Consultant Outcome Indicator Consultant Outcome Indicator ProgrammeProgramme

Mr K.W.O. ThomsonMr K.W.O. ThomsonChief ExecutiveChief Executive

North West Wales NHS TrustNorth West Wales NHS Trust

Topics coveredTopics covered The Consultant ContractThe Consultant Contract

BackgroundBackground

The pilot projectThe pilot project

The Consultant Outcome Indicator reportThe Consultant Outcome Indicator report

The implementation processThe implementation process

Future developmentsFuture developments

The consultant ContractThe consultant Contract Several elements to the contract which differ slightly across the UK: Several elements to the contract which differ slightly across the UK:

Welsh ExampleWelsh Example

Job Planning The Working Week On Call / Emergency Work Pay and Pay Progression Commitment and Clinical Excellence Awards Disciplinary Arrangements Modernisation & Innovation Clinical Academics Private Practice Equal Opportunities

Part Timers Flexible Working

The Consultant ContractThe Consultant Contract The Job PlanThe Job Plan

Mandatory for all consultantsMandatory for all consultants

Set out consultant duties, responsibilities and Set out consultant duties, responsibilities and expected objectivesexpected objectives

Where consultants work for more than one NHS Where consultants work for more than one NHS employer, a lead employer will be designated and an employer, a lead employer will be designated and an integrated single job plan agreedintegrated single job plan agreed

The Consultant ContractThe Consultant Contract Annual job plan review, supported by the agreed appraisal system Annual job plan review, supported by the agreed appraisal system

and benchmarked information and benchmarked information

Objectives and outcomes will set out a mutual understanding of Objectives and outcomes will set out a mutual understanding of what the consultant and employer will be seeking to achieve over what the consultant and employer will be seeking to achieve over the next 12 monthsthe next 12 months

Expected outputs and outcomes may vary but the headings under Expected outputs and outcomes may vary but the headings under which they could be listed include: activity and safe practice; clinical which they could be listed include: activity and safe practice; clinical outcomes; clinical standards; local service objectives; management outcomes; clinical standards; local service objectives; management of resources; service development; multi-disciplinary team working; of resources; service development; multi-disciplinary team working; and quality of careand quality of care

BackgroundBackground The Welsh Assembly Government embark on negotiations re The Welsh Assembly Government embark on negotiations re

Consultant Contract Jan 2003-Nov 2003Consultant Contract Jan 2003-Nov 2003

North West Wales and Bro Morgannwg NHS Trusts named as Pilot North West Wales and Bro Morgannwg NHS Trusts named as Pilot Sites mid July – Sept 2003Sites mid July – Sept 2003

Pilot results audited by Audit Commission WalesPilot results audited by Audit Commission Wales

WAG ask North West Wales and Bro Morgannwg to develop WAG ask North West Wales and Bro Morgannwg to develop outcome indicators to make job planning more robustoutcome indicators to make job planning more robust

CHKS commissioned by both trusts to undertake a project to CHKS commissioned by both trusts to undertake a project to develop consultant-level outcome indicators involving both develop consultant-level outcome indicators involving both organisations for all specialtiesorganisations for all specialties

Pilot projectPilot project Conducted late 2003 / early 2004Conducted late 2003 / early 2004

Top led Bottom upTop led Bottom up

Consultants from over 30 specialities were interviewedConsultants from over 30 specialities were interviewed

Some other specialities made suggestions in writingSome other specialities made suggestions in writing

Reports were devised for 44 specialities although 59 have been Reports were devised for 44 specialities although 59 have been identified in totalidentified in total

Fed back to negotiating team inc. BMA for acceptance.Fed back to negotiating team inc. BMA for acceptance.

Pilot project – examples of researchPilot project – examples of research Much research was conducted – examples include:Much research was conducted – examples include:

Pioneers in Patient Care: Consultants leading change, British Pioneers in Patient Care: Consultants leading change, British Medical AssociationMedical Association

British Association of Urological Surgeons (BAUS), Section of British Association of Urological Surgeons (BAUS), Section of Oncology, Cancer Registry, Analysis of 2002 data, October 2003Oncology, Cancer Registry, Analysis of 2002 data, October 2003

Changing the Way We Operate, The 2001 Report of the National Changing the Way We Operate, The 2001 Report of the National Confidential Enquiry into Perioperative DeathsConfidential Enquiry into Perioperative Deaths

Good Surgical Practice, Royal College of Surgeons of England, Good Surgical Practice, Royal College of Surgeons of England, September 2002September 2002

Knee Replacement, A Guide to Good Practice, British Orthopaedic Knee Replacement, A Guide to Good Practice, British Orthopaedic AssociationAssociation

Categories of clinical practitionerCategories of clinical practitioner

Practitioner: Services are delivered primarily by Practitioner: Services are delivered primarily by consultants or members of their teamconsultants or members of their team

Leader of multi-disciplinary team: Consultant is the Leader of multi-disciplinary team: Consultant is the strategic director of a multi-disciplinary team, of which strategic director of a multi-disciplinary team, of which there is onethere is one

Member of department: Entire department works as a Member of department: Entire department works as a single teamsingle team

Key considerationsKey considerations Evolution of Indicators. The field of clinical information is Evolution of Indicators. The field of clinical information is

fast-evolving field with many dynamicsfast-evolving field with many dynamics A phased implementation of the indicatorsA phased implementation of the indicators The reports represent a feasible start-point and further The reports represent a feasible start-point and further

iteration and development of the indicators may take place, iteration and development of the indicators may take place, such as patient-captured outcome indicatorssuch as patient-captured outcome indicators

Some local investment in data capture is likely to be Some local investment in data capture is likely to be requiredrequired

A bias towards “modernisation” has been includedA bias towards “modernisation” has been included The reports will show that consultants work under different The reports will show that consultants work under different

variable resourcing arrangements variable resourcing arrangements

Specialisms coveredSpecialisms covered Accident & EmergencyAccident & Emergency Acute MedicineAcute Medicine Adult Mental IllnessAdult Mental Illness AnaestheticsAnaesthetics Breast SurgeryBreast Surgery CardiologyCardiology Care of the ElderlyCare of the Elderly Chemical PathologyChemical Pathology Child & Adolescent Child & Adolescent

PsychiatryPsychiatry Clinical HaematologyClinical Haematology Clinical OncologyClinical Oncology Colorectal SurgeryColorectal Surgery Community PaediatricsCommunity Paediatrics Critical CareCritical Care DermatologyDermatology

EndocrinologyEndocrinology ENTENT Forensic PsychiatryForensic Psychiatry GastroenterologyGastroenterology Genito-Urinary MedicineGenito-Urinary Medicine General Medicine General Medicine General SurgeryGeneral Surgery Gynaecology Gynaecology OncologyOncology HistopathologyHistopathology Learning DisabilitiesLearning Disabilities Medical OncologyMedical Oncology MicrobiologyMicrobiology NephrologyNephrology Obstetrics & GynaecologyObstetrics & Gynaecology

Old Age PsychiatryOld Age Psychiatry OphthalmologyOphthalmology Oral Surgery (including Oral Surgery (including

Maxillo-Facial)Maxillo-Facial) Paediatric DentistryPaediatric Dentistry PaediatricsPaediatrics Pain ManagementPain Management Palliative MedicinePalliative Medicine RadiologyRadiology RehabilitationRehabilitation Respiratory MedicineRespiratory Medicine RheumatologyRheumatology Trauma & OrthopaedicsTrauma & Orthopaedics Upper GI SurgeryUpper GI Surgery UrologyUrology Vascular SurgeryVascular Surgery

The Consultant Outcome Indicator ReportThe Consultant Outcome Indicator Report Annual report per consultantAnnual report per consultant

Developed in conjunction with consultantsDeveloped in conjunction with consultants

Specialty specific indicators Specialty specific indicators

Uses contract minimum data setUses contract minimum data set

Utilises other data sourcesUtilises other data sources

Data entry Data entry

Programme includes on site support and implementationProgramme includes on site support and implementation

The Consultant Outcome Indicator ReportThe Consultant Outcome Indicator ReportMain HeadingsMain Headings

SummarySummary

Activity, Safe Practice and Clinical StandardsActivity, Safe Practice and Clinical Standards

Quality of Care and Clinical OutcomesQuality of Care and Clinical Outcomes

Local Service RequirementsLocal Service Requirements

Management of resourcesManagement of resources

Modernisation Modernisation

The The Consultant Consultant Outcome Outcome Indicator Indicator ReportReport

The Consultant Outcome Indicator ReportThe Consultant Outcome Indicator Report

The Consultant Outcome Indicator ReportThe Consultant Outcome Indicator Report

Dynamic processDynamic processIndicator selection should beIndicator selection should be

Regularly reviewed to remain relevantRegularly reviewed to remain relevant

which could lead to the indicator being: which could lead to the indicator being:

RefinedRefined

RevisedRevised

ReplacedReplaced

RemovedRemoved

RelocatedRelocated

Outcome indicator principlesOutcome indicator principles Participation in professional body and local audit Participation in professional body and local audit

Volume of sentinel cases within the specialismVolume of sentinel cases within the specialism

Complication ratesComplication rates

Efficient use of resourcesEfficient use of resources

Management of the interface with other clinical areas as appropriateManagement of the interface with other clinical areas as appropriate

Multi-disciplinary practice where appropriateMulti-disciplinary practice where appropriate

Presence of specialist facility or arrangementPresence of specialist facility or arrangement

Extended professional roles within the specialismExtended professional roles within the specialism

Demand management where appropriateDemand management where appropriate

Sample generic indicatorsSample generic indicators Process in place to ensure awareness of and adherence to Process in place to ensure awareness of and adherence to

requirement to seek permission to undertake new interventional requirement to seek permission to undertake new interventional procedureprocedure

NICE Guidelines implemented April – May 2004 across England, Scotland and WalesNICE Guidelines implemented April – May 2004 across England, Scotland and Wales

% Day case overstays% Day case overstays Risk adjusted mortalityRisk adjusted mortality Risk adjusted readmissions Risk adjusted readmissions Risk adjusted complicationsRisk adjusted complications % DNA out-patients% DNA out-patients Risk adjusted length of stayRisk adjusted length of stay Out-patient new to follow-up ratioOut-patient new to follow-up ratio

Specialism specific indicatorsSpecialism specific indicatorsBreast SurgeryBreast Surgery

Number of breast surgery procedures for patients with breast Number of breast surgery procedures for patients with breast cancer cancer

% Breast conservation procedures for breast cancer patients% Breast conservation procedures for breast cancer patientsGuidance on Cancer Services, Improving Outcomes in Breast Cancer, manual Update (Aug 2002)

Colorectal SurgeryColorectal Surgery

Contribution to and use of the Association of Coloproctology of Contribution to and use of the Association of Coloproctology of Great Britain and Ireland colorectal cancer databaseGreat Britain and Ireland colorectal cancer database

Specialism specific indicatorsSpecialism specific indicators

NephrologyNephrology Adherence to the nutritional and biochemical standards for Adherence to the nutritional and biochemical standards for

patients on haemodialysis and peritoneal dialysis is patients on haemodialysis and peritoneal dialysis is monitoredmonitored

Audit of all late referrals Audit of all late referrals Treatment of adults and children with renal failure, Renal Association (August 2002)Treatment of adults and children with renal failure, Renal Association (August 2002)

Genito-urinary MedicineGenito-urinary Medicine Waiting times for access to GUM clinic are monitoredWaiting times for access to GUM clinic are monitored

Specialism specific indicatorsSpecialism specific indicatorsOphthalmologyOphthalmology % Cataract procedures that were Phako cataract extractions% Cataract procedures that were Phako cataract extractions

Paediatric MedicinePaediatric Medicine % Activity aged < 1% Activity aged < 1 Individual appointed to lead on children's issues and represent them Individual appointed to lead on children's issues and represent them

on the Boardon the Board Processes in place to ensure that no child about whom there are Processes in place to ensure that no child about whom there are

child protection concerns are discharged from hospital without a child protection concerns are discharged from hospital without a plan in place to ensure their safetyplan in place to ensure their safety

National Service Framework for Children, Standard for Hospital Services (April 2003).National Service Framework for Children, Standard for Hospital Services (April 2003).

% Emergency admissions that had a primary diagnosis of asthma % Emergency admissions that had a primary diagnosis of asthma

The implementation processThe implementation process

Liaison with individual trusts to explain process and key Liaison with individual trusts to explain process and key taskstasks

Validation with trusts of a Consultant List and confirmation Validation with trusts of a Consultant List and confirmation of consultant characterisationsof consultant characterisations

Entry of data and interface with IT systemsEntry of data and interface with IT systems

CHKS produces and disseminates reports CHKS produces and disseminates reports

CHKS presents reports to individual trustsCHKS presents reports to individual trusts

Programme managementProgramme management

Programme Steering GroupProgramme Steering Group

Programme Technical GroupProgramme Technical Group

Establishment of ad hoc groups as necessaryEstablishment of ad hoc groups as necessary

Trust level project team potentially including Medical Director, Trust level project team potentially including Medical Director, Business Managers, Information Manager and CHKS consultant Business Managers, Information Manager and CHKS consultant

Future developmentsFuture developments Expand the number of specialities to include those not present at Expand the number of specialities to include those not present at

the pilot truststhe pilot trusts

Extending the coverage of the reports to all types of indicatorExtending the coverage of the reports to all types of indicator

Using the reports to monitor the ongoing modernisation of clinical Using the reports to monitor the ongoing modernisation of clinical carecare

Keeping the reports up to date to reflect clinical developmentsKeeping the reports up to date to reflect clinical developments