Minutes of the meeting held on 24th September 2012 Meeting ...€¦ · 1 of 37 Commissioning Outcomes Framework Advisory Committee Minutes of the meeting held on 24th September 2012

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Commissioning Outcomes Framework Advisory Committee

Minutes of the meeting held on 24th September 2012

Meeting held at Manchester

Attendees Committee Members: Sarah Baker (SB), Nigel Beasley (NB), Derek Chase (DC), Andy Cotgrove (AC), Sarah Dougan (SD),

Richard Garlick (RG), Simon Hairsnape (SH), Danny Keenan [Chair] (DK), Gillian Laurence (GL), Colette Marshall (CM),

Richard Mindham (RM), Frances Reid (FR), Sarah Scobie (SS), Lynn Woods (LW)

NICE Attendees: Nick Baillie (NB), Anna Brett (AB), Gavin Flatt (GF), Craig Grime (CG), Laura Hobbs (LH), Gillian Leng

(GLg), Liane Marsh (LM), , Rachel Neary (RNy), Carl Prescott, Beth Shaw (BS), Tony Smith (TSm), Tim Stokes (TS), Daniel

Sutcliffe (DS), and Andrew Wragg (AW).

NHS Information Centre: Julie Henderson (JH) and Alison Roe (AR).

Observers: Tonya Gillis (TG), Catherine Jenkins (CJ) and Lyndsey Unwin (LU).

Apologies Mark Davis (MD), Raj Nagaraj (RN), Guy Pilkington (GP) and Sharon Tuppeny (ST).

Authors Liane Marsh (LM) and Rachel Neary (RN).

*For internal use only ( to be

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Removed for publication)

Agenda item Discussions/ Indicators Rationale

1. Welcome, outline of committee meeting and apologies

The Chair DK, welcomed everyone to the meeting and noted apologies. The Chair outlined the schedule for the day and reminded Commissioning Outcomes Framework Advisory Committee (COF AC) members that their decision making was supported by a number of documents including the key considerations document, the NICE consultation report, the HSCIC testing reports, the NICE Equality analysis reports and the prioritisation spreadsheet. DK advised that Jane Mulholland had resigned from the Committee due to other commitments. He expressed his gratitude to Jane for her contribution to the work and confirmed that the NICE team would recruit a replacement. DK also regrettably informed the COF AC that Niru Goenka had recently passed away. Members recognised the highly valuable contribution that Niru had made as a COF AC member and to the NHS as a whole. DK confirmed that he would write to Niru’s family to express condolences on behalf of the Committee.

2. Introduction to the Meeting and Code of conduct for members of the public attending the meeting.

DK briefed the Committee and members of the public on NICE’s code of conduct for meetings held in public.

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3. COF Policy Update

CJ updated the Committee on changes in COF policy since the last meeting. DK questioned whether the COF indicators would be refined into subsets in the future and if they would be used to set priorities? CJ stated that the COF is not intended to set national priorities. Instead it is intended as a dashboard to help Clinical Commissioning Groups (CCG’s) decide what their priorities are and compare their performance against other CCG’s. It is anticipated that data will not be collected locally. The Committee questioned the relationship between the COF and the Public Health Outcomes Framework (PH OF). CJ responded that there will be overlap between the COF and the PH OF and that integration would be encouraged. She confirmed that the Committee should recommend things that CCGs can make a large contribution to, but that the focus of the COF shouldn’t be public health. The Committee asked whether COF indicators will be retired over time. CJ advised that this issue hasn’t been decided yet and that there was still no indication of the optimum number of indicators within the COF. She did however suggest that it is unlikely that the COF will infinitely extend. Finally, the Committee asked about whether the position around the quality premium had been agreed. CJ confirmed that engagement events were currently being held across the country to discuss this but that it had not yet been fully defined. She suggested however that it was likely that the COF will be used to calculate the quality premium.

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4. Update on COF process and the role of NICE.

GL updated the Committee on COF process and the role of NICE.

5. Declarations of Interest

DK advised the COF AC that if they had any new interests to declare since the last meeting then they should contact LM who will provide them with a new Declarations of Interest form to be completed.

6. Minutes of the last meeting held on 21st and 22nd May 2012

Members agreed that the minutes taken at the COF AC meetings held on 21

st and 22

nd May 2012 were

an accurate record of the meetings that took place.

7. Structured decision making

DK briefed the Committee on the structured decision making criteria that should inform their decision making.

8. Position statements

DK briefed the Committee on position statements.

9. Prioritisation criteria

DK briefed the Committee on the prioritisation criteria that should inform their decision making.

10. Patient and service user experience.

The committee discussed the proposed methodology for collecting data for patient experience indicators.

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4b Patient experience of hospital care The Information Centre presented an update on how hospital based patient experience data could be assigned to CCGs for the 2013/14 COF. They advised that arrangements had been made for hospital based patient experience surveys to capture the GP practice code of survey respondents. This would enable survey results to be directly ascribed to CCGs, with suitable weightings applied to address variations in response rates. The Committee asked how the data for this indicator would be provided. Colleagues from the Information Centre explained that an aggregated figure would be provided across a CCG. In terms of the usefulness of the indicator for commissioning, Committee members questioned the value of an indicator that measured patient experience at CCG level across all hospitals from which a CCG commissions care. The Committee considered that a single aggregated figure would hide variation, where patients at different hospitals had different experiences. The Committee felt that for these indicators to fit into the commissioning process and support improved outcomes, commissioners would require patient experience data for each provider, and to be able to monitor change over time. However, the Committee noted that patient experience is an important outcome (along with outcomes that are clinical in nature, and which are measured at CCG level). In common with other outcomes, commissioners would need to break down the overall CCG figure by provider to address poor outcomes. The Committee noted that the inclusion of an indicator in the COF was dependent on the purpose of the COF: for purely commissioning purposes, an aggregate patient experience would not be useful. The Committee agreed not to recommend this indicator for progression based on these considerations.

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5a Patient safety incident reporting The Information Centre presented an update on how provider based patient safety data could be assigned to CCGs for the 2013/14 COF. They advised that data from the National Reporting and Learning System (NRLS) was collected at provider level, and that there was no direct way to ascribe patient safety incidents to CCGs. The Information Centre proposed a ‘proxy method’ of apportioning trust level data to CCGs. This would be based on assigning a proportion of the overall incidents in a provider to a CCG, based on the proportion of that provider’s activity commissioned by the CCG in question. The Information Centre also noted potential issues around data completeness due to the non-mandatory nature of reporting arrangements to the NRLS. The Information Centre advised that the figures should be classed as ‘estimates’ and should not be used as the basis for the allocation of quality payments to CCGs. Committee members felt that this indicator would not be useful in driving quality improvement or determining high quality commissioning and that there was a high risk of incorrect attribution of patient safety incidents to CCGs. Committee members queried whether the aspiration was for higher or lower rates for this indicator: a higher level of incident reporting may indicate a good reporting culture rather than poor levels of safety. The Committee agreed that the patient safety indicator was too problematic and agreed not to recommend this indicator for progression.

5.2ii Incidence of Healthcare Associated Infections – C.Difficile

Committee members felt that this indicator would not be useful in determining high quality commissioning The Committee noted that there are already significant reporting and monitoring arrangements at provider level.

5.9 VTE risk assessment on admission to hospital Committee members felt that this indicator would not be useful in determining high quality commissioning.

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General comments The Committee noted that they understand and welcomed the drive to use commissioning as a tool for improving patient safety and experience, but that there is more work to be done before this can be adequately measured. The Committee queried whether the NHS patient survey could be amended to better capture this data. . The Committee suggested that it would be better to wait for indicators developed from the patient experience NICE quality standards.

11. Breast cancer

The Committee considered the supporting information presented by the NICE technical team and recommended that the following indicators should be progressed for further development.

BC30 Breast cancer mortality rates The Committee agreed that this indicator is important in determining high quality breast cancer services and would indicate that the whole pathway was being commissioned appropriately.

BC32 Recurrence rates of breast cancer by site and type of primary surgery

The Committee agreed that this indicator was valuable in measuring the quality of surgical services.

BC09 Patient satisfaction with outcome of breast surgery

The Committee agreed that this indicator is important in determining high quality breast cancer services as it represents patient experience. They also agreed that data is likely to be available soon from a national audit.

BC23 Of people having treatment for early breast cancer, the proportion who receive personalised information and support, including treatment options, a written follow-up care plan and details of how to contact a named healthcare professional following the completion of initial surgical treatment.

The Committee agreed that this indicator was important in determining high quality breast cancer services as it is vital that patients receive information and a high-quality care plan in order to effectively manage their condition. They also felt that information for this indicator is already being collected although acknowledged that there may be an issue of data quality. However, the Committee also acknowledged that this is a composite indicator, and may therefore be of limited value in identifying specific aspects of care for quality improvement. They therefore agreed that the indicator guidance should make clear definitions of and describe how this data is to be collected.

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General comments The Committee recommended that a breast cancer indicator on enhanced recovery and reduced length of stay should be developed for the COF as this would improve patient experience.

The Committee required further evidence to make recommendation on the following indicators.

BC01, 02, 03, 04, 05, 06, 07, 08, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 31, 33, 34, 35

There was particular discussion regarding the following indicators:

BC31 Survival rates by cancer stage at diagnosis at one, two and five years.

The Committee agreed that this indicator would be affected by a time-lag in the survival data. Although they noted that the time-lag had now improved and survival data is now published within 1 year, the indicator would still be affected and they felt it was better to consider diagnosis at each stage instead.

BC33 Rates of specific complications detected, within one year of discharge from hospital, among patients having undergone in-patient treatment for breast cancer.

The Committee felt that this indicator is too specific for the purposes of the COF.

BC01 Of people with newly diagnosed breast cancer, the proportion who had been previously seen with symptoms suggestive of breast cancer and discharged undiagnosed within one year of initial presentation.

The Committee acknowledged that this indicator is a good indication of quality during the early part of the breast cancer pathway. However, they also stated that the numbers involved are likely to be small in secondary care, the indicator would be difficult to measure and it would be hard to define and attribute the ‘symptoms suggestive of breast cancer.’

BC14 Of people with newly diagnosed invasive breast cancer, the proportion who have the HER2 status of the tumour assessed.

The Committee considered that this indicator had the potential to prevent unnecessary treatment and agreed there is currently significant variation in practice. However they concluded that this was better dealt with through peer review.

BC19 Of people older than 70 with early invasive breast cancer, the proportion who receive appropriate therapy. BC20 Of people aged 70 and under with early invasive breast cancer, the proportion who receive appropriate therapy.

The Committee agreed that this was an important age issue as elderly people often have much poorer outcomes. However, following discussion, it was agreed that these issues should be addressed at a local level rather than through the COF.

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BC24 Of women treated for early breast cancer and 45 or older at the time the post-treatment surveillance started, the proportion who have had 5 years of annual mammography before entering the NHS Breast Screening Programme.

The Committee agreed that this indicator is too process focused.

BC25 Of women treated for early breast cancer and younger than 45 when post-treatment surveillance started, the proportion who have had annual mammography until they entered the NHS Breast Screening Programme at the age of 50.


BC26 Of women treated for early breast cancer who are within 5 years of finishing their treatment, the proportion who have had a mammography within the previous year.


12. End of life care


ELC05 Of people who have stated their preferred place of death, the proportion who died in their preferred place of death.

The Committee agreed that this indicator is useful in determining high quality end of life care as it reflects whether good services are in place across the pathway and refers to patient care plans and whether these are being delivered. Committee members felt that this was a strong outcome indicator. The Committee agreed that the indicator guidance should include some additional text regarding access to services in the preferred place of death.

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General comments The Committee suggested that it would be useful to have an end of life care indicator that addresses the adequacy of symptom control It is possible that patients could be more likely to have an uncomfortable death at home due to less access to services. The Committee also felt that it would be useful to have an end of life care indicator that addressed death within 24 hours of admission to an acute unit for those people already on a palliative care register. They did however acknowledge that not all areas have palliative care registers and so may be difficult to attribute to CCGs. The Committee also noted that there is a recognised issue around the inconsistent recording of death and that this could be problematic for end of life care indicators. They did however feel that proper recording should be encouraged and therefore requested that this be taken back to the review group. The Committee felt that it is important to support local hospices and questioned whether an indicator around this should be developed.


ELC28 Of [people] [closely affected] by a death, the proportion who report a satisfactory experience of:

Communication

Information

Co-ordination of care

Addressing their own needs

Care around the time of death

Bereavement care

The Committee agreed that a composite indicator should be developed from ELC28 to include symptom control. This indicator would be a valuable commissioning tool as it measures user satisfaction. The Committee also agreed that the definition of this indicator should be expanded to include people approaching death and their carers. There may be some issues associated with the data sources for this indicator as it relies on the VOICES survey. There may be some issues with numbers and the volume of responses nationally. There are also concerns over the copyright which need further clarification. The Committee agreed that an alternative may be required if VOICES survey is not amenable to change.

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The Committee recommended that the following indicators should not be progressed for further development.

ELC01, 02, 04, 08, 09, 13, 14, 15, 16, 17, 20, 22, 24, 25, 26, 27, 29


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ELC14 Of [people who have died], the proportion who had [timely] [access] from request to the following services 24/7 in their [usual place of residence]:

District nurse – within 1 hour

GP – within 1 hour

[Medication] – within 1 hour

Stay in nursing services (nursing care at home including overnight stays) – within 1 hour

Specialist palliative are telephone advice – within 1 hour

[Equipment] – within 4 hours ELC15 Of [people who have died], the proportion who had [timely] [access] from request to the following services 24/7 in an [inpatient setting]: • Nursing assessment – within 1 hour • Medical assessment – within 1 hour • [Medication] – within 30 minutes • Specialist palliative care telephone advice – within 1 hour • Specialist palliative care face to face assessment - within 24 hours ELC16 Of [people who have died] who required social and practical care to maximise independence in the last 12 months of life, the proportion who had [timely] [access] from request to: • Specialist allied health professional [assessment] – urgent (within next working day)/routine (within 1 week) • Social care [assessment] – as defined in the social care outcomes framework • Provision of [specialised interventions] – urgent (within next working day)/routine (timescale not specified)

The Committee agreed that these indicators are too detailed for the purposes of the COF. If end of life care indicators are too detailed then they may restrict individualised care within the family context. However, members acknowledged that the indicators detail a multidisciplinary approach to care, patient choice and access to specialist care which is important.

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13. Chronic heart failure


CHF01 Of people presenting in primary care with [suspected heart failure], the time [from referral to specialist assessment], in those with: i) Previous MI [is no longer than 2 weeks] ii) No previous MI but high serum natriuretic peptide levels [is no longer than 2 weeks] iii) No previous MI but intermediate serum natriuretic peptide levels [is no longer than 6 weeks

The Committee recognised that this is an important indicator in determining high quality commissioning for people who have chronic heart failure as many of these people are not being referred to specialist care quickly enough which affects their health outcome. There is a need to commission access to urgent cardiology services. If people who have chronic heart failure are referred to the appropriate specialist services early on, they have significantly better survival rates. Members suggested that it should be made clear that this indicator is about the urgency of referral rather than the GP’s ability to identify heart failure.

CHF11 Of people with heart failure who are discharged from hospital following an admission to hospital [for heart failure], the proportion who are readmitted as an emergency because of heart failure [within 30 days of discharge]

The Committee agreed that this is a useful process measure in determining quality chronic heart failure commissioning.

CHF12 All cause mortality – up to 30 days from admission to hospital for heart failure

The Committee agreed that this is an important indicator in determining high quality chronic heart failure commissioning and was easily measurable.

CHF13 All cause mortality – 12 months following admission to hospital for heart failure

The Committee felt that this indicator is a good overall measure of quality chronic heart failure commissioning. Members questioned whether the definition of ‘admission’ in this indicator refers to the first admission and requested that this be considered further.

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General comments The Committee discussed including an indicator addressing access to multidisciplinary teams (MDT’s) and the management of chronic heart failure. They agreed that this would be useful but felt that it was not disease specific and should therefore be included as a composite indicator covering all long-term conditions.


CHF03, 04, 05, 06, 07, 08, 09 There was particular discussion regarding the following indicators:

CHF04 Of people with chronic heart failure due to LVSD, the proportion who are prescribed an ACE Inhibitor (or ARBs licensed for heart failure if there are [intolerable side effects] with ACE inhibitors) CHF06 Of people with chronic heart failure due to LVSD, the proportion who are prescribed a Beta Blocker [licensed for heart failure] CHF08 Of people with chronic heart failure due to LVSD who are on either ACE inhibitors or ARBs licensed for heart failure the proportion on an ACE inhibitor

The Committee felt that these indicators are important as patients are often not put on appropriate drugs and this can lead to poor symptom control. However, the Committee did not recommend these indicators for progression as they are already being measured by the QOF. Members however noted the concern that people with chronic heart failure do not get appropriate treatment even though this is measured through the QOF.

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CHF03 Of people with chronic heart failure (or their carer), the proportion who report that they have:

i. Had their [personalised care plan] discussed with them ii. A named member of the heart failure [MDT] to contact iii. Been given choice to self-manage iv. Been offered an exercise-based rehabilitation programme v. Had their symptoms and concerns addressed vi. Been offered educational and psychological support

The Committee agreed not to recommend this indicator for progression. They did however acknowledge that cardiac rehabilitation is a priority in chronic heart failure and noted that it is likely to be covered within further quality standards (QS). Therefore indicators on cardiac rehabilitation will be referred for consideration by the COF Committee after the publication of these QS and the Committee noted that they look forward to considering these.

CHF05 Of people with chronic heart failure due to LVSD on ACE Inhibitor, the proportion on [target dose] CHF07 Of people with chronic heart failure due to LVSD on Beta Blocker [licensed for heart failure], the proportion on [target dose]

The Committee agreed not to recommend these indicators for progression as they are already included within the QOF.

General comments Committee members asserted that the majority of these indicators were very specific clinical management indicators as opposed to being overarching indicators which are generally regarded as more useful to commissioners.

14. Alcohol dependence and harmful alcohol


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use ALC35 Of adults [accessing] specialist alcohol services, the proportion who receive evidence-based psychological interventions in [accordance with NICE clinical guideline 115].

Committee members felt that this indicator was aspirational and complemented psychological assessment.

ALC43 Alcohol related hospital admissions The Committee felt that this is a useful indicator in determining high quality alcohol dependence and harmful alcohol use commissioning. Members noted that this indicator is particularly useful as many of these people would have also hypertensive disease. The data for this indicator is already collected.

ALC44 [Alcohol related] readmission to any hospital within [X days/months] after the last previous discharge following an alcohol related admission

Committee members noted that indicator ALC44 complements ALC43.

ALC47 Reduction] in AUDIT score of [screened/intervention] population.

The Committee felt that this was a good commissioning tool although questioned how widely the AUDIT tool was used. They agreed however that this could be tested at consultation.

General comments Members noted that local authorities will commission a large proportion of alcohol services so there will be some crossover with the PH OF. However, CCG’s can influence this area, especially as many of these people will have hypertension. The Committee discussed the possibility of including an indicator on the success of treatment but felt that all of the indicators presented were too complicated.


ALC05 Of people aged 16 years and older in the [defined target population], the proportion who receive [alcohol screening] at least once within [defined time period].

Members suggested that this indicator might be better suited to the QOF.

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ALC06 Of people aged 16 years and older [screening positive for hazardous or harmful drinking], the proportion who receive [a brief intervention].

Members suggested that this indicator might be better suited to the QOF.


ALC05, 06, 08, 09, 10, 11, 13, 14, 15, 16, 23, 24, 29, 33, 36, 37, 38, 40, 42, 45, 46


ALC42 Of people [accessing] specialist alcohol services, the proportion who achieve their treatment goals.

The Committee agreed that this indicator could be a useful tool in determining high quality care in alcohol services. However, they felt that it could not be measured.

15. Hip fracture The Committee considered the supporting information presented by the NICE technical team and recommended that the following indicators should be progressed for further development.

HFra05 Of people with hip fracture, the proportion receiving recorded [preoperative] cognitive assessment and measurement using a [validated tool].

The Committee agreed that this indicator is important in determining high quality hip fracture commissioning.

HFra10 Of people with hip fracture, the proportion who receive surgery [on the day of, or the day after], admission.

The Committee agreed that this is an important indicator in influencing high quality hip fracture commissioning as people who have a hip fracture do not always receive surgery quickly. They acknowledged the overlap with the best practice tariff but still felt that it was important.

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HFra20 Of people with hip fracture, the proportion who receive a [multifactorial risk assessment*] of future falls risk, led by the Hip Fracture programme team [evidenced by GMC number of responsible clinician].

At least medication review, visual acuity, postural BP measurement.

The Committee agreed that this indicator is important in determining high quality hip fracture commissioning.

HFra24 Hip fracture incidence The Committee agreed that this indicator is important in determining high quality hip fracture commissioning. The Committee agreed that it is vital that commissioners should aim to lower the incidence of hip fractures. Members noted that this indicator may overlap with the PH OF.

Hfra26 Mortality following hip fracture [within 30 days and 12 months].

The Committee agreed that this indicator is important in determining high quality hip fracture commissioning and is a pure outcome measure.

HFra28 Reoperation [after 12 months (allowing 6-12 months for complications)]

Committee members asserted that this is a useful indicator when commissioning hip fracture services as reoperation rates are a good marker of the quality of surgical services. However, the Committee noted that 12 months is a long time to wait for reoperation.

HFra01 Of people with hip fracture, the proportion who receive a [formal Hip Fracture Programme] from admission [evidenced as having a [joint acute care protocol] at admission, and [evidence of MDT rehabilitation] agreed with a [named responsible orthogeriatrician and orthopaedic surgeon, with GMC numbers recorded]].

The Committee agreed that this indicator is important in determining high quality hip fracture commissioning. This indicator was considered important by the Topic Expert Group (TEG) and the TEG Chair during the development process. The group felt that the indicator may need slight amendment to make feasible but that it was incredibly important.

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General comments Committee members questioned whether there is an overlap between the COF indicators for hip fracture and the Best Practice Tariff. NICE advised the Committee that the question of overlap with the Best Practice Tariff is an issue for the NHS Commissioning Board to consider. The Committee also considered consistency across topic areas and felt that it could be odd to have indicators on enhanced recovery and follow up for breast cancer but not hip fracture although they recognised that covering all areas for all topics would result in a lot of indicators. ACTION - The COF team agreed to bring the issue of cross cutting indicators to the next Committee meeting.


HFra31 Return to pre-fracture mobility [within 6-12 months]

The Committee felt that this indicator would be difficult to measure as pre-fracture mobility is not assessed. It was however felt this is an important issue and further consideration is needed.


HFra03, 06, 07, 08, 09, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 25, 27, 29, 30


HFra30 Length of stay The Committee felt that this indicator is not helpful on its own as length of stay in hospital is a complex issue, optimal length of stay cannot be defined and in some cases an extended length of stay might be appropriate.

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HFra03 Of people with hip fracture transferred from hospital for early supported discharge or intermediate care, the proportion for whom the [Hip Fracture Programme team] makes (and documents the objectives of) the decision to transfer, with a plan for follow-up. HFra18 Of people with hip fracture who are [eligible] for early supported discharge, the proportion who receive early supported discharge [led] by the Hip Fracture Programme team. [evidenced by a co-ordinated care plan, GMC number of responsible clinician].

The Committee agreed that these indicators focus on supported discharge and are important but not specific to hip fracture care.

16. Lung cancer

LC02 3-month and 1-year survival rates from diagnosis.

The Committee agreed that this is a useful indicator in determining high quality lung cancer commissioning.

LC03 Stage at diagnosis.

The Committee agreed that this indicator is a good marker of quality in the early lung cancer care pathway as leads to improved outcomes.

LC09 Of people with lung cancer, the proportion who have been seen by a lung cancer clinical nurse specialist.

The Committee agreed that this is a useful indicator in determining high quality lung cancer commissioning as it is important for patient experience.

LC21 Resection rates The Committee agreed that this indicator is important in improving the quality of lung cancer services as resection rates vary across the country and the UK currently has low resection rates. The Committee discussed the possibility of positively incentivising these and suggested that something should be added to the definitions regarding relevant margins.

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LC22 Of people with lung cancer, the proportion who receive assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.

The Committee agreed that this indicator is important in determining high quality lung cancer commissioning as it promotes a multi-disciplinary team approach.

General discussion The Committee suggested that it might be useful to have a lung cancer indicator that measures survival. Although, members noted that there may be overlap with the PH OC, as outcomes are dependent on other programmes such as smoking cessation. The Committee noted that thoracic surgery will be an area of specialised commissioning and that CCG’s may have limited control over commissioning in this area. Colleagues from NICE advised that this issue is for consideration by the NHS CB.


LC01, 04, 05, 06, 07, 08, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40


LC15 Of people with non-small-cell lung cancer, the proportion who have tumour sub-type identified.

The Committee stated that this is not a useful indicator in determining quality lung cancer care.

LC01 Of people with a first diagnosis of lung cancer, the proportion whose first contact with secondary care for their cancer is an emergency hospital visit or admission.

The Committee felt that this issue was addressed elsewhere.

LC04 Of people reporting one or more symptoms suggesting lung cancer, the proportion who are referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.

The Committee noted that X-ray rates of people with lung cancer in England are relatively low but did not feel that it was access to X-rays which was causing this.

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17. Prioritisation of new indicators from other sources


1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

The Committee agreed that this is a key priority in the NHS Outcomes framework (NHS OF).

1.5 Excess under 75 mortality rate in adults with serious mental illness

The Committee agreed that this is a key priority in the NHS OF.

1.7 Reducing premature death in people with learning disabilities (to be developed)

The Committee agreed that this is a key priority in the NHS OF.

1.9 Cancers diagnosed via emergency routes

The Committee agreed that this indicator is useful in determining high quality commissioning.

1.10 Cancers stage at diagnosis


1.11 Cancers detected at stage 1 or 2


1.13 Stage at diagnosis of COPD

The Committee agreed that this indicator is useful in determining high quality commissioning. The Committee noted that this is captured in the QOF disease register. Although this data is most likely being captured in the QOF, members agreed that it would be useful to develop this indicator for the COF as this it is a commissioning issue.

1.18 Outcome of cardiac arrest – ambulance journey

The Committee agreed that this indicator is useful in determining high quality ambulance commissioning. In addition, the data for this indicator is already being collected.

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1.19 Outcome of cardiac arrest – survival to discharge


1.21 Outcome from acute ST elevation MI – timely angioplasty


1.22 Outcome from acute ST elevation MI – timely appropriate care bundle

The Committee agreed that this indicator is useful in determining high quality commissioning. Colleagues from NICE initially rated this indicator as ‘unsuitable to progress’ as there is no NICE accredited evidence to support it. However, the Committee asserted that they thought there is evidence to support this indicator. ACTION NICE COF team to liaise with the NICE Accreditation team and investigate.

1.33 Smoking rates in people with SMI


2.4 Health-related quality of life for carers


2.6 Enhancing quality of life for people with dementia: i)Estimated diagnosis rate (QOF GP practice registers/expected prevalence) ii)Health related quality of life for patients with dementia

The Committee agreed that this indicator is useful in determining high quality commissioning. Members also asserted that it is important for commissioners to understand the quality of life for people with dementia.

2.19 Carers identified on practice registers

The Committee agreed that this indicator is useful in determining high quality commissioning as it is very important to identify carers. Members queried whether this is already measured in the QOF, however they agreed that it is important to develop this indicator for the COF.

2.21 Number of information prescriptions for carers

The Committee stated that if identifying carers is going to be a priority then this indicator is also a key priority.

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3.3 Improving recovery from injuries and trauma (to be developed)


3.4 Improving recovery from stroke (an indicator to be derived based on the proportion of stroke patients reporting an improvement in activity/lifestyle on the Modified Rankin Scale at 6 months)


3.5 (i) The proportion of patients recovering to their previous levels of mobility / walking ability at 30 days


3.5 (ii) The proportion of patients recovering to their previous levels of mobility / walking ability at 120 days


3.6 (i) Proportion of older people (65 and over) who were still at home 91 days after discharge


3.6 (ii) Proportion of older people (65 and over) who were offered rehabilitation following discharge from acute or community hospital


4.6 An indicator to be derived from the survey of bereaved carers


4.8 An indicator to be derived from a Children’s Patient Experience Questionnaire


4.11 Patient experience of cancer services


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4.17 Carers of people with dementia assessed as needing psychological interventions who receive psychological interventions


5.1 Incidence of hospital-related venous thromboembolism (VTE)

The Committee agreed that this indicator is useful in determining high quality commissioning. Members noted that this indicator is difficult to measure but felt that this is an inadequate reason to exclude the indicator.

5.3 Incidence of newly-acquired category 2, 3 and 4 pressure ulcers


General comments The Committee felt that a strategy is needed for carers of people with dementia, in addition to having indicators covering this in the COF.


1.8, 1.14, 1.15, 1.20, 1.35, 1.36, 1.37, 1.38, 1.39, 2.9, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18, 2.20, 2.22, 2.29, 2.30, 2.31, 2.76, 2.78, 2.82, 2.83, 2.84, 3.12, 2.76, 3.13, 3.16, 3.17, 4.12, 4.13, 4.24


1.8 Asthma deaths systematically investigated

The Committee agreed that this indicator is not useful in determining high quality commissioning.

1.14 Referral, timely assessment and treatment of patients with COPD

Committee members felt that this indicator lacked definition and it isn’t clear what the indicator is measuring.

1.15 Progression (stage) of COPD

The Committee agreed that this indicator is not useful in determining high quality commissioning as it is about the individual and not commissioning.

1.20 Outcome from acute ST elevation MI – timely thrombolysis

The Committee agreed that this indicator is not useful in determining high quality commissioning as it doesn’t reflect current best practice.

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1.35 Stroke patients eligible for thrombolysis – timely transfer to stroke centre


1.36 Stroke patients who receive a timely appropriate care bundle


1.37 Early detection and treatment of atrial fibrillation The Committee agreed that this indicator is not useful in determining high quality commissioning.

1.38 Time to answer call


1.39 Time to treatment – life threatening


2.9 People with LTCs who develop a further preventable LTC

The Committee agreed that this indicator is not useful in determining high quality commissioning. Members noted that when people have a LTC then it is clinically more likely that they will develop another LTC.

2.11 Patient Reported Outcomes Measures (PROMs): asthma

The Committee agreed to review PROMS indicators at a future meeting. At present they exist for some conditions but not others.

2.12 Risk categorisation of asthma


2.13 Assessments based on RCP scores of patients with asthma

The Committee agreed that this indicator is not useful in determining high quality commissioning as it assesses individuals and is not necessarily a marker of good commissioning.

2.14 Self-management plans for patients with asthma


2.15 Reviews of patients with asthma


2.16 Use of medicines by patients with asthma


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2.17 Days lost from work by patients with asthma


2.18 Patient Reported Outcomes Measures (PROMs): cancer


2.20 Delayed discharge from hospital


2.22 Referrals to LAs and the voluntary sector for advice and support


2.29 Return to normal social function: COPD


2.30 CAT (disability) score: COPD


2.31 Employment rates ages <65: COPD


2.78 Variation in liver disease admissions/attendances between practices in a CCG


2.82 Improvement after 6 months based on Health of the Nation Outcome Scale for patients with SMI starting a new spell of care


2.83 People with SMI in settled accommodation


2.84 Reported incidents of physical assaults on users of specialised mental health services


3.12 Patients in acidotic respiratory failure who receive Non-Invasive (NI) ventilation (within 1 hour)


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3.13 Standby treatment packs with instructions available to patients with COPD


2.76 Patient Reported Outcomes Measures (PROMs): cataract extraction


3.16 Patient Reported Outcomes Measures (PROMs): PTCA


3.17 Patient Reported Outcomes Measures (PROMs): CABG


4.12 Involvement of carers: unplanned readmissions with or without care plan


4.13 Involvement of carers: delayed discharge from hospital


4.24 Patient experience of ambulance services


18. Further prioritisation of indicators


2.57 People with newly diagnosed diabetes who complete structured education

The Committee agreed that this indicator is useful in determining high quality commissioning. Members noted that this indicator is currently a NHS Commissioning Board (NHS CB) priority.

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4.18 Patient experience of diabetes services The Committee noted that it is important that patients have positive experiences of diabetes services.

1.40 VTE mortality


2.26 People with COPD referred to a pulmonary rehabilitation programme who complete the programme


2.44 People presenting with suspected dementia who are referred and seen by memory assessment services within 3 months


2.46 Staff who work with people with dementia who have had dementia care training


2.48 Health related quality of life for people with dementia (assessed using DEMQol)


2.49 Carers of people with dementia referred for an assessment of their social needs

The Committee agreed that this indicator is useful in determining high quality commissioning. Committee members noted that looking after the carers of people with dementia is a priority.

2.68 People with diabetes who have a documented care plan which includes agreed goals and an action plan which has been updated in the previous 12 months

The Committee agreed that this indicator is useful in determining high quality commissioning. Members questioned whether it might be more appropriate for this indicator to be in the QOF.

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3.36 Patients who have acute stroke ,who spend 90% or more of their stay on a stroke unit

The Committee agreed that this indicator is useful in determining high quality commissioning. Members noted that this indicator is already being used.


2.50 People with suspected dementia or a diagnosis of dementia admitted to hospital, or attending the emergency department, who are referred to a liaison service

The Committee requested more information on the definition of a liaison service and how the data for this indicator would be collected before making a decision on whether to progress it or not.


1.6i, 1.6ii, 1b i, 1b ii, 2.2, 2.5, 2.10, 2.28, 3.29, 2.54, 2.55, 2.56, 2.58, 2.59, 2.71, 2.85, 3.22, 3.31, 5.9, 1.12, 2.24, 2.25, 2.27, 2.37, 2.38, 2.39, 2.40, 2.41, 2.43, 2.45, 2.47, 2.65, 2.66, 2.67 2.69, 2.70, 2.72, 2.73, 2.74, 2.75, 2.86, 3.9, 3.19, 3.20, 3.21, 3.3, 4.19


1.6 (i) Infant mortality The Committee agreed that rates of infant mortality are too small to be useful to Commissioners.

1.6 (ii) Neonatal mortality and stillbirths The Committee agreed that rates of neonatal mortality and stillbirth are too small to be useful to Commissioners.

1b (i) Life expectancy at 75: males The Committee agreed that this indicator is not useful in determining high quality commissioning. Members noted that there could be wider socio-economic factors that contribute to life expectancy that are outside of the control of commissioners.

1b (ii) Life expectancy at 75: females The Committee agreed that this indicator is not useful in determining high quality commissioning. Members noted that there could be wider socio-economic factors that contribute to life expectancy that are outside of the control of commissioners.

2.2 Employment of people with long-term conditions The Committee didn’t feel like this is an appropriate indicator for the COF as this may be outside of commissioners’ control.

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2.5 Employment of people with mental illness The Committee didn’t feel like this is an appropriate indicator for the COF as this may be outside of commissioners’ control.

2.54 People with established diabetes who are offered structured education


2.55 People with newly diagnosed diabetes who start structured education


2.56 People with established diabetes who start structured education

The Committee agreed that this indicator is not useful in determining high quality commissioning as the data numbers are not large enough to be helpful.

2.58 People with established diabetes who complete structured education


2.59 People with established diabetes whose structured education has been reviewed and reinforced within the last 15 months


2.71 Age-stratified incidence of certification of visual impairment (at each level of registration) with COAG as the primary cause


2.85 People who have had a stroke who have been free from vascular events for 6 months following initial (index) admission for stroke (case-mix adjusted)


3.22 People with diabetes with a new diagnosis of foot ulceration requiring urgent medical attention who are seen by the MDT foot care team within 24 hours of referral


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3.31 For those people assessed as having a stroke and seen by ambulance services, the proportion who are taken to a hospital with a acute stroke unit within 1 hour of arrival at the emergency


5.9 Adult patients who have had a VTE risk assessment [on admission] to hospital, using the clinical criteria of the national tool


1.12 People with COPD who smoke and who are not smoking in a sustained way at 12 months from the agreed quit date


2.24 People with COPD with oxygen saturation less than or equal to 92% when clinically stable, who are referred to a specialist oxygen service for long term oxygen therapy assessment


2.25 People with COPD with oxygen saturation less than or equal to 92% when clinically stable, who are assessed for LTOT by a specialist oxygen service


2.27 People with COPD who have completed a pulmonary rehabilitation programme who have a clinically significant improvement in health related quality of life from baseline


2.37 People known for >90 days to the renal unit who started chronic dialysis without requiring hospital admission

The Committee felt that this indicator is not appropriate for the COF as specialist renal services come under specialised commissioning.

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2.38 People on long-term HD who receive a minimum of three sessions of HD per week of at least 4 hours duration

The Committee felt that this indicator is not appropriate for the COF as specialist renal services come under specialised commissioning.

2.39 People with known CKD stages 4 and 5 CKD (with or without diabetes) who have been referred for specialist assessment


2.40 People with newly diagnosed CKD who are assessed for cardiovascular risk at the time of diagnosis


2.41 People with stages 3b, 4 and 5 CKD with latest recorded haemoglobin less than 10 g/dl


2.43 People presenting with suspected dementia who are referred to a memory assessment service


2.45 People newly diagnosed with dementia with early stage of dementia (as a proportion of all people newly diagnosed)


2.47 Staff who have a record of appropriate dementia care training within the last 3 years


2.65 People with diabetes starting insulin therapy that is initiated by an appropriately trained healthcare professional


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2.66 In-patients with diabetes who are reviewed by an appropriately trained healthcare professional with access to the specialist diabetes team


2.67 Women with diabetes of child-bearing potential age who have had a documented discussion about contraception, pre-conception care and pregnancy risks in the previous 12 months


2.69 People with diabetes who have an agreed target for HbA1c

The Committee agreed not to progress this indicator as it already covered in indicator 2.68 which has been progressed for development.

2.70 People with diabetes achieving their HbA1c target

The Committee agreed not to progress this indicator as it already covered in indicator 2.68 which has been progressed for development.

2.72 People with a new diagnosis of COAG who have a definitive diagnosis made by a consultant ophthalmologist


2.73 People with newly diagnosed COAG who first present at defined stage of COAG (see guideline 3 categories)


2.74 People with suspected COAG or with OHT who are recommended to receive medication whose most recent review was within the specified risk-based monitoring interval (+/-15%) following the last previous review


2.75 People with COAG whose most recent review was within the specified risk-based monitoring interval (+/-15%) following the last previous review


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2.86 Evidence that services provide information and support to carers, commissioned to include a named contact for stroke information and written information about the patient’s diagnosis and management plan

The Committee felt that this indicator is not suitable for the COF as the provision of information for carers is not topic specific and it would be more useful if this data was measured generically.

3.9 People with COPD who have had an exacerbation of COPD who have a written management plan with advice on the management of future exacerbations

The Committee agreed that it is important to have a generic COF indicator that addresses management plans for all people with long term conditions (LTC’s). This would be more useful than a topic specific indicator. The Committee also stated that it would be appropriate to share this management plan with carers.

3.19 People who receive treatment from supervised practitioners as defined - at least 1 hour per fortnight


3.20 People with chronic physical ill health and new presentation of severity depression who receive appropriate treatment

The Committee agreed that this indicator is not useful in determining high quality commissioning as the definition is vague.

3.21 People with new presentation of depression who are assessed as non-case 6 months after the initiation of treatment

The Committee felt that this indicator is not suitable for the COF as it may generate perverse incentives to discharge.

3.37 People who have had a stroke who receive a minimum of 45 minutes physiotherapy a day for 70% of their hospital stay

The Committee felt that this indicator is not suitable for the COF as it is too specific for CCG assessment.

2.10 Emergency attendance at A&E: asthma

The Committee agreed that this indicator is not useful in determining high quality commissioning. Members noted that this indicator may be difficult to measure due to A&E coding problems. The Committee also felt that this indicator is not an indication of good long term care.

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2.28 Emergency attendance at A&E: COPD

The Committee agreed that this indicator is not useful in determining high quality commissioning. Members also felt that this indicator is not an indication of good long term care.

3.29 Total time: time from the start of the original call or arrival at the urgent care or out-of-hours base until discharge, admission or transfer to another service.

The Committee agreed that this indicator is not useful in determining high quality commissioning as too much information is included within this indicator. Members also noted that this indicator is partially covered by an existing four hour target.

4.19 Patient experience of IAPT (improved access to psychological therapies) services

The Committee suggested that it would be more useful to develop a generic indicator that addresses patient experience of various services rather than just IAPT.

31. Update on indicators recommended for further work

1.32 The number of those with first onset psychosis taken on by early intervention (EI) services as a proportion of local incidence

The Committee felt that this indicator is not a useful measure in determining high quality commissioning at present. Members noted that the system is changing and this data is unlikely to be suitable for CCG level.

2.32 People with CKD on long term dialysis who start on home dialysis [peritoneal dialysis (PD) or home haemodialysis (HD)] or self-care

The Committee agreed that this indicator is not useful in determining high quality commissioning. The measurement of this indicator may be problematic due to small numbers.

2.42 Cardiac rehabilitation

The Committee agreed that this indicator is not suitable for inclusion in the COF. An indicator which has been referred to the COF Committee outside of the NICE process covering cardiac rehabilitation is already going to be included in the COF.

2.80 Patterns of care

The Committee agreed that this indicator is not useful in determining high quality commissioning as the definition is too vague.

3.18 People with new presentation of depression who receive appropriate treatment

The Committee agreed that this indicator is not useful in determining high quality commissioning. The term ‘appropriate treatment’ is too vague and will vary from person to person.

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5.5 Admission of full term babies to neonatal care

The Committee agreed that the decision about whether or not to include this indicator in the COF will depend on the NHS OF.

32. Review of decisions and general discussion

Committee members suggested that it would be helpful if the briefing papers focused more on the commissioning angle. ACTION NICE to consider whether this is possible. Members suggested that it would be useful if NICE could prepare information for COF review group chairs which could influence the development of indicators so that they might be more suitable for the COF. Committee members felt that it would be useful if NICE provided a guidance document that could be sent out with the Committee papers and outlined what exactly is expected of members.

Documents

Minutes of the meeting held on 24th September 2012 Meeting ...€¦ · 1 of 37 Commissioning Outcomes Framework Advisory Committee Minutes of the meeting held on 24th September 2012