How the NHS Outcomes Framework can help KAMs align value propositions with customer need.

The NHS Outcomes Framework is an important information tool for both the health service and the pharmaceutical industry in the UK. The framework sets out to provide a benchmark for measuring NHS performance against agreed national indicators in areas identified as health priorities. First introduced in 2010, the framework has subsequently been updated annually to reflect patients’ evolving healthcare needs and encourage a stronger focus on tackling known health inequalities. It aims to provide an accountability mechanism between the Secretary of State for Health and the NHS Commissioning Board, and to act as a catalyst for driving quality improvements and outcome measurements throughout the NHS. Crucially, the framework is designed to help NHS organisations understand what a focus on health outcomes means in practical terms – and as such provides a powerful level for the pharmaceutical industry to engage with customers in ways that help them deliver local and national objectives.

Integrated frameworks

The 2012/13 framework follows the passing of the Health & Social Care Act and advocates an increased emphasis on improving the alignment of care sectors, encouraging collaboration and integration between health and social care. The Adult Social Care Outcomes Framework and the Public Health Outcomes Framework – which was published in March 2012 – compliment the Government’s ambitions to improve the integration of services. Collectively, the three frameworks are an attempt to create an “outcome-based health and social care system where success is measured in terms of the actual results achieved for patients, service users and whole populations.” The Government hopes that this approach at a national level will cascade down to local level, where Health & Wellbeing Boards will play a critical role in identifying shared outcomes goals for local populations – and also in understanding the contribution that different commissioners can make individually and collectively in achieving these goals.

The NHS Operating Framework is divided into five domains:

1. Preventing people from dying prematurely.
2. Enhancing quality of life for people with long-term conditions.
3. Helping people to recover from episodes of ill health or following injury.
4. Ensuring that people have a positive experience of care.
5. Treating and caring for people in a safe environment; and protecting them from avoidable harm.
   

Each domain has a series of overarching indicators covering its broad aims. These combine to form:

• One framework defining how the NHS will be accountable for outcomes
• Five domains articulating the responsibilities of the NHS
• Twelve overarching indicators covering the broad aims of each domain
• Twenty-seven improvement areas looking in more detail at key areas within each domain
• Sixty indicators in total, measuring overarching improvement area outcomes.

Whilst pharma can help the NHS drive improvements in all five domains, it is perhaps in the first three domains where medicines can make their biggest and most obvious contribution. Domain four includes outcomes that relate to the quality of the patient experience. Here, pharma can potentially support the NHS in areas such as redesigning care pathways or joint working arrangements. The final domain includes outcomes that relate to patient safety.

Indicators and coverage

Since the last Outcomes Framework was published, the DH says it has made considerable progress in refining the definitions of indicators. The majority now have been finalised, although work is continuing to develop further indicators to ensure the breadth of NHS activity is covered.

Two new indicators have been identified for 2012/13: improving recovery from stroke and improving children and young people’s experience of healthcare. Both of these are now subject to technical work to ensure they are suitable for inclusion to the Framework. Additionally, work is also being conducted by the DH to identify outcomes for groups or areas which the original framework failed to cover and capture. One such group is people with learning difficulties and another area is the quality of life of people with dementia. Again, these are being considered for more focused inclusion, and have been added as ‘placeholders’ on the 2012/13 framework.

Key aims

The main improvement areas in domain one include reducing premature mortality from the major causes of death such as cardiovascular disease, respiratory disease and liver disease in those aged under 75. Additionally, improvement is sought in one and five year survival rates in colorectal, breast and lung cancer. The domain also outlines metrics for improvement in: premature death in people with serious mental illness, reducing deaths in babies and young children and reducing premature death in people with learning disabilities. Undoubtedly, pharma can help shape new care pathways in these areas.

Domain two focuses on helping patients manage their condition, improve the functional ability in those with long-term illnesses and reducing the time these patients spend in hospital. In particular, a reduction of unplanned hospitalisation for chronic ambulatory care sensitive conditions in adults and unplanned hospitalisation for those under the age of 19 with asthma, diabetes and epilepsy is a key focus.

Domain three highlights the need to reduce emergency admissions for acute conditions that should not usually require hospitalisation and readmissions within 30 days of discharge. Improvement areas focus on continuing the development of Patient Reported Outcomes Measures for hip and knee replacements, groin hernia and varicose veins. The Framework also outlines a requirement to prevent and reduce emergency admissions in children with lower respiratory tract infections and improve recovery from fragility fractures, injuries, trauma and stroke – although these indicators are to be developed.

Domain four – which lists its overarching indicator as patient experience of primary and hospital care – cites eight improvement areas, such as improving people’s experience of outpatient care and improving hospitals’ responsiveness to personal needs.

Finally, the overarching indicators for domain five focus on patient safety incidents reported and safety incidents involving severe harm or death. The framework aims to reduce the incidence of hospital-related venous thromboembolism (VTE), infections such MRSA and C.difficile, category 2,3 and 4 pressure ulcers and incorrect medication errors which cause serious harm to patients. The admission of full-term babies to neonatal care and the incidence of harm to children due to ‘failure to monitor’ are also highlighted.

Moving forward

The DH says the NHS Outcomes Framework will continue to evolve as more indicators are developed. It will be refined on an annual basis to ensure the indicators are fit for purpose. In the meantime, it remains a vital resource for pharmaceutical sales and marketing professionals – enabling them to identify areas of national priority and develop value propositions that align with customer needs.

Macmillan Cancer Support has attacked NICE for not including key cancer survival indicators in the first ‘menu’ of the NHS Commissioning Outcomes Framework (COF).

NICE published 44 indicators including ones for stroke patients, COPD, maternal care and access to mental health services.

However, Ciarán Devane, Chief Executive at the charity, said Macmillan is “shocked” at the omission of key cancer indicators.

He added that the absence of these indicators would result in commissioners lacking “strong incentives to improve cancer survival rates” and that NICE must include a revised list of indicators if the NHS is to hit survival targets.

From April next year, the COF will be used to hold CCGs to account for improvement in quality of local healthcare and patient outcomes through the services they commission.

The indicators have been developed using the Outcomes Framework, NICE Quality Standards and existing indicator collections, such as national audits.

A further menu of indicators will now be developed using NICE’s quality standards to ensure that all topics are covered.

NICE has defended its first ‘menu’ of indicators insisting the Framework will allow the NHS Commissioning Board to “identify the contribution” of CCGs in achieving national priorities.

CCGs in poorer areas of the country will have their targets adjusted to reflect the demographic of their patients, the NHS Commissioning Board (NHSCB) has said.

The decision comes after NICE published its recommended indicators for inclusion in the NHS Commissioning Outcomes Framework (COF) – the system by which GPs will be assessed and financially rewarded.

A spokesperson for the NHSCB said that a “robust approach to case-mix adjustment will be needed”.

The BMA backed the proposal and called for potential indicators to be piloted across the country in order not to discriminate against GPs based in poorer areas.

Dr Mary-Louise Irvine, BMA Council member, said that anything that “unfairly discriminates” GPs who need resources the most should be tested first. “If my resources are shrunk it’s more difficult to deliver good care,” said the south-east London GP. “I think the indicators should be piloted and evaluated to get them right.”

Indicators in the COF include reducing emergency admissions and providing care for stroke patients, plus ones for COPD, maternal care and access to mental health services.

More than 44 new indicators have been proposed in the first Commissioning Outcomes Framework (COF) by NICE.

The proposed indicators include care for stroke patients, plus ones for COPD, maternal care and access to mental health services.

The ‘menu’ of indicators covers the five domains outlined in the NHS Outcomes Framework.

Professor Danny Keenan, COF Advisory Committee Chair, said he hoped the “robust” set of indicators would “lead to improved health outcomes”.

From April next year, the COF will be used to hold CCGs to account for improvement in quality of local healthcare and patient outcomes through the services they commission.

The indicators have been developed using the Outcomes Framework, NICE Quality Standards and existing indicator collections, such as national audits.

A further menu of indicators will now be developed using NICE’s quality standards to ensure that all topics are covered.

Dr Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said the indicators will “support high quality commissioning”.

“Each indicator has been through public consultation and feasibility testing (conducted by the Health and Social Care Information Centre), so commissioners can be reassured that they will work in practice,” she said.

The final selection of indicators that will be included within the 2013/14 COF will be decided by the NHS Commissioning Board later this year.

NICE has proposed 16 new indicators for inclusion in the 2013/14 Quality and Outcomes Framework (QOF) and rheumatoid arthritis (RA) as a new clinical area.

The recommendations include four for RA, two for men with diabetes, plus indicators for COPD rehabilitation and hypertension.

Dr Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said the potential indicators “can make a real difference” to improve standards of care.

QOF is a voluntary incentive scheme that rewards GPs for implementing systematic improvements in care for patients. It operates through a points system which rewards doctors for their performance against the indicators.

Indicators for RA include GP practices creating a register of patients aged over 16, and patients being assessed for cardiovascular risk and fracture risk.

In men with diabetes, indicators focus on offering advice on erectile dysfunction and on available treatment options.

The final ‘menu’ of indicators will be decided by NHS Employers and the British Medical Association later this year.

NICE has published a proposed ‘menu’ of Quality and Outcomes Framework (QOF) indicators for 2012/2013.

The proposed list includes three new indicators for the support and treatment for smokers, two to assess physical activity, one for asthma, plus a set on fragility fractures in osteoporosis patients.

Christine Carson, Programme Director of NICE’s Centre for Clinical Practice, says the indicators have already been tested “to make sure they work”.

The Framework is a voluntary incentive scheme that rewards GP practices for improvements in the quality of care for patients.

Introduced in 2004, NICE took over the management of arranging the development and review of indicators in April 2009.

The Institute has recommended that 12 existing indicators be retired, including three for depression and two for diabetes, and also advised replacing a further four.

The selection of the final indicators for inclusion within the Framework will be decided by NHS Employers, on behalf of the UK health departments, and the General Practitioners Committee (GPC) of the British Medical Association (BMA) and published later in the year.