The Framework for Managing Choice Cooperation and Competition supports SHAs and PCTs in understanding the roles, responsibilities, values and behaviours required for the effective management of choice and competition within the NHS. The Framework is the outcome of a series of workshops and seminars with senior SHA and PCT leaders. The Framework should be read in conjunction with the
Principles and rules for Cooperation and Competition (Annex D of the 2008/9 Operating Framework) and the PCT Procurement Guide (published 16 May 2008). Additionally, the Framework signals a further series of tools and guidance for system managers to be released throughout the year.

Public perceptions of privacy and dignity in hospitals is research, conducted by Ipsos MORI, involved 2,000 interviews with members of the public across the country. It was designed to explore perceptions towards privacy and dignity in hospitals, with particular emphasis on the importance of single-sex accommodation. Key findings are that cleanliness and staff attitudes are the most important factors for patients to feel they are treated with privacy and dignity in hospital.

• Allogeneic pancreatic islet cell transplantation for type 1 diabetes mellitus
• Intraoperative red blood cell salvage during radical prostatectomy or radical cystectomy
• Interstitial photodynamic therapy for malignant parotid tumours
• Perioperative hypothermia (inadvertent)
• Ulcerative colitis - infliximab
• Abatacept for the treatment of rheumatoid arthritis

Patient Experience Scores for the PSA target – April 2008 updates the patient experience scores published on 29 January 2007. They include scores derived from survey results published by the Healthcare Commission for 2006/07. There are new data points for ‘adult inpatients’ and ‘community mental health’ in 2006/07. These figures report on progress against the PSA target for sustained improvement in patient experience.

• The overall patient experience score for adult inpatients in 2006/07 has increased slightly to 76.4 from the score of 76.2 in 2005/06. The score is 0.7 points higher than in the earliest fully comparable year of 2003/04 (75.7).
• The overall patient experience score for community mental health services in 2006/07 has increased to 75.2, up 0.7 points from the score of 74.5 in 2005/06. 
• Scores for ‘involvement in decisions about healthcare’ cannot be compared across sectors.  The baseline scores for emergency services (2004/05) is 77.1.  The baseline score for outpatients (2004/05) is 81.7.  For adult inpatients, the latest score of 70.9 is unchanged from 2003/04.  Results for community mental health services show a slight increase to 63.7 in 2006/07 (from 63.3 in 2003/04) whilst primary care results are slightly lower at 81.9 in 2005/06, compared to 82.1 in 2003/04
• The baseline score for ‘choice of provider’ is 27.3 from the 2005/06 DH survey of PCTs.  This score represents the baseline position in the last year before the choice of provider policy was introduced. 

This is the third quarterly practice survey (National summary of results), covering a sample of practices from each primary care trust (PCT). The aims of the survey are to get feedback from practices on their perception of the support offered by their PCT and on the clinical and financial engagement of practices with PBC.  The survey is part of a group of indicators that will be assessed together to give a picture of PBC implementation.

Key findings:

• There has been a rise in the number of practices commissioning new services through PBC (+8 percentage points since Wave 1 and +5 percentage points since Wave 2). 41 percent have commissioned new services through PBC.
• The percentage of practices who have agreed a commissioning plan with their PCT has continued to increase (+11 points since Wave 1 and +3 points since Wave 2). 57 per cent of practices have now agreed a commissioning plan.
• 62 percent of practices support the policy of PBC (a rise of 5 percentage points since Wave 1, and 3 percentage points since Wave 2).
• The percentage of practices agreeing that PBC has improved patient care has marginally increased from 12 percent in Wave 2 to 16 percent in Wave 3. The proportion who disagree that PBC has improved patient care is in line with that of the previous two waves (31% in Wave 3, 30% in Wave 2, and 31% in Wave 1).
• 71 percent of practices claim to have a good relationship with their PCT, a decline of 3 percentage points on Wave 2.
• The proportion of practices who have received a financial incentive scheme has marginally declined since Wave 2 to the levels recorded in Wave 1 (down 4 percentage points since Wave 2 - now 62 percent).
• There has been a rise in the proportion of practices who engage with their local population from 61 per cent in wave 2 to 70 per cent in Wave 3 (an increase of nine percentage points).
• Around 4 in ten practices continue to rate their PCT’s managerial support for PBC as good (40 per cent in Wave 3, 42 per cent in Wave 2 and 37 per cent in Wave 1), however, half continue to rate managerial support for PBC as poor (49 per cent in Wave 3).
• As in previous waves, around a third of practices continue to rate the quality, format and frequency of information provided by their PCT as being good

Patients will be able to choose where they are treated from any provider meeting Healthcare Commission standards from 1 April, but Free Choice at the Point of Referral a King’s Fund’s briefing on the latest official data finds the policy has some way to go before it is likely to drive improvements in the quality of hospital services.

One of the ambitions of free choice is to create incentives for hospitals to drive up quality standards as they compete for patients, but official data shows that:

• use of ‘Choose and Book’ — the computer system designed to facilitate choice — whilst increasing still falls short of the government’s target, with only 50 per cent of referrals from GP to hospital being made using the system
• although increasing numbers of patients say they remember being offered a choice of hospital by their GP since the policy began in 2006, the proportion is still only 45 per cent
• of those 45 per cent, only 27 per cent said their GP gave them a booklet containing comparative information on hospital performance to help them make a decision.

The Report of the Office of Health Economics Commission on NHS Outcomes, Performance and Productivity identifies that the collection and use of outcomes measures in the NHS is both practical and essential.   In order to do so effectively the report makes the following recommendations:

• Measurement of patient outcomes and use of that information to drive better commissioning of services should be made an explicit element of the Government’s vision of “world class commissioning”.

• Mortality and survival data should be collated and published for all condition/treatment areas at the same time as collection of other outcomes data is initiated. Data on casemix must be collected, so that the crude mortality/survival data can be adjusted for the casemix treated. Confidence intervals should be estimated and reported to permit comparisons to be made over time and between providers.

• For elective surgery, condition-specific measures should be collected beforeand after surgery simultaneously with the generic EQ-5D for all NHS patients undergoing common procedures.

• Measurement of mental health outcomes in secondary care should be reinvigorated with collection of HoNOS data being incentivised in addition to mental health providers being reminded of its mandatory nature as part of the Mental Health Minimum Data Set. Routine collection at annual intervals of the CORE-OM measure for all patients receiving community based mental health services be piloted in a range of NHS Trusts at the earliest practical opportunity in 2008/09.

• Research is required to identify a generic measure of health related quality of life that is suitable for application to mental health patients as well as recipients of other kinds of health care.

• The practicality and value of collecting and using measures of outcomes for COPD patients should be piloted by a range of commissioners and their secondary and primary care providers, commencing in 2008/09. The preferred disease specific measure is either the Chronic Respiratory Disease Questionnaire (CRDQ) or the St George’s Respiratory Questionnaire (SGRQ).

• For colorectal cancer patients, mortality data (1 year and 5 years after diagnosis) should continue to be monitored and assessed as an important but partial measure of health service productivity in this disease area given its relatively high rate of mortality. But at the same time instigation in 2008/09 of pilot programmes of routine use of the EORTC QLQ-CR38 instrument to measure outcomes in colorectal cancer patients simultaneously with the EQ-5D or an SF- series generic measure should be undertaken.

• Collection of data about the wider benefits from health services by addition of questions on patients’ experience of care to the patient questionnaires used to measure health outcomes. Aspects covered should include: access, care co-ordination, autonomy, choice, communication, confidentiality, dignity, quality of amenities and support for carers.Further research is needed into the relative values of the wider benefits referred to in recommendation 8 and by compassion with health outcomes.This should be commissioned during the course of 2008/9.

• Information on wider benefits is already collected in national patient surveys. Building on its ‘customer experience information’ project, the Department of Health should work with its counterparts in Northern Ireland, Scotland and Wales on a UK-wide stock-take of patient surveys in process and planned, and then use this as the basis for discussion with all the interested parties how to co-ordinate those surveys in future.

• After a short period of research to identify the most practical way of collecting such data, including working days lost, measurement of productivity effects should be commenced for patients being treated for mental health problems, diseases of the nervous system and diseases of the musculo-skeletal system should be identified.

• Modification of existing national surveys of a sample of the general population should be investigated as one way of collecting at a general level data relevant to the wider societal impacts of health care interventions, including impacts on carers.

• Health care professional bodies, including the Royal Colleges, should explicitly and actively support the collection and use by their members of patient outcome measures, including the provision of training in their collection and use for both existing and new clinicians.

• Training in understanding and using outcome measures should be provided to NHS commissioner and provider managers.

• Investment should be made in IT and appropriately trained staff to enable user-friendly information collection, collation and analysis of outcome measures.

• The NHS should, commencing as early as possible in 2008/09, pilot, monitor and evaluate explicit incentives to collect, collate, analyse, feedback and use patient outcome measures. Initially at least this would not be extended to rewarding providers for the measured levels of outcomes achieved, although that could be considered once experience with use of outcomes measures has accumulated.

• There should be an expectation that within 5 years (i.e. by the end of 2012/13) routine measures of patient outcomes comprising the impact of an NHS intervention in terms of patient survival, quality of life, and experience of care, are collected for the majority of NHS activity. Within 10 years it should be the exception rather than the rule to find an area of NHS activity that is not assessed and actively managed according to the outcomes achieved.

• The NHS should work with the ONS Centre for the Measurement of Government Activity to ensure that the health outcomes data used by the NHS can also used by ONS in its periodic assessments of NHS productivity and, subsequently, in the National Accounts.

• Antenatal care
• Diabetes in pregnancy
• Prophylaxis for Infective Endocarditis
• Maternal and child nutrition
• Mental wellbeing of children in primary education
• Sleep apnoea hypopnea syndrome (obstructive) - continuous positive airway pressure
• Asthma (in adults) - corticosteroids
• Intraoperative nerve monitoring during thyroid surgery
• Suburethral sling insertion for stress urinary incontinence in men

Today’s post based on the excellent material from the NLH Search 2.0 SHA Representatives group.

When to use them?

Whenever you need ready done quality synthesised reviews of the best available evidence.

The Content

• Bandolier - advice about particular treatments for health professionals and consumers based on primary and secondary research.
• Cochrane Library Database of Systematic Reviews - systematic reviews and protocols for future reviews.
• Database of Abstracts of Reviews of Effects - abstracts of systematic reviews published in places other than the Cochrane Library Database of Systematic Reviews.
• NHS Economic Evaluation Database - structured economic evaluations of health care interventions.
• Health Technology Assessment Database - focussing on prevention and rehabilitation, vaccines, pharmaceuticals and devices, medical and surgical procedures and the systems within which health is protected and maintained.

Searching Evidence Based Reviews

Check the Evidence Based Reviews check box in the search box at the top of the NLH page.

This will allow you to conduct a simple search across all of the evidence based review databases and materials.

As yesterday’s post suggested there are key linking phrases available to allow you to define the relationship between concepts in your search. As a reminder we’ve detailed them again below.

• AND - to make sure the words used appear in the results - this will limit your search results.
• OR - to create an either/or link to expand your search
• NOT - to exclude a word from a search (this will limit your search).
• EXACT PHRASE - by putting your search in “speech marks” you will search for the phrase as you type it. This technique also works with Google and other search engines and is a Fade top tip to find relevant material on the internet.

Searching indivdual or Multiple Evidence Based Reviews Whilst Ignoring Others

If you click on the Evidence Based Reviews Link (as illustrated below)

You will be taken to a specific Evidence Based Reviews Search where you can use the check boxes to select the resources as illustrated below. The usual range of linking terms are available to design your search to bring back optimum results (as detailed above).

Advanced searches can also be run using the same set of parameters as described yesterday.

Saving Search Results

To save results requires you to be logged into Athens (which you can get from the NHS here, providing you work for the NHS). Check the check boxes of the items you want to save and then click the button. Alternatively just click on Save Search Result for individual items.

To retrieve items you’ve saved when you’ve logged in with your Athens password jsut click on the Saved Search Results link in the MY SEARCH section of the page.

This is also where you can find Saved Search Histories, Saved Search Criteria and your Search Profiles.

E-Mailing Search Results

You can e-mail individual search results by clicking on the More Details link. This will then bring up an e-mail form (shown below) which you can mail to yourself or a colleague you think will be interested in the item. It has space for you to add your own message.

A consultation on the framework for the registration of health and adult social care providers follows on from the previous consultation on the future regulation of health and adult social care (November 2006), and the response to that consultation, which was published in October 2007. It seeks views on: which health and adult social care services should require registration with the Care Quality Commission; and what the requirements for registration should be. It also seeks views on when providers of regulated services should be required to have a registered manager, and how primary care services should be included in the new registration system.

A partial Impact Assessment of the Scope of Registration of Primary Medical and Dental Care has been completed as part of this consultation.

In Regulating Complementary Medical Practitioners: An international review from the King’s Fund , the experiences of 16 countries considers the registration of complementary practititioners in response to the World Health Organization recommendation that governments develop national policies that include regulation of practice, education, training and licensing.

Code of practice for promotion of NHS services sets out rules around promotional material issued by providers of NHS services to ensure that: the information patients receive is not misleading, inaccurate, unfair or offensive, that the brand and reputation of the NHS is protected, and that expenditure on promotional activity is not excessive.

Breast Cancer Services In Trafford And North Manchester: An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services - The Baker Report explains the reasons behind the misreading of mammograms by a consultant radiologist at Trafford and North Manchester General hospitals between April 2003 and April 2005.

As part of the investigation into the incident, over 150 women were recalled to check their diagnosis and treatment. Eighteen women had a delayed diagnosis of more than 3 months, which experts believe is significant – 14 were from Trafford and 4 were from North Manchester.

Personal Beliefs and Medical Practice from the GMC is guidance for medical staff that states  doctors must not allow their personal beliefs to compromise patient care. The guidance explores how doctors should deal with a range of dilemmas including abortion, the wearing of face-veils and male circumcision.  It also looks at patients’ own beliefs and how they can affect the doctor/patient relationship.  It aims to balance a doctors’ right to practise in accordance with their views and beliefs, and the patients’ right to receive timely and appropriate medical care.

Tackling health inequalities: 2007 Status Report on the Programme for Action provides a review of developments against the data since the publication of the Programme for Action in 2003. It considers progress against the Public Service Agreement (PSA) target, the national headline indicators and against government commitments. The report shows:

• Further slight narrowing of the infant mortality gap, little change in the gap in male
  life expectancy and a widening of the gap in female life expectancy since 2003–05.

• An encouraging picture on the cross-government indicators, with long-term progress in reducing child poverty and narrowing inequalities in housing quality, educational
  attainment and uptake of flu vaccinations. Cancer and circulatory (heart) disease
  mortality, child road accident casualties and teenage conceptions show a narrowing of
  inequalities in absolute terms (but not in relative terms); other areas, for example
  smoking, show a general reduction in prevalence but no narrowing of the gap between social groups

• Most departmental commitments set out in the Programme for Action and due for
  delivery by the end of 2006 have been wholly or substantially achieved.

The Commissioner Volume 3 Issue 3 from the North West Primary Care Librarian’s Group was published today with its podcast ( Standard Podcasts [6:22m]) contents are:

• PBC: Personalise your Improvement with the No Delays Achiever

• Dental Commissioning and Contract Monitoring - Tendering, Procurement & Contracting

• Evaluation of One-Stop Shop (Oss) Models of Sexual Health Provision

• Improving Access to Psychological Therapies implementation plan

• National Infarct Angioplasty Project (NIAP) interim report

• Practice-based commissioning : tips for preparing and pitching a proposal

• Strategic commissioning for older people

• Apply for Beacon Status

• Other documents and conferences

Feed for Podcast

Standard Podcasts [6:22m]

The Government’s Response to the Health Select Committee’s First Report of Session 2007-08 on the National Institute for Health and Clinical Excellence sets out the Government’s response to the Health Select Committee’s report on the National Institute for Health and Clinical Excellence (NICE). It welcomes and endorses the Committee’s expression of support for and confidence in NICE. Separate reports by the World Health Organisation on NICE’s technology appraisal and clinical guidelines programmes have commended the way in which it discharges its vital responsibilities.

Safe Births: Everybody’s business: An independent inquiry into the safety of maternity services in England from the Kings’s Fund makes the following recommendations:

• Teams themselves should:
  • agree safety-focused objectives
  • identify clear roles and responsibilities
  • utilise clear communication standards and protocols
• Safety should be placed at the heart of shared objectives for maternity services in quality joint working The Royal College of Midwives (RCM) and Royal College of Obstetricians and
• Regular reviews of demand and staffing should be conducted with an emphasis on deliveringthe right skill mix todeliver safe services
• Trust boards and managers should regularly receive information employment levels, skill mix and deployment achieved across all shift.
• Simple and effective tools to help maternity managers to manage employment and deployment, to map demand, capacity and patient flow and to provide timely feedback on levels achieved across all shifts and locations should be developed using work used in other specialties.
• A designated maternity unit manager should keep information on all training completed and planned.  Managers and Boards should reveive regular reports on training.
• RCOG, the Nursing and Midwifery Council (NMC) and the Postgraduate Medical Education and Training Board (PMETB) should spread expertise on skills training and emergency drills to all maternity units by adapting elements of existing simulation based training models and turning them into high-quality training tools that can be
  used locally at minimal cost and disruption
• Safety awareness training must be mainstream professional education at all levels.
• A single set of evidence-based guidelines that are backed by professional organisations, National Institute for Health and Clinical Excellence (NICE) and other organisations shoulddeveloped.
• Guidelines must be supplemented by short one page summaries and usable, consistent protocols.
• All disciplines should be encouraged to familiarise themselves with using guidelines in a local setting and should be trained to use the relevant protocols.  Their use should be regularly audited.
• Annual evidence digests and a national briefing system, tools like Map of Medicine should reinforce use of guidelines.
• A small set of reliable, safety-critical information measures should be collected.
• Simple systems for capturing local information on safety should be designed, implemented and maintained locally.
• Boards must prioritise safety, communicate that to staff and patients and make data on safety publicly available.
• Board members should be trained to strengthen advocacy for maternity safety.
• Governance structures must be in place to assure safety, this should strengthen safety committees and systems for collecting and reporting safety information.
• Regular executive walk-rounds, analysis of claims data, incident reports and other safety indicators, and by reviewing safety incidents in detail should be undertaken.
• Safety must be recognised as a business imperative.
• Standards for the safety of maternity services should be set and monitored only by the Healthcare Commission (in future the Care Quality Commission), with approarpiate advice received by professional bodies.
• Existing standards hould be distilled into a smaller number that are critical to safety, and can beconnected to data that can be collected by teams.
• Strategic health authorities and others providing regional leadership for maternity services should be primed to offer specific support to trusts undergoing reconfiguration.
• DH shouldensure financial incentives are aligned to promote the safest care and to galvanise boards into prioritising safety commissioning and patient choice should act as drivers for improvement.

Latest guidance from NICE.

• Prostate cancer
• Osteoarthritis
• Ventilation tubes (grommets) in children with OME
• Irritable bowel syndrome
• Liposuction for chronic lymphoedema
• Laparoscopic mobilisation of the greater omentum for use in breast reconstruction
• Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal metastases
• Psychosis (first onset) - neuroimaging
• Follicular non-hodgkins lymphoma (recurrent or refractory stage III or IV) - rituximab
• Community engagement
• Smoking cessation

In the Know  (Executive Summary) from the Audit Commision aims to encourage people to think about the information they use whenever they make decisions. It has examples, drawn from many different sources, of how information has been used in improving public services. It notes:

When decision makers use information well, local public services improve.

• The quality and cost of our local public services depend upon the decisions that many people make: users make choices; professionals exercise judgement; managers prioritise; and politicians allocate resources.
• Using information well in decision making leads to better local public services. Examples vary from reducing the number of young people not in education, employment or training to increasing the number of ambulances reaching incidents quickly; improvements include reducing fly-posting by 90 per cent, and increasing library membership by 58 per cent.
• Two-thirds of 3 and 4 star councils use information well, but only a tenth of 1 and 2 star councils do.

Information needs to be relevant for the decision at hand.

• Different decisions require different information, and judging what information is relevant for a decision is not easy.
• Performance indicators alone will not be adequate for important decisions.
• Aggregating information (for example over geography or time), using a range of information from different sources, and sharing information, will generate a fuller picture.

Good quality data are the foundation of good quality information.

• Data should be captured once and used numerous times.
• Data should be sufficiently accurate for the intended purpose. Highly accurate data are often neither cost-effective nor possible for many decisions.
• Decision makers need to judge how quickly and frequently they need information. Some information may need to be updated and available immediately, in real-time, but for many political, financial and strategic issues, understanding trends over time is more important than immediacy.

The way information is presented is important for accurate interpretation.

• Relevant, good quality, information will not help decision makers if they cannot understand it.
• How information is presented, and what story it helps to tell, can affect the decisions based upon it.
• The way information is presented, therefore, needs to be tailored for both the audience and the decision at hand.

Using information well requires decision makers and analysts to have particular skills.

• Decision makers need to be able to identify the information they need and to interpret it accurately.
• Those providing information need strong analytical and presentation skills.
• Evidence suggests that these skills are in short supply.

People need to think carefully about the information they use whenever they make decisions.

• Those who make important decisions about local public services should demand better and clearer information.
• Public bodies need to evaluate whether their information is fit for purpose and used to best effect.
• Relevance, quality and presentation, summarised as RQP, are the key characteristics for useful information.