Consultant Outcome Indicator Programme Mr K.W.O. Thomson Chief Executive North West Wales NHS Trust

Topics covered l The Consultant Contract l Background l The pilot project l The Consultant Outcome Indicator report l The implementation process l Future developments

The consultant Contract l Several elements to the contract which differ slightly across the UK: Welsh Example 4 4 Job Planning 4 4 The Working Week 4 4 On Call / Emergency Work 4 4 Pay and Pay Progression 4 4 Commitment and Clinical Excellence Awards 4 4 Disciplinary Arrangements 4 4 Modernisation & Innovation 4 4 Clinical Academics 4 4 Private Practice 4 4 Equal Opportunities s s Part Timers s s Flexible Working

The Consultant Contract l The Job Plan 4 Mandatory for all consultants 4 Set out consultant duties, responsibilities and expected objectives 4 Where consultants work for more than one NHS employer, a lead employer will be designated and an integrated single job plan agreed

The Consultant Contract l Annual job plan review, supported by the agreed appraisal system and benchmarked information l Objectives and outcomes will set out a mutual understanding of what the consultant and employer will be seeking to achieve over the next 12 months l Expected outputs and outcomes may vary but the headings under which they could be listed include: activity and safe practice; clinical outcomes; clinical standards; local service objectives; management of resources; service development; multi-disciplinary team working; and quality of care

Background l The Welsh Assembly Government embark on negotiations re Consultant Contract Jan 2003-Nov 2003 l North West Wales and Bro Morgannwg NHS Trusts named as Pilot Sites mid July – Sept 2003 l Pilot results audited by Audit Commission Wales l WAG ask North West Wales and Bro Morgannwg to develop outcome indicators to make job planning more robust l CHKS commissioned by both trusts to undertake a project to develop consultant-level outcome indicators involving both organisations for all specialties

Pilot project l Conducted late 2003 / early 2004 l Top led Bottom up l Consultants from over 30 specialities were interviewed l Some other specialities made suggestions in writing l Reports were devised for 44 specialities although 59 have been identified in total l Fed back to negotiating team inc. BMA for acceptance.

Pilot project – examples of research l Much research was conducted – examples include: 4 Pioneers in Patient Care: Consultants leading change, British Medical Association 4 British Association of Urological Surgeons (BAUS), Section of Oncology, Cancer Registry, Analysis of 2002 data, October Changing the Way We Operate, The 2001 Report of the National Confidential Enquiry into Perioperative Deaths 4 Good Surgical Practice, Royal College of Surgeons of England, September Knee Replacement, A Guide to Good Practice, British Orthopaedic Association

Categories of clinical practitioner l Practitioner: Services are delivered primarily by consultants or members of their team l Leader of multi-disciplinary team: Consultant is the strategic director of a multi-disciplinary team, of which there is one l Member of department: Entire department works as a single team

Key considerations l Evolution of Indicators. The field of clinical information is fast-evolving field with many dynamics l A phased implementation of the indicators l The reports represent a feasible start-point and further iteration and development of the indicators may take place, such as patient-captured outcome indicators l Some local investment in data capture is likely to be required l A bias towards “modernisation” has been included l The reports will show that consultants work under different variable resourcing arrangements

Specialisms covered l Accident & Emergency l Acute Medicine l Adult Mental Illness l Anaesthetics l Breast Surgery l Cardiology l Care of the Elderly l Chemical Pathology l Child & Adolescent Psychiatry l Clinical Haematology l Clinical Oncology l Colorectal Surgery l Community Paediatrics l Critical Care l Dermatology l Endocrinology l ENT l Forensic Psychiatry l Gastroenterology l Genito-Urinary Medicine l General Medicine l General Surgery l Gynaecology l Oncology l Histopathology l Learning Disabilities l Medical Oncology l Microbiology l Nephrology l Obstetrics & Gynaecology l Old Age Psychiatry l Ophthalmology l Oral Surgery (including Maxillo-Facial) l Paediatric Dentistry l Paediatrics l Pain Management l Palliative Medicine l Radiology l Rehabilitation l Respiratory Medicine l Rheumatology l Trauma & Orthopaedics l Upper GI Surgery l Urology l Vascular Surgery

The Consultant Outcome Indicator Report l Annual report per consultant l Developed in conjunction with consultants l Specialty specific indicators l Uses contract minimum data set l Utilises other data sources l Data entry l Programme includes on site support and implementation

The Consultant Outcome Indicator Report Main Headings l Summary l Activity, Safe Practice and Clinical Standards l Quality of Care and Clinical Outcomes l Local Service Requirements l Management of resources l Modernisation

The Consultant Outcome Indicator Report

Dynamic process Indicator selection should be l Regularly reviewed to remain relevant which could lead to the indicator being: which could lead to the indicator being: l Refined l Revised l Replaced l Removed l Relocated

Outcome indicator principles l Participation in professional body and local audit l Volume of sentinel cases within the specialism l Complication rates l Efficient use of resources l Management of the interface with other clinical areas as appropriate l Multi-disciplinary practice where appropriate l Presence of specialist facility or arrangement l Extended professional roles within the specialism l Demand management where appropriate

Sample generic indicators l Process in place to ensure awareness of and adherence to requirement to seek permission to undertake new interventional procedure NICE Guidelines implemented April – May 2004 across England, Scotland and Wales l % Day case overstays l Risk adjusted mortality l Risk adjusted readmissions l Risk adjusted complications l % DNA out-patients l Risk adjusted length of stay l Out-patient new to follow-up ratio

Specialism specific indicators Breast Surgery l Number of breast surgery procedures for patients with breast cancer l % Breast conservation procedures for breast cancer patients Guidance on Cancer Services, Improving Outcomes in Breast Cancer, manual Update (Aug 2002) Colorectal Surgery l Contribution to and use of the Association of Coloproctology of Great Britain and Ireland colorectal cancer database

Specialism specific indicators Nephrology l Adherence to the nutritional and biochemical standards for patients on haemodialysis and peritoneal dialysis is monitored l Audit of all late referrals Treatment of adults and children with renal failure, Renal Association (August 2002) Genito-urinary Medicine l Waiting times for access to GUM clinic are monitored

Specialism specific indicators Ophthalmology l % Cataract procedures that were Phako cataract extractions Paediatric Medicine Paediatric Medicine l % Activity aged < 1 l Individual appointed to lead on children's issues and represent them on the Board l Processes in place to ensure that no child about whom there are child protection concerns are discharged from hospital without a plan in place to ensure their safety National Service Framework for Children, Standard for Hospital Services (April 2003). l % Emergency admissions that had a primary diagnosis of asthma

The implementation process l Liaison with individual trusts to explain process and key tasks l Validation with trusts of a Consultant List and confirmation of consultant characterisations l Entry of data and interface with IT systems l CHKS produces and disseminates reports l CHKS presents reports to individual trusts

Programme management l Programme Steering Group l Programme Technical Group l Establishment of ad hoc groups as necessary l Trust level project team potentially including Medical Director, Business Managers, Information Manager and CHKS consultant

Future developments l Expand the number of specialities to include those not present at the pilot trusts l Extending the coverage of the reports to all types of indicator l Using the reports to monitor the ongoing modernisation of clinical care l Keeping the reports up to date to reflect clinical developments