Post on 19-May-2018
The NHS PerformanceAssessment Framework
A C T I O N
Distribution For Action
HAs (England) – Chief Executives
NHS Trusts – Chief Executives
For Information
HAs (England) – Chairpersons
NHS Trusts – Chairpersons
PCG – Chairpersons
CHC – Chief Officers
LA – London Borough Chief Executives
LA – Metropolitan Districts – Chief
Executives
LA – Non- Metropolitan Districts – Chief
Executives
Social Services Directors (England)
Medical School Deans
Post Graduate Deans
Regional Advisers in Dental Practice
Further copies from NHS Staff
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0541 555 455
Others
Department of Health
PO Box 410
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LS23 7LN
Fax 0990 210 260
Catalogue number 16431
Date of issue March 1999
A C T I O N
matters requiring action
The NHS PerformanceAssessment Framework
Contents
Page
Executive summary .......................................................................................................1
Introduction ....................................................................................................................3
Section 1: Revised Framework ....................................................................................7
Section 2: Using the Framework in the New NHS................................................10
Section 3: Developing the Framework and HLPI set ...........................................16
Attachment A: The National Framework for assessing performance..............18
Attachment B: The High Level Indicator Set in 1999 - 2000 ..............................19
Attachment C: Developing Benchmarking ............................................................21
The NHS Performance
Assessment Framework
i
Executive summary
This document:
• sets out the NHS Performance Assessment Framework, revised
following the consultation and road test over the Spring and Summer of
1998, for implementation from April 1999;
• explains the ways in which the Framework should be used from April
to:
- move towards assessing performance of the NHS in the round,
covering quality and efficiency;
- encourage benchmarking between similar NHS organisations;
and
- underpin national and local performance and accountability
arrangements.
• lists the High Level Performance Indicators to be used to ensure a
more rounded assessment of NHS performance during 1999-2000; and
• explains the proposed next steps to develop the High Level
Performance Indicators and the use of the Framework.
The NHS Performance
Assessment Framework
1
Introduction - assessing performance in the new NHS
1. The new NHS made a commitment to a National Health Service which - by
delivering quick, high quality, better-integrated services which reduce health
inequalities - will secure better health for the population. It promised to
concentrate on assessing the things which count most to patients and the
public - high quality, cost-effective care that leads to improved health. And
it emphasised the need to pursue quality and efficiency together, since
patients suffer if resources are not used efficiently or to best effect just as
they suffer if quality standards vary.
2. A First Class Service , published for consultation in July 1998, set a three
pronged strategy to drive performance improvement by setting clear
standards, promoting effective delivery of high quality services locally and
ensuring that there are strong monitoring mechanisms in place externally:
• Setting Standards The National Institute for Clinical Excellence
(NICE) will promote clinical and cost effectiveness through guidance
and audit, and advise on best practice. National Service Frameworks
will set national standards and define service models for a specific
service or care group, put in place programmes to support
implementation and establish performance measures against which
progress within an agreed timescale will be measured;
• Delivering Standards Clinical Governance, underpinned by modern
mechanisms for professional self regulation and lifelong learning, will
ensure that national standards and guidance are reflected in the local
delivery of services;
• Monitoring Standards Health Authorities and Primary Care Groups
should use the Framework to monitor service delivery against plans for
improvement across the six areas. The NHS Executive will use the
framework to assess the performance of the NHS. The Commission for
Health Improvement will carry out local reviews to check that systems
to monitor, assure and improve clinical quality are in place. It will
also have a troubleshooting role to help address serious problems. A
National Survey of Patient and User Experience to assess the quality of
NHS care will also be conducted nationally and the results could be
used to initiate action to secure improved services.
The NHS Performance
Assessment Framework
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Figure 1 A simple illustration of the key elements of the NHS quality strategy (from
A First Class Service)
3 Performance assessment is central to all these activities. A First Class Service
highlighted the need for a performance framework which would support the
drive for higher quality standards by ensuring that performance assessment is
focused on the delivery of clinically and cost effective, appropriate and timely
health services to meet local needs.
4 The Performance Assessment Framework has two main purposes. It has been
developed to assist the NHS in work to improve the health of the population
and in providing better care and outcomes for the people who use its
services by encouraging action across the six areas. It will also be used to
assess how the NHS is doing to deliver this work. Using the Framework to
make improvements will be a long term process and will require changes
both nationally and locally. The indicator sets supporting the Framework are
not direct measures of quality but should be used to draw attention to issues
that may need further investigation or action. This means:
at the NHS Executive Headquarters, the development of better and
more useful indicators the encouragement of appropriate action at
local level;
The NHS Performance
Assessment Framework
4
WHAT THE QUALITY FRAMEWORK MEANS FOR PATIENTS
Performance Assessment FrameworkCommission for Health Improvement
National Patient and User Survey
ClinicalGovernance
LifelongLearning
Professionalself regulation
National Service FrameworksNational Institute for Clinical
Excellence
STANDARDS OFSERVICE CLEAR
MONITOREDSTANDARDS
PATIENT &PUBLIC
INVOLVEMENT DEPENDABLELOCAL
DELIVERY
that the NHS Executive Regional Offices have appropriate performance
assessment processes in place to assist and encourage appropriate
action at local level;
that Health Authorities, Primary Care Groups and NHS Trusts consider
the six areas in drawing up Health Improvement Programmes and
work together to ensure that robust Clinical Governance processes are
in place including clinical audit, that data are quality assured and that
local enquiry and learning is encouraged through CPD and life-long
learning.
Messages from the consultation and theroad test
5 The responses to the consultation demonstrated widespread support for the
aims and approach set out in the Framework. They recognised the
significant development agenda which would be necessary to ensure a
comprehensive indicator set across the six areas of the Framework, and to
achieve confidence in using the Framework across the NHS.
6 Over last summer a further stage of refinement to the Framework and
indicator set was undertaken. A road testing programme involving all health
authorities examined the practical use of the Framework and high level
performance indicators. The road test covered a range of applications,
including the assessment of local cancer services, mental health services,
learning disability services and services for the elderly; the development of
the Health Improvement Programme; and involving the public. Road testing
has reinforced the main messages emerging from the consultation: support
for a wider focus on performance and the use of comparative information to
help improve performance by benchmarking and sharing good practice.
7 The road test revealed the importance of the Framework in enhancing joint
working across the partners in local health care systems. At the simplest
level, the six areas of the Framework have been used as the structure for
agendas for meetings between partners. At a more sophisticated level, the
Framework has enabled partners to focus their combined efforts on
improving the quality and efficiency of health care for their population.
5
The Framework involvedwell known concepts butthey had not been broughttogether in this way forplanning purposes before.The health communityendorsed the Framework,it enabled them to moveaway from simplemeasures of efficiencytowards the key healthcare priorities.
Leicestershire HealthAuthority
The Framework hasencouraged a different wayof working within thehealth community.
Calderdale and KirkleesHealth Authority
The conceptual frameworkhelped to reinforce theimportant political messagethat we were moving awayfrom money and activity.It has therefore helped tobegin the process ofrebuilding bridges betweenclinicians ...... andmanagers.
Northamptonshire HealthAuthority
8 The consultation and road test confirm the need for the use of the
Framework and the high level indicator set to develop over time so that:
- Primary Care Groups, for example, can work with their Health
Authorities to determine how to improve performance locally across
the six areas of the Framework;
- the set of HLPIs supports a rounded assessment of the overall success
of the local health care system in delivering high quality, efficient
services for its population;
- the set of HLPIs are used to flag areas where attention might lead to
improved performance - rather than giving information on how the
improvements might be achieved. The latter is a core function of
performance management, which will almost certainly need to focus
on process as well as outcome measures.
6
Ownership of theFramework at all levels inthe NHS is critical to itsuse and usefulness andcontinuing involvement inthe process of refinementat operational levels willbe needed
NW Lancashire HealthPromotion Unit
The Framework providedideas on how to focus oureffort in investigatingperformance standards
Tyne and Wear HealthAction Zone
We should use theindicators for the purposesof learning so that causescan be understood andimprovements agreed.
Royal College of Nursing
Section 1: Revised Framework
9 The Framework was published in January 1998 for consultation. Since then,
there have been a number of significant developments which need to be
taken into account in assessing the performance of the NHS, including:
- the Green Paper and forthcoming White Paper, Our Healthier Nation;
- the outcome of the Comprehensive Spending Review, including the
Modernisation Fund;
- the White Paper, Modernising Social Services ;
- completion of the consultation on A First Class Service; and
- completion of the consultations on Clinical and Clinical Effectiveness
Indicators
These have been taken into account, alongside the consultation and road test,
in revising the Framework and the High Level Indicator Set (the HLPIs).
10 The move to assessing the performance of the NHS in the round was warmly
received in both the consultation and in the road test. The six areas of the
Framework - Health improvement, Fair access, Effective delivery of
appropriate health care, Efficiency, Patient/carer experience and Health
outcomes of NHS care - met with almost unanimous support.
11 A seventh area, focused on human resources, was suggested by some. The
new Strategic Framework for Human Resources will address this important
area and includes targets for improved performance - initially for sickness
absence, violence against staff and participation rates - as well as action on
healthy workplaces, staff involvement, equality in the workplace and
recruitment and retention. But the Performance Assessment Framework is
intended to focus on outcomes for patients. Improved performance on HR
issues across the NHS is a key supporting strategy, essential in securing
success across all six areas by ensuring the NHS can continue to recruit and
retain a high quality workforce.
12 The six areas of the Framework therefore remain as outlined in the
consultation document (Attachment A). The circular presentation in figure 2
reinforces the inter-dependence of the six areas. From an initial view of the
health of the diverse communities of the local population under consideration
(Health Improvement), we need to ensure that everyone with health care
needs (Fair Access) receives appropriate and effective health care (Effective
Delivery) offering good value for money for services (Efficiency) as sensitive
The NHS Performance
Assessment Framework
7
and convenient as possible (User/Carer Experience) so that good clinical
outcomes are achieved (Health Outcome of NHS Care), to maximise the
contribution to improved health (back to Health Improvement).
Figure 2 NHS Performance Assessment Framework
The NHS Performance
Assessment Framework
8
Health Improvementto reflect the over-arching aimsof improving the general healthof the population and reducing
health inequalities, which are influenced by many factors, reaching well
beyond the NHS.
Health Outcomes of
NHS careto assess the direct contribution of NHS careto improvements in overallhealth, and complete the circleback to the over-arching goal ofhealth improvement.
Patient/Carer Experienceto assess the way in which patientsand their carers experience and view the quality of the carethey receive, to ensure
that the NHS is sensitive to
individual needs.
Efficiencyto ensure that
the effective care isdelivered with the
minimum of waste, and that the NHS uses its resources to
achieve value for money.
Effective Delivery ofAppropriate Healthcare
to recognise that fair access must be to care that is effective, appropriate and
timely, and complies with agreed
standards.
Fair Accessto recognise that
the NHS’s contribution must begin by offering
fair access to health services in relation to people’s needs,
irrespective of geography, socio-economic group, ethnicity, age or sex.
The High Level Indicator Set for 1999-2000
13 Each of the original set of High Level Performance Indicators has been
reviewed in the light of the many helpful suggestions and comments from
the consultation exercise and the road test. Some have been removed from
the set - district nurse contacts and avoidable diseases, for example - and
others have been revised. Some new indicators have been included in the
set of HLPIs for 1999-2000 to reflect the four key areas of Our Healthier
Nation and the development of new condition focused unit cost measures.
14 Each key area of Our Healthier Nation provides one indicator for the
health improvement area of the Framework so that deaths rates from heart
disease and stroke, cancer, accidents and from suicide and undetermined
injury are now all included in the HLPI set.
15 New measures of efficiency are under development for use at both HA and
NHS Trust level to support HAs and PCGs in commissioning high-quality,
cost-effective services and to support NHS Trusts in tackling variations in the
costs of the services they provide. Two new unit cost indicators, covering
mental health and maternity services, have been included in the HLPI set to
encourage a more patient-centred assessment of relative efficiency in these
areas, and to inform Service Agreements with NHS Trusts. These will
complement information available at NHS Trust level through the Reference
Cost Index.
16 The original set of HLPIs contained four indicators which relate directly to
performance at the Health/Social Care Interface. Improving performance
in this area will require a coordinated response from both the NHS and Social
Services, working in partnership. These indicators are therefore described as
‘interface indicators’. They will be included in both the HLPI set for the NHS
Framework and the indicator set for the Personal Social Services Performance
Assessment Framework.
17 The results of these changes are summarised in Attachment B, which lists the
revised HLPIs under the headings of the six areas of the Framework. The
baseline figures for each HLPI will be published later this year, with the
Clinical Indicators, to highlight the move towards a broader based assessment
of NHS performance, covering outcomes for patients and the public.
18 The HLPIs are intended to flag up the need for further investigation and
action. In some cases the indicators are already associated with the need for
improved performance and are linked to national targets set out in the
National Priorities Guidance or in the specific conditions and objectives
associated with Modernisation Fund resources. Others may be linked to the
aims and objectives set out in local Health Improvement Programmes. The
link with national and local targets is shown in Attachment B.
The NHS Performance
Assessment Framework
9
The framework has madeus use routinely availabledata in new ways
Buckinghamshire HealthAuthority
Section 2: Using the Framework in the New NHS
Supporting the move towards a broader assessment of performance
19 The NHS Performance Assessment Framework provides a structure for
reviewing NHS performance against outcomes of importance to patients and
the public. As such, it will be of key interest to all players in a local health
community, including health care professionals and NHS managers, social
services and other key local agencies and voluntary organisations as well as
patients, their representatives and the public. It will encourage assessment of
performance in delivering high quality NHS services across a range of
dimensions including:
• population group, for example geographic area, ethnic minority or
social class;
• condition/client group, for example coronary heart disease, asthma
and chronic respiratory disease, children;
• service organisation, for example Health Authority, NHS Trust or
PCG.
Supporting benchmarking
20 The Performance Assessment Framework, together with the high level
indicator set, will enable and encourage benchmarking across the NHS. Over
time, more information - with increasing comprehensiveness, reliability and
comparability - will be provided across each of the six areas. And
information at Health Authority level will be supplemented by comparative
information at NHS Trust level. To support HAs and PCGs in commissioning
high quality services, information will also become available by
condition/client groups.
21 As set out in Information for Health, the aim is to ensure that this
information is accessible to help managers and clinicians assess their own
performance and to support the identification of best practice, so that links
can be made with others in similar organisations to compare progress and
agree ways to improve performance. The identification of some NHS trusts
and general practices as Beacon organisations in the coming year will assist
in this process. The NHS Executive has a work programme to facilitate
benchmarking including the development of an NHSnet site on sharing best
practice. Attachment C gives further details.
The NHS Performance
Assessment Framework
10
The most important way inwhich these data can beused is to show thoseinvolved in a particularpathway of care how theyare performing comparedto other similar areas inthe country..... Then,examples of good practicecan be celebrated andlearned from and examplesof sub optimalperformance can beaddressed.
Rotherham HealthAuthority
The Health Authority havedeveloped a balancedscorecard approach toCHD. The approachincorporates all the areasof the Framework..........andprovides solutions foroperationalising andapplying the Framework atlocal level.
St Helens and KnowsleyHealth Authority
The indicators have aparticular relevance inexploring where theAuthority appears to beperforming less well thanmight be expected, and inconsidering the reasonswhy. This may also behelpful in deciding ifbenchmarking approachescan yield actions toimprove performance.
Southern DerbyshireHealth Authority
Supporting performance improvement and accountability
22 Key players within the local health community will want to use the
Framework to identify areas where change is needed. Discussion about the
pace of change and action required, including any re-allocation of resources,
will contribute to the development of local work programmes. The resulting
agreements on plans, milestones and targets will be highlighted in the Health
Improvement Programme and associated Service and Financial Frameworks.
23 These agreements will be reinforced through formal accountability
arrangements between the NHS and the NHS Executive Regional Offices;
between local NHS organisations; and between a local health system and its
patients and local population. These accountability arrangements, set out in
Figure 3 below, form the backbone of NHS performance management
systems to ensure high quality services are delivered across the NHS and
offer value for money.
11
We will work with primarycare to examine alternativemeasures, possiblyavailable from primary carehealth data, these cancomplement or enhancethe main indicators andlinkage to other activity eghealth promotion contractdata.
North NottinghamshireHealth Authority
Each local strategy shouldaddress how it contributesto the six areas of theFramework. This couldalso be used as aframework for the HealthImprovement Programme
Kensington & Chelsea andWestminster HealthAuthority
Figure 3 Accountability arrangements in the new NHSThe NHS Performance
Assessment Framework
12
Local Authorities NHS
Primary Care Groups
Health Authorities
NHS ExecutiveRegional Offices
Health improvement Programmewith associated SaFF
Statutory accountability
Service accountability
A Performance Agreement
B Financial Duties & Clinical Governance
C Accountability Agreement
D Service Agreement
A B
C
D
D
Supporting public involvement
24 The Framework will support public involvement in developing the local
Health Improvement Programme. Through their involvement in decisions on
priorities for tackling health inequalities and achieving overall improvements
in health, local populations will want to know how their local health system
performs across all six areas of the Framework. The publication of the local
Health Improvement Programme will show how the key players intend to
address the need for improvements in health and will include targets for
improvement for the NHS across the six areas of the Framework. Over time,
the HImP will demonstrate the progress of the NHS towards these targets.
Using the Framework in 1999-2000
25 In the first year of use, the Framework should be used by:
• local health communities to review current performance across all six
areas of the Framework and thereby to support decisions to secure
improvements in local health and health care;
• Health Authorities, NHS Trusts and Primary Care Groups to inform
performance and accountability arrangements and support the
assessment of planned and actual progress across each of the six areas
of the Framework; and
• Ministers and the NHS Executive to account for the use of public
resources in delivering the Government’s objectives for the Department
of Health, particularly those set out for the NHS in the National
Priorities Guidance and the Department’s Public Service Agreement.
26 Over time the Framework will have an important role in the formal
accountability arrangements of the NHS, to ensure that all the organisations in
health communities are playing their part in working to improve performance
across the six areas of the Framework, including:
• The Health Improvement Programme, which will identify targets for
measurable improvements in health and health care. For the NHS,
these targets will reflect the scope for improvement across all six areas
of the Framework. These targets for improvement should be
quantified via Service and Financial Frameworks (SaFFs) which should
include plans to meet key baseline requirements, such as emergency
pressures and financial balance, as well as Modernisation Fund targets,
such as waiting list, primary care and mental health objectives.
The NHS Performance
Assessment Framework
13
We worked closely withrepresentatives of the localmedia. Further closeworking will be anessential feature of takingthe framework forward.
Croydon Health Authority
The decayed missing andfilled teeth index has beenextremely useful inpresenting to healthvisitors, community nursesand school nurses toexplain the size of thedental health problem andenlist their help in dietaryadvice and encouragingregistrations.
Barnsley Health Authority
Identification of outlierscan be an invaluablemeans of focusingattention on previouslyunsuspected differences.
Royal College ofPsychiatrists
The indicator set hasproved useful inconfirming issues requiringpriority attention within theHImP (eg cancers, heartdisease, accidents, suicides,cost effective prescribing,access to hip/ kneereplacements). This isparticularly useful inproviding evidence topartners of why theseissues are a priority.
Doncaster Health Authority
• Annual accountability agreements between a Health Authority and
its local Primary Care Groups which will contain key targets, objectives
and standards for the provision or commissioning of services. These
agreements will be consistent with national priorities and the local
Health Improvement Programme. Progress should be assessed in the
context of the Framework, using locally available information where,
for example, HLPIs are not suitable for use at PCG level.
• Service agreements between Health Authorities/Primary Care Groups
and NHS Trusts which will be patient/service based and developed
typically at Clinical Directorate level. Each Service Agreement should
have jointly owned measures of performance and be linked to targets
for improved performance. Performance against Service Agreements
should be monitored in line with the broader based approach set out
in the Framework.
• NHS Executive Regional Offices and the Regional Offices of the Social
Services Inspectorate, which will continue to monitor jointly
performance across the NHS/Social care interface. The interface
indicators, common to both the HLPI set and the proposed indicator
set for the PSS Framework, aim to help promote a common
understanding and ownership of performance issues at the interface.
• Each HA working with its Regional Office to develop an annual
performance agreement covering all the key objectives of the HA
for the year. The agreement should incorporate plans set out in the
Service and Financial Framework for the year, along with specific
objectives concerned with the development of the HA and PCGs.
These agreements should include an assessment of the expected
influence on performance against local plans across each of the six
areas of the Framework.
The NHS Performance
Assessment Framework
14
The power of theFramework approach liesin its potential to form thebasis of target setting inthe Health ImprovementProgramme andsubsequent performancemanagement andmonitoring.
Southampton and SWHants HA
North Yorkshire HealthAuthority is examiningsome of the HLPIs at PCGlevel to give a fullerunderstanding ofperformance and key localhealth priorities.Preliminary analysisindicates some importantvariations within andacross PCGs.
North Yorkshire HealthAuthority
Obtaining multi-disciplinary input wascritical in enabling us tofully understand and testthe Framework in relationto a clinical service. Wehosted a multi agencyworkshop attended byconsultants and nursingstaff from both the acuteand community trusts,local hospicerepresentatives, the CHC,staff from primary care andNYCRIS.
Wakefield Health Authority
Now Health and SocialCare agencies are workingtogether applying suchconcepts as ‘quality of life’that portray users’ andcarers’ view of their ownhealth and well-being.
Sefton Health Authorityand Sefton Social Services
Section 3: Developing the Framework and HLPI set
27 In the short term, the indicator set will be extended to:
- support the assessment of NHS Trust performance, through the
development of more detailed clinical indicators which can be used to
compare performance across a range of conditions/interventions;
through the publication of Trust Reference Costs and to support
benchmarking and inform differential efficiency targets; and through
the publication of the Audit Commission’s NHS Trust profiles;
- include quality indicators following the development of National
Service Frameworks. The two recently announced NSFs on coronary
heart disease and mental health will build on current work on cancer
services, for which indicators should be available for consultation and
road testing during 1999-2000; and
- support the development of the new NHS Charter programme.
These developments will help demonstrate how the pursuit of quality and
efficiency must go together for the NHS to deliver the best for patients.
28 Work continues to develop a comprehensive, high quality indicator set which
is capable of providing a basis for both national and local assessment. The
many helpful suggestions made in response to the consultation and the ro a d
test will contribute to this work. The development of more and better
indicators for the Fair Access area of the Framework is a high priority - work is
in hand, for instance, to develop HLPIs to assess the availability of primary and
community care services more generally. Attachment C sets out some of the
work in hand to develop comparative information across all six areas of the
F r a m e w o r k .
29 Improving the quality of the data from which the indicators are generated
will be a priority for the NHS in implementing the information strategy,
Information for Health. The strategy acknowledges that the information
requirements of the Framework are beyond the scope of currently established
information flows. It identifies the need for the NHS and the NHS Executive
to work closely together to review data sets and data collection systems in
order to ensure that data are relevant, complete, comparable, stable over time
and available readily and promptly.
The NHS Performance
Assessment Framework
15
The selection of the HLPIset is of critical importanceif the Framework is toadequately cover all healthcare services, eliminateperverse incentives andprovide flexibility for localpriorities.
Northern and YorkshireTrusts
Whilst it is important notto increase overall datacollection in the NHS,there needs to be a morefocused approach so thatfuture indicatordevelopment, reflectingeffective and high qualitycare, is not hampered bypoor data availability.
Wirral Hospital NHS Trust
30 To ensure the continued development of the Framework, the NHS Executive
intends to establish a Performance Framework Reference Group (PFRG). The
PFRG will advise on the development of indicators to support performance
assessment across all six areas of the Framework and on the effective
dissemination and use of the Framework and indicators across the NHS.
Links with other indicator sets
31 The development of the Framework and its high level indicator set has been
complemented by work over the past year to develop a range of indicators,
including:
- a set of clinical indicators;
- clinical effectiveness indicators;
- NHS Trust reference costs;
- primary care effectiveness indicators; and
- in due course, the results of the first survey of NHS patients.
The products of many of these initiatives are reflected directly in the HLPI set.
The Framework will provide the overall structure for the development of all
such performance indicator sets in the future.
National publications
32 A number of perf o rmance indicators will be published, as the inform a t i o n
becomes available. The first of these, Reference Costs, were published in
November 1998. The baseline data for the revised High Level Perf o rm a n c e
Indicators listed in Attachment B will also be available later this year, alongside
the clinical indicators. These will support the assessment of both the quality and
e fficiency of services.
33 In future years, these publications will be brought together under the umbre l l a
of the Perf o rmance Assessment Framework. Publications will be used to
demonstrate pro g ress in improving health and health care year on year acro s s
all six areas of the Framework, so that NHS perf o rmance can be assessed in the
round, against the outcomes that matter most to patients and the public.
The NHS Performance
Assessment Framework
16
The participative way inwhich the Framework hasbeen introduced iswelcomed ..............and theFramework will need toevolve to reflect emergingcurrent key performanceissues within the NHS.
Lincolnshire HealthAuthority
Attachment AThe NHS Performance AssessmentFramework
The NHS Performance
Assessment Framework
17
Areas Aspects of performance
I Health improvement The overall health of populations, reflecting socialand environmental factors and individualbehaviour as well as care provided by the NHSand other agencies
II Fair access The fairness of the provision of services inrelation to need on various dimensions:- geographical- socio-economic- demographic (age, ethnicity, sex)- care groups (eg. people with learning
difficulties)
III Effective delivery of The extent to which services are:appropriate health care - clinically effective (interventions or care
packages are evidence-based)- appropriate to need- timely- in line with agreed standards- provided according to best practice service
organisation- delivered by appropriately trained and
educated staff
IV Efficiency The extent to which the NHS provides efficientservices, including:- cost per unit of care/outcome- productivity of capital estate- labour productivity
V Patient/carer The patient/carer perceptions on the delivery of experience services including:
- responsiveness to individual needs and preferences
- the skill, care and continuity of service provision
- patient involvement, good information and choice
- waiting times and accessibility- the physical environment; the organisation
and courtesy of administrative arrangements
VI Health outcomes of NHS success in using its resources to:NHS care - reduce levels of risk factors
- reduce levels of disease, impairment and complications of treatment
- improve quality of life for patients and carers- reduce premature deaths
Attachment B -the High Level Indicator Set in 1999-2000
The NHS Performance
Assessment Framework
18
I. Health Improvement
Deaths from all causes (for people aged 15-64)
Deaths from all causes (for people aged 65-74)
Cancer registrations
Deaths from malignant neoplasms 1,2
Deaths from all circulatory diseases 1,2
Suicide rates 1,2
Deaths from accidents 1,2
II. Fair Access
Surgery rates 1
Size of inpatient waiting list per head of population (weighted) 5
Adults registered with an NHS dentist 5
Children registered with an NHS dentist 5
Early detection of cancer 1
III. Effective Delivery of Appropriate Health care
Disease prevention and health promotion 1,5
Early detection of cancer 1
Inappropriately used surgery
Surgery rates 1
Acute care management 5
Chronic care management 5
Mental health in primary care 5
Cost effective prescribing
Discharge from hospital 3,4
IV. Efficiency
Day case rate
Length of stay in hospital (case-mix adjusted)
Unit cost of maternity (adjusted) 5
Unit cost of caring for patients in receipt of specialist mental health services (adjusted)5
Generic prescribing
continued over page
Footnotes
1 Associated with objectives and/or targets in National Priorities Guidance
2 Proposed indicators for Our Healthier Nation
3 Indicators on interface with PSS Performance Framework
4 Clinical Indicators
5 Amended for 1999-2000, following consultation and road test.
The NHS Performance
Assessment Framework
19
V. Patient / Carer experience of the NHS
Patients who wait less than 2 hours for emergency admission (through A&E)
Patients with operation cancelled for non-medical reasons
Delayed discharge from hospital for people aged 75 or over 3
First outpatient appointments for which patient did not attend
Outpatients seen within 13 weeks of GP referral 1
% of those on waiting list waiting 12 months or more 1,5
VI. Health Outcomes of NHS health care
Conceptions below age 16 2
Decayed, missing and filled teeth in five year old children 1
Adverse events / complications of treatment 4
Emergency admissions to hospital for people aged 75 and over 1,3
Emergency psychiatric re-admission rate 1,3
Infant deaths
Survival rates for breast and cervical cancer 1
Avoidable deaths
In-hospital premature deaths 4
Attachment C – Developing Benchmarking
“The new performance framework will encourage greater benchmarking of
performance in different areas, and the publication of comparative information will
allow people to compare performance and share best practice. Coupled with the new
National Service Frameworks, the Government will use these measures for a
systematic drive to challenge and reduce unacceptable variations in all aspects of
performance across the NHS.”
The new NHS, Paragraph 8.7
Introduction
1 The government’s commitment to improve performance through greater
benchmarking, requires action at national and local level. This attachment
sets out plans to support benchmarking across the NHS.
Objectives of Benchmarking; The Role of the NHS Executive
2 The essence of benchmarking is the identification, understanding,
dissemination and implementation of best practice.
3 In the new NHS, the objective of benchmarking is to improve the overall
performance of the NHS across all six areas of the Performance Assessment
Framework. The potential for improvement through emulation and extension
of best practice is high. Currently there are substantial variations in unit costs,
in treatment rates and in outcomes. Where variations are due to varying
standards of care and efficiency, there is potential for improvement through
benchmarking.
4 To support local action to increase the priority given to benchmarking, the
NHS Executive will:
- support the development of the comparative information needed to
underpin benchmarking activity;
- encourage the use of comparative information to support the
implementation of best practice, including by providing easy access to
the comparative data on the ‘Learning Zone’ intranet website (see
paragraph 10 below); and
- identify and publicise beacon providers in the fields of waiting lists
and times; primary care; mental health; staff development; cancer
services and health improvement. These sites will disseminate their
work actively, for example through receiving visitors and placing
material on the ‘Learning Zone’ Intranet website (see paragraph 10
below).
The NHS Performance
Assessment Framework
20
Creating robust comparisons across the six areas
5 In the long term, comparative information will be needed:
- across each of the six areas of the Performance Assessment
Framework, and
- at each level of service provision (including comparisons of different
service providers for particular client or disease groups and
comparisons between NHS Trusts, PCGs and HAs).
Such information needs to be relevant, reliable, sensitive to legitimate cost
drivers (eg case-mix), and coherent.
6 Two important developments will be needed to help secure information that
meets these criteria:
• first, the establishment of appropriate units of account in order to
allow more meaningful comparisons. Over time, two new units of
account (in addition to the Finished Consultant Episode, FCE) will be
developed:
- a ‘Provider Spell’, to be the focus of comparisons of providers’
technical efficiency. A provider spell covers the care provided from
admission to discharge; is classified by the type of care provided (e.g.
by HRG), irrespective of the setting of care and the length of stay; and
is costed by the provider.
- a ‘Programme Spell’ to be the focus of broader comparisons of the
performance of the NHS as a whole, and of the services commissioned
by HAs and PCGs through long term service agreements. A
Programme Spell includes all care delivered to a patient from
beginning to end of the treatment relating to a particular need. (For
patients with chronic conditions, this could relate to a particular time
period - for example, a year). Programme Spells will be classified by
the condition of the patient. Work to develop these measures will be
facilitated by the work set out in the Information Strategy to introduce
Electronic Patient Records and Electronic Health Records.
• second, data quality and timeliness will be improved as set out in
the Information Strategy in order to enhance the quality, consistency,
credibility and value of comparisons.
7 Weakness associated with current data quality and scope, however, should
not prevent action to deliver some comparisons soon, both to allow local
investigations of outliers to begin, and as a spur to improvements in data
quality. The table below indicates some of the initiatives that are currently in
place or are under consideration to extend the range of comparative
information available to different NHS organisations.
The NHS Performance
Assessment Framework
21
Comparisons under development shown in italics.
Ensuring that comparisons are exploited
8 Moving from “acceptable” to “best” practice will require a culture change in
some parts of the NHS. Sharply focused comparisons will challenge the NHS
to improve performance across all six areas of the Performance Assessment
Framework.
22
SCOPE OF Programmes Trusts Health Authorities
BENCHMARKING of care and PCGs
HEALTH Assessments for NSF Public Health Common
IMPROVEMENT conditions. Data Set
HLPIs
FAIR ACCESS Assessment of variation in Assessment of variation HLPIs
utilization rates for in admission rates for Performance Tables:
effective treatments for effective treatments relative various access measures
different conditions, to need.
relative to need.
EFFECTIVE DELIVERY Assessment of utilization Assessment of admission HLPIs
OF APPROPRIATE rates for more or less rates relative to need for Clinical Effectiveness
HEALTH CARE effective treatments for more or less effective Indicators
NSF conditions. treatments.
Effectiveness indicators Voluntary national audits
being developed for (e.g. Intensive Care
specific conditions National Audit and
Research Centre)
EFFICIENCY Database of Reference Audit Commission Trust HLPIs
Costs “developed to Profiles: acute hospital
support ... programmes of unit costs allowing for
care for patients with casemix and other cost
different needs” drivers.
(White Paper, para 9.22); Investigation of Drivers of
in the first instance, for Trust efficiency
NSF conditions. Schedule of Reference
Costs and Reference
Cost Index
PATIENT/CARER National Patient Survey Performance Tables: HLPIs
EXPERIENCE (hospitals) complaints performance; Performance Tables:
waiting times waiting times etc
National Patient Survey National Patient Survey
HEALTH OUTCOMES Outcome Measures being Clinical Indicators - HLPIs
OF NHS CARE developed for particular Trust level mortality rates Clinical Indicators
diseases for particular procedures.
23
The NHS Performance
Assessment Framework
9 Regional Offices will encourage and facilitate local efforts to improve
performance and to attain and advance best practice, through supporting
local benchmarking groups, dissemination of re-engineering techniques and
mentoring to bring together NHS organisations to improve understanding of
the reasons for variations in performance and to identify mechanisms for
improvement.
10 A “Learning Zone” Intranet website is now being piloted. It makes available
the results of this work, and of linked initiatives. It will be used to provide:
- comparative information tailored to the needs of different users
(commissioners, NHS Trusts, clinical teams, etc);
- information on initiatives to encourage and enable the identification
and spread of best practice across the six areas of the Performance
Framework;
- suggestions of good practice in the process of health care
commissioning and provision;
- information on identified beacon performers for different services; and
- contact points from whom further information could be obtained, and
to whom suggestions of how the NHS Executive could further support
benchmarking across the NHS could be sent.