Climbing Frameworks

Every new development in the NHS generates its new buzz words.  Protocols were followed by guidelines which were followed by targets.  The latest buzzwords are Frameworks and Domains.

The first emergence of a Framework was in about 2000 with the toothless National Service Frameworks.  The government eventually realised that a rod without bait would catch no fish and brought in the GMS Quality and Outcomes Frameworks.

Now we have two new Frameworks:  the NHS Outcomes Framework and the Commissioning Outcomes Framework.

Eh?

OK, let’s explain.

One of the stated aims of the government is to devolve down to GP’s the management of the NHS.  Primary Care Trusts (PCT) have been renamed Clinical Commissioning Groups (CCG) but they are essentially the same.

As part of this downward devolution, instead of the situation where PCT’s were accountable to local Strategic Health Authorities, CCG’s will be accountable to a new national NHS Commissioning Board.  So instead of local accountability, we have a new national quango (as these bodies used to be called).

The NHS Outcomes Framework will (hopefully) provide national level accountability for the outcomes that the NHS delivers.  It is a sort of charter for the NHS Commissioning Board itself and has been developed by the Department of Health.

The Commissioning Outcomes Framework does the same for CCGs and was developed by the NHS Commissioning Board in consultation with NICE and others.

The first Framework Indicators have now been published.  They have certain things in common but differ in others.  The Frameworks are based on five so-called domains or sections.  These are:

Domains

Effectiveness

  • Domain 1    Preventing people from dying prematurely
  • Domain 2    Enhancing quality of life for people with long-term conditions
  • Domain 3    Helping people to recover from episodes of ill health or following injury

Patient experience

  • Domain 4    Ensuring that people have a positive experience of care

Safety

  • Domain 5    Treating and caring for people in a safe environment and protecting them from avoidable harm

All criteria that apply to Domain 1 are numbered 1.x, Domain 2 2.x and so on.  However, the criteria in the NHS Outcomes Framework are set out and numbered in a different way from those in the Commissioning Outcomes Framework.  This will become apparent as the criteria are listed.

NHS Outcomes Framework

So, here are the criteria for the NHS Outcomes Framework.  Within each Domain, they are divided into Overarching Indicators (numbered with the appropriate number and a letter e.g. 1b) and Improvement Areas (numbered with the appropriate number and a figure e.g. 1.2)

Domain 1
Overarching Indicators
1a    Mortality from causes considered amenable to healthcare
(The NHS Commissioning Board would be expected to focus on improving mortality in all the components of amenable mortality as well as the overall rate)
1b    Life expectancy at 75

Improvement Areas
Reducing premature mortality from the major causes of death
1.1    Under 75 mortality rate from cardiovascular disease
1.2    Under 75 mortality rate from respiratory disease
1.3    Under 75 mortality rate from liver disease
1.4    Cancer survival

  • 1.4.i    One- and five-year survival from colorectal cancer
  • 1.4.iii    One- and five-year survival from breast cancer
  • 1.4.v    One- and five-year survival from lung cancer

Reducing premature death in people with serious mental illness
1.5    Under 75 mortality rate in people with serious mental illness

Reducing deaths in babies and young children
1.6.i    Infant mortality
1.6.ii    Perinatal mortality (including stillbirths)

Domain 2
Overarching Indicators
2    Health-related quality of life for people with long-term conditions

Improvement Areas
Ensuring people feel supported to manage their condition
2.1    Proportion of people feeling supported to manage their condition

Improving functional ability in people with long-term conditions
2.2    Employment of people with long-term conditions

Reducing time spent in hospital by people with long-term conditions
2.3.i    Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)
2.3.ii    Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Enhancing quality of life for carers
2.4    Health-related quality of life for carers

Enhancing quality of life for people with mental illness
2.5    Employment of people with mental illness

Domain 3
Overarching Indicators
3a    Emergency admissions for acute conditions that should not usually require hospital admission
3b    Emergency readmissions within 28 days of discharge from hospital

Improvement Areas

Improving outcomes from planned procedures
3.1    Patient-reported outcomes measures (PROMS) for elective procedures

Preventing lower respiratory tract infections (LRTIs) in children from becoming serious
3.2    Emergency admissions for children with LRTIs

Improving recovery from injuries and trauma
3.3    An indicator needs to be developed.

Improving recovery from stroke
3.4    An indicator needs to be developed.

Improving recovery from fragility fractures
3.5    The proportion of patients recovering to their previous levels of mobility/ walking ability at 30 days and 120 days

Helping older people to recover their independence after illness or injury
3.6    The proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into rehabilitation services

Domain 4
Overarching Indicators

4a    Patient experience of primary care
4b    Patient experience of hospital care

Improvement Areas

Improving people’s experience of outpatient care
4.1    Patient experience of outpatient services

Improving hospitals’ responsiveness to personal needs
4.2    Responsiveness to inpatients’ personal needs

Improving people’s experience of accident and emergency services
4.3    Patient experience of A&E services

Improving access to primary care services
4.4    Access to i] GP services and ii] dental services

Improving women and their families’ experience of maternity services
4.5    Women’s experience of maternity services

Improving the experience of care for people at the end of their lives
4.6    An indicator needs to be developed based on the survey of bereaved carers.

Improving experience of healthcare for people with mental illness
4.7    Patient experience of community mental health services

Improving children and young people’s experience of healthcare
4.8    An indicator needs to be developed.

Domain 5
Overarching Indicators

5a    Patient safety incident reporting
5b    Severity of harm
5c    Number of similar incidents

Improvement Areas

Reducing the incidence of avoidable harm
5.1    Incidence of hospital-related venous thromboembolism (VIE)
5.2    Incidence of healthcare-associated infection (HCAI)
5.2.i    MRSA
5.2.ii    C difficile
5.3    Incidence of newly acquired category 3 and 4 pressure ulcers
5.4    Incidence of medication errors causing serious harm

Improving the safety of maternity services
5.5    Admission of full-term babies to neonatal care

Delivering safe care to children in acute settings
5.6    Incidence of harm to children due to ‘failure to monitor’

Commissioning Outcomes Framework

Although this is based on the Domains (although there are no criteria applicable to Domain 5), the listing is based on clinical grounds rather than by domain.  These criteria (dare one say “not surprisingly”) tie in in no way (either in the order in which they appear nor the numbering) with the GMS Quality and Outcomes Framework.

Cardiovascular
Domain 1
1.1    Under 75 mortality rate from cardiovascular disease
1.34    Mortality within 30 days of hospital admission for stroke

Domain 2
2.87    People with stroke who are discharged from hospital with a joint health and social care plan
2.88    People who have received psychological support for mood behaviour and cognitive disturbance by 6 months after stroke
2.89    People with stroke who are reviewed 6 months after leaving hospital
2.90    People with stroke who are supported to leave hospital by a skilled stroke early supported discharge team

Domain 3
3.33    People who have had an acute stroke who receive thrombolysis
3.34    People who have had a stroke who are admitted to an acute stroke unit within 4 hours of arrival at hospital
3.35    People who have had an acute stroke whose swallowing is screened by a specially trained healthcare professional within 4 hours of admission to hospital

Gastrointestinal
Domain 2
2.77    Emergency admissions for alcohol related liver disease

Respiratory
Domain 1
1.2    Under 75 mortality rate from respiratory disease

Domain 2
2.23     People with COPD and Medical Research Council (MRC) Dyspnoea Scale 3 referred to a pulmonary rehabilitation programme

Domain 3
3.2    Emergency admissions for children with lower respiratory tract infections
3.10    Emergency re-admissions: COPD

Mental health
Domain 1
1.23    People with dementia prescribed anti-psychotic medication
1.30    People with severe mental illness who have received a list of physical checks

Domain 2
2.79    People on Care Programme Approach (CPA) followed-up within 7 days of discharge from psychiatric inpatient stay

Domain 3
3.26.i    Recovery following talking therapies for people of all ages
3.26.ii    Recovery following talking therapies for people older than 65

Domain 4
4.20    Access to community mental health services by people from black and minority ethnic groups
4.21    Access to psychological therapies services by people from black and minority ethnic groups

Endocrine, nutritional and metabolic
Domain 1
1.24    Myocardial infarction, stroke and stage 5 chronic kidney disease in people with diabetes

Domain 2
2.52    People with diabetes who have received nine care processes
2.53    People with diabetes diagnosed less than a year who are referred to structured education
2.60/2.63     People with diabetes who have an emergency admission for diabetic ketoacidosis
2.61    Complications associated with diabetes
2.62    Lower limb amputation in people with diabetes

Maternity and reproductive
Domain 1
1,25    Antenatal assessments <13 weeks
1.26    Maternal smoking in pregnancy
1.27    Maternal smoking at delivery
1.28    Breast feeding initiation
1.29    Breast feeding prevalence at 6-8 weeks

Cancers and tumours
Domain 1
1.4    Under 75 mortality rate from cancer

Other/cross-cutting
Domain 2
2    Health-related quality of life for people with long-term conditions
2.1    Promotion of people feeling supported to manage their condition
2.3i    Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)
2.3ii    Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Domain 3
3a    Emergency admissions for acute conditions that should not usually need hospital admission
3b    Emergency re-admissions within 30 days of discharge from hospital
3.1.i    Patient reported outcome measures for elective procedures: hip replacement
3.1.ii    Patient reported outcome measures for elective procedures: knee replacement
3.1.iii    Patient reported outcome measures for elective procedures: groin hernia
3.1.iv    Patient reported outcome measures for elective procedures: varicose veins

Domain 4
4a    Patient experience of GP out-of-hours services

Save for the few criteria which are identical with criteria in the NHS Outcomes Framework and are numbered the same (e.g. 2.1) the numbering of the criteria seems to have no logical basis.  Perhaps one of our readers can help!

You will see that these Frameworks are, as yet, incomplete but at least there is enough of a framework of the Frameworks to give the movers and shakers within the new Commissioning Groups something to get their teeth into.

One final thing, we loved the inclusion of “Breast Feeding Initiation” in the Domain entitled “Preventing people from dying prematurely”.  Yes, we can see where they’re coming from but…

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