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 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 

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.

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.

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.

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.

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.

Is a local PCT approval process for providers to encourage competition  within a range of services rather than for them. This means a variety of providers can offer the same service in different locations.  Tendering is not required.

In an any willing provider’ model, there are no guarantees of volume or payment in any contract given.  PCTs, through contracts, give permission for the provider to supply services to their population without any promises regarding income.

Any Willing Provider rules currently cover

• Routine elective services;
• Services to be delivered in a community setting and
• Where provision of the service will encourage competition

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

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 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.

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.

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 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.

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 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.
 

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.

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.

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.

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.

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).

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.

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)

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

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.

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.

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.

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.

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

This is an NHS agency responsible for delivering the NPfIT  programme (click here)

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).

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.

 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.

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

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.

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 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.

(DES) click here.

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

Planned care for a pre-existing illness or condition.

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.

Prioritising need in the context of Putting People First: a whole system approach to eligibility for social care - guidance on eligibility criteria for adult social care, England 2010 describes the framework for assessing the seriousness of the risk to independence and well-being or other consequences if a person's needs are not addressed. The four bands are as follows

Critical - when

life is, or will be, threatened; and/or

significant health problems have developed or will develop; and/or

there is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or

serious abuse or neglect has occurred or will occur; and/or

there is, or will be, an inability to carry out vital personal care or domestic routines; and/or

vital involvement in work, education or learning cannot or will not be sustained; and/or

vital social support systems and relationships cannot or will not be sustained; and/or

vital family and other social roles and responsibilities cannot or will not be undertaken.

Substantial – when

there is, or will be, only partial choice and control over the immediate environment; and/or

abuse or neglect has occurred or will occur; and/or

there is, or will be, an inability to carry out the majority of personal care or domestic routines; and/or

involvement in many aspects of work, education or learning cannot or will not be sustained; and/or

the majority of social support systems and relationships cannot or will not be sustained; and/or

the majority of family and other social roles and responsibilities cannot or will not be undertaken.

Moderate – when

there is, or will be, an inability to carry out several personal care or domestic routines; and/or

involvement in several aspects of work, education or learning cannot or will not be sustained; and/or

several social support systems and relationships cannot or will not be sustained; and/or

several family and other social roles and responsibilities cannot or will not be undertaken.

Low - when

there is, or will be, an inability to carry out one or two personal care or domestic routines; and/or

involvement in one or two aspects of work, education or learning cannot or will not be sustained; and/or

one or two social support systems and relationships cannot or will not sustained; and/or

one or two family and other social roles and responsibilities cannot or will not be undertaken.


In constructing and using their eligibility criteria, and also in determining eligibility for individuals, councils should prioritise needs that have immediate and longer-term critical consequences for independence and well-being ahead of needs with substantial consequences. Similarly, needs that have substantial consequences should be placed before needs with moderate consequences and so on.”

Most councils have a moderation panel to ensure consistency across social worker assessors.

The Care Quality Commission report for 2009/10 says three councils set their eligibility threshold for care-managed services at “critical” (indicating the most restricted level of access to services), while 107 set their threshold at “substantial”. Only three councils were planning to raise their eligibility threshold in 2010/11, while one was expecting to lower its threshold from “substantial” to “moderate”. However, the number of people receiving publicly funded services in 2009/10 fell by nearly 5% against the previous year, according to (provisional) national statistics, (see page 47).

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

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   In May 2010 the GMC published new guidance Treatment and care towards the end of life: good practice in decision making. The guidance comes into effect on 1 July 2010 and replaces the booklet Withholding and withdrawing life-prolonging treatments: Good practice in decision-making (2002).  Important additions to the new guidance include:


• Advice on advance care planning and responding to requests for treatment 

• Handling decisions involving neonatal and infant care 

• Approaching discussions about organ and tissue donation 

• Doctors’ responsibilities to the patient after death 

• Making decisions on clinically assisted nutrition and hydration
   

The National Council for Palliative Care has a website Dying Matters to raise awareness about dying, death and bereavement.  It supports the new GMC guidance.

Related Words  Advance Care Plans ; Advance decision

 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)

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.

NHS  organisations will have to comply with the Equality Act 2010, that comes into force April 2011: the important difference is that the definition of disability has been changed to apply to "a person who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities."  A person no longer has to show that their impairment affects a particular capacity such as mobility.

 Direct discrimination in services has been extended to cover disability.    It also applies to discrimination against a carer - a person is treated less favourably because they are associated with someone with a disability.

Discrimination by association, by perception and indirect discrimination are all new additions to the Act.  For useful legal websites go to

www.equalityhumanrights.com
0845 604 6610
Law Centres Federation
www.lawcentres.org.uk
Citizens Advice
www.citizensadvice.org.uk
Advice UK
www.adviceuk.org.uk
Government Equalities Office
www.equalities.gov.uk
National Council forVoluntary Organisations
www.ncvo-vol.org.uk
Charity Commission for England and Wales
www.charity-commission.gov.uk
Office of the Scottish Charity Regulator
www.oscr.org.uk
Scottish Council forVoluntary Organisations
www.scvo.org.uk
Wales Council forVoluntary Action
www.wcva.org.uk

 

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.

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.

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.

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.

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.

Framework for procuring External Support for Commissioners launched by the DH in England  in 2007. This includes an approved list of 14 commercial providers of support to commissioners. The companies are:
Aetna Health Services (UK) Limited
AXA PPP Healthcare Administration Services Limited
BUPA Membership Commissioning Limited
CHKS Ltd – trading as Partners In Commissioning
Dr Foster Limited, trading as Dr Foster Intelligence
Health Dialog Services Corporation - now part of Bupa
Humana Europe, Ltd
KPMG LLP
McKesson Information Solutions UK Limited
McKinsey and Company, Inc. United Kingdom
Navigant Consulting, Inc
Tribal Consulting Limited
UnitedHealth Europe Limited
WG Consulting Healthcare Limited, trading as WG

They are approved to offer some, or all of these services: Assessment and planning, contracting and procurement, performance management, settlement and review and patient and public engagement.

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.

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)

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).

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

These will be statutory bodies from April 2012 to enable councils to lead on integrated working and commissioning across the NHS, public health and social care in collaboration with other agencies.

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.

– see Next Stage Review

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.

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.

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.

An umbrella term for all non-NHS bodies delivering healthcare, including a wide range of private companies and voluntary organisations.

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.

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)

High Quality Care for All, the final report of the NHS Next Stage Review, defined quality in the NHS as safe and effective care of which the patient's whole experience is positive. The NHS Information Centre and the Department of Health have identified an initial, but evolving, set of over 200 indicators to describe the quality of a broad range of services. The long-term vision is to produce an extensive menu of indicators. Some will be used at national level; others will be included as part of local contract negotiations. See also here

Related Words  National Quality Board; Quality; Quality observatory; Quality Standards

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 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)

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)

 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

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.

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

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)

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.

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)

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.

Recent report by the British Lung Foundation that used Mosaic data to identify hot spots for COPD.  Download the pdf report here.

See here

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.

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. From 2011/12, GP consortia will start to engage in this work too.  For more information from the Department of Health see this page here. For more IMPRESS information click here.

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.

 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

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.

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.

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.

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.

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.

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.

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).

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.

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

Go to the Direct Government website here.

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.

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)

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)

– see Clinical Strategy

Related Words  Clinical Strategy

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.

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

. 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.

(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.

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 [email protected] and ask for 'NHS Comparators log-in'. Click here for more information.

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.

(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.

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.

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

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.

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 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. 

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.

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.

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. 

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.

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.

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.

See Your Health Your Way

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:

1. Strengthen diagnosis, procedure and casemix classifications and the timeliness and quality of data available to PCTs
2. Increase the scope for unbundling so that different care pathways can be accommodated more easily – such as hospital at home
3. 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
4. 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

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 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.

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 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.

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

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.

 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)

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

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.

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

The collective term for all services which are people’s first point of contact with the NHS.

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.

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.

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).

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 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)

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)

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 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

 – see patient-reported outcome measures.

Related Words  Patient reported outcome measures (PROMs)

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.

See commissioning intentions. Also known as Patient Prospectus.

A generic term for an organisation that delivers a healthcare or care service.

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

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

Quality, innovation, productivity and prevention - announced in June 2009 by the Chief Executive of the NHS.  This will be the next phase of the Darzi  Review and will be led personally by the Chief Executive.  He will be supported by a new NHS National Director for Improvement and Efficiency (Jim Easton).  The challenge, in times of economic downturn, is to improve  quality whilst improving productivity (more and different for less).    The respiratory community will need to rise to the challenge of finding reliable and sustainable ways to do this.  System-wide networks and shared analysis of the data will be a good place to start.

Central to High Quality Care For All is improving quality which it defines in three dimensions: ensuring that care is safe, effective, and provides patients with the most positive experience possible.  The principles of how this will be achieved are also listed:

Co-production – implementation should be discussed and decided in partnership with the NHS, Local Authorities and key stakeholders;
 
Subsidiarity – where necessary, the centre will play an enabling role, but wherever possible, the details of implementation will be determined locally;
 
Clinical ownership and leadership – all  staff must continue to be active participants and leaders as the work progresses;
 
System alignment – in doing this work people should ensure that the whole system is aligned around the same vision, allowing them to use their combined leverage at every level to drive up quality. 

The National Quality Board is leading on the quality agenda, which is described by a framework pyramid model: at the base are local clinical initiatives to improve services; then provider services will publish quality accounts ; then there is the regional activity, to enable benchmarking, using services from the Quality Observatory; and finally, at the top of the pyramid are national priorities and reporting, overseen by the National Quality Board.

Related Words  CQUIN Commissioning for higher quality and innovation; National Quality Board; QIPP; Quality Accounts ; Quality and outcomes framework (QOF); Quality Standards

The Health Act 2009 requires acute, mental health, learning disability and ambulance services to make publicly available from April 2010 a Quality Account just as they publish annual financial accounts. As of February 2010, what will be included, timings and how they will be scrutinised remain a matter for debate but consultation has ended.  The duty to publish quality accounts will apply to primary care and community services in 2011.  The framework and toolkit was published in February 2010 and is available here.

Related Words  Operating Framework; Quality

This is part of the GP contract aimed to incentivise practices to provide systematic care for people with long term conditions. Participation is voluntary but most practices participate because it carries significant funds with it for achievement of QOF targets. It has also raised the standard of record-keeping in many places and enabled the development of disease registers for COPD and asthma. However these registers are only as good as the accuracy of the diagnosis. PCOs analyse QMAS (see below) data to determine the level of achievement against the indicators. Practices score points up to a maximum of 1050 points (in 2011 a point will be worth £130.51).

The fourth edition of indicators were announced on 11 March and were advised by NICE that took responsibility for review from 2010. 

Particularly relevant to respiratory care are clinical indicators for COPD and asthma and points for annual recording of smoking status. Appendix 1 to this glossary describes these clinical indicators and is worth reading.

The PCRS-UK and BTS contribute to the development of new QOF standards in asthma and COPD.

From 2011 for the first time there are indicators for quality and productivity.  See Appendix 1.

Related Words  National Quality Board; Quality

This is the IT system used to give PCTs/Health Boards and GPs in England and Scotland feedback on practice performance against the QOF in the GMS contract.  It is used to calculate what GPs will be paid under the GMS contract.  In Wales MSDs Contract Manager is used, and in Northern Ireland the Payments Calculation and Analysis System (PCAS) is used.
 

Part of the national quality agenda. 1 quality observatory per Strategic Health Authority will be a centre of expertise that will play a key role in driving up quality across the region through support and indicator development and assistance with quality accounts. They directly link in with the Measuring for Quality Improvement programme.

Related Words  National Quality Board; QIPP; Quality; Quality Accounts ; Quality and outcomes framework (QOF); Quality Standards; Strategic Health Authority (SHA)

Part of the NHS Quality Agenda 2009. A NICE quality standard (qualitative statements with quantitative measures) is a set of specific, concise statements that:

1. act as markers of high-quality, cost-effective patient care across a pathway or clinical area;
2. are derived from the best available evidence; and
3. are produced collaboratively with the NHS and social care, along with their partners and service users.

NICE will be producing about 20 per year. Four pilots will be complete by March 2010: stroke care, specialist neonatal care, VTE prevention and dementia. Where possible NICE clinical guidelines will be used as the basis for these pilots.

Related Words  National Quality Board; QIPP; Quality; Quality Accounts ; Quality and outcomes framework (QOF)

The Resource Allocation System (RAS) is designed to be a fair funding system and to allocate money from adult social services. The RAS works against a set of strict guidelines to ensure it remains fair. It relies on a scoring system based on answers given to a series of questions and then places people within a series of funding bands.

PCTs received in their baseline  £70 million in 2010/11 for reablement.  This increases to  £150 million in 2011/12  and £300 million from 2012/13.  For the latest guide to these allocations see NHS support for social care: 2010/11 – 2012/13  There might be scope to use this to fund post-discharge support for people with COPD.   PCTs should be able to tell clinicians what they have spent/are planning to spend it on by sharing a written plan that is due by 31 December 2010.

Current policy to provide services for people with poor physical or mental health and to help them accommodate their illness (or condition) by learning or re-learning the skills necessary for daily living.  Home re-ablement is typically offered as an intermediate care service by  local authorities  post-discharge free for six weeks, as part of intermediate care packages.

To help people accommodate their illness (or condition) by learning or re-learning the skills necessary for daily living such as the ability to get out of doors and walk down the road; wash face and hands; have a bath, shower or wash all over; get dressed and undressed; have bladder control

How is it different from traditional home care?
In traditional home care things are done for the individual. The home carer might wash and dress the individual, or prepare their meal. With reablement, the idea is to help the person to re-learn how to do things for themself in a safe way, gradually over a six-week period.  The reablement carer will work with the person on how, for example, to wash and dress themself, or prepare and cook their own meal.  Many people who receive reablement find they need less care and support afterwards, or even none at all.
 
Outcomes
An interim study by the DH Care Services Efficiency Delivery (CSED) found post re-ablement phase, service users were reporting fewer problems with mobility, self-care, usual activities, pain/discomfort, anxiety/depression and improvements in their general health. Research commissioned by CSED amongst four councils showed that levels of independence achieved from a completed phase of homecare re-ablement are sustained see CSED’s Retrospective Longitudinal Study http://www.csed.dh.gov.uk/homeCareReablement/prospectiveLongitudinalStudy/

• 53% to 68% left re-ablement requiring no immediate homecare package
• 36% to 48% continued to require no care package 2 yrs after re-ablement
• 34% to 54% had maintained or reduced their homecare package 2 yrs after reablement
 

Who would benefit?
As an example, an older person who
•    lacks confidence following a fall or poor mobility
•    would benefit from a health screen and health promotion, e.g. someone with poor diet or who is not managing their medication)
•    needs guidance on how to manage long term conditions e.g. Diabetes or C.O.P.D.
•    needs to learn easier ways to manage own personal care (e.g. washing, dressing and toileting)
•    needs to learn how to undertake daily living activities (e.g.) cooking
•    would like to socialise and join community groups (e.g. Age concern etc.)

The services typically offer a multi-disciplinary approach and aim to
•    Help people to remain at home and be as independent as possible
•    Prevent unnecessary admission to hospital
•    Help people recover faster from illness
•    Support discharge from hospital
•    Prevent unnecessary admission to long-term care homes

The DH re-ablement toolkit is available here

Funding for post-discharge support

On 28 October 2010 The DH England wrote to SHA Chief Executives giving details of the £70 million 2010/11 funding allocations for re-ablement to improve hospital discharge.   See the letter here   The sum will be given to PCTs who have to have plans in place by the end of December 2010, agreed with the local authority.  It is for post-discharge support. The money is available for four years - increasing to over £100 million  per year from 2012.

From April 2011, as announced in the June 2010 revisions to the Operating Framework, acute trusts will not be paid for readmissions within 30 days subject to local negotation with commissioners and this will help fund these re-ablement services.  From April 2012, there will be a new tariff to cover the costs of post-discharge support, including re-ablement.

Emergency re-admissions increased by 50 per cent between 1998 and 2008.  At the launch of the reablement fund the Secretary of State for Health Andrew Lansley said : 'Too often, patients end up back in hospital because they haven’t had help readjusting to life at home. We need to do more to prevent this from happening.

'Re-ablement will give opportunities for the NHS and councils, by working together locally,
to make savings. Services of this kind have shown dramatic benefits in supporting people and
cutting readmission to hospital. Our objective is for people to be once again independent, in
their own homes.

'This new funding will mean people will benefit right now and around 35,000 will start to
get the help and support they need.' The additional funding for re-ablement has come from
savings from central Department of Health budgets.

The re-ablement funds could be used to support existing intermediate care schemes or to facilitate discharge in new ways (for example care bundle approaches) or to fund new services such as pulmonary rehabilitation. 

The DH distinguishes between re-ablement from rehabilitation and prevention as follows:

Prevention
    •    Services for people with poor physical or mental health
    •    To avoid unplanned or unnecessary admissions to hospital or residential care
    •    Can include short-term and longer term low-level support
Rehabilitation
    •    Services for people with poor physical or mental health
    •    To help them get better
Re-ablement
    •    Services for people with poor physical or mental health
    •    To help them accommodate their illness (or condition) by learning or re-learning the skills necessary for daily living
 

These are used in calculating the tariff. They are average costs for providing a defined service in a given financial year. They cover a broad range of NHS treatments and clinical procedures and have been collected since 1998. Their main purpose is to provide a basis for comparison within (and outside) the NHS between organisations, and down to the level of individual treatments. The 2008/09 costs show how £48 billion was spent. Each Trust has a Reference Cost Index – the lower the score, the higher their relative efficiency. Eg a score of 92 means costs are 8% below the average, a score of 125 means that the costs were 25% higher than the national average. The RCI is adjusted for the same market forces factor as the tariff. See here. 

Related Words  Tariff

 see Clinical Assessment Services and also BMA guidance here.

Related Words  Clinical Assessment Service (CAS) and Clinical Assessment and Treatment Service (CATS)

RIEPs play a key role in supporting councils.

The nine RIEPs were created in April 2008 with a three-year funding package of £185 million from Communities and Local Government. The RIEPs harness the expertise of councils to add new capacity to local government in order to accelerate the drive for greater improvement and efficiency. They build on the successful foundations laid by the former Regional Improvement Partnerships and Regional Centres of Excellence.

Put simply, they help councils deliver the ambitious outcomes, set through local area agreements (LAAs), by supporting them in their efforts to become more efficient, innovative and engaged with citizens.

The report ‘Leading the Way by Working Together’ demonstrates that local government has taken responsibility for its own improvement by working together at a local, regional and national level. It celebrates the achievements of the sector, illustrated with a series of recent case studies and is published July 2009.

Related Words  Local Area Agreement (LAA)

This is one of the workstreams of the quality and productivity programme (QIPP) in the NHS in England led by Sir Muir Gray, Chief Knowledge Officer ""Empowering patients make the right choices and empowering commissioners to improve value.”  It is also being piloted by the NHS London Respiratory Programme.  See the Rightcare pages.    Health Investment Packs were made available to every PCT in September 2010 by programme budget some of which highlight respiratory spend and outcome.

Previously there was a Right to Request  in the Next Stage Review of the NHS, published in June 2008. The Right to Provide creates the opportunity for NHS staff to set up and lead new social enterprises.   We could see the establishment, for example, of AHPs setting up services.It enables NHS staff, specifically nurses and allied health professionals, who may be interested in establishing a social enterprise to put their proposals to their PCT board, and if approved, have their proposal supported.  See this link here for a series of 'webinars'.

Initiated as a term in 2009 by the Department of Health in England, it is part of the Quality, Improvement, Productivity and Prevention (QIPP)  programme led by Sir Muir Gray, Chief Knowledge Officer for the NHS.  RightCare is doing the right things and doing things right to achieve value based care.    http://www.rightcare.nhs.uk/index.html

Whatever commissioner’s plan, it needs to be put into practice at the front line where a clinician is face to face with a patient. Sir Muir argues that "This is the crucial interaction in health care, where the clinician and the patient discuss the options available: treatment A, treatment B, and ‘let’s not do anything now as the benefit to you does not outweigh the risk’. Shared decision making provides a set of tools and behaviours that allow an honest and informed conversation to agree on the ‘highest value’ decision in that situation and at that time for the patient." 
 

How will it come about?

Sir Muir states that "Changing the NHS in this way, to one where each treatment decision is considered by both patient and clinician together in terms of value, requires a much wider cultural shift than one constrained to within current commissioning arrangements. It needs a move to: long term rather than short term and population wide rather than patient and service planning. This broad cultural movement to support the change in what is expected by the population from the health service must be led by the NHS but can only succeed if this conversation engages with society as whole."
 

To download the RightCare Project Document go here.

To download the IMPRESS guide to value in respiratory care: More for Less.

The concept is being tested in Respiratory by the NHS London team.

Related Words  QIPP

See Combined Predictive Risk and PARR

Related Words  Combined predictive risk model; Patients At Risk of Re-hospitalisation (PARR)

Registered Social Landlords are government-funded not-for-profit organisations that provide affordable housing. They include housing associations, trusts and cooperatives. They work with local authorities to provide homes for people meeting the affordable homes criteria. As well as developing land and building homes, RSLs undertake a landlord function by maintaining properties and collecting rent.

The collective term for services to which a person is referred after  the first point of contact. Usually this refers to hospitals in the NHS offering specialised medical services and care (outpatient and inpatient services).

Individuals taking responsibility for their own health and wellbeing and to care for themselves. This includes taking exercise, eating well, taking action to prevent illness and accidents, the better use of medicines, treatment of minor ailments, and better care of long term conditions.

Self-directed support is the term used for when people choose their services, organise their care and arrange for payments to be made. This is because the individual who requires the service is directing their own care and has choice when it comes to their support.

The agreement between the commissioner and provider is in two parts.  The SLA, or contract, and the service specification (see below). The SLA is a formal written agreement and is a standard document written by the Department of Health.

Trusts are moving to service line management as a way of engaging clinicians more in the management of services. It identifies specialist clinical areas and manages them as distinct operational units, supported by service line reporting  on financial and quality performance to support decision-making. Monitor has produced a toolkit for trusts to use.

This is part of the  SLA (see above) and specifies in detail how and what services will be provided, including the quality standards that the service should maintain. It is useful to read the service specification because it also explains how the services will be  monitored.  IMPRESS is developing a generic service specification for COPD.

Businesses with primarily social objectives.  Their surpluses are reinvested principally in the business or the community rather than to shareholders. A  number of provider services from PCTs are exploring the social enterprise model as a way of setting themselves up apart from the PCT, supported by the Department of Health. The Big Issue, the Eden Project, and John Lewis Partners are good examples, but there are increasing numbers of health examples. See here for Chartered Society of Physiotherapy briefing see here;  for NHS briefing see here. 

This is a sub-type of one of the main types of contract, PMS, that PCOs can have with primary care providers. This type of contract is where patients do not have to be registered with the provider to receive care.  The agreement sets out which services are to be provided – it does not require the full range of essential services.  For example, it might be an appropriate contract for providing primary care for homeless people, travellers or refugees.  It is being tested now as a vehicle for providing integrated primary and secondary care services where colleagues work together across an integrated care pathway, retaining their existing employment.  For example, there is a musculoskeletal service in Oldham and could be used for an integrated respiratory service. 

Related Words  Alternative Provider of Medical Services (APMS) contract; General Medical Services (GMS); Primary Care Trust – led Medical Services (PCTMS)

The continuous period from a patient’s admission to discharge from a hospital, even if they are under the care of several consultants during that time hence different from the previously used Finished Consultant Episode (FCE).  So, if a patient with acute coronary syndrome and COPD is admitted through the emergency department with breathlessness, and is under a cardiologist but then transferred to a respiratory physician, that might count as two FCEs but just one spell.

in Department of Health England as part of the Commercial Operating Model, it takes responsibility for leadership and support to commissioners in market analysis and market-making.  It will be responsible for producing a COPD commissioning pack in 2011.

See here.

Related Words  Commercial Operating Model; Commercial Support Units (CDUs); Procurement, Investment and Commercial and Division (PICD)

The local headquarters of the NHS in England, responsible for ensuring that national priorities are integrated into local plans and for ensuring that Primary Care Trusts (PCTs) are performing well. They are the link between the Department of Health and the NHS.

The World Class Commissioning assurance system requires every PCT to have a strategic plan (by October 2008 in the first year of operation).  The governance of the PCT will be assessed against this plan.  It is the core PCT plan for commissioning over a five-year period.  Therefore it is an important document and you should find it available from your PCT's website or by asking for a copy.  According to the assurance system it must tell the story about how the PCT will move over a five-year period from assessing the needs of its population to delivering services that will drive improvements in health outcomes.  These outcomes will be locally chosen to reflect local priorities and have been agreed with the local population and partners such as healthcare providers and local authority.  It will reflect the PCTs commissioning intentions and be informed by the clinical visions that are developed as part of the Next Stage Review and the Local Area Agreement with local authorities.  As it will be affected by changes in health needs, priorities and resources, it is expected to be refreshed every year and rewritten  every three years. It will be accompanied by 3 more detailed plans:

1. A five-year financial plan
2. An organisational development plan
3. An annual operating plan

Described in the 2009/10 Operating Plan for NHS in England as one of the guiding principles of the NHS. Means "ensuring that decisions are taken at the right level of the system, which means as close to the patient as possible. It means an enabling role for the NHS centrally, with more power and responsibility residing with patients and clinicians. And it means looking ‘out, not up’ wherever possible. rather than patrolling the boundaries of their own organisations."

Support brokers provide help to people looking for care services. They are at the behest of the service user and provide the technical assistance to put the support package in place. Often they will be work independently from the local authority and will mediate between their client and the authority. Support brokers can be anybody from close friends and family to members of a local charity or voluntary organisation or a social worker.

You will find the terms self care and self management used interchangeably in many documents.  However, the term self management or supported self care also recognises the role of  health and social care providers. The  implication of “management” is that the individual needs others to deliver some of their care, but they are in charge of the process.  Supporting people to self care is a major part of Your Health, Your Way, http://www.nhs.uk/yourhealth/Pages/Homepage.aspx See personal care plan.
 
The development of direct payments and individual budgets for social care can be seen as important developments in the area of self management and is now being extended to health care 

See also IMPRESS pages
 

Related Words  Personalisation (health and social care); Personalised care planning ; Self Care; Your Health Your Way

The primary use of data in the NHS is to support patient care.   Its use for planning and commissioning is a secondary use, hence the name.  SUS is the single data warehouse and analysis centre created by the NHS Information Centre pooling Hospital Episode Statistics (HES), and other data collected by providers of NHS care to meet the dataset requirements of NHS commissioners. Every secondary care provider in England has to send a set of standard data files (Commissioning Data Sets) to the SUS system. These files contain details of all the care they have provided, including that covered by PbR.  SUS data is then used to provide a range of services including NHS Comparators The Operating Framework  for 2008/09 stated that SUS should be the standard repository for performance monitoring, reconciliation and payments by April 2009.  Further  information  here.  

The Secondary Uses System (SUS) is designed to provide anonymous patient-based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development. 

The data currently managed within SUS is derived from the commissioning datasets, which providers of NHS care must submit and make available to commissioners. In future, the plan is for data to be captured automatically from NHS operational systems including the NHS Care Records Service and other National Programme for IT services including Choose and Book, the Patient Demographics Service and the Electronic Prescribing System.

Every secondary care provider in England has to send a set of standard data files (Commissioning Data Sets) to the SUS system. These files contain details of all the care they have provided, including that covered by PbR.

See the Information Centre page for further information

This is the amount that a commissioner will pay for a particular package of care including out-patient appointments, spells and procedures. Commissioners now only pay for work that has been done, according to the nationally set tariff with minor local differences when a market forces factor is applied. The tariff is based on a reference cost (see above) created from a large retrospective analysis of average costs incurred by NHS hospital providers, plus an annual increase for inflation. See here.

The tariff  is defined using an HRG; a currency –a spell rather than an FCE; and a cash amount.   The tariff has a different rate for children and adults, emergency and elective care, and first outpatient and follow-up outpatient appointment.  The tariff for admissions  has trimpoints; that is the length of stay up to which the tariff will be paid, and over which an excess bed day charge can be claimed but at a much lower rate. There is also work underway to “unbundle” care such as stroke rehabilitation from acute care so that it is easier to compare costs of elements that might be provided in the community.

29 August 2009: two papers in the BMJ describe the impact of the tariff: Has payment by results affected the way that English hospitals provide care (compared to Scottish hospitals studied at the same time) doi:10.1136/bmj.b3047 and editorial doi:10.1136/bmj.b3081  The main paper concludes that there has been a reduced length of stay/increased throughput and no increased risk to patients.  However,  it is important to note the limitations of the study. Although the authors do look at readmissions, this appears to be limited to patients discharged following orthopoedic procedures and it would have been interesting to see whether medical readmission rates went up (by choosing a high volume casemix e.g. COPD). They did look at 30 day mortality which is better  than inpatient mortality although neither are particularly good at indicating whether Payment by Results has been beneficial for patients. such studies are very difficult  to do and so this has acted as a baseline and further studies might be able to reduce some of the limitations identified.

In 2010/11 best practice pathway tariffs will be introduced: cataracts, cholecystectomy, fragility hip fracture and a medical condition - stroke has been chosen. The timescale is for road-testing in November 2009.  This has been road-tested.
 
Guidance for 2009/10 is now available here.

A summary of COPD tariffs using HRG4 codes (see Appendix 2 and also the BTS Guide to Respiratory Coding). Note that when the market forces factor is applied there will be minor differences, so that the local tariff may not be exactly as listed below.

Related Words  Payment by Results (PbR)

This is another GP computer system.  See EMIS, TPP, VAMP Vision

Related Words  EMIS; TPP

Total Place was launched in the 2009 Budget as an initiative  led by the Treasury to look at how a ‘whole area’ approach to public services can lead to better services at less cost. It seeks to identify and avoid overlap and duplication between organisations, look at freedoms from central control, and taking away ring-fences and bureaucratic burdens.

There have been 13 pilot areas participating in the scheme, with different socio-economic and demographic profiles. Each reported in February 2010.

Birmingham
Bradford
Coventry, Solihull and Warwickshire
Croydon
Dorset, Poole and Bournemouth
Durham
Kent
Leicester and Leicestershire
Lewisham
Luton and Central Bedfordshire
Manchester City-Region including Warrington
South Tyneside, Gateshead and Sunderland
Worcestershire

It is being considered as an important part of the QIPP agenda in healthcare and is likely to continue despite government change.

Total Place final report: Total Place: "A whole area approach to public services  63 local authorities, 34 primary care trusts, 13 police authorities and other partners, with more than 70 other local areas engaged in similar work. Together the pilots have a population of more than 11 million people and they mapped more than £82 billion of public spending in their areas."  

Total Place website.

Practitioner’s Guide 

 

Related Words  EMIS; Torex; VAMP Vision

These are the length of stay up to which an individual tariff applies. They are spell not FCE-based and, like the tariff itself, are calculated from a large retrospective analysis of average length of stays for particular HRGs. There are separate trimpoints for elective and non-elective activity and some non-elective activity is divided into subgroups according to complexity but this is not very sophisticated at present.

Trimpoints can provide a perverse incentive for PCTs to reduce the efforts they have previously been making to reduce lengths of stay because they pay the same tariff if a person with COPD without complications stays in hospital 3 days or 16 days. However, from an acute provider’s perspective, their costs relative to the price paid increase each day the patient stays unnecessarily. See here.

Transfer of Undertakings (Protection of Employment) Regulations (2006).  Designed to protect the rights of employees in a transfer situation (when a new employer takes over).  Further information in this complex area: Chartered Institute of Professional Development (CIPD), and The Statutory Instrument

Another GP computer system. 

Related Words  EMIS; Torex; TPP

In practice is the focus for many commissioners. Two broad definitions of variation are usually considered: avoidable variation (“unwarranted”) by healthcare professionals and variation (“warranted”) due to differences between patients that need to be considered by professionals when offering personalised care.  There is much work in the NHS looking at both sides - how to reduce variation applying reliability science as well as how to empower patients to achieve shared decisions with their healthcare professionals.  See  here and here for more information.

These are part of Croydon PCT’s award-winning approach to reducing admissions using the Combined Predictive Risk Model to identify people at risk of admission and to provide a team approach to managing their care in the community.  See here for Information for Healthcare Staff and here.

This is the new performance management framework for PCTs described in the 2009/10 Operating Plan for NHS in England.

Tier one or "must do" indicators apply to all PCTs and provide national standards and performance measurement. The most important tier one targets are for access to primary care and capacity.   Each PCT must produce a plan to be signed off by the SHA.

Tier two national priorities for local delivery must do’s but with more flexibility about how it is done locally. Each PCT must produce a plan to be signed off by the SHA.

Tier three is a range of indicators which PCTs can use in consultation with partners and local communities to set targets for improvement. Performance management is left to the PCT.
To download a summary poster click here.

An umbrella term referring to registered charities as well as non-charitable non-profit organisations, associations, self-help groups and community groups, for public or community benefit.

(see here). Entitled Securing Good Health for the Whole Population this report for the Treasury forecasts that the only way health service provision will be affordable in the UK in the future is if the “fully engaged” scenario is achieved, where people take a greater responsibility for their health, and services transform themselves through efficient use of resources and a high rate of uptake of technology.

Welfare to Work  In England there is a White Paper Raising expectations and increasing support: reforming welfare for the future http://www.dwp.gov.uk/welfarereform/raisingexpectations/  and a Welfare Reform Bill going through Parliament (May 2009).  Included in the Bill is provision for giving disabled people the right to control provision of services to them, in some cases through having the money to procure services themselves. The Green Paper was called No-one Written Off, and remains the title used by some to describe the reforms. http://www.dwp.gov.uk/welfarereform/noonewrittenoff/

(see here) is a very useful resource aimed at general practice to improve capacity and includes information and toolkits on HCAs, general practice nurses (GPN), self-care, workload analysis, practice management, sickness absence, repeat medication, and database of good practice.  The project closed in August 2008 but the site is still currently available.

(see here). This is the Department of Health’s programme to transform commissioning.  11 world class commissioning competences are described that PCTs’ will be expected to develop and perform:

• lead the NHS at a local level
• work collaboratively with partners
• engage with the community
• work closely with clinicians
• manage knowledge and assess needs
• prioritise for improved outcomes
• influence and shape the market
• promote innovation and improvement
• procure robust contracts
• support and manage providers
• demonstrate sound financial management.

 See also IMPRESS personalising care web pages.

Related Words  Co-production ; Personalisation (health and social care); Personalised care planning

Previously known as the Patients’ Prospectus.  Launched in England by the DH in November 2008, 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 prescriptions: not tested in COPD yet, but written asthma action plans have well-documented effectiveness
2. Skills and knowledge training e.g.EPP or condition specific: Pulmonary rehabilitation is an effective intervention and needs to be made available to all those for whom it would be impactful.  Also Expert Patient programmes for asthma.
3. Tools and self-monitoring devices including assistive technology: COPD self-management plans have a cautious endorsement from the most recent Cochrane review.
4. Healthy lifestyle choices: eg smoking cessation: The most important risk factor for COPD is smoking, followed by other aspects of social deprivation, diet and occupational exposure to dust, indoor pollution such as smoke from wood and coal fires, and, in a small number of cases, inherited faulty genes.  So, prioritise smoking cessation and dietetic advice for those with low and high BMIs. Smoking stops certain asthma medications working and smoke can trigger asthma symptoms so smoking cessation programmes are a priority.  These should include strategies to reduce maternal smoking
5. Support networks eg Breathe Easy Groups and Asthma UK helpline.
   
   Guidance for the social care workforce is being taken forward through the adult social care workforce strategy.  DH will monitor uptake of care planning routinely through the quarterly GP Patient Survey.

Related Words  Personalisation (health and social care); Personalised care planning ; Self Care; Supported self care/self management