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The COF story so far

What will be the marker of a good CCG? One that bans GPs from routinely prescribing antipsychotic medication to patients with dementia? Or requires clinicians to discuss contraception and pregnancy risks to diabetic women of childbearing age? Could it be one that guarantees brain imaging to patients with suspected stroke within an hour of hospital admission? Or compels hospitals to transport dialysis patients home within 30 minutes? Could a good CCG even be responsible for ensuring people with long-term conditions get back to work?

These questions and more are being grappled with by NICE as it pores over 120 proposed quality indicators, published for consultation last month. The Department of Health has asked NICE to recommend which of these indicators should make the final cut of the commissioning outcomes framework (COF), the instrument by which the NHS Commissioning Board will hold CCCs to account for their performance. CCG performance against the indicators could also determine whether groups receive a ‘quality premium' pay-out, proposed in the health bill.

Keep in, leave out

In an interview with Practical Commissioning, Dr Gillian Leng, NICE's deputy chief executive and director of evidence and practice, stresses that ‘woolly' indicators will be rejected. Those that pass muster should be underpinned by robust evidence and not require data collection activity that staff find too burdensome, she adds.

The proposed indicators are divided between five domains:

• preventing people from dying prematurely

• enhancing quality of life for people with long-term conditions

• helping people to recover from episodes of ill health or following injury

• ensuring that people have a positive experience of care

• treating and caring for people in a safe environment and protecting them from avoidable harm.

The COF indicators have been selected from existing NICE quality standards, the NHS Outcomes Framework (introduced in late 2010)

and other sources. COF will sit alongside new frameworks for adult social care and public health as well as the QOF.

Dr Leng says the COF will be similar to the QOF in that it will largely measure processes rather than true outcomes: ‘That's because we know that at a more local level, process is a better measure because it's more directly influenced by what care is being provided.'

But the COF will differ from the QOF in that it will not be a set of standards formally negotiated between the profession and the DH. Instead, clinicians sitting on NICE's COF advisory committee will have an opportunity to debate the suitability of indicators before a choice is suggested to the DH and NHS Commissioning Board for a final decision. NICE's 20-strong COF committee includes five GPs – most of whom chair CCGs (see box, above), and is chaired by a consultant cardiothoracic surgeon.

Defining ‘good' outcomes

So what defines a ‘good' indicator?

‘It should have a clear numerator and a clear denominator that are defined sufficiently, which means you can make accurate comparisons. For instance, you don't want something woolly – to use an extreme example,"the number of people who had funny turns",' Dr Leng says. ‘Then you've got to know your system and your workers have that information, because if it's going to take them years to collect it, it's not going to work. We also need to know whether it's meaningful at CCG level, as it might be something that isn't common.'

NICE will also consider the grading that the NHS Information Centre has given on each indicator's feasibility to be measured. Proposed indicators that have come from outside NICE's own quality standards will be scrutinised for the evidence underpinning them, Dr Leng adds.

‘I suspect the committee will be quite firm that if there's no evidence underpinning [an indicator], they won't pass it,' she says.

She agrees it is ‘a fair point' that proposed indicators like those measuring employment of people with long-term conditions or mental illness could be unfair for CCGs, given groups' potential lack of control over this.

‘If it's not going to be heavily or largely influenced by what CCGs themselves can do, then it wouldn't be an appropriate indicator,' Dr Leng says.

Another big focus of COF is patient experience. The consultation reveals plans to extend patient-reported outcome measures (PROMs) – currently covering hip replacement, knee replacement, groin hernia and varicose veins – to broader disease areas of asthma and cancer, as well as cataract extraction, percutaneous transluminal coronary angioplasty and coronary artery bypass graft.

Dr Leng says one school of thought in the literature around quality says the only thing that matters is what your patients say: ‘I personally don't think that's all that matters, but it is an important component.

It gives you balance across the whole but I wouldn't want to [solely] rely on it.'

Rejections so far

Minutes of the advisory committee's first meeting show it gave 66 proposed indicators – spanning chronic kidney disease, COPD, dementia, depression, diabetes, glaucoma, stroke, specialist neonatal care and venous thromboembolism – a green light to ‘progress for development'. The committee sent 15 indicators back for ‘clarification' and decided ‘not to progress' five of them.

Reasons for rejection were to avoid duplication with QOF indicators or to recommend that groups of similar indicators be replaced with a single composite one. However, the committee did not reject QOF overlap in all cases. It agreed to test one indicator that would extend the scope of QOF diabetes care by requiring GPs to agree a HbA1c target with diabetes patients, not just monitor levels.

NICE's committee also debated whether some indicator outcomes could be attributed to CCG actions, such as rates of complications associated with diabetes, and whether measuring limb amputations would involve sums too small to measure meaningfully at CCG level. Both indicators were backed, subject to testing.

Dr Leng concedes that ‘at the end of the day, it's the NHS Commissioning Board that will agree what the indicators are'.

She believes the board will want to financially incentivise ‘some' of the indicators, but she does not know how they will be chosen: ‘The general view on financial incentives is that the evidence shows that they work – they focus attention and things improve as a consequence.'

The DH and NHS Commissioning Board have not stipulated the final number of indicators they want in the COF. Ms Leng would personally prefer to start with a small number in the first year and build up from that. NICE is discussing with the DH how to prioritise them.

‘Over the years, NICE's work programme has been informed by prioritisation criteria, particularly around prevalence of disease, burden of morbidity, mortality rates, costs to the NHS and variation in practice, so I think it would be sensible to apply that in some way to this,' she says.

The 55-page consultation document on the COF was only out for the 29 days of February, unlike NICE's usual three-month exercise, in order to ensure indicators are ready by April next year when the NHS Commissioning Board goes live.

More information about the proposed indicators is available at

Rebecca Norris is a freelance journalist

GP members of NICE's COF Advisory Committee

Dr (and Rev) Sarah Baker

GP and designate accountable officer, Warrington Health Consortium

Dr Derek Chase

GP and former chair of Central London Healthcare commissioning group

Dr Mark Davis

GP and board member of Leodis CCG in Leeds

Dr Richard Garlick

GP in Camden, north London, and consultant in public health for NHS Hertfordshire

Dr Guy Pilkington

GP and chair of Newcastle Bridges CCG in Newcastle upon Tyne