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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 See Your Health Your Way   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.  The first report of the Darzi Review in July 2009 claims over 9 million people now have a personal care plan.  See Your Health Your Way and IMPRESS pages on personalising care and delivering supported self care Related Words  Care Pathway; Co-creation of health; Personalisation (health and social care); Self Care; Supported self care/self management; Your Health Your Way 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) 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) 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) 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. Also Programme Budgeting Marginal Analysis - interactive learning video and University of Oxford Bandolier.       Related Words  Needs assessment; NHS Comparators PROMS  – see patient-reported outcome measures. Related Words  Patient reported outcome measures (PROMs) Proportionality One of four principles of procurement  which means making procurement processes proportionate to the value, complexity and risk of the services contracted, and critically not excluding potential providers through overly bureaucratic or burdensome procedures.   Prospectus See commissioning intentions. Also known as Patient Prospectus.   Provider A generic term for an organisation that delivers a healthcare or care service.   Public and Patient Engagement (PPE) The process of engaging patients and the public at an individual and collective level throughout the commissioning cycle in order to create localised, personalised and effective services.  The process moves from information, to feedback, to influence and can be done at each stage of the cycle: needs assessment, decisions about priorities and strategies, service improvement, procurement and contracting and monitoring and performance management.  Click here for a guide to PPE from the NHS.   Related Words  Engagement Public Service Agreement (PSA) This sets out the Department of Health in England’s 3 year targets.  There are four objectives and eight targets.  The targets that affect people with respiratory disease are:       3. Tackle the underlying determinants of health and health inequalities by reducing adult smoking rates to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less. 4. To improve health outcomes for people with long-term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008, through improved care in primary care and community settings for people with long-term conditions. 5. To ensure that by 2008 no one waits more than 18 weeks from GP referral to hospital treatment. 7. Secure sustained national improvements in NHS patient experience by 2008, as measured by independently validated surveys, ensuring that individuals are fully involved in decisions about their healthcare, including choice of provider. 8. Improve the quality of life and independence of vulnerable older people by supporting them to live in their own homes where possible, by: increasing the proportion of older people being supported to live in their own home by 1% annually in 2007 and 2008; and increasing, by 2008, the proportion of those supported intensively to live at home to 34% of the total of those being supported at home or in residential care. Further information can be found here