissioning,TowerHamletsPCT

MelanieCraig,DeputyDirectorofPerformance,NHSSuffolk

DrPeterBarker,ConsultantinPublicHealth,CoventryPCT

SophieRuiz,CommissioningManager–ContractManagement,WestminsterPCT

StephenDietch,AssociateDirectorofPerformance,NHSHaringeyPCT

Stakeholders CatherineJenkins,HeadofQualityTeam,PrimaryMedicalCareBranch, CommissioningandSystemManagementDirectorate,DH

HemlataFletcher,Equality&DiversityLead,TransformingCommunityServices,DH

JillMatthews,Director–PrimaryCareandCommunityServicesStrategy, PrimaryCare–CommissioningandSystemManagement,DH

ZawarPatel,PolicyAdvisor,EqualityandInclusion,DH

Ifyouwantmoreinformationontheexamplescontainedinthisguide,pleasecontact [email protected]

28

mailto:[email protected]

mailto:[email protected]