the nhs performance assessment framework - uk ...webarchive.nationalarchives.gov.uk/20031117030514/...

The NHS PerformanceAssessment Framework

A C T I O N

Distribution For Action

HAs (England) – Chief Executives

NHS Trusts – Chief Executives

For Information

HAs (England) – Chairpersons

NHS Trusts – Chairpersons

PCG – Chairpersons

CHC – Chief Officers

LA – London Borough Chief Executives

LA – Metropolitan Districts – Chief

Executives

LA – Non- Metropolitan Districts – Chief

Executives

Social Services Directors (England)

Medical School Deans

Post Graduate Deans

Regional Advisers in Dental Practice

Further copies from NHS Staff

NHS ResponseLine

0541 555 455

Others

Department of Health

PO Box 410

Wetherby

LS23 7LN

Fax 0990 210 260

Catalogue number 16431

Date of issue March 1999

A C T I O N

matters requiring action

The NHS PerformanceAssessment Framework

Contents

Page

Executive summary .......................................................................................................1

Introduction ....................................................................................................................3

Section 1: Revised Framework ....................................................................................7

Section 2: Using the Framework in the New NHS................................................10

Section 3: Developing the Framework and HLPI set ...........................................16

Attachment A: The National Framework for assessing performance..............18

Attachment B: The High Level Indicator Set in 1999 - 2000 ..............................19

Attachment C: Developing Benchmarking ............................................................21

The NHS Performance

Assessment Framework

i

Executive summary

This document:

• sets out the NHS Performance Assessment Framework, revised

following the consultation and road test over the Spring and Summer of

1998, for implementation from April 1999;

• explains the ways in which the Framework should be used from April

to:

- move towards assessing performance of the NHS in the round,

covering quality and efficiency;

- encourage benchmarking between similar NHS organisations;

and

- underpin national and local performance and accountability

arrangements.

• lists the High Level Performance Indicators to be used to ensure a

more rounded assessment of NHS performance during 1999-2000; and

• explains the proposed next steps to develop the High Level

Performance Indicators and the use of the Framework.

The NHS Performance


1

Introduction - assessing performance in the new NHS

1. The new NHS made a commitment to a National Health Service which - by

delivering quick, high quality, better-integrated services which reduce health

inequalities - will secure better health for the population. It promised to

concentrate on assessing the things which count most to patients and the

public - high quality, cost-effective care that leads to improved health. And

it emphasised the need to pursue quality and efficiency together, since

patients suffer if resources are not used efficiently or to best effect just as

they suffer if quality standards vary.

2. A First Class Service , published for consultation in July 1998, set a three

pronged strategy to drive performance improvement by setting clear

standards, promoting effective delivery of high quality services locally and

ensuring that there are strong monitoring mechanisms in place externally:

• Setting Standards The National Institute for Clinical Excellence

(NICE) will promote clinical and cost effectiveness through guidance

and audit, and advise on best practice. National Service Frameworks

will set national standards and define service models for a specific

service or care group, put in place programmes to support

implementation and establish performance measures against which

progress within an agreed timescale will be measured;

• Delivering Standards Clinical Governance, underpinned by modern

mechanisms for professional self regulation and lifelong learning, will

ensure that national standards and guidance are reflected in the local

delivery of services;

• Monitoring Standards Health Authorities and Primary Care Groups

should use the Framework to monitor service delivery against plans for

improvement across the six areas. The NHS Executive will use the

framework to assess the performance of the NHS. The Commission for

Health Improvement will carry out local reviews to check that systems

to monitor, assure and improve clinical quality are in place. It will

also have a troubleshooting role to help address serious problems. A

National Survey of Patient and User Experience to assess the quality of

NHS care will also be conducted nationally and the results could be

used to initiate action to secure improved services.

The NHS Performance


3

Figure 1 A simple illustration of the key elements of the NHS quality strategy (from

A First Class Service)

3 Performance assessment is central to all these activities. A First Class Service

highlighted the need for a performance framework which would support the

drive for higher quality standards by ensuring that performance assessment is

focused on the delivery of clinically and cost effective, appropriate and timely

health services to meet local needs.

4 The Performance Assessment Framework has two main purposes. It has been

developed to assist the NHS in work to improve the health of the population

and in providing better care and outcomes for the people who use its

services by encouraging action across the six areas. It will also be used to

assess how the NHS is doing to deliver this work. Using the Framework to

make improvements will be a long term process and will require changes

both nationally and locally. The indicator sets supporting the Framework are

not direct measures of quality but should be used to draw attention to issues

that may need further investigation or action. This means:

at the NHS Executive Headquarters, the development of better and

more useful indicators the encouragement of appropriate action at

local level;

The NHS Performance


4

WHAT THE QUALITY FRAMEWORK MEANS FOR PATIENTS

Performance Assessment FrameworkCommission for Health Improvement

National Patient and User Survey

ClinicalGovernance

LifelongLearning

Professionalself regulation

National Service FrameworksNational Institute for Clinical

Excellence

STANDARDS OFSERVICE CLEAR

MONITOREDSTANDARDS

PATIENT &PUBLIC

INVOLVEMENT DEPENDABLELOCAL

DELIVERY

that the NHS Executive Regional Offices have appropriate performance

assessment processes in place to assist and encourage appropriate

action at local level;

that Health Authorities, Primary Care Groups and NHS Trusts consider

the six areas in drawing up Health Improvement Programmes and

work together to ensure that robust Clinical Governance processes are

in place including clinical audit, that data are quality assured and that

local enquiry and learning is encouraged through CPD and life-long

learning.

Messages from the consultation and theroad test

5 The responses to the consultation demonstrated widespread support for the

aims and approach set out in the Framework. They recognised the

significant development agenda which would be necessary to ensure a

comprehensive indicator set across the six areas of the Framework, and to

achieve confidence in using the Framework across the NHS.

6 Over last summer a further stage of refinement to the Framework and

indicator set was undertaken. A road testing programme involving all health

authorities examined the practical use of the Framework and high level

performance indicators. The road test covered a range of applications,

including the assessment of local cancer services, mental health services,

learning disability services and services for the elderly; the development of

the Health Improvement Programme; and involving the public. Road testing

has reinforced the main messages emerging from the consultation: support

for a wider focus on performance and the use of comparative information to

help improve performance by benchmarking and sharing good practice.

7 The road test revealed the importance of the Framework in enhancing joint

working across the partners in local health care systems. At the simplest

level, the six areas of the Framework have been used as the structure for

agendas for meetings between partners. At a more sophisticated level, the

Framework has enabled partners to focus their combined efforts on

improving the quality and efficiency of health care for their population.

5

The Framework involvedwell known concepts butthey had not been broughttogether in this way forplanning purposes before.The health communityendorsed the Framework,it enabled them to moveaway from simplemeasures of efficiencytowards the key healthcare priorities.

Leicestershire HealthAuthority

The Framework hasencouraged a different wayof working within thehealth community.

Calderdale and KirkleesHealth Authority

The conceptual frameworkhelped to reinforce theimportant political messagethat we were moving awayfrom money and activity.It has therefore helped tobegin the process ofrebuilding bridges betweenclinicians ...... andmanagers.

Northamptonshire HealthAuthority

8 The consultation and road test confirm the need for the use of the

Framework and the high level indicator set to develop over time so that:

- Primary Care Groups, for example, can work with their Health

Authorities to determine how to improve performance locally across

the six areas of the Framework;

- the set of HLPIs supports a rounded assessment of the overall success

of the local health care system in delivering high quality, efficient

services for its population;

- the set of HLPIs are used to flag areas where attention might lead to

improved performance - rather than giving information on how the

improvements might be achieved. The latter is a core function of

performance management, which will almost certainly need to focus

on process as well as outcome measures.

6

Ownership of theFramework at all levels inthe NHS is critical to itsuse and usefulness andcontinuing involvement inthe process of refinementat operational levels willbe needed

NW Lancashire HealthPromotion Unit

The Framework providedideas on how to focus oureffort in investigatingperformance standards

Tyne and Wear HealthAction Zone

We should use theindicators for the purposesof learning so that causescan be understood andimprovements agreed.

Royal College of Nursing

Section 1: Revised Framework

9 The Framework was published in January 1998 for consultation. Since then,

there have been a number of significant developments which need to be

taken into account in assessing the performance of the NHS, including:

- the Green Paper and forthcoming White Paper, Our Healthier Nation;

- the outcome of the Comprehensive Spending Review, including the

Modernisation Fund;

- the White Paper, Modernising Social Services ;

- completion of the consultation on A First Class Service; and

- completion of the consultations on Clinical and Clinical Effectiveness

Indicators

These have been taken into account, alongside the consultation and road test,

in revising the Framework and the High Level Indicator Set (the HLPIs).

10 The move to assessing the performance of the NHS in the round was warmly

received in both the consultation and in the road test. The six areas of the

Framework - Health improvement, Fair access, Effective delivery of

appropriate health care, Efficiency, Patient/carer experience and Health

outcomes of NHS care - met with almost unanimous support.

11 A seventh area, focused on human resources, was suggested by some. The

new Strategic Framework for Human Resources will address this important

area and includes targets for improved performance - initially for sickness

absence, violence against staff and participation rates - as well as action on

healthy workplaces, staff involvement, equality in the workplace and

recruitment and retention. But the Performance Assessment Framework is

intended to focus on outcomes for patients. Improved performance on HR

issues across the NHS is a key supporting strategy, essential in securing

success across all six areas by ensuring the NHS can continue to recruit and

retain a high quality workforce.

12 The six areas of the Framework therefore remain as outlined in the

consultation document (Attachment A). The circular presentation in figure 2

reinforces the inter-dependence of the six areas. From an initial view of the

health of the diverse communities of the local population under consideration

(Health Improvement), we need to ensure that everyone with health care

needs (Fair Access) receives appropriate and effective health care (Effective

Delivery) offering good value for money for services (Efficiency) as sensitive

The NHS Performance


7

and convenient as possible (User/Carer Experience) so that good clinical

outcomes are achieved (Health Outcome of NHS Care), to maximise the

contribution to improved health (back to Health Improvement).

Figure 2 NHS Performance Assessment Framework

The NHS Performance


8

Health Improvementto reflect the over-arching aimsof improving the general healthof the population and reducing

health inequalities, which are influenced by many factors, reaching well

beyond the NHS.

Health Outcomes of

NHS careto assess the direct contribution of NHS careto improvements in overallhealth, and complete the circleback to the over-arching goal ofhealth improvement.

Patient/Carer Experienceto assess the way in which patientsand their carers experience and view the quality of the carethey receive, to ensure

that the NHS is sensitive to

individual needs.

Efficiencyto ensure that

the effective care isdelivered with the

minimum of waste, and that the NHS uses its resources to

achieve value for money.

Effective Delivery ofAppropriate Healthcare

to recognise that fair access must be to care that is effective, appropriate and

timely, and complies with agreed

standards.

Fair Accessto recognise that

the NHS’s contribution must begin by offering

fair access to health services in relation to people’s needs,

irrespective of geography, socio-economic group, ethnicity, age or sex.

The High Level Indicator Set for 1999-2000

13 Each of the original set of High Level Performance Indicators has been

reviewed in the light of the many helpful suggestions and comments from

the consultation exercise and the road test. Some have been removed from

the set - district nurse contacts and avoidable diseases, for example - and

others have been revised. Some new indicators have been included in the

set of HLPIs for 1999-2000 to reflect the four key areas of Our Healthier

Nation and the development of new condition focused unit cost measures.

14 Each key area of Our Healthier Nation provides one indicator for the

health improvement area of the Framework so that deaths rates from heart

disease and stroke, cancer, accidents and from suicide and undetermined

injury are now all included in the HLPI set.

15 New measures of efficiency are under development for use at both HA and

NHS Trust level to support HAs and PCGs in commissioning high-quality,

cost-effective services and to support NHS Trusts in tackling variations in the

costs of the services they provide. Two new unit cost indicators, covering

mental health and maternity services, have been included in the HLPI set to

encourage a more patient-centred assessment of relative efficiency in these

areas, and to inform Service Agreements with NHS Trusts. These will

complement information available at NHS Trust level through the Reference

Cost Index.

16 The original set of HLPIs contained four indicators which relate directly to

performance at the Health/Social Care Interface. Improving performance

in this area will require a coordinated response from both the NHS and Social

Services, working in partnership. These indicators are therefore described as

‘interface indicators’. They will be included in both the HLPI set for the NHS

Framework and the indicator set for the Personal Social Services Performance

Assessment Framework.

17 The results of these changes are summarised in Attachment B, which lists the

revised HLPIs under the headings of the six areas of the Framework. The

baseline figures for each HLPI will be published later this year, with the

Clinical Indicators, to highlight the move towards a broader based assessment

of NHS performance, covering outcomes for patients and the public.

18 The HLPIs are intended to flag up the need for further investigation and

action. In some cases the indicators are already associated with the need for

improved performance and are linked to national targets set out in the

National Priorities Guidance or in the specific conditions and objectives

associated with Modernisation Fund resources. Others may be linked to the

aims and objectives set out in local Health Improvement Programmes. The

link with national and local targets is shown in Attachment B.

The NHS Performance


9

The framework has madeus use routinely availabledata in new ways

Buckinghamshire HealthAuthority

Section 2: Using the Framework in the New NHS

Supporting the move towards a broader assessment of performance

19 The NHS Performance Assessment Framework provides a structure for

reviewing NHS performance against outcomes of importance to patients and

the public. As such, it will be of key interest to all players in a local health

community, including health care professionals and NHS managers, social

services and other key local agencies and voluntary organisations as well as

patients, their representatives and the public. It will encourage assessment of

performance in delivering high quality NHS services across a range of

dimensions including:

• population group, for example geographic area, ethnic minority or

social class;

• condition/client group, for example coronary heart disease, asthma

and chronic respiratory disease, children;

• service organisation, for example Health Authority, NHS Trust or

PCG.

Supporting benchmarking

20 The Performance Assessment Framework, together with the high level

indicator set, will enable and encourage benchmarking across the NHS. Over

time, more information - with increasing comprehensiveness, reliability and

comparability - will be provided across each of the six areas. And

information at Health Authority level will be supplemented by comparative

information at NHS Trust level. To support HAs and PCGs in commissioning

high quality services, information will also become available by

condition/client groups.

21 As set out in Information for Health, the aim is to ensure that this

information is accessible to help managers and clinicians assess their own

performance and to support the identification of best practice, so that links

can be made with others in similar organisations to compare progress and

agree ways to improve performance. The identification of some NHS trusts

and general practices as Beacon organisations in the coming year will assist

in this process. The NHS Executive has a work programme to facilitate

benchmarking including the development of an NHSnet site on sharing best

practice. Attachment C gives further details.

The NHS Performance


10

The most important way inwhich these data can beused is to show thoseinvolved in a particularpathway of care how theyare performing comparedto other similar areas inthe country..... Then,examples of good practicecan be celebrated andlearned from and examplesof sub optimalperformance can beaddressed.

Rotherham HealthAuthority

The Health Authority havedeveloped a balancedscorecard approach toCHD. The approachincorporates all the areasof the Framework..........andprovides solutions foroperationalising andapplying the Framework atlocal level.

St Helens and KnowsleyHealth Authority

The indicators have aparticular relevance inexploring where theAuthority appears to beperforming less well thanmight be expected, and inconsidering the reasonswhy. This may also behelpful in deciding ifbenchmarking approachescan yield actions toimprove performance.

Southern DerbyshireHealth Authority

Supporting performance improvement and accountability

22 Key players within the local health community will want to use the

Framework to identify areas where change is needed. Discussion about the

pace of change and action required, including any re-allocation of resources,

will contribute to the development of local work programmes. The resulting

agreements on plans, milestones and targets will be highlighted in the Health

Improvement Programme and associated Service and Financial Frameworks.

23 These agreements will be reinforced through formal accountability

arrangements between the NHS and the NHS Executive Regional Offices;

between local NHS organisations; and between a local health system and its

patients and local population. These accountability arrangements, set out in

Figure 3 below, form the backbone of NHS performance management

systems to ensure high quality services are delivered across the NHS and

offer value for money.

11

We will work with primarycare to examine alternativemeasures, possiblyavailable from primary carehealth data, these cancomplement or enhancethe main indicators andlinkage to other activity eghealth promotion contractdata.

North NottinghamshireHealth Authority

Each local strategy shouldaddress how it contributesto the six areas of theFramework. This couldalso be used as aframework for the HealthImprovement Programme

Kensington & Chelsea andWestminster HealthAuthority

Figure 3 Accountability arrangements in the new NHSThe NHS Performance


12

Local Authorities NHS

Primary Care Groups

Health Authorities

NHS ExecutiveRegional Offices

Health improvement Programmewith associated SaFF

Statutory accountability

Service accountability

A Performance Agreement

B Financial Duties & Clinical Governance

C Accountability Agreement

D Service Agreement

A B

C

D

D

Supporting public involvement

24 The Framework will support public involvement in developing the local

Health Improvement Programme. Through their involvement in decisions on

priorities for tackling health inequalities and achieving overall improvements

in health, local populations will want to know how their local health system

performs across all six areas of the Framework. The publication of the local

Health Improvement Programme will show how the key players intend to

address the need for improvements in health and will include targets for

improvement for the NHS across the six areas of the Framework. Over time,

the HImP will demonstrate the progress of the NHS towards these targets.

Using the Framework in 1999-2000

25 In the first year of use, the Framework should be used by:

• local health communities to review current performance across all six

areas of the Framework and thereby to support decisions to secure

improvements in local health and health care;

• Health Authorities, NHS Trusts and Primary Care Groups to inform

performance and accountability arrangements and support the

assessment of planned and actual progress across each of the six areas

of the Framework; and

• Ministers and the NHS Executive to account for the use of public

resources in delivering the Government’s objectives for the Department

of Health, particularly those set out for the NHS in the National

Priorities Guidance and the Department’s Public Service Agreement.

26 Over time the Framework will have an important role in the formal

accountability arrangements of the NHS, to ensure that all the organisations in

health communities are playing their part in working to improve performance

across the six areas of the Framework, including:

• The Health Improvement Programme, which will identify targets for

measurable improvements in health and health care. For the NHS,

these targets will reflect the scope for improvement across all six areas

of the Framework. These targets for improvement should be

quantified via Service and Financial Frameworks (SaFFs) which should

include plans to meet key baseline requirements, such as emergency

pressures and financial balance, as well as Modernisation Fund targets,

such as waiting list, primary care and mental health objectives.

The NHS Performance


13

We worked closely withrepresentatives of the localmedia. Further closeworking will be anessential feature of takingthe framework forward.

Croydon Health Authority

The decayed missing andfilled teeth index has beenextremely useful inpresenting to healthvisitors, community nursesand school nurses toexplain the size of thedental health problem andenlist their help in dietaryadvice and encouragingregistrations.

Barnsley Health Authority

Identification of outlierscan be an invaluablemeans of focusingattention on previouslyunsuspected differences.

Royal College ofPsychiatrists

The indicator set hasproved useful inconfirming issues requiringpriority attention within theHImP (eg cancers, heartdisease, accidents, suicides,cost effective prescribing,access to hip/ kneereplacements). This isparticularly useful inproviding evidence topartners of why theseissues are a priority.

Doncaster Health Authority

• Annual accountability agreements between a Health Authority and

its local Primary Care Groups which will contain key targets, objectives

and standards for the provision or commissioning of services. These

agreements will be consistent with national priorities and the local

Health Improvement Programme. Progress should be assessed in the

context of the Framework, using locally available information where,

for example, HLPIs are not suitable for use at PCG level.

• Service agreements between Health Authorities/Primary Care Groups

and NHS Trusts which will be patient/service based and developed

typically at Clinical Directorate level. Each Service Agreement should

have jointly owned measures of performance and be linked to targets

for improved performance. Performance against Service Agreements

should be monitored in line with the broader based approach set out

in the Framework.

• NHS Executive Regional Offices and the Regional Offices of the Social

Services Inspectorate, which will continue to monitor jointly

performance across the NHS/Social care interface. The interface

indicators, common to both the HLPI set and the proposed indicator

set for the PSS Framework, aim to help promote a common

understanding and ownership of performance issues at the interface.

• Each HA working with its Regional Office to develop an annual

performance agreement covering all the key objectives of the HA

for the year. The agreement should incorporate plans set out in the

Service and Financial Framework for the year, along with specific

objectives concerned with the development of the HA and PCGs.

These agreements should include an assessment of the expected

influence on performance against local plans across each of the six

areas of the Framework.

The NHS Performance


14

The power of theFramework approach liesin its potential to form thebasis of target setting inthe Health ImprovementProgramme andsubsequent performancemanagement andmonitoring.

Southampton and SWHants HA

North Yorkshire HealthAuthority is examiningsome of the HLPIs at PCGlevel to give a fullerunderstanding ofperformance and key localhealth priorities.Preliminary analysisindicates some importantvariations within andacross PCGs.

North Yorkshire HealthAuthority

Obtaining multi-disciplinary input wascritical in enabling us tofully understand and testthe Framework in relationto a clinical service. Wehosted a multi agencyworkshop attended byconsultants and nursingstaff from both the acuteand community trusts,local hospicerepresentatives, the CHC,staff from primary care andNYCRIS.

Wakefield Health Authority

Now Health and SocialCare agencies are workingtogether applying suchconcepts as ‘quality of life’that portray users’ andcarers’ view of their ownhealth and well-being.

Sefton Health Authorityand Sefton Social Services

Section 3: Developing the Framework and HLPI set

27 In the short term, the indicator set will be extended to:

- support the assessment of NHS Trust performance, through the

development of more detailed clinical indicators which can be used to

compare performance across a range of conditions/interventions;

through the publication of Trust Reference Costs and to support

benchmarking and inform differential efficiency targets; and through

the publication of the Audit Commission’s NHS Trust profiles;

- include quality indicators following the development of National

Service Frameworks. The two recently announced NSFs on coronary

heart disease and mental health will build on current work on cancer

services, for which indicators should be available for consultation and

road testing during 1999-2000; and

- support the development of the new NHS Charter programme.

These developments will help demonstrate how the pursuit of quality and

efficiency must go together for the NHS to deliver the best for patients.

28 Work continues to develop a comprehensive, high quality indicator set which

is capable of providing a basis for both national and local assessment. The

many helpful suggestions made in response to the consultation and the ro a d

test will contribute to this work. The development of more and better

indicators for the Fair Access area of the Framework is a high priority - work is

in hand, for instance, to develop HLPIs to assess the availability of primary and

community care services more generally. Attachment C sets out some of the

work in hand to develop comparative information across all six areas of the

F r a m e w o r k .

29 Improving the quality of the data from which the indicators are generated

will be a priority for the NHS in implementing the information strategy,

Information for Health. The strategy acknowledges that the information

requirements of the Framework are beyond the scope of currently established

information flows. It identifies the need for the NHS and the NHS Executive

to work closely together to review data sets and data collection systems in

order to ensure that data are relevant, complete, comparable, stable over time

and available readily and promptly.

The NHS Performance


15

The selection of the HLPIset is of critical importanceif the Framework is toadequately cover all healthcare services, eliminateperverse incentives andprovide flexibility for localpriorities.

Northern and YorkshireTrusts

Whilst it is important notto increase overall datacollection in the NHS,there needs to be a morefocused approach so thatfuture indicatordevelopment, reflectingeffective and high qualitycare, is not hampered bypoor data availability.

Wirral Hospital NHS Trust

30 To ensure the continued development of the Framework, the NHS Executive

intends to establish a Performance Framework Reference Group (PFRG). The

PFRG will advise on the development of indicators to support performance

assessment across all six areas of the Framework and on the effective

dissemination and use of the Framework and indicators across the NHS.

Links with other indicator sets

31 The development of the Framework and its high level indicator set has been

complemented by work over the past year to develop a range of indicators,

including:

- a set of clinical indicators;

- clinical effectiveness indicators;

- NHS Trust reference costs;

- primary care effectiveness indicators; and

- in due course, the results of the first survey of NHS patients.

The products of many of these initiatives are reflected directly in the HLPI set.

The Framework will provide the overall structure for the development of all

such performance indicator sets in the future.

National publications

32 A number of perf o rmance indicators will be published, as the inform a t i o n

becomes available. The first of these, Reference Costs, were published in

November 1998. The baseline data for the revised High Level Perf o rm a n c e

Indicators listed in Attachment B will also be available later this year, alongside

the clinical indicators. These will support the assessment of both the quality and

e fficiency of services.

33 In future years, these publications will be brought together under the umbre l l a

of the Perf o rmance Assessment Framework. Publications will be used to

demonstrate pro g ress in improving health and health care year on year acro s s

all six areas of the Framework, so that NHS perf o rmance can be assessed in the

round, against the outcomes that matter most to patients and the public.

The NHS Performance


16

The participative way inwhich the Framework hasbeen introduced iswelcomed ..............and theFramework will need toevolve to reflect emergingcurrent key performanceissues within the NHS.

Lincolnshire HealthAuthority

Attachment AThe NHS Performance AssessmentFramework

The NHS Performance


17

Areas Aspects of performance

I Health improvement The overall health of populations, reflecting socialand environmental factors and individualbehaviour as well as care provided by the NHSand other agencies

II Fair access The fairness of the provision of services inrelation to need on various dimensions:- geographical- socio-economic- demographic (age, ethnicity, sex)- care groups (eg. people with learning

difficulties)

III Effective delivery of The extent to which services are:appropriate health care - clinically effective (interventions or care

packages are evidence-based)- appropriate to need- timely- in line with agreed standards- provided according to best practice service

organisation- delivered by appropriately trained and

educated staff

IV Efficiency The extent to which the NHS provides efficientservices, including:- cost per unit of care/outcome- productivity of capital estate- labour productivity

V Patient/carer The patient/carer perceptions on the delivery of experience services including:

- responsiveness to individual needs and preferences

- the skill, care and continuity of service provision

- patient involvement, good information and choice

- waiting times and accessibility- the physical environment; the organisation

and courtesy of administrative arrangements

VI Health outcomes of NHS success in using its resources to:NHS care - reduce levels of risk factors

- reduce levels of disease, impairment and complications of treatment

- improve quality of life for patients and carers- reduce premature deaths

Attachment B -the High Level Indicator Set in 1999-2000

The NHS Performance


18

I. Health Improvement

Deaths from all causes (for people aged 15-64)

Deaths from all causes (for people aged 65-74)

Cancer registrations

Deaths from malignant neoplasms 1,2

Deaths from all circulatory diseases 1,2

Suicide rates 1,2

Deaths from accidents 1,2

II. Fair Access

Surgery rates 1

Size of inpatient waiting list per head of population (weighted) 5

Adults registered with an NHS dentist 5

Children registered with an NHS dentist 5

Early detection of cancer 1

III. Effective Delivery of Appropriate Health care

Disease prevention and health promotion 1,5

Early detection of cancer 1

Inappropriately used surgery

Surgery rates 1

Acute care management 5

Chronic care management 5

Mental health in primary care 5

Cost effective prescribing

Discharge from hospital 3,4

IV. Efficiency

Day case rate

Length of stay in hospital (case-mix adjusted)

Unit cost of maternity (adjusted) 5

Unit cost of caring for patients in receipt of specialist mental health services (adjusted)5

Generic prescribing

continued over page

Footnotes

1 Associated with objectives and/or targets in National Priorities Guidance

2 Proposed indicators for Our Healthier Nation

3 Indicators on interface with PSS Performance Framework

4 Clinical Indicators

5 Amended for 1999-2000, following consultation and road test.

The NHS Performance


19

V. Patient / Carer experience of the NHS

Patients who wait less than 2 hours for emergency admission (through A&E)

Patients with operation cancelled for non-medical reasons

Delayed discharge from hospital for people aged 75 or over 3

First outpatient appointments for which patient did not attend

Outpatients seen within 13 weeks of GP referral 1

% of those on waiting list waiting 12 months or more 1,5

VI. Health Outcomes of NHS health care

Conceptions below age 16 2

Decayed, missing and filled teeth in five year old children 1

Adverse events / complications of treatment 4

Emergency admissions to hospital for people aged 75 and over 1,3

Emergency psychiatric re-admission rate 1,3

Infant deaths

Survival rates for breast and cervical cancer 1

Avoidable deaths

In-hospital premature deaths 4

Attachment C – Developing Benchmarking

“The new performance framework will encourage greater benchmarking of

performance in different areas, and the publication of comparative information will

allow people to compare performance and share best practice. Coupled with the new

National Service Frameworks, the Government will use these measures for a

systematic drive to challenge and reduce unacceptable variations in all aspects of

performance across the NHS.”

The new NHS, Paragraph 8.7

Introduction

1 The government’s commitment to improve performance through greater

benchmarking, requires action at national and local level. This attachment

sets out plans to support benchmarking across the NHS.

Objectives of Benchmarking; The Role of the NHS Executive

2 The essence of benchmarking is the identification, understanding,

dissemination and implementation of best practice.

3 In the new NHS, the objective of benchmarking is to improve the overall

performance of the NHS across all six areas of the Performance Assessment

Framework. The potential for improvement through emulation and extension

of best practice is high. Currently there are substantial variations in unit costs,

in treatment rates and in outcomes. Where variations are due to varying

standards of care and efficiency, there is potential for improvement through

benchmarking.

4 To support local action to increase the priority given to benchmarking, the

NHS Executive will:

- support the development of the comparative information needed to

underpin benchmarking activity;

- encourage the use of comparative information to support the

implementation of best practice, including by providing easy access to

the comparative data on the ‘Learning Zone’ intranet website (see

paragraph 10 below); and

- identify and publicise beacon providers in the fields of waiting lists

and times; primary care; mental health; staff development; cancer

services and health improvement. These sites will disseminate their

work actively, for example through receiving visitors and placing

material on the ‘Learning Zone’ Intranet website (see paragraph 10

below).

The NHS Performance


20

Creating robust comparisons across the six areas

5 In the long term, comparative information will be needed:

- across each of the six areas of the Performance Assessment

Framework, and

- at each level of service provision (including comparisons of different

service providers for particular client or disease groups and

comparisons between NHS Trusts, PCGs and HAs).

Such information needs to be relevant, reliable, sensitive to legitimate cost

drivers (eg case-mix), and coherent.

6 Two important developments will be needed to help secure information that

meets these criteria:

• first, the establishment of appropriate units of account in order to

allow more meaningful comparisons. Over time, two new units of

account (in addition to the Finished Consultant Episode, FCE) will be

developed:

- a ‘Provider Spell’, to be the focus of comparisons of providers’

technical efficiency. A provider spell covers the care provided from

admission to discharge; is classified by the type of care provided (e.g.

by HRG), irrespective of the setting of care and the length of stay; and

is costed by the provider.

- a ‘Programme Spell’ to be the focus of broader comparisons of the

performance of the NHS as a whole, and of the services commissioned

by HAs and PCGs through long term service agreements. A

Programme Spell includes all care delivered to a patient from

beginning to end of the treatment relating to a particular need. (For

patients with chronic conditions, this could relate to a particular time

period - for example, a year). Programme Spells will be classified by

the condition of the patient. Work to develop these measures will be

facilitated by the work set out in the Information Strategy to introduce

Electronic Patient Records and Electronic Health Records.

• second, data quality and timeliness will be improved as set out in

the Information Strategy in order to enhance the quality, consistency,

credibility and value of comparisons.

7 Weakness associated with current data quality and scope, however, should

not prevent action to deliver some comparisons soon, both to allow local

investigations of outliers to begin, and as a spur to improvements in data

quality. The table below indicates some of the initiatives that are currently in

place or are under consideration to extend the range of comparative

information available to different NHS organisations.

The NHS Performance


21

Comparisons under development shown in italics.

Ensuring that comparisons are exploited

8 Moving from “acceptable” to “best” practice will require a culture change in

some parts of the NHS. Sharply focused comparisons will challenge the NHS

to improve performance across all six areas of the Performance Assessment

Framework.

22

SCOPE OF Programmes Trusts Health Authorities

BENCHMARKING of care and PCGs

HEALTH Assessments for NSF Public Health Common

IMPROVEMENT conditions. Data Set

HLPIs

FAIR ACCESS Assessment of variation in Assessment of variation HLPIs

utilization rates for in admission rates for Performance Tables:

effective treatments for effective treatments relative various access measures

different conditions, to need.

relative to need.

EFFECTIVE DELIVERY Assessment of utilization Assessment of admission HLPIs

OF APPROPRIATE rates for more or less rates relative to need for Clinical Effectiveness

HEALTH CARE effective treatments for more or less effective Indicators

NSF conditions. treatments.

Effectiveness indicators Voluntary national audits

being developed for (e.g. Intensive Care

specific conditions National Audit and

Research Centre)

EFFICIENCY Database of Reference Audit Commission Trust HLPIs

Costs “developed to Profiles: acute hospital

support ... programmes of unit costs allowing for

care for patients with casemix and other cost

different needs” drivers.

(White Paper, para 9.22); Investigation of Drivers of

in the first instance, for Trust efficiency

NSF conditions. Schedule of Reference

Costs and Reference

Cost Index

PATIENT/CARER National Patient Survey Performance Tables: HLPIs

EXPERIENCE (hospitals) complaints performance; Performance Tables:

waiting times waiting times etc

National Patient Survey National Patient Survey

HEALTH OUTCOMES Outcome Measures being Clinical Indicators - HLPIs

OF NHS CARE developed for particular Trust level mortality rates Clinical Indicators

diseases for particular procedures.

23

The NHS Performance


9 Regional Offices will encourage and facilitate local efforts to improve

performance and to attain and advance best practice, through supporting

local benchmarking groups, dissemination of re-engineering techniques and

mentoring to bring together NHS organisations to improve understanding of

the reasons for variations in performance and to identify mechanisms for

improvement.

10 A “Learning Zone” Intranet website is now being piloted. It makes available

the results of this work, and of linked initiatives. It will be used to provide:

- comparative information tailored to the needs of different users

(commissioners, NHS Trusts, clinical teams, etc);

- information on initiatives to encourage and enable the identification

and spread of best practice across the six areas of the Performance

Framework;

- suggestions of good practice in the process of health care

commissioning and provision;

- information on identified beacon performers for different services; and

- contact points from whom further information could be obtained, and

to whom suggestions of how the NHS Executive could further support

benchmarking across the NHS could be sent.

the nhs performance assessment framework - uk ...webarchive.nationalarchives.gov.uk/20031117030514/...

Documents