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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.     Care trust Care trusts were first announced in the NHS Plan in 2000 and powers to create them were iincluded in the Health and Social Care Act 2001.  Care trusts combine NHS and local authority responsibilities under a single statutory body and focus on services such as the care of older people and people with mental illness. They are NHS organisations, but include local authority councillors on their boards.    They have been set up to promote integration. Examples drawn from Ham C, Oldham J.  Journal of Integrated Care, 17(6), December 2009, pp.3-9.   North East Lincolnshire has given priority to primary care-led integration. It includes co-location of health and social care in new primary care premises, work to integrate information technology and development of integrated mental health provision. Building on these developments, the North East Lincolnshire Care Trust Plus was established in 2007. A care trust plus differs from a care trust in that partnership involves working across all services and not just health and social care. Under this arrangement, responsibility for adult social care commissioning and provision has transferred from the local authority to the primary care trust, whereas responsibility for public health has transferred to the local authority - which will be the future of public health announced in the December 2010 white paper on public health in England. Torbay established a care trust in 2005 to promote closer health and social care integration for older people. It is based on a previous history of good relations between the primary care trust and the local authority, coterminous boundaries, support from local politicians, involvement in the NHS Kaiser Beacon site programme and a joint desire to improve service delivery. Efforts to achieve closer integration have focused on establishment of five health and social care teams organised in zones or localities aligned with general practices. Each team has a single manager and a single point of contact, and makes use of pooled budgets to commission services based on a single assessment process The Mrs Smith test used by Torbay The test is whether Mrs Smith, a fictional 85 year old requiring support from a variety of health and social care professionals, receives better integrated care that overcomes the fragmentation and lack of co-ordination that often characterise people like her.  Early findings suggest reduced hospital admissions. See also Lavender A (2006) Creation of a care trust: managing the project. Journal of Integrated Care 14 (5) 14–22.     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 Commissioning 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 Standards