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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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 2003 4 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 2002 4 Knee Replacement, A Guide to Good Practice, British Orthopaedic Association

9. 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

10. 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

11. 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

12. 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

13. 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

14. The Consultant Outcome Indicator Report

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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