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Academic Health Science Centre (AHSC) Academic Health Science Centre (AHSC). This is a partnership between a number of hospitals and universities supported by the Healthcare for London report by Sir Ara Darzi (click here). The purpose is to bring together world-class research, teaching and patient care. One is proposed between St Mary’s NHS Trust, the Hammersmith Hospitals NHS Trust and Imperial College London. As Lord Sir Ara Darzi is also heading an England-wide review of services, the term is included here.   Advance Care Plans Advance care planning (ACP) is a voluntary process of discussion about future care between an individual and their care providers, irrespective of discipline. If the individual wishes, their family and friends may be included. It is recommended that, with the individual’s agreement, this discussion is documented, regularly reviewed and updated, and communicated to key persons involved in their care. Advance care planning discussions may lead to an advance statement (a statement of wishes and preferences), an advance decision to refuse treatment (link – covered below!) or the appointment of a Lasting power of Attoney (LPA). Guide for health and social care staff and RCP Advance Care Planning: concise evidence based guidelines.  And also Advance Care Planning website    Advance decision The Mental Capacity Act 2005 gives people in England and Wales a statutory right to refuse treatment, through an 'advance decision'. An advance decision allows a person to state what forms of treatment they would or would not like should they become unable to decide for themselves in the future.  It is a binding decision.   An advance decision cannot be used to: refuse basic nursing care essential to keep a person comfortable, such as washing, bathing and mouth care refuse the offer of food or drink by mouth refuse the use of measures solely designed to maintain comfort, for example, painkillers demand treatment that a healthcare team considers inappropriate ask for anything that is against the law such as euthanasia or assisting someone in taking their own life An example from Alzheimer’s Society.   ALMO (housing) An ALMO is a company set up to manage and improve council housing stock. It is owned by the local authority but operates under a management agreement between it and the local authority.ALMOs are designed to encourage both the participation of the local community in the management of their homes and the continuous improvement of council housing services. Government funding is provided on the condition that local authorities separate their management and strategic functions. An ALMO must:     deliver major repairs and improvements to bring homes up to the Decent Homes Standard     collect rents, deal with arrears and debt counselling     maintain properties     manage lettings and deal with empty properties. The local authority is still responsible for:     the housing strategy     housing benefit and rent rebate administration     the overall policy on rents.     Alternative Provider of Medical Services (APMS) contract This is one of the types of contract that Primary Care Organisations (PCOs)  can have with any provider of primary care to increase capacity and offer more choice.  It could be a contract to provide care for a specific population, or a different way of providing care.  It can exclude some essential services. For example, a private provider could provide a walk-in centre service.  See also GMS, PMS, PTMS and SPMS.   Ambulatory Care Sensitive Conditions (ACS) A number of organizations including the NHS Institute are looking to help commissioners predict who might be at risk of admission, and to find ways to divert that admission.  Work by the Institute, Imperial College and Dr Foster’s has identified nineteen ACS conditions which account for 6%-13.2% of total hospital costs for which there is a community-based alternative to admission. The variation in that proportion gives scope for improvement.  COPD, asthma, flu and pneumonia are significant in this list of nineteen. See here for how it can be used. The Kings Fund together with New York University and Health Dialog has also developed the Patients At Risk of Re-hospitalisation (PARR) Case Finding Tool and a later version called the Combined Model.   Annual health check This is undertaken in England by the Healthcare Commission, which is the watchdog for England's healthcare - checking quality and safety provided by the NHS and independent organisations.  The third annual health check performance ratings for NHS trusts in England were published on 17 October 2008. They show major improvements in performance with trusts improving the quality of services and managing money more effectively.   One in five trusts were inspected, the rest of the ratings were derived from analysis of thousands of data items. To see how your trust has done, click here. For detailed reports, click here.     Autonomous Provider Organisation (APO) The NHS Operating Framework for 2008/09 required PCTs to ‘create an internal separation of their operational provider services and agree service level agreements (SLAs), based on the same business and financial rules as applied to all other providers.’ Therefore by April 2009 all PCTs should have divested themselves of service provider functions*  to focus entirely on commissioning and moved into a contractual relationship with their PCT provider function, using the national model contract for community services in 2009/10. This has meant ensuring sufficient separation of roles within the PCT to avoid direct conflicts of interests.  It will have An activity plan with unit costs (for PBR and Cost and Volume services). A Data Quality Improvement Plan. Formal contract management arrangements with regular formal contract meetings and policies for dispute resolution. Initially,  ALMOs were formed: arms length management organisations. However, in order to be treated like other service providers they needed to make formal changes in structure, governance, finance and their contractual relationship with the PCT. This meant a separate senior management team and board,   These organisations, still part of the same statutory body, the PCT, are known as APOs.  The relationship between an APO and PCT is described within a memorandum of understanding because they remain one financial entity.  However, an APO can have a separate finance team, separate assets and liabilities, its own income and expenditure statement and management reports,   The readiness of the ALMO to become an APO is assessed by the local SHA in a formal assessment process. Transforming Community Services: Enabling new patterns of provision” (Jan 2009 DH) required PCTs to develop a commissioning strategy and plan for transforming community services by October 2009 that will introduce sufficient competition to drive up quality and value for money. In the context of this commissioning strategy, PCTs should also have developed a proposal for the most appropriate organisational form for existing PCT provided services that best suits local circumstances. Transforming Community Services suggests that there are several possible organisational models (such as PCT provider services, community foundation trusts and social enterprise companies, and services integrated with other organisations. In August 2009 the timetable (to set up a new structure by October 2009) and approach was changed to ensure the focus was not on organisational structures but on the point of the organisations: “[plans must be] “cost effective” and “consistent with implementing a robust approach to quality, innovation, productivity and prevention”. SHAs will now  lead the process but it is clear that PCTs' ability to deliver World Class Commissioning (WCC) depends on them divesting themselves of their provider function.   The likely effect would mean that some services may be vertically integrated with secondary care providers or horizontally integrated with other community services (including potentially Social Care). For a significant proportion of services, the preferred service model is likely to be a stand-alone community organisation.  Increasingly, APOs are looking to secure their future and reduce their exposure to risk by spreading contract income across several commissioners.  This might be through successful tenders. Example of stages of development from Nottinghamshire County PCT Stage 1 : Arms-length managedorganisation (ALMO) Finance:Separate income and expenditure only Governance: Provider subcommittee with dedicated non-executive chair Strategy - Limited contestability (no real incentive to create contestability) Stage 2: Autonomous provider organisation (APO) Current examples: Havering Finance: “Shadow” separate financial statements (income and expenditure, cash flow, balance sheet) Governance: Provider subcommittee with dedicated non-executive chair – No cross-over with PCT Board – Clear scheme of delegation, memorandum of understanding and terms of reference in place for Provider Board Strategy: Commissioning of service increasingly for individual services, fewer block contracts Stage 3: Externalised organisation and competition Current examples: South Birmingham PCT (DH Community FT pilot) Finance: Separate audited financial statements Governance: Two independent boards, without overlap Strategy: Contestability in system.  National policy context will influence true degree of freedom * Typically they provide community services such as health centres, community hospitals, community nursing including district nurses, health visitors and school nurses, continence, contraception and sexual health, dietetics and nutrition, intermediate care, minor injuries, occupational therapy, physiotherapy and speech and language therapy.   Related Words  Operating Framework; Service level agreement (SLA) ; Social enterprise Benchmarking (social care) A method for councils to work out how well they are doing by comparing their performance with other similar councils, and with performance indicators (PIs).  It is also used by PCTs, and various information sources such as the NHS Information Centre now enable statutory organisations to select benchmarking groups and national data sets in health and social care to compare performance.   Best Value (social care) Best value was a local government performance framework introduced into England and Wales by the Local Government Act 1999. The aim of the framework was to promote continuous improvement in local authorities’ performance. Under the framework, English and Welsh councils were required to monitor a set of best value performance indicators (BVPIs), undertake best value reviews of services and cross-cutting themes, prepare performance improvement plans and report on their performance annually. Subsequent regulations, including statutory instruments and the Local Government and Public Involvement in Health Act 2007, have removed requirements to publish performance indicators (PIs), undertake best value reviews or publish a best value performance plan (BVPP). However, the general duty to make arrangements to secure continuous improvement in the way in which their functions are exercised, having regard to a combination of economy, efficiency and effectiveness, remains.   Caldicott Guardians Senior professionals working within the NHS and local authorities to ensure that the confidentiality of patient-identifiable information is maintained and that manual and IT systems are secure. Caldicott Guardians oversee issues such as confidentiality and security, information clarity, rights of access and documentation accuracy.   Care Pathway To improve the person-centred nature of care, commissioners and service planners now try to understand how patients experience their care from prevention, to diagnosis and assessment, to treatment and where appropriate, to palliative care. This normally involves mapping the journey and the experience using a range of techniques with patients, clinicians, and managers. They describe this journey as a care pathway. Their aim is to improve the flow of patients along this pathway by reducing inefficiencies and improving reliability.   Care plans (social care/long term conditions care) Care plans bring together all the information about the individual into a single, overarching care plan produced by health and social services.  This can be a written document; electronically recorded, e.g as a electronic care plan or recorded in the patient’s notes, and be accessible to the patient and all carers, including emergency/urgent care services. Care plans should focus on the aspirations of the patient. These are different from an asthma action plan or a COPD plan, which would be one element of a whole care plan. Some PCTs in England are using care plan templates to capture this information, others are building on existing shared records between health and social care.   Care Quality Commission (CQC) CQC brings together the  independent regulation of health, mental health and adult social care. Before 1 April 2009, this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. These organisations no longer exist. CQC’s  main activities are: • Registration of health and social care providers to ensure they are meeting essential common quality standards using one common regulatory framework for the first time • Monitoring and inspection of all health and adult social care • Using its enforcement powers, such as fines and public warnings or closures, if standards are not being met • Improving health and social care services by undertaking regular reviews of how well those who arrange and provide services locally are performing and special reviews on particular care services, pathways of care or themes where there are particular concerns about quality • Reporting the outcomes of its work so that people who use services have information about the quality of their local health and adult social care services. It helps those who arrange and provide services to see where improvement is needed and learn from each other about what works best  CQC website has more information Since 1 April 2009, NHS providers have been required to register with the Care Quality Commission and comply with its requirement on cleanliness and infection control. The new system for registration will be introduced for the NHS in April 2010, and for independent and voluntary healthcare, and adult social care providers from October 2010.  Primary dental care providers will and private ambulances will be brought into registration in 2011 and primary medical care providers in 2012. The framework is available in draft form from http://www.opsi.gov.uk/si/si2009/draft/ukdsi_9780111487006_en_1 In a speech to the NHS Alliance in October, the Chair of the CQC, Barbara Young suggested that the Care Quality Commission will focus initially on ensuring that all NHS organisations reach minimum standards, rather than monitoring all organisations or supporting the best to do more.     Choice Since January 2006 in England, patients are offered the choice of at least four hospitals and a booked appointment when they need a referral for elective care. By 2008, patients will be able to choose any healthcare provider that meets NHS standards – that is, it may be an independent/private sector provider - and can provide care within the price the NHS is prepared to pay.  The extension of the Choice Agenda to the care of people with long term conditions is under review and if it becomes policy, would enable people to choose how certain aspects of their care, along the care pathway, would be delivered to them personally.   Choose and Book An English NHS initiative that allows people to make their first outpatient appointment, after discussion with their GP, at a time, date and place that suits them with the booking made electronically at the GP practice.   Clinical Assessment Service (CAS) and Clinical Assessment and Treatment Service (CATS) Also known as Referral Management Centres (RMCs). This is a model of providing the equivalent of outpatients services for identified care pathways in either primary or secondary care.  The CAS provides a clinical evaluation of a patient’s condition and treatment. Patients are referred to the service by their GP and may be reviewed in person or virtually, using medical records and a phone conversation with the patient. If necessary, they will then be treated or referred on for further investigation or treatment. GPwSIs (see below) may staff the service. Referral to the CAS will be part of the Choose and Book programme. Typically it is this assessment service that offers the choice, rather than the initial referrer.  The CAS/CATS may be provided by the independent sector. There is recent BMA guidance about RMCs, with a response from David Colin Thome, National Clinical Director for Primary Care and 18 weeks suggesting that the set up of RMCs needs to be done in negotiation with practice-based commissioning, and will not be the only model. Access both documents here.   Clinical Strategy Previously known as National Service Framework for COPD. The clinical strategy for COPD is expected to go live in Spring 2009.  It will be accompanied by the evidence base, a commissioning toolkit and communications strategy.  Further work on workforce and medicines management is also expected.   Co-creation of health Is also used to refer to the joint production of outcomes between patients with long term conditions and clinicians; an innovative approach to self-management. The Health Foundation is currently funding a Co-creating Health project. See here. There are two COPD pilot sites in NHS Ayrshire and Arran and Cambridge University Hospitals NHS Foundation Trust, Cambridgeshire Primary Care Trust (PCT).   Combined predictive risk model A risk stratification process developed by the Kings Fund, New York University and Health Dialog and piloted successfully by Croydon PCT as part of the virtual wards programme. See here.   Commercial Operating Model Launched by DH  England June 2009 Necessity - not nicety. Some services decommissioned and new regional Commercial Support Units established (CSUs),  the Procurement, Investment and Commercial and Division (PICD), National Procurement Council, and Strategic Market Development Unit. Related Words  Commercial Support Units (CDUs); National Procurement Council; Procurement, Investment and Commercial and Division (PICD); Strategic Market Development Unit (SMDU) Commercial Support Units (CDUs) Part of new DH England Commercial Operating Model June 2009; regional units "to help commissioners raise their game, focusing on World Class Commissioning competencies 7, 9 and 10 – analysing, stimulating and managing healthcare markets, securing and applying procurement skills, and managing contracts effectively as a ‘demanding’ customer. Alongside support, a key element of the offer will be skills transfer, creating permanent PCT capability in these key areas. The CSUs will also provide the third and private sectors wishing to provide NHS funded services a point of commercial contact in each region. The document emphasises the commitment to maximise the contribution of third and private sector organisations. Governance and funding arrangements will be put in place to guard against any conflict of interest, real or perceived, and to support an appropriate blend of co-operation and competition. Providers will also be able to draw on CSUs for a wide range of commercial and procurement support. Related Words  Commercial Operating Model Commissioning The full set of activities that PCTs and GPs and local authorities undertake to make sure that services funded by them, on behalf of the public, are used to meet the needs of the individual fairly, efficiently and effectively see here. It is a cyclical process, often taking at least a year and involving many people, both clinicians and managers.  It is not a single action carried out by one person.  There are specific deadlines during the year for production of plans, consultations and monitoring. It happens at several levels: at GP level, practice-based commissioning is intended to increase the responsiveness of this cycle to individual and local need, by involving all GP practices either singly or in clusters.  A single GP population will range from about 2000 to 12000 and clusters from about 50,000 to 90,000.  It may also involve practices in providing more services in primary care through reinvestment of savings released from managing referrals more effectively.  As 80% of a practice workload is managing long term conditions, it is likely that there will be scope for doing things differently. PCTs and clusters of PCTs will also commission services for populations.  A PCT population will range from just over 100,000  in Darlington to over 1 million in Hampshire; whilst Greater Manchester Association of PCTs, a cluster of PCTs represents about 2.5 million people. For some rare or costly interventions, commissioning will continue at regional or national levels.  A useful website is here.   Commissioning Framework for Health and Wellbeing This was published in March 2007 by the Department of Health as a consultation document as part of the implementation of the White Paper Our Health our care our say.  (See here). It aims to give commissioners more “teeth” and to address the “fully engaged” scenario envisaged in the Wanless Report.  It supports the development of personalised services for people with long term conditions Most will be “permissive”, that is, commissioners will be encouraged rather than forced to implement it. However it also describes the Joint Strategic Needs Assessment (JSNA) that will be obligatory from 2008.  It lays down an expectation that providers and commissioners of care will actively seek out ways to reduce health inequalities and to support people who are socially excluded.  This might include commissioning from alternative providers offering new models of care.  Chapter 4 and Pages 81-82 describe the state of play regarding data sharing.   Commissioning intentions or Prospectus English PCTs publish this annually in about November to signal the direction for local services and to get local feedback. They will include a discussion of the key priorities and investment changes.  The local authority Overview and Scrutiny Committee, public and Practice Based Commissioners (see above) practices are all being encouraged to respond. This is a very important document that clinicians should look through as soon as it is available.  From October 2008 these will be reflected in the PCT’s five-year strategic plan.   Competitive Dialogue See DH England information about the new EU public procurement directive - competitive dialogue. It is used in the award of complex contracts (particularly for the Private Finance Initiative PFI).   It needs expert guidance. See Office of Government Commerce briefing.   Comprehensive Area Assessment (CAA) This is one of three regulation activities for health and social care.  In addition to World Class Commissioning and the Care Quality Commission regulation of health and adult social care, the CAA, led by the Audit Commission  will assess outcomes delivered by councils working alone or in partnership and comment on how well local organisations are working together to deliver high quality outcomes. The CAA will focus on: joint working between councils and their partners in delivering the area’s priorities, as agreed in the local area agreement (LAA) and sustainable community strategies how the quality of people’s lives is improved. Local public organisations will be collectively accountable for the outcomes they deliver for an area. CAA will consider how partnerships are working to address challenges facing communities and deliver better outcomes. It will seek to highlight best practice and innovation, but also identify any barriers to improvement. CAA will also provide information to local people about their local services. This will increase their awareness of the services available to them, empowering them to make better decisions and get value for money.  CAA will consist of two assessments: area assessment and organisational assessment. Related Words  Care Quality Commission (CQC); World Class Commissioning Connecting for Health This is an NHS agency responsible for delivering the NPfIT  programme (click here)   Contracts As part of the procurement process, Primary Care Trusts must set contracts with providers.  From April 2008 a standard NHS contract for acute services (click here) has been used.  From April 2009, there will also be a standard contract for all providers of community services (download pdf here).   Co-production This is a phrase used differently by different parts of the NHS and social care system.  In the 2009/10 Operating Framework it is described as one of the principles of the Next Stage Review High Quality Care for All. The other principles are subsidiarity, clinical ownership and leadership and system alignment.  It is defined there as: ”all parts of the system need to continue to work together on shaping and implementing change. … it means in essence .. engaging people across the system to work together to make change happen. “ It is also used to mean the co-production of health, through the partnership of the NHS and patients and the public either at a policy level or at the level of a 1:1 interaction.  See also co-creation.   CPAP  Continuous positive airway pressure: treatment comprising a portable, electrically powered pump which delivers air through a tight fitting nasal mask or similar device. , Used overnight by for people with obstructive sleep apnoea syndrome (OSAS). NICE approved. See here.   CQUIN Commissioning for higher quality and innovation AKA CQUIN  — “sequin” scheme was announced in the Darzi Review High Quality Care for All (June 2008). Hospital payment will be linked to quality. It will allocate a proportion of the tariff  uplift for rewarding quality. In the first year of operation (from April 2009) hospital providers will trigger payments by simply submitting data - ensuring data flows are in place. However from 'no later than 2010' payments will be linked directly to outcomes.  The 2009/10 Operating Framework states "All PCTs will need to agree with NHS providers how to link payment to quality in their 2009/10 contracts. In the first year, organisations may choose to link the 0.5 per cent of contract value to measurement of quality. Acute contracts should include a CQUIN scheme linking payment to specific locally determined goals that cover the domains of quality and innovation. For community, mental health and ambulance service providers, payment may be linked to a quality improvement plan. In future years, the proportion will increase and will start to reflect quality improvements. The new Care Quality Commission will also recognise where quality has been achieved through high-profile publication of trusts’ results.” Reports from Healthcare Financial Management Association (HFMA) (see here) suggested that an average district hospital with a turnover of £250m could expect up to £9m through the quality payments system. A range of quality measures covering safety (including cleanliness and infection rate), clinical outcomes and patients' views about the success of their treatment (recorded in patient-reported outcome measures or PROMs) will be used. Related Words  National Quality Board; QIPP; Quality; Quality Accounts ; Quality and outcomes framework (QOF); Quality Metrics/Indicators; Quality Standards Deprivation of Liberty The Mental  Capacity Act (2005) amended by the Mental Health Act 2007 introduced new deprivation of liberty safeguards.  From 1 April 2009 healthcare professionals and managers working in the NHS, independent hospitals and care homes must have clear procedures in place to comply with the new Deprivation of Liberty Safeguards (DoLS) introduced under the Mental Capacity Act (MCA).  A code of practice is available here. The safeguards provide a framework for approving the deprivation of liberty for people who lack the capacity to consent to treatment or care in either a hospital or care home that, in their own best interests, can only be provided in circumstances that amount to a deprivation of liberty.  There is a written application for authorisation  required. The PCT must commission 6 assessments including age, mental health (undertaken by a doctor approved under s12 MHA or has special expertise in mental disorder) , mental capacity, and “best interests” assessments (assessor must have specified qualification including social work).  The assessment must be carried out within 21 days of the application.   Dignity Ensuring that a person receives the type of care that makes them feel respected as an individual and helps them develop or maintain self-esteem and take pride in themselves. This should take place in every setting whether in the community or in the acute sector. The Dignity in Care Campaign launched in 2006 across health and social care, aims to stimulate a national debate around dignity in care and create a care system where there is zero tolerance of abuse and disrespect of adults.  Key areas are care for older people and people with mental health problems. There are now four thousand dignity champions. http://www.dh.gov.uk/en/SocialCare/Socialcarereform/Dignityincare/index.htm  and http://www.dhcarenetworks.org.uk/dignityincare/index.cfm   Direct Payments (social care) Direct Payments are means-tested payments made instead of receiving social care. The money received should be enough to meet your care needs. Direct Payments have been available since 1997 and are made to a wide variety of people, including carers, adult service users and people with short-term needs. Direct Payments should not be confused with direct payment; this is the method in which Personal Budgets and Individual Budgets are paid.   Directed enhanced service (DES) click here.   Dyspnoea shortness of breath/distressing breathing. May or may not be associated with a low oxygen level in the blood (hypoxia/hypoxaemia). Related Words  Hypoxia/hypoxaemia Elective care Planned care for a pre-existing illness or condition.   Elective centre A new term coined by Professor Sir Ara Darzi as part of the review of London’s health services published in July 2007 (see here).  It will focus  on particular types of high-throughput surgical procedures such as knee replacements, arthroscopies and cataract operations. It will be separate from emergency surgery and will support the achievement of increased day cases and reduced waiting times.  Critical care support will be available.  The example used is South West London Elective Orthopaedic Centre (SWLEOC) on the Epsom General Hospital site. As Professor Sir Ara Darzi is due to head an England-wide review of services, the term Elective Centre is included here.  See also Urgent Care Centres.   EMIS One of the  main GP computer systems. Virtually every practice is computerized in the UK. These rely on Read coding to record activity. The systems have many templates to prompt users to ask certain questions and to ensure data are collected to enable QOF points to be awarded. There may be more than one system in use in a PCT,  which can make it hard to systematize protocols and care as there may be different templates in use.  Related Words  Torex; TPP; VAMP Vision End of life This term  is now used to cover both advance care and palliative care in different care settings such as care homes, hospitals, primary care and hospices for adults with advanced, progressive illness. there are national generic end of life care strategies in England, Wales and Scotland. In Northern Ireland there is a Respiratory Strategy including a chapter on end of life.   The Department of Health in England website has a useful set of resources.   In addition, IMPRESS has produced a response to DH England consultation on end of life care quality  metrics that explore the challenges of achieving for people with advanced chronic respiratory illness the same quality of care as those with malignant disease.  We have also produced a communications skills education pack including filmed testimonies from patients and carers called Effective Care - Effective Communication: Living and Dying with COPD   Engagement  The process of involving others at an individual and collective level.   It starts with information, then feedback, then influence. See public and patient engagement (PPE)   Enhanced services Services within the GMS contract that are not essential or additional.  Their main role is to help PCOs reduce demand on secondary care by providing more local services responsive to local need and that also provide value for money. Any provider could apply to provide the enhanced service, including an acute trust.  It is worth knowing what plans the PCO has for enhanced services.  For example, there may be a COPD enhanced service that goes over and above the QOF requirements.  Directed Enhanced Service (DES) Services that PCOs must provide for their populations, but not all practices are obliged to provide them eg childhood immunizations. English practices currently receive a DES fee to engage with their PCT in practice-based commissioning.  Northern Ireland example.  Local Enhanced Service (LES) A locally developed service that PCOs have determined necessary to meet the needs of their population.  For an example from Tower Hamlets aiming to optimise COPD care see here.  EMIS template here.     Equality Impact Assessment (EqIA) (social care) An Equality Impact Assessment (EqIA) is a tool for identifying the potential impact of a council’s policies, services and functions on its residents and staff. It can help staff provide and deliver excellent services to residents by making sure that these reflect the needs of the community. By carrying out EqIAs, a council may also ensure that the services it provides fulfil the requirements of anti-discrimination and equalities legislation.   Equitable Access to Primary Medical Care programme EAPMC see here was introduced in the Next Stage Review. See GP-led health centre. There are currently two features, supported by a £250, investment to support PCTs in establishing: - at least 100 new general practices in the 25% of PCTs with the poorest provision; and - one new GP-led health centre in each PCT in easily accessible locations.   Essential and additional services These are what we would expect our GP to provide. All  General Medical Services (GMS) and Personal Medical Services (PMS) practices are expected to provide essential services to their registered patients and include management of patients who are ill, terminally ill or think they are ill, and management of long term conditions. There are also a set of 7 additional services that practices can choose to opt out of: cervical cytology, child health surveillance, maternity medical services, contraceptive services, minor surgery, childhood immunisations and pre-school boosters and vaccinations and immunisations: See Enhanced services.   Expert Patient Programme (EPP) An NHS in England programme designed to spread good self-care and self-management skills to a wide range of people with long-term conditions. Based originally on work by Kate Lorig from Stanford University it uses trained non-medical leaders, on a voluntary basis, as educators and equips people with long-term conditions with the skills to manage their own conditions. Most programmes are for groups of people with a variety of conditions who meet on a weekly basis for 6 weeks and skills taught are not disease-specific. There is likely to be an EPP programme running in your PCT; See here. It is likely to reinforce the benefits of a pulmonary rehabilitation programme rather than to substitute for it, as its strengths are in improving self-efficacy (confidence), energy, and also, an emerging finding, improving social inclusion. The formal evaluation is now published in J Epidemiol Community Health. 2007 Mar;61(3):254-61. It does not show reduced use of health services. One of the hypotheses for this is that the health system is insufficiently flexible to cope with more empowered patients –  for example if a patient is still offered six-monthly appointments, they will probably attend,  even if they no longer believe they need them.   Fair Access to Care http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009653 Social care for adults, unlike healthcare, is not free for everyone.  Everyone is entitled to a free assessment, including carers, but councils only have a limited amount of money, and cannot provide services direct to everyone. They use the Government’s Fair Access to Care Services guidance as part of their assessment, to help decide what level of risk the individual has, and whether to pay for support. There are four levels of risk set out in the guidance. These are: Low - when there is little risk to the person’s independence Moderate - where there is some risk to the person’s independence either now or in the near future Substantial - where there are significant risks to the person’s safety and independence Critical - where there are immediate risks to the person’s safety and independence Most councils currently fund support for adults with a substantial or critical risk to their safety, independence or wellbeing.  There is different guidance for children. The support offered will be means tested through a financial assessment.    A social care team would be able to provide health colleagues with client information categorised by level of risk, but not by diagnosis.   General Medical Services (GMS) This is one of the main types of contract  that PCOs can have with primary care providers. It is a nationally negotiated contract that sets out the core range of services provided by family doctors (GPs) and their staff and a national tariff.  It remains the most common way for primary care services to be provided in most areas. See APMS, PCTMS, PMS, and SPMS.   General Practitioners with Special Interest in respiratory medicine (GPwSIs) These are practising GPs with a special expertise in respiratory medicine whose role often includes in service development as well as clinical care. In respiratory care there are, as yet, very few and the roles vary. See here.  Related Words  Practitioner with Special Interests (PwSI) GP-led health centre The DH requires every PCT in England to develop a GP led Health Centre in response to concerns expressed nationally about difficulty in accessing primary care (now enshrined as The Equitable Access to Primary Medical Care programme (EAPMC). It is also partly a policy agenda to increase competition into primary care by opening up the market to new players. For this reason the contract for the GP Led Health Centre has to be let in a specific way, according to a national timetable.  The contracts should be let by April 2009.  At September 18 2008, all PCTs had met Milestone 3 (advertised and short-listed bidders), and 1/3 have issued invitations to tender (ITTs) to short listed bidders (milestone 4: 31 October).   Grouping related to data Inpatient activity can be grouped and reported at 3 different levels: High Level: Point of Delivery, e.g. Day Case, Elective or Non Elective Medium Level: Specialty, e.g. General Surgery, General Medicine Low Level: Healthcare Resource Group (HRG - see below), e.g. D22, D39   Healthcare Resource Groups (HRGs) A way of grouping the hospital treatment of patients by casemix to allow analysis of the appropriateness, efficiency and effectiveness of care. Each group contains cases that are clinically similar and will consume similar quantities of healthcare resources. There are, for example, a number of codes which would naturally map to the HRG 'COPD' e.g.emphysema; chronic obstructive pulmonary disease, unspecified; chronic obstructive pulmonary disease with acute exacerbation etc..These should all represent a similar demand on resources. Currently, the cost of such an admission is derived from an average length of stay in hospital and to define the care in somewhat greater detail, the HRGs are split on the basis of complications and comorbidity. One can almost add on an extra day for every comorbid factor e.g. diabetes, A/F. The national tariff (see below) is calculated at HRG level, but activity is usually reported at specialty level.  Steve Connellan of the BTS is leading work to refine the Respiratory HRGs further (v4). For example he hopes there will be the option to code for ambulatory care and for short COPD admissions (eg Hospital at Home), acute exacerbations without or with ventilatory support and whether it is via NIV or intubation. HRGs do not include primary care coding or resource use.  See Appendix 2. For the full respiratory list see letter D in the HRG definitions manual: click here. On behalf of the BTS, Steve Connellan has produced (September 2008) an extremely useful guide to coding respiratory care (see here) that can act as a discussion with governance leads about diagnosis and coding ambiguities, the importance of recording complications and comorbidities, greater use of the new OPCS codes including physiology measurement, AHP activity and interventions such a NIV support and oxygen assessment, creation of formal links with commissioners to consult on care packages, activity outside PbR and innovative approaches to integrated care.   High Quality Care For All – see Next Stage Review   Hospital Episode Statistics (HES) This is a national data warehouse for England of care provided by NHS hospitals and NHS hospital patients treated elsewhere.  Click here for further information.   Hypoxia/hypoxaemia shortage of oxygen/low oxygen level in the blood.  Identified using a pulse oximeter, a peg-like probe usually placed on the finger,  that measures oxygen saturation in the blood. May or may not be associated with breathlessness.   ICD International classification of diseases. Version 10 is currently in use. Every patient admitted to hospital should have an associated ICD code – this contributes to defining the HRG. The reports generated from this data are only as good as the coding and analysis but are often used to analyse demand for services. Local coding and  information departments can tell you know more about how they are applied and interpreted locally. See here. Chapter X is diseases of the respiratory system. Chronic lower respiratory diseases are J40-J47.   Independent sector (IS) An umbrella term for all non-NHS bodies delivering healthcare, including a wide range of private companies and voluntary organisations.   Independent sector treatment centre (ISTC) and Treatment centres (TCs) These are providers of elective surgery and tests for patients.  Commercial providers have won a number of tenders from the NHS to expand capacity.  The price is normally agreed outside the national tariff.   A new book by Player and Leys, with foreward by Dr Wendy Savage, Confuse and Conceal on the story has just been published, see here.   Indicative Allowance (social care) The Indicative Allowance is also known as the Gross Individual Budget and is the maximum amount of funding made available to meet an individual’s social care support needs. It is worked out through the RAS Related Words  RAS - resource allocation system (social care) Indicators for Quality Improvement IQI In response to High Quality Care for All these indicators have been developed by the NHS Information  Centre drawn from national datasets and are primarily intended for use by NHS staff to inform quality improvement activities, supported by appropriate statistical techniques to analyse and interpret the data.  There are over 200 available from the Information Centre   Indirect payments (social care) Indirect Payments are similar to Direct Payments, but instead of being paid to the individual who needs the service, payments are made to a nominated individual or into a trust. The trustees or nominated people then pay for services on the individual’s behalf. Related Words  Direct Payments (social care) Individual Budgets (social care) Service users/patients receive an Individual Budget and use this to pay for a variety of services. The individual budget contains funding from several sources, including social services, the Independent Living Fund, Supporting People, Disabled Facilities Grant and Access to Work. It can also be used to purchase equipment if this is needed. Crucially, individual budgets encompass a number of different agencies but are accessed at a single point, making the system easier to navigate for service users compared to the old multi-agency approach. Related Words  Direct Payments (social care); Individual Health Budget (IHB); Personalisation (health and social care) Individual Health Budget (IHB)  IHB's are being piloted at present (autumn 2009) for participating PCTs. They offer the following budget options to patients Notional budget held by commissioner Budget managed by a third party on pts behalf e.g care provider, independent user trust  Direct Payment to service user for health care   Individual Service Fund (social care) An Individual Service Fund is an individual budget that a service provider manages on behalf of a service user. Payments are made with the understanding that the service provider can deliver what is needed and it meets the criteria set out in the service user’s support plan.   Information Prescriptions (IP) http://www.informationprescription.info/index.html One of five core elements of self care identified in patient prospectus Your Health, your way 2008. April 2009.  The NHS Constitution, published in January 2009, makes the provision of patient information a right and is backed up by legislation for the first time.  The NHS Constitution also states that they “will help people to access relevant information about their long-term condition.’ Information prescriptions will contain a series of links or signposts to guide people to sources of information about their health and care – for example information about conditions and treatments, care services, benefits advice and support groups.  Online resource to help set up a system http://www.informationprescription.info/resource/index.html. Final report of evaluation of pilots: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086889   Integrated care organisations (ICOs) These form part of the Next Stage Review and are seen as a means of achieving improved coordination of care, delivering better services between secondary, primary and social care, and providing improved overall care for patients more economically. A national pilot in England is due to start in 2009.  Core features include primary care involvement.  They may be disease-specific or generic services. Social care is not compulsory. Indeed, the term integrated care can be used, as it is for IMPRESS, to mean care crossing primary, community and secondary care boundaries, but it can also mean integration between health and social care. There is a very good literature review by Naomi Fulop, as well as a prospectus on the integrated care pilots (see here)   Integrated Service Improvement Programme (ISIP) An NHS in England approach and set of tools to help health and social care communities work together to plan and make changes that will address current national priorities to achieve financial balance, bring care closer to home and out of hospital and address the 18-week waits target. It looks daunting, but is a systematic and thorough approach to ensure the changes planned will make a positive difference. See here There are nine useful principles to judge your service against, to help make the case for service change: (see here) Health Equality Across Populations Support Individual Wellbeing Care Provided in the Right Setting Appropriate Access and Choice for All Timely, Convenient and Responsive Services High Quality Clinical Outcomes Optimise Workforce Capacity and Capability Efficient and Effective Delivery of Services Financial Balance Across the Local Health Economy.   Integration IMPRESS, as a joint initiative between two clinical societies, started from the point of wanting to explore how to improve patient care through improvments in the care pathway across primary and secondary care. Therefore, in effect, it was advocating integration between primary and secondary care.  As community providers have moved at arms length from primary care trusts, so IMPRESS has explicitly included community service providers too. It is also aware that for many, integration - and see entry on integrated care organisations and pilots - means integration with social care providers  so that patients get the services they need without the need to understand or negotiate boundaries.    There are many useful resources for the evidence base on integration.  Few, as yet, can describe significant benefits, particularly from integration of organisations.  See Rebecca Rosen's review  In addition, Naomi Fulop and colleagues produced a review of the literature on integration to support the selection of the DH pilot sites.     See IMPRESS good practice examples for updates.    In terms of making a difference, integration of DATA seems to be an important  step, but so is finding a common vocabulary.  This Jargon Buster includes both health and social care vocabulary.  The Practical Guide to Integrated Working from the Integrated Care Network (2008) offers some further insights itnto what integration means - between health and local authority services.  It also offers a definition: "In its most complete form, integration refers a single system of needs assessment, service commissioning and /or service provision." The end point is improved outcomes. Related Words  Integrated care organisations (ICOs) Intermediate care Also known as step up, step down and transitional care – this is care out of hospital for people who are medically stable but still need temporary care in a community bed or home-care for recovery and rehabilitation. Commissioners are increasing their investment in such services in order to provide care closer to home, to reduce avoidable admissions and excess lengths of stay. The services are often nurse-led but there needs to be clear agreement about medical responsibility, See also Opportunity Locator. Further information can be found here. Care Service Improvement Partnership change agent team here.   Invisible Lives Recent report by the British Lung Foundation that used Mosaic data to identify hot spots for COPD.  Download the pdf report here.   Invitation to tender (ITT) See here   Joined up working Joined-up working involves working in partnership with others, whether in the public, private or voluntary sector, in order to identify and solve local problems. The government increasingly regards joined-up working as a means of fostering efficiency, effectiveness and community engagement in the improvement of local government performance.   Joint Strategic Needs Assessment (JSNA) This was announced in the new Commissioning Framework for Health and Wellbeing launched by the Department of Health on 6 March 2007 to take effect in 2008.  It is the means by which Primary Care Trusts and local authorities will describe the future health, care and well-being needs of local populations and the strategic direction of service delivery to meet those needs.  JSNAs form the basis of a new duty to co-operate for PCTs and local authorities that is contained in the current Local Government and Public Involvement in Health Bill.  JSNAs will take account of data and information on inequalities between the differing, and overlapping, communities in local areas and support the meeting of statutory requirements in relation to equality audits. For more information from the Department of Health see this page here. For more IMPRESS information click here.   Key Lines of Enquiry (KLOE) (social care) Key Lines of Enquiry (KLOE) are detailed questions that help inspectors inform their inspection judgements. They are used by inspection teams, but they are also published to help audited and inspected bodies with their own assessments.   Lasting Power of Attorney (LPA)  is a statutory form of power of attorney created by the Mental Capacity Act (2005). Anyone who has the capacity to do so may choose a person (an ‘attorney’) to take decisions on their behalf if they subsequently lose capacity. A LPA must be in a prescribed form and be registered with the Office of the Public Guardian www.publicguardian.gov.uk/index.htm  More information here. Related Words  Advance Care Plans LINks Local Involvement Networks are independent networks  that exist in every local authority area of England to give people  more influence over how their local health and social care services are planned and delivered.  They are funded by the local authority. They are publicly accountable and must produce an annual report for the Secretary of State.   Participants are volunteers, and both individuals and organisations can join. An NHS organisation is excluded from joining, but an individual employee can, as long as they declare their interest.  The challenge will be to avoid involving just the "usual suspects".     Each LINk sets its own work programme. In addition to surveying the population about its needs, and joining steering groups, they have responsibility for monitoring services.  They have the legal power to make visits to health and social care services provided by the NHS, local authority, private and third sector providers.  Health and social care commissioners and providers should be working with their LINk to understand the needs of their community and to deliver services in appropriate ways.  Engaging and responding to communities. A brief guide to Local Involvement Networks Gateway ref 10443  from DH in England and the NHS Alliance (Jan 2010) is aimed at professionals.  It gives a description of what they are, how they can be used, and a few examples  of how the NHS has engaged with them.  For further information see NHS Centre for Involvement  and the LINks Exchange  online network.   Local Area Agreement (LAA) A three-year agreement setting out the priorities for funding and delivery for a local area in certain policy fields as agreed between central government (represented by the Government Office), and a local area, represented by the local authority and Local Strategic Partnership (LSP – see below) and other partners at the local level. It sets out the ‘deal’ between central government and local authorities and their partners to improve the quality of life for local people. As such, the LAA is also a shorter-term delivery mechanism for the Sustainable Community Strategy (SCS). It describes how performance will be measured using locally collected data. The LAA aims to improve the quality of life for people through improving performance on a range of national and local priorities such as safer communities, neighbourhood renewal, healthier communities, children and young people.  It is worth finding out what your local includes and to see how respiratory care might fit as this is a planning and resourcing process that includes resources other than PCTs’. In the current Communities and Local Government statutory guidance to 'Creating Strong, Safe and Prosperous Communities' and from the local government perspective, LAAs are a key feature of a more devolved central and or local settlement. Through these, different localities can channel public resources towards the priorities of their own areas, alongside national outcomes and targets.   Local authority Democratically elected local body with responsibility for discharging a range of functions as set out in local government legislation. Local authorities have Overview and Scrutiny Committees (OSC – see below) that have an increasingly important role in calling PCTs to account for their plans.   Local Delivery Plan (LDP) A plan that every PCT prepares and agrees with its Strategic Health Authority (SHA) on how to invest its funds to meet its local and national targets, and improve services. It allows PCTs to plan and budget for the delivery of services over a three-year period. The LDP gives an overview of what the priorities are for a PCT and how it intends to manage its resources and is a public document.   Local Health Boards (Health Boards) in Scotland These are the health organisations within each region such as Lanarkshire, Grampian and Greater Glasgow Health Boards, that are responsible for health protection, health improvement and health promotion. They focus on needs assessment, service development and resource allocation and utilisation. See here.   Local Health Boards (LHBs) in Wales There are 21 LHBs and one unified healthcare board, each of which is co-terminous with (has the same boundaries as) local government unitary authorities.  The main roles of the LHBs are corporate and clinical governance; securing and providing primary and community care health services, securing secondary care services through long term agreements with trusts; improving the health of communities; partnership; public engagement and provision of services. For more information see here.   Local Strategic Partnerships (LSPs) LSPs bring together representatives of all the different sectors (public, private, voluntary and community) and thematic partnerships. They have responsibility for developing and delivering the Sustainable Communities strategy and Local Area Agreement (LAA).   Long term conditions (LTC) management Previously known as chronic disease management; into which fits the management of patient with many respiratory diseases including COPD, asthma and pulmonary fibrosis.  Informed by the Long Term Conditions policy.  Best guide is the  Long term conditions compendium of information by Department of Health in England.  Long term conditions Management  is based on categorizing care according to a risk stratification. See here for the model used by all four UK nations. Level 1 is for patients who can manage their own care and care for themselves, as long as they receive education and support from primary care. Level 2 care management is where there is a structured, protocol driven approach to care. Level 3 case management is where a patient needs help to coordinate their care if they are to avoid a succession of unplanned interventions. This is where community matrons, Evercare pilots and others have been focused. Commissioners will talk about and use these categorisations. They may know through disease registers approximately how many people are in each category.  For example, Tower Hamlets PCT with a population of 230,000 has an identified total population with COPD  of 3000, split 350 in  level 3, 650 in level 2 and 2000 in level 3. This is a relatively high figure, reflecting an inner city population with  high smoking prevalence and social  deprivation. A fourth element, health promotion, has received little attention or budget up to now, although this has been identified by government as a gap, and will be monitored by the Healthcare Commission more closely in 2007/08. The LTC model is not static and varies with disease; patients with COPD gradually move up the levels where as patients with asthma may move up or down.  Nor is it purely related to severity of disease, because patients’ coping abilities also influence how and when they seek professional help. The diagram below from Castlefields Health Centre develops the model showing how self-care and self management happens at all levels, and how well they are enabled is probably the most important factor in determining how patients use services. To conclude, who provides the care, and where, is up for negotiation. Currently about 80% of a GP workload is the management of long term conditions and government policy is to promote the role of GPs both as commissioners of care, and as providers.   Long term oxygen therapy (LTOT) is the provision of oxygen for continuous use at home for people with chronic (long-standing) hypoxaemia, most commonly due to COPD. Related Words  Hypoxia/hypoxaemia Mental Capacity Act (MCA) 2007 Go to the Direct Government website here.   Mosaic Mosaic is an innovative example of new ways of assessing needs using combinations of public databases and mapping software. It was used by the BLF for its Invisible Lives document. For more information about Mosaic click here.   National Procurement Council part of June 2009 Commercial Operating Model launched by DH England. Has  oversight of the delivery of Comprehensive Spending Review 2007 savings, and includes professional training and development and procurement policy. Related Words  Commercial Operating Model; Commercial Support Units (CDUs) National Quality Board In England, as part of High Quality Care for All, a new National  Quality Board met for the first time on 30 March 2009 to provide strategic oversight and leadership on quality.   It oversees 8 dimensions (and these will be underpinned by the clinical revalidation programme): Quality Standards (led by NICE – 20 per year) Quality Metrics (led by Information Centre approx 200) Quality Accounts CQINs (led by PCTs) Quality Observatories (1 per SHA) Clinical Excellence Awards (led by ACCEA) QOF (led by NICE) QIPP The Quality Board’s work programme includes the Mid Staffs Review, clinical prioritisation to influence 2010/11 Operating Framework, NICE quality standards (4 so far: stroke care, specialist neonatal care, VTE prevention and dementia), indicators for quality improvement (IQI), quality accounts, MRSA new target and clinical excellence awards  all in the context of QIPP. Its membership, aims and papers are available here  Related Words  QIPP; Quality; Quality Accounts ; Quality and outcomes framework (QOF); Quality Metrics/Indicators National Service Framework – see Clinical Strategy Related Words  Clinical Strategy Needs assessment This is an activity led by PCTs to inform what services are needed by the local population. It combines population-level data eg the prevalence of COPD by age, sex and GP practice, with an understanding drawn from patients and clinicians  about what every individual patient or person at risk of the disease needs.  It highlights inequalities in access to healthcare and in health outcomes, which then informs the planning of local services and changes in investment. Need is defined as an ability to benefit from an intervention. The intervention for COPD might be the provision of information, advice and treatment on smoking cessation, a prescription for drugs or any other service that would improve a person’s quality of life, independence, and sense of wellbeing. Given that the best person to judge what makes such a difference is the patient, there is a strong obligation on commissioners to involve patients and the public in both needs assessment and the design of services.  An example of public health data that uses QOF (see below) and hospital data can be found here giving prevalence rates and emergency admission rates in the North West. Detail is often found in Public Health Reports that focus on health inequalities, and variation. See also Mosaic. See also JSNA.   Never events The National Patient Safety Agency is working with the NHS to develop a national set of Never Events and guidelines for their use during 2009/10.  An initial list of Never Events is developed.  Primary Care Trusts will choose priorities from this list in their annual operating plan. The initiative will launch in Spring 2009. The proposed list as at Dec 2008 is here. 1. Wrong site surgery 2. Retained instrument post-operation 3. Wrong route administration of chemotherapy 4. Misplaced naso or orogastric tube not detected prior to use 5. Inpatient suicide using non-collapsible rails or whilst on one-to-one observations 6. Absconding of transferred prisoners from medium or high secure mental health services 7. In-hospital maternal death from post-partum haemorrhage after elective Caesarean 8. IV administration of concentrated potassium chloride   Next Stage (Darzi) Review, High Quality Care For All . The NHS "once in a generation" review by Lord Darzi: High Quality Care For All was published in June 2008.  A downloadable copy of the review is available from the Our NHS website here. For more information go to our IMPRESS policy pages.   NHS Choices (click here) This is a 50/50 venture between the NHS and Dr Foster and is the public’s gateway to choosing a hospital, booking appointments and gathering validated health information.  It is an important development and one in which clinicians should take an interest, including validating the data that is provided to help the public make choices.   NHS Comparators Provides comparative data to enable commissioners and providers to investigate local activity, costs and outcomes.  It includes SUS data as well as QOF  information, GP practice demographic information and prescribing data.  It is  available to all GP practices, SHAs, PCTs, NHS Trusts, and other “relevant organisations".  You first need to request a log-in from The NHS Information Centre's Contact Centre by calling on 0845 300 6016 or email enquiries@ic.nhs.uk and ask for 'NHS Comparators log-in'. Click here for more information.   NHS Constitution (England) was published on 21 January 2009. It brings together in one place for the first time in the history of the NHS, what staff, patients and public can expect from the NHS.   As well as capturing the purpose, principles and values of the NHS, the Constitution brings together a number of rights, pledges and responsibilities for staff and patients alike.  These rights and responsibilities are the result of extensive discussions and consultations with staff, patients and public and it reflects what matters to them.   Subject to Parliamentary approval, all NHS bodies, and private and third- sector providers supplying NHS services in England will be required by law to take account of the Constitution in their decisions and actions. The Government will have a legal duty to renew the Constitution every 10 years. No Government will be able to change the Constitution, without the full involvement of staff, patients and the public.   NHS Institute for Innovation and Improvement (click here) It has a huge array of tools to support commissioners and clinicians to improve services. For example see the sustainability model and 10-point checklist here.   NHS Supply2Health From 1 October 2008, all NHS commissioners in England will be required to post information about tendering opportunities and contract awards on NHS Supply2Health  nww.supply2health.nhs.uk The public site is here.   Non-invasive ventilation (NIV) is the provision of ventilatory support using an electrically powered portable ventilator and a tight-fitting nasal or face mask or similar device.  It is an effective treatment for selected patients with respiratory failure. It may be used acutely for a limited time in hospital and a small number of patients may also have NIV at home, usually for overnight use. For guidelines and further  information click here. Note that the British Thoracic Society Standards of Care Committee - Thorax 2002; 57:192-211. while produced in 2002, it is a very detailed and helpful guide.  For a patient information leaflet, and a discussion on how to use it, please download this document. Related Words  End of life NPfIT is the National Programme for IT Is charged with creating a multi-billion pound infrastructure that aims to improve patient care by enabling clinicians and other NHS staff to increase their efficiency and effectiveness.  It will be delivered by Connecting for Health. The programme includes the NHS Care Record, the Choose and Book scheme, electronic prescriptions, and developing a new IT infrastructure.   OPCS4 Office of Population Censuses and Survey Classification of Surgical Operations and Procedures, 4th revision (OPCS-4) is the classification used of surgical procedures and is used in defining the appropriate HRG.  See here.   Open Book open book negotiation may be a required part of the tendering or procurement process, by which providers may be expected to fully disclose paperwork, calculations and agreed variations.    Operating Framework For the NHS in England is produced annually to give NHS organisations the Department of Health's priorities and planning guidance.  See the DH website.   and the IMPRESS guide.   Opportunity locator See here. This is analysis commissioned by the NHS Institute to demonstrate the potential for “shift” in services out of hospital either by avoiding an admission, or by facilitating earlier discharge.  You can select the data by PCT or SHA.   Oxygen concentrator is a way of providing oxygen to people at home who need it on a long term basis because they have a low oxygen level (LTOT). It is an electrically powered machine that extracts oxygen from the air and delivers it by plastic tubing to nasal cannulae (plastic prongs that fit into each nostril) or a face mask.    Patient reported outcome measures (PROMs) High Quality Care For All, Lord Darzi’s Next Stage Review Final Report June 2008, states that “we will make payments to hospitals conditional on the quality of care given to patients as well as the volume.  A range of quality measures covering safety, clinical outcomes, patient experience and patient's views about the success of their treatment - known as patient reported outcome measures or PROMs – will be used.”.  Currently there is no nationally agreed PROM for respiratory care. What are they? PROMs employ short, self-completed questionnaires which measure the patient’s health status or health-related quality of life at a single point in time and can be repeated to derive a measure of the impact of health care interventions A number of PROMs already exist, such as the well-known generic tools EQ5D and the longer SF-36.  The criticism of these has been that they were designed for research rather than use in every encounter. Others are now now in development. Some are generic, some disease specific. They can be integrated with clinical outcomes. They can be used at an individual patient level and also at an organisational level. How is the NHS using them? The 2008/9 NHS Operating Framework announced that PROMs for these high volume elective procedures in support of the 18-week programme in England will be routinely collected from April 2009 using these national standards as part of the the NHS Contract for Acute Services  for: Primary Unilateral Hip Replacement: Oxford Hip Score or generic EQ5D Primary Unilateral Knee Replacement: Oxford Knee Score or generic EQ5D Groin Hernia Repair: no condition specific measure just  generic EQ5D Varicose Vein Procedures: Aberdeen Varicose Vein Questionnaire or generic EQ5D (The LHSTM report also looked at cataract surgery). The scope will be all  patients, not a sample, to ensure sufficient volumes of data are collected (the DH estimates it could generate up to 250,000 reports over a 3 year period).  However, it accepts some people will decline to participate, some will only complete the pre-operative questionnaire, and others may not be eligible for a range of  reasons including illiteracy. These will enable comparability across the country, and are based on  research with 2,400 patients at 24 sites by the London School of Hygiene and Tropical Medicine. See here. Why? The Next Stage Review describes the several reasons for collecting these PROMs: To assess the relative clinical quality of providers of elective procedures, for clinicians and managers and commissioners benchmarking their own performance, for regulators, clinical audit and for patients and GPs exercising choice. To research what works. Efficacy and cost-effectiveness of different technical approaches to care can be evaluated using PROMs in association with other measures that assess what would have happened to patients in the absence of treatment or with alternative treatment. To assess the appropriateness of referrals to secondary care. In the future, PROMs will be linked to payment. In Year 1 (2009-10) the payment will be to reward collection of the information, not for the content, but in future years, it will be linked to the content. The Standard NHS Community Contract comes into place in April 2009.  It is likely that this too will include similar requirements in 2010.  So what is the current state of PROMs for long term conditions? PROMs for  long term conditions There is a lot of research looking at this. For example, York University is testing ways of measuring outcomes for different HRGs in circulatory disease.  Some systems are already in operation for people who use hospital care, for example, CHKS has input a system across all BUPA hospitals and some NHS trusts that uses SF-12 and EQ5D prior to admission and 3  months post-discharge.  However, given the low proportion of respiratory patients that would be admitted electively, this will not provide a particularly useful tool in respiratory care. There are several questions: when should the data be collected?  Using what tool and by whom?  For example,  there is currently  more potential  in primary care as implementation of the Quality and Outcomes Framework means general practices have the computer systems, as well as the contact with most patients. However, if they are to be used to provide feedback to change and improve clinical practice, they will need to engage secondary care as well. The challenge for PROMs developers is to come up with a simple  tool, the use of which becomes habitual, which is validated and available on all computer systems. There is also value, given the issues of comorbidities, of a PROM that is not condition-specific. The National COPD Resources and Outcomes Project (NCROP) study in COPD by the Royal College of Physicians with the Health Foundation and the latest 2008 National COPD  Audit may give a steer as to how PROMs in COPD might be used. The Clinical Strategy for COPD may also produce guidance. The RCP 3 questions is a tool that is used in primary care for asthma. Further information: DH background Feb 2009 to support the Acute Contract Requirements: click here. London School of Hygiene and Tropical Medicine report to the DH can be downloaded here.   Patient-initiated petition The public may use such a petition to raise concerns or issues about local services.  It is the responsibility of the Overview and Scrutiny Committees and the PCT Board to ensure there are clear mechanisms to petition and for the petition to be considered formally by the two authorities.   Patients At Risk of Re-hospitalisation (PARR) Case Finding Tool.  See here.  This software tool developed by the Kings Fund for the Department of Health links a number of datasets in order to accurately predict the risk of re-admission to hospital.  The idea is that patients identified using this tool, and local data will receive case management to avoid admission. The latest development of the software is called Combined Predictive Risk Assessment.  It is worth asking colleagues how useful they have found this.   Patient's Prospectus Launched in England by the DH in November 2008, entitled Your Health Your Way.  It aims to inform the public about how their local NHS will discuss with them the choices that are available to help them self-care as part of the supporting people with long term conditions programme. Five areas of self care have been identified as being key to achieving these aims: 1.  Information 2.  Skills and knowledge training 3.  Tools and self-monitoring devices 4.  Healthy lifestyle choices 5.  Support networks   Payment by Results (PbR) How acute providers in England are now paid.   There is a national fixed tariff for emergency care, elective in-patients, day cases and outpatients bought by NHS commissioners.  It does not yet include community services. The important principle is that only work done and recorded using appropriate coding is paid for.  A report by the Audit Commission published 14 Feb 2008 analyses progress to date (summary found here). It suggests that it has improved the fairness and transparency of the payment system and understanding of costs and the importance of data quality within hospital trusts.  It has probably had a positive impact on day case and the efficiency of elective activity (although there are other drivers too such as the 18-week wait target) . It also concludes that PCTs have much room for improvement for negotiating and monitoring provider activity. It makes four recommendations: Strengthen diagnosis, procedure and casemix classifications and the timeliness and quality of data available to PCTs Increase the scope for unbundling so that different care pathways can be accommodated more easily – such as hospital at home Introduce some normative tariffs for selected HRGs. These would be based not on average costs but on the costs that high performing efficient providers, offering a good quality service, might expect to incur Consider separate funding streams for capital and quality, for example, as is the case internationally See the tariff entry that refers to 29 August 2009 BMJ articles on the impact of Payment by Results. Related Words  Tariff PCT Fitness for Purpose Programme There is some concern amongst policy makers that PCTs are not yet commissioning as effectively as they could. So, the Fitness for Purpose exercise assesses how competent PCTs are, and benchmarks them.   It has been a time-consuming process for PCTs.  Ultimately it will link to a development programme, and also in the future PCTs may be able to ask for expert help such as actuarial skills to support them.  In turn, PCTs have a responsibility to develop GP commissioners.   Personal budgets (social care) Personal Budgets are similar to Individual Budgets, but are made up solely from social services funding. Personal Budgets are not multi-agency payments, so people would still have to contact other organisations if they receive some level of support from them. People also have a choice as to whether they receive the money as a direct payment, to receive a standard care service, or a mixture of both.   Personal Medical Services (PMS) contract This is one of the main types of contract that PCOs can have with primary care providers. It is a locally negotiated contract unlike GMS (see above). It allows the option of salaried GPs.  More than 40% of GPs in England now work under PMS contracts. PMS practices have often reviewed their skill mix and have enhanced teamworking and extended roles for nurses and other primary care professionals.  See APMS, GMS, and PCTMS, and SPMS.   Personalisation (health and social care) Personalisation is the all-encompassing term for the Government’s agenda to give people more choice about the care they receive. The system places the service user at the centre of the process and allows them to choose the agencies they use and the manner in which they receive support.   Personalised care planning High quality care for all,  the final report of the NHS Next Stage review re-affirmed the commitment made by the Department of Health in England that over the next two years (2009-2011), every one of the 15 million people with one or more long term conditions should be offered a personalised care plan. Personalised care planning addresses all the needs of an individual:  not just health, but personal, social, economic, educational, and cultural.  A COPD plan or an asthma action plan would fit into this overarching personal care plan.    See here   and guide for commissioners here. Related Words  Care Pathway; Co-creation of health; Self Care; Supported self care/self management Polyclinics A new term coined by Lord Sir Ara Darzi as part of the review of London’s health services published in July 2007 (available here)   In the proposed model, polyclinics will be community-based facilities for the diagnosis and care of populations of up to 50,000. Some may be located at hospitals, as discrete facilities.  They will be open 18-24/7 and house a range of diagnostic equipment, and accommodate a range of specialist clinics and provide urgent care. The model argues for most GP practices to shift premises into the polyclinics so that there would be about 25 FTE Gps in each; to enable access to a wider range of services.  Critics argue that this would reduce access for patients and be difficult to achieve in terms of estates planning and negotiation with GPs. 05/06/08 The Kings Fund published a report Under One Roof: Will polyclinics deliver integrated care?, by Candace Imison, Chris Naylor and Jo Maybin available for download here. This suggests planners should be careful to assess benefits and costs and in particular, recommends the focus for PCTs should be on developing new pathways, not new facilities, which are just a means to an end; that alternative models exists that do not require mass centralisation of family doctor services such as hub-and-spoke and federated models; and that strong clinical and managerial leadership supported by clear governance structures and workforce planners will be necessary.   Power of Attorney  Legal document allowing someone else to manage another person’s affairs, or specific elements of their affairs, on their behalf. If the individual has a physical illness or an accident resulting in physical injury and they want someone else to look after their affairs, they should create an ordinary power of attorney. However, an ordinary power of attorney should not be used if the individual has been diagnosed as having, or likely to develop, any mental illness or degenerative disease that can lead to mental incapacity; this is because an ordinary power of attorney automatically comes to an end if you lose your mental capacity. Related Words  Advance Care Plans ; Lasting Power of Attorney (LPA) Practice-based commissioning (PbC) All English GP practices are now responsible for commissioning at least the care covered by the tariff for their practice's population. They are given indicative budgets, based on historical referral and utilization data. Analysis of these data, together with an understanding of the national tariff allows practices to consider alternative ways of providing the services their patients need, including by providing more services in their practice. PbC is structured differently in different places. There may be individual practices, GP practice clusters who commission together, or there may be just one GP cluster to cover the whole area. There is usually a local GP lead for each PBC cluster. As a provider, it is important to understand how PbC works locally and what the priorities are. For example, a practice-based commissioner might look at the number of respiratory outpatient follow-up appointments and decide it could provide a follow-up service in the practice. It has to submit a PbC business case (see here) to the PCT for approval if it wishes to make such a change. The PCT, often via its Professional Executive Committee (PEC), must make a decision within 8 weeks and if it addresses a national or local priority the PCT should approve it. The PCT will include the planned change in the agreements it makes with local acute providers. GPs are incentivised to engage actively in PbC by a promise that 70% of the savings released through the alternative provision can be used by the practice to address national or local priorities. The Audit Commission has recently published a review of progress, Putting Commissioning into Practice (November 2007) see here where it agrees that there are commissioning groups hampered by lack of information. It has presented a schema for judging the PCT's management of practice-based commissioning as follows; Practice-based Commission: Evolutionary Stages of PBC Development   Practitioner with Special Interests (PwSI) The term covering all primary care professionals working with an extended range of practice. A PwSI in respiratory medicine might be a nurse or physiotherapist running a community respiratory service. See GPwSI.   Preferred Priorities for Care http://www.endoflifecareforadults.nhs.uk/eolc/CS310.htm  is an example of an advance care plan. It is a document that individuals hold themselves and take with them if they receive care in different places. It has space for the individual’s thoughts about their care and the choices they would like to make, including saying where, if possible, they would want to be when they die. Information about choices and who might be involved in their care can also be recorded so any care staff can read about what matters to the individual, thereby ensuring continuity of care. Guidance http://www.endoflifecareforadults.nhs.uk/eolc/files/F2111-PPC_Staff_Guidance_Dec2007.pdf  An example form: http://www.endoflifecareforadults.nhs.uk/eolc/files/F2110-Preferred_Priorities_for_Care_V2_Dec2007.pdf   Primary care The collective term for all services which are people’s first point of contact with the NHS.   Primary Care Trust – led Medical Services (PCTMS) One of the main types of contract where general medical services are provided by PCO-employed health care professionals.  See also APMS, GMS, PMS, and SPMS.   Primary Care Trusts (PCTs) Freestanding statutory NHS bodies in England with responsibility for delivering healthcare and health improvements to their local areas. They commission or directly provide a range of community health services such as district nursing as part of their functions.   Prior approval (PA) A process to help commissioners ensure that patients receive appropriate care and secure value for money. Prior approval from the PCT/practice is required before the proposed treatment can be provided. It requires clinicians in secondary care to confirm the appropriateness of a treatment with the referring GP (now including consultant-to-consultant referrals).   Procurement This is the phase of the commissioning cycle after the service specification when the commissioner decides how to procure the service - by competitive process, or through changing an existing service level agreement. Increasingly, Primary Care Trusts will be expected to consider a competitive process, if the investment reaches levels that meet the European Union threshold for an open competitive process.  A new guide to procurement has been published in May 2008 by the Department of Health to support PCTs.  A useful guide to procurement, using a case study of a COPD service is available from IMPRESS.  See Procurement pages of the IMPRESS website in the Commissioning section. In social care terms,  procurement is the process of acquiring goods and services from third parties. Various policy drivers encourage local authorities to review procurement services and modernise procurement practices to achieve greater efficiencies. These include: Best value Implementing Electronic Government (IEG) The Office of Government Commerce Gateway programme The annual efficiency statement for each local authority, as outlined in the Spending Review 2004, which identified scope for significant efficiencies in the procurement workstream.   Procurement, Investment and Commercial and Division (PICD) Procurement, Investment and Commercial and Division (PICD) of the Department of Health England June 2009 - to strengthen commercial and procurement support for the DH and the system. Related Words  Commercial Operating Model; Commercial Support Units (CDUs) Procurement, Investment and Commercial and Division (PICD) of the DH England; established  June 2009 to strengthen commercial and procurement support for the DH and the system. Related Words  Commercial Operating Model; Commercial Support Units (CDUs) Professional Executive Committee (PEC) These clinical committees of PCTs have, amongst other duties, responsibility for setting practice indicative budgets and to approve proposals for the use of efficiency savings by practices.  In some areas PECs are well organized and motivated to take on this role, in other areas PEC  membership is under review due to PCT mergers and changes.   Programme Budgeting Programme Budgeting is a well-established technique for assessing investment in programmes of care (eg respiratory care) rather than services. All PCTs in England have submitted an annual programme budgeting return since 2003/4.  So, for example, the latest figures available show that Estimated England level gross expenditure by respiratory Programme Budget for 2007/08 was £3.85billion out of a total spend of £93.18bn; that is 4%.    This compares to problems of circulation of £7.31 bn, or 7.8. Programme budgets can compare relative growth of each programme, y ear on year.   So, for example, nationally (England), respiratory programme budgets grew  by 8.86% between 2006/07 and 2007/08 compared to problems of circulation wehre the comparative figure is 5.97%.   See for tools from the Department of Health in England.  These offer atlases that link health outcomes, QOF data and HES activity ito programme budgets, and a PCT Spend and Outcome Factsheet and Tool (SPOT)  NHS Comparators is another useful tool.     Related Words  Needs assessment; NHS Comparators PROMS  – see patient-reported outcome measures. Related Words  Patient reported outcome measures (PROMs)