Health Inequalities National Support Team
Enhanced Support Programme
How to develop and implement a Balanced Scorecard to tackle health inequalities
2
DH INFORMATION READER BOX
Policy EstatesHR/Workforce CommissioningManagement IM&TPlanning/Performance FinanceClinical Social Care/Partnership Working
Document purpose Best Practice Guidance
Gateway reference 13768
Title How to Develop and Implement a Balanced Scorecard to Support Primary Care Development
Author Jane Leaman
Publication date 05 Mar 2010
Target audience PCT CEs, NHS Trust CEs, Care Trusts CEs, Foundation Trust CEs, Directors of PH, Local Authority CEs
Circulation list SHA CEs, Medical Directors, Directors of Nursing, Directors of Adult SSs, PCT PEC Chairs, PCT Chairs, NHS Trust Board Chairs, Special HA CEs, Directors of HR, Directors of Finance, Allied Health Professionals, GPs, Communications Leads, Emergency Care Leads, Directors of Children’s SSs, Voluntary Organisations/NDPBs
Description One in a series of “How to” guides published as part of the Redoubling efforts to achieve the 2010 National Health Inequalities Life Expectancy Target resource pack
Cross ref Systematically Addressing Health Inequalities
Superseded docs N/A
Action required N/A
Timing N/A
Contact details Health Inequalities National Support TeamNational Support Team (NSTs) Wellington House 133-155 Waterloo Road London SE1 8UG 0207 972 3377 www.dh.gov.uk/hinst
For recipient’s use
HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Systematic and scaled interventions by frontline services
(B)
Partnership, vision and strategy,
leadership and engagement (A)
Personal health
Community health
Population health
Systematic community
engagement (C)
Frontline service engagement with the community (D)
Population focus Optimal population outcome
Challenge to providers
10. Supported selfmanagement
9. Responsive services
7. Expressed demand
8. Equitable resourcing
6. Known population
needs
1. Known intervention
efficacy
13. Networks, leadership and coordination
5. Engaging the public
4. Accessibility
2. Local service effectiveness
3. Costeffectiveness
12. Balanced service portfolio
11. Adequate service volumes
Bentley C (2007). Systematically Addressing Health Inequalities, Health Inequalities National Support Team.
Foreword TheHealthInequalitiesNationalSupportTeam(HINST)haschosentoprioritisethe developmentandimplementationofaBalancedScorecardasoneofits‘Howto’guides forthefollowingreasons:
• Inconsistentqualityofprimarycarewilldeliverinequitableoutcomes.Inorderto addressthisandhaveanimpactatpopulationlevel,approachestodevelopment willneedtobesystematicandsustainable,andmustaddressclinicalandmanagerial systemsandcompetencies.
• Specificallywithinthe‘Christmastree’diagnostic,itparticularlyaddressesthe followingcomponents:
– localserviceeffectiveness(2)
– engagingthepublic(5)
– knownpopulationhealth(6)
– responsiveservices(9).
• ActioninthisareaofworkwillhelptocontributetotheQualityandProductivity Challengebyprovidingamechanismtodevelopsystematicallythequalityand productivityofprimarycare.
• Successfuladoptionofprocessessimilartothoseoutlinedherewoulddemonstrate gooduseofthefollowingWorldClassCommissioningcompetencies:
– primarycaretrusts(PCTs)aslocalleadersoftheNHS(1)
– patientandpublicengagement(3)
– collaborationwithclinicians(4)
– stimulatesthemarket(7)
– performancemanagement(10).
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
CoNTexT Theaimofthis‘Howto’guideistoproduceasimpletooltohelpSpearheadareasto developwaysinwhichtomeasurethequalityandcapacityofprimarycareanddeliver the2010PublicServiceAgreementtargettoreducehealthinequalities.Itdoesnot providenewguidancebutwilldrawonthefindings/learningfromareaswherethese toolsarebeingused,andcomplementsPrimary Care & Community Services: Improving quality in primary care,particularlyfocusingontwoofthesevenidentifiedelements: measuringqualityandpublishingqualityinformation.1
ThisguidehasbuiltontheNHSPrimaryCareCommissioning(NHSPCC)paperQuality Development Methodology Using a Balanced Scorecard.2Itusesexamplesofandlessons fromanumberofPCTswhoareatdifferentstagesintheirdevelopmentofaScorecard. However,whiletheseareasprovideexamplesforthisguide,localissuesofqualitymaynot beofthesameorderofmagnitudeorinexactlythesamedevelopmentalareas;therefore alocallyrelevantandlocallyownedScorecardprocessshouldyieldthegreatestbenefit.
Allresidentsneedaccesstoeffectiveprimarymedicalcare,particularlyinrelation tothemajorcontributorstoearlydeath.Thesearecardiovasculardisease,cancer andrespiratorydisease,andallareespeciallyrelevantintermsofaddressinghealth inequalities.Therefore,inordertoachievethe2010PSAtarget,HINSTregardsrapid developmentofthequalityofthissectorascritical.ImplementationofaBalanced Scorecardcanimprovebothspecifichealthinequalityindicatorstargetsandthequalityof generalpracticemorewidely,whichshouldhaveapositiveimpactonhealthoutcomes.
APCThasalegalresponsibilityforensuringdeliveryofprimarymedicalcaretothewhole residentpopulation.Indischargingthisresponsibility,thePCTcanexpecttoinvesttime, expertiseandotherresourcestosecureimprovedqualityandproductivity,andincreased costeffectivenessofcare.Strategically,theBalancedScorecardcanthereforesupportthe deliveryofthePCT’squalityandproductivityagendaforthelocalpopulation.Theapproach alsodemonstratesthatthecommissionersareworkingtoachievehighlevelsofWorld ClassCommissioningassuranceandcanusetheevolvingproductasassuranceevidence.
High Quality Care for All3reinforcestheNHSNextStageReviewvisionofanNHS inwhichqualityistheorganisingprinciple.Thiswillhelptoensurethatimproved qualityandinnovationcanberealised.ItsgoalisforeveryproviderofNHSservices tosystematicallymeasure,analyseandimprovequality.Tosupportthis,service commissionerswillneedtodeveloptheirownqualityframeworks,combiningrelevant indicatorsdefinednationallywiththoseappropriatetolocalcircumstances.
MostPCTshavenowbeguntodevelopBalancedScorecards,themethodologyof whichhasbeenevolvingoverthelastcoupleofyears.BalancedScorecardsareseen byPCTsasfundamentalto‘mappingthebaseline’inordertoensurethatprimarycare iscontributingtohealthoutcomeswithinacommunity,andtoinformcommissioning decisions.4However,thisapproachisnotconsistentacrossallPCTs,andforsomethis maybetimeforreview,asallarebeingcalledtoevidencequalityandproductivityinall areasofcommissioning.Theguide,itishoped,willalsohelpPCTstoreviewthepurpose
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
oftheirBalancedScorecardsrelevanttotheircurrentrequirements,withregardtohealth inequalitiesandtheirprocessesofimplementation.
TheBalancedScorecardwillalsosupporttheCareQualityCommission’splanned registrationofgeneralpracticesfrom2012;andtheGeneralMedicalCouncil’s revalidationprocessofGPs.Ideally,thereshouldbetheaimofhavingthisonedataset formanyuses.
Atwhateverstageofitsdevelopment,inthoseareaswhosecommunitiesexperiencea highlevelofhealthinequality,theBalancedScorecardshouldbesetwithinthecontext ofaprimarycareimprovementplanorprimaryandcommunitycarestrategywhich aimstoaddresshealthinequalitiesandimprovelifeexpectancyintheshortterm.NHS Next Stage Review: Our vision for primary and community care(www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085937) statesthatallPCTsshouldhaveaprimaryandcommunitycarestrategy,whichincludes theprimarycareimprovementplan.
Todothis,indicatorsshouldfocusondemonstrating,forexample:
• thatthenumbersofpeopleonprimaryregistersandthepredictedprevalenceofa particulardiseasematch(throughcasefinding)
• thatQualityOutcomesFramework(QOF)indicatorsaremetorexceededforchronic diseasemanagement
• thatexceptionandexclusionreportingisataminimum
• thelevelofhealthserviceaccessofparticularcommunitieswhoarelikelytoexperience ahigherlevelofhealthinequalitiesthantheaverageforthepopulation.
ExamplesofspecificindicatorsaresetoutinAppendix4.
ABalancedScorecardforprimarycareisacollectionofdatafromallgeneral practicesinaPCTarea,acrossarangeoflocallyrelevantmetrics.Thiswillenablethe managementofperformanceandtheidentificationofbothdevelopmentalsupport needsandgapsinserviceprovision.
AdvANTAgeS ANd CHAlleNgeS oF developINg ANd ImplemeNTINg A BAlANCed SCoreCArd ForHeAlTH INequAlITIeS
Local leadership and ownership
PCTleadershipandexecutiveaccountabilityforimprovingqualityinprimarycare, togetherwitheffectiveclinicalleadershipandownership,iscrucialforthesuccessful implementationofaBalancedScorecard.ThisguideispremisedonthefactthatthePCT hasclearcommitmenttoimprovingqualityinprimarycareandthatithasexpressedthat aBalancedScorecardapproachisthebestapproachtomeasured,sustainablequality improvement.Ithasbeenidentifiedthatallsuccessfulprogrammestoimproveprimary
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
carequalitythatuseaBalancedScorecardhavefullBoardsign-upandengagement.The Scorecardshouldcomplementotherknowledgemanagementtools,whichthemselves canpopulatefurtheriterationsoftheScorecard;forexample,thePrimaryCare CommissioningSupport(PCCS)applicationpublishedbytheDepartmentofHealth(DH) tosupportPCTsinassessingpractice-leveldata,togetherwiththeNHSPCCqualityand productivitycalculatorwhichlooksatcomparativePCTperformance.
PCTscouldalsoconsiderinvolvingtheirequalityanddiversityleadstoexplorehowthis toolcanbelocalised,incorporatingotherequalitydimensions,nationalequalityguidance andlocalequalitypolicies.
Clarity of purpose
PCTSneedtobeclearofthepurposeofhavingaBalancedScorecard.Examplesacross thecountryhavebeenasadevelopmental,performancemanagementorcommissioning tool,or(ideally)allthree.Morerecently,followingtheintroductionofWorldClass Commissioning,anumberofPCTshaveusedaBalancedScorecardto‘stimulatethe market’,usingitasawayofensuringadequateserviceprovisioninalocalcommunity andachieveagreedhealthoutcomesdescribedinthebestpracticeguidance.NHS NorthamptonshireusedaBalancedScorecardtosupporttheproductionofan excellentprimarycaremarketmanagementstrategy.Itcanbeusedtodetermine keycommissioningprioritiesandinformthewiderprimaryandcommunitycare commissioningstrategy.
examples of purpose from pCTs
Transparentlyassessthequalityofgeneralpracticeonanannualbasis,andspeedup therateofimprovement.(NHSTowerHamlets,2007)
Addresslocalissuesandlocalneed,addressinghealthinequalities,particularlyinrelation toaccesstoprimarycareservicesandpublichealth.(NHSTowerHamlets,2009)
Provideafocusforsupportingthedevelopmentofprimarycareratherthan performancemanagement.(NHSKnowsley,2009)
Paintapictureofthepracticeandthecontextitisworkingin.Thematchingof deprivationanddemographicdatatopublichealthindicatorsprovidesausefulcontext forperformanceandprovidesaninsightintounderstandingwhatinterventionsmaybe appropriate.(DoncasterPCT,2009)
However,thereisanationalmovetofocusontheperformanceofprimarycarethrough thismethodology,ratherthanusingitonlyasadevelopmentaltool.Thisisdescribed inthebestpracticeguidancePrimary Care and Community Services: Improving GP services.5ThispublicationdescribeshowthePCTscan‘mapthebaseline’tobegina processofmonitoringpracticeperformanceinanumberofareasandsupporteffective commissioningofprimarycare.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Thismaychangeovertime,dependingonthecircumstancesofprimarycare.For example,TowerHamletschangedtheScorecardfromadevelopmentaltooltoa performance/commissioningtoolin2008/09–tostrengthencommissioning,allowing practicestoearnautonomyandimprovethequalityofservicedeliveryandredesign.
Whatevertheultimategoal,aBalancedScorecardcanalsofulfilarangeof supplementaryfunctions,including:
• topromotegoodquality,andsupportimprovementinefficiencyandeffectiveness
• todetectfallingperformanceearlyenoughtopreventadverseconsequences
• toidentifyappropriatecapacitytodeliveroutcomes
• toidentifyareaswherethereisneedforserviceredesign
• toprovidecommissioningdata/information(forcommissioningprimarycareand integratedservices)
• toreassurepatientsintermsofthequalityofserviceandpublishedinformation, enablingpatientstomakerobustchoicesaboutwhichprimarycareservicestheywish toaccess
• todemonstratethevalueofprimarycare–makingitsroleandimpactvisible
• todemonstratethatprimarycareis‘fitforpurpose’
• tounpickandimprovethequalityofdata,whichcanreassurepracticesthattheyhave theappropriatelevelsofinvestment
• tosupportthedevelopmentofaneffective,local,contractualperformanceframework wherepersonalmedicalservices(PMS)andalternativeprovidersofmedicalservices (APMS)contractsareinplace.
The process for implementation in itself is useful in identifying where there is a need to improve quality.
example of practice
CoventryPCTincludedpracticeresourceandpopulationneed(age,percentageof SouthAsianethnicorigin–derivedfromNamPehchansurnameanalysis–andpractice indicesofmultipledeprivation(IMD)score)inadditiontoperformancemeasures.This wasespeciallyusefulbecauseithighlightedresourceinequityandshowedthat‘good’ performancecouldbeachievedfordeprivedpopulations.
Knowledge management, data quality and data reporting
Thisisoftenabigissue.Therecanbedifferentresultsfromdifferentdatasources,for exampleinmeasuringcervicalscreeninguptakeusingthequalitymanagementand analysissystem(QMAS)orusingpublichealthsubmissionstoDH.Asaprinciple,as muchdataaspossibleshouldbesourcedusingthepracticelistofpatients;wheredata isactuallyaprojectionorderivedfromasecondarysourceitmaybemoreopento challenge,lessreproducibleandthereforeseenaslessreliable.Training,particularlyin goodcoding,mayberequiredtoimprovedataquality.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Thereareotheremergingtools,suchasthequalityandproductivitychallenge(QPC) calculatordevelopedbyNHSPCC,andthePCCSapplicationdevelopedbytheDH,both ofwhichaimtosupportcommissionersintheeffectiveuseofinformationgainedfrom existingprimarycaredatatosupportqualityandproductivity.Therehaspreviouslybeen acultureinsomeareaswithinprimarycareofnotsharinginformation,butwiththe emergenceofmoreeffectivetoolsandthedevelopmentoftheNHSChoiceswebsite, PCTsarebeginningtobeabletoapplyknowledgemanagementmuchmoreeffectively.
Ownershipandbetterunderstandingofdatabypractices,throughaprocessof verificationofdata-useandanagreementaboutwhichdatasourcesareused,willalso helpinthesharingofdata.
Tosupportthesharingofdata,theBritishMedicalAssociation(BMA)6adviseseffective co-operationbetweenpracticesandthePCT:
Much of the information that PCTs will seek to compile in the balanced scorecards is already in the public domain. However, there are some indicators which are not part of the routine contract data collected by PCTs, which practices will not wish to pass on, such as the access and capacity indicators.
However, paragraph 77(1) of Schedule 6 to the GMS [generalmedicalservices] regulations and paragraph 73(1) of Schedule 5 to the PMS regulations stipulate that practices must provide information reasonably required by the PCT. Moreover, the Freedom of Information Act 2000 states that all primary medical service providers are subject to requests of this Act, should they be made. It is therefore unfeasible for a practice to withhold this information from a PCT that requests it. Instead, GPs should proactively and collectively engage with PCTs, supported by their LMC [localmedical council], to influence the local use of such information and to mitigate against potentially adverse consequences of its publication.
TheScorecardcanalsoserveasaneffectivequalityaccreditationscheme,allowingfor standardisedcomparisonsbetweenpractices,e.g.benchmarking.Seethe‘Howto’guide, ‘How to develop a Taxonomy of General Medical Practices to support and encourage performance development’.
Clinical engagement
Clinicalengagementiscrucialforthesuccessfulimplementationofthiscommissioning tool.TheBMA6statesthatitisessentialthatLMCsandpracticesengagewithPCTs andtheBMAthroughoutthedevelopmentandimplementationprocess.Itneedsto beseenasacollaborativeapproach,anditisvitalthatconstructiverelationshipsare sought.“Practices should be working with PCTs, so that problems[inperformance] are identified and addressed at an early stage.”Clinicalleadershipfromwithinthe PCTisalsocrucialtosuccess(forexample,inNHSKnowsleythemedialdirector leadstheagenda),asisengagementwithlocalclinicalleadersattheearlystagesof implementation.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
examples of practice
TowerHamletsPCThasajointLMC/PCTimplementationgrouptocompileindicators andtoworkontheaspectsoftheScorecard.FinalreportsaresenttotheLMCfor ratification.
NHSCoventryaskedGPstobeinvolvedintheweightingscoreforthebanding scheme,whichproducedaveryconstructivedebate.
NHSSuffolkhasworkedveryhardtodeveloptransparentandconstructive relationshipswiththeirLMCthroughsix-weeklynegotiationmeetingswithPCT seniormanagers.Informalpre-meetingssupportthis.Thesemeetingsalsoprovidean opportunitytodiscussthewidercontextwithinwhichthePCTisworking,forexample theirfinancialposition.ThePCTkeepstheLMCinformedaboutpoorperforming practice,andtheLMChashelpedsupportthepracticeandfacilitateimprovement.
InNHSMedway,aqualitydevelopmentframeworkhasbeendevelopedwiththe supportofKentLMC,whorecognisedthatPCTswouldberequiredtoproducea ‘mappingthebaseline’toolandadvisedpracticesaccordinglyintheirnewsletter.
NHSKnowsleyusesitsCommunitiesofPracticeGroups8toagreeitsBalancedScorecard.
NHSHaringeyworkswithitspractice-basedcommissioninggroups.
GPsareoftenconcernedabouttheirratingoneachindicator–inparticularwhen comparedwithpeers.Thereforesharingresultsbetweenclinicianscanbeapowerful motivator.
examples of practice
NHSSuffolkproducesmonthly‘performancepacks’foritsGPs,whichallowpractices toseehowtheyareperformingcomparedtopeersandagainstnational,regionaland localtargets.Thishasbeenseentoimproveperformance.
NHSStokefoundthatmostpracticeswerekeentoimprovewhenshowntheir performanceagainsttheirpeers.Theuseof‘leaguetables’wasamorepowerful motivatorthanmoney.
Public engagement
TheNHSandotherhealthcarebodiesarerequiredtoensurethatpublicengagement isattheheartofservicedelivery.ABalancedScorecardwouldprovidethepublicwitha
8 MembersoftheCommunityofPracticeGroupsaredrawnfromGPsandnursesinprimarycare,cliniciansinsecondaryand communitycare,workersinpublichealth,medicinesmanagement,informationgovernance,education,intelligenceand commissioning,andmembersofthepublic.Inadditiontothecoremembership,individualcliniciansandotherinterestedparties willjointhecommunityonanadhocbasis.TheCommunityPracticeprovidesaforumforclinicaldialogueanddebate;responds toquestionsorissuesidentifiedbycommissioners,cliniciansandotherswithaninterestinthequalityofclinicalcare;utilisesdata toidentifygapsinpatientcareanddiseasemanagement;providesclinicaladviceandsupporttoinformthecommissioningprocess; supportspracticesindeliveringservicesinprimarycare;developsanddisseminatesguidance,pathwaysandtreatmentprotocols; identifiesandshareseffectivepractice;providessupportforclinicalaudit;developspatienteducation;anddevelopsprofessional educationandhorizonscanningfornewdevelopments.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
clearunderstandingofwhatisbeingmeasuredandthecontextwithinwhichapracticeis operating.Inordertoreinforcepublicaccountabilityforquality,High Quality Care for All3 committedallhealthcareproviderstoproducequalityaccounts.Thesewillprovideeasily accessibleinformationaboutthequalityofservicestopatients.Itisexpectedthatproviders ofmedicalanddentalcarewillberequiredtopublishqualityaccountsbetween2011and 2012.TheinformationproducedthroughBalancedScorecardscouldinformtheseaccounts.
Itisalsoimportantaspartoftheprocessofdevelopment,thatpracticesengagewith theirpatientstodiscusstheirexpectationsandaspirations.Thiswouldenhancethe choiceagendaforthepatient,helppracticesunderstandthebestmeansofdelivering care,improveaccessandresponsivenessandsupportthedeliveryofcareclosertohome. ThiscouldalsobenefitpracticesbyimprovingtheirGPsurveyscores.
ManyPCTsareintheprocessofconsideringwhethertopublishpracticeperformance information.Asprimarycareperformancemanagementanddevelopmentisnotalways wellunderstood,itisimportantthataPCTseekstoensurethatthepublicunderstand whataBalancedScorecardissaying,asitcanbemisrepresentedinthemedia,which couldleadtolossofpublicconfidence.ItisalsocrucialthataPCTboardisfully supportiveofpublishingtheresultssothatitispreparedforanypublic/mediafeedback, andcanthereforemanageitsreputationascommissionersofhealthservices.(Seestep9, ‘Decidehowtousetheresults’.)
How To develop A BAlANCed SCoreCArd Step 1: DevelopaclearvisionatthePCTofwhatconstitutesgoodperformance, acceptableperformanceandwhatconstitutesunacceptableperformanceinprimary medicalcare,withinastrategicvisionforlocalhealthcare.Thisneedstobeledwithclear executiveaccountability.
Thevisionshouldbesimpleandfunctional,notstructural.Itshouldbeaboutthings thatareimportanttopatients,commissionersandserviceproviders,including,but notexclusively:
• improvingthehealthofthepopulationandprotectingthem(e.g.vaccinationprogrammes)
• corporateambitionaroundhealthinequalities
• accessandresponsiveness
• premisesandprimarycareestate
• convenience
• safety
• quality
• productivityandcapacity
• compliancewithregulationsandregulators
• localissuesandconcerns
• patientandpublicengagement.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
examples of practice
NHSSuffolkBoardhadaveryclearmandateforthedevelopmentoftheirgeneral practiceperformanceframeworkinsupportingequalitiesofinvestmentandcare throughlocalcontracting.
NHSNorthamptonshirealsohasaclearvisionforqualityimprovementanddevelopment.
TowerHamlets,in2007,afterdiscussionandagreementwiththeLMC,agreedwith thePCTexecutiveboardtheperformancemanagementofallGPcontractsusingthe BalancedScorecard.Thisensuredthattherewasunifiedunderstandingthroughout seniormanagementandavoidedanypotentialconfusionofdivisionsappearinginthe statedapproach.
Step 2:Developthevisionintoaclearandagreedstrategyforprimarycare,within whichthereisunderstandingof:
• whatthehealthneedsofthepopulationanddesiredoutcomesare
• whatisacceptableordesirableactivityinaprimarycaresetting
• theplaceofperformanceimprovementandroleoftheBalancedScorecard
• performancemanagement
• competition
• collaboration
• howchoiceanddevelopmentfitwithintheoverallstrategy
• whattoolsandtechniqueswillbedeployed.
examples of practice
TheTowerHamletsstrategyisbroadlydefinedundertheirImprovingHealthandWell-beingStrategy2006–2016.7
Step 3:Agreemeasurableindicators(theseneedtobereferencedagainstthose recommendedbytheorganisationsthatdeveloptheindicatorssuchastheRoyal CollegeofGeneralPractice,theNHSClinicalGovernanceSupportTeamorCareQuality Commission)andfollowthequalitystandardssetbyNICEwhichunderpinthevision.8
ThevisionofqualityandperformanceisthefoundationofwhatthePCTmightwantto measurethroughasetofindicatorswhich:
• describegoodpractice
• areagreedlocallyasafairwayofmeasuringpractice
• aimtosupportqualityimprovementandtoidentifylesseffectiveperformance
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
• canbebandedintogood,acceptableandunacceptablelocallydeterminedlevelsofcare
• demonstrateproductivityandvalueformoneyofservicestosupporttheQPC.
Theindicatorsandlocallydeterminedlevelsofcaremustbe:
• simple
• nottoogreatinnumber
• clearlydescribed
• basedoneverydaypractice
• measurable.
examples of practice
NHSHaringeyfounditbeneficialtoseparatetheinformationitcollectsintothe followingthreelevels:
• alargedatabasewhichisusedforannualcontractmonitoring
• amorefocusedBalancedScorecard
• informationforeachpractice.
Tosupporttheretrievalofthisdata,NHSHaringeyhasdevelopedaMIQuESTquery forminordertoextracttheinformationrequired.
TowerHamletsstructuresitsBalancedScorecardintothreesections:
• Section1–contractualcompliance
• Section2–keyindicators
• Section3–developmentalindicators.
Anationalindicatorsetiscurrentlybeingproposedto‘mapthebaseline’(seeAppendix1). Developmentofnewindicatorscanbehighlytechnical,anditisoftenbesttouse indicatorsdescribedelsewhere,toavoidproblemswithrecording,reliabilityand reproducibility.
Step 4:Introduceaprocessofchangemanagement,tochange‘heartsandminds’. TheapproachmustbebackedupbyPCTinvestmentinseniorstafftimeforprimarycare commissioningandcontractmanagement,includingastrongprogrammeofvisitsto eachpractice.Thisresourcecommitmentmustnotbeunderestimated.
ExamplesofmembersofaPCTteaminclude:
• prescribingadvisers
• primarycarefinancelead(itisessentialtoincludethis–NHSSuffolkwassupportedby thefullfinanceteam,acrucialcontributortotheoverallprogrammeofperformance management)
• medicaldirector
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
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• estatesmanager
• primarycarecommissioninglead
• controlofinfection
• QOFindicatorslead
• clinicalgovernancelead
• layassessor
• adminsupport.
How To ImplemeNT A BAlANCed SCoreCArd Step 5: Developaclearsupportprogramme.
Primary Care & Community Services: Improving quality in primary care9statesthatthe standardpositionforPCTsshouldbethattheywillassistGPpracticesinimprovingtheir services:“Direct support should be explicitly linked to the overall approach to managing performance… and PCTs should clearly define the circumstances in which they will provide support.”
SupportthatPCTscouldconsideroffering,whenrequired,includes:
• providingPCTstaffwithspecialistskillstoworkdirectlywithpractices
• sharingexamplesofbestpracticefromotherpractices
• theestablishmentoflocallearningnetworksacrosspractices
• brokeringsupportforpracticesfromsupportagencies.
ThereforethePCTneedstoprovide:
• aclearsystemofrobustcontractualmanagement
• expertinformationmanagementandanalyticalsupport
• trainedassessorswhocanrecommendandimplementsupporttopracticesandprovide educationalpackagesforleading-edgeandtrailing-edgepractices
• supportarrangementsforpracticesindifficulty
• facilitationandnegotiationskills
• primary-care-specificfinancialskills.
Inaddition,thePCTneedstohavepoliciesandasupportframeworkinplacefor education,developmentandperformanceimprovement.Thesewouldbeimplemented assoonaspossiblewhenperformancefallsshortofexpectationsandlocallydetermined levelsofcare.
HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
examples of practice
NHSSuffolkfundsapracticemanagerconsultantfromanestablishedpooloflocal practicemanagerswhowillworkalongsideaprimarycarecommissioningmanager andthepracticemanagerfromafailingpracticetosupportimprovementsidentified inanagreedremedialactionplan(priortoaBreachofContractnotice).NHSSuffolk alsofundsGPmentorstoprovideconfidentialsupportandcustomerservicetraining packagesforreceptionists.
However,ifpracticescontinuallydeliverpoororunresponsiveservicestopatients,PCTs mayusethefollowingformalcontractleversoncelegaladvicehasbeensought:
• decommissioningenhancedoradditionalservices
• issuingremedialorbreachnotices
• terminatingcontracts.
examples of use of remedial action
TowerHamletshasdevelopedaContractReviewProcessthatislinkedtothenumber ofredscoresapracticehasbeengiven.Practicesarerequiredtoproduceactionplans oneachareaofunderperformanceandarevisitedquarterlyforreview.Failureto achieveintheseareascanformpartofaremedialnotice.
NHSSuffolkagreesaSpecificMeasurableAchievableRealisticTimescaled(SMART) remedialactionplanwithpracticespriortoapossibleBreachofContractnotice.
Step 6:ConsidersettingupaClinicalGovernanceGroup(CGG)asasubcommittee ofthePCT(reviewingenablesclearleadershipfromtheboard)inordertodevelopthe agendaforqualityanddelivery.Withappropriatemembershipandtermsofreference theClinicalGovernanceGroupcanfacilitatethedevelopmentanddeliveryofthe Scorecard.
Thegroupitselfneedsto:
• includeandbesupportedbyseniormanagersandclinicalchampions
• bemulti-disciplinaryincludingPCT–commissioners,publichealth,finance,clinical governance,pharmacyandIT–andlocalclinicians’andLMCrepresentation
• useauthorityasasubcommitteeofthePCT(andthereforealsohaveaccountability)
• beabletorequestinformationfrompublichealthpracticesorelsewhereinthePCT
• besupportedbyanalyticcapacity
• havethepowertorecommendactiontothePCTboard
• reassessindicators
• reviewprocess
• introducenewindicatorsandagreetodropoldones.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
examples of practice
TowerHamletsPCThasajointLMC/PCTimplementationgrouptoworkupindicators andotheraspectsoftheScorecard.
NHSKnowsleyhassetupCommunitiesofPracticeGroups(seefootnotepage7) whichprovideanoverviewofaclinicalareaandareinstrumentalinsupportingthe implementationoftheBalancedScorecard(seealso‘Clinicalengagement’onpage6).
Thecontextandtherelationshipwithprimarycareandtheclarityofexpectationsis reallyimportantforanyofthistowork.
Step 7:Developaclearstrategyandtimetableforadministration,thedevelopment ofaScorecardandformanagingtheresults.TheDepartmentofHealth4hassetoutan illustrativetimeline(seeAppendix2)foraperformancecycle.TheBMAstatesthatit “would not expect this process to have an unreasonable impact on GPs’ time”.6PCTs areencouragedtoensurethatthereissufficientcommissionercapacitycommittedtothe developmentandimplementationoftheBalancedScorecard.
Step 8:undertakepreliminarydiscussionsonindicatordevelopments.
Theseneedtoincludethefollowing:
• adecisioninprincipleontheareasforindicatordevelopment
• anexaminationofotherscorecardsagainstthefollowingcriteria:
– relevancetothePCT
– existingexperienceofotherPCTs
– easeofimplementation
• acomparisonoftheindicatorswantedwithanassessmentofhowavailablethe informationis.TheDHPCCSapplicationmaybeausefultoolforthis13
• acomparisonoftheareaswithnationalandlocalstrategicpriorities
• areviewofhowmeasurementmightcontributetounderstandingandfulfillingthe PCTstrategicobjectives
• areviewofsecondaryusesofthedata,forplanningandcommissioningaswellas servicedevelopmentandimprovement–NHSPCCQualityandProductivityChallenge Calculatorcanhelpsupportthisprocess.
Contractualcompliancecanberigorouslycheckedbuttheneedforpracticestoverify thattheymeetcontractual,specifiedlevelsofcarerequiresthedevelopmentofmore guidance/audittools.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
PCTsshouldensurecontractual,specifiedlevelsofcare(suchasforopeningtimes)are beingupheldfullybeforeincludingmoreadvancedindicators(basedonthecontract)in theScorecard.
The following are examples of how contractual obligations are dealt with:
TowerHamletsincludesthisinpartAofitsScorecardasaselfassessmentthatis verifiedbypractices.Randomindicatorsarecheckedforcomplianceatcontract reviewmeetings.
NHSSuffolkusesscorecardmethodologytodevelopaperformanceframeworkto supportthemanagementofitslocalPMScontracts.
Step 9:DecidehowtousetheresultsfromtheScorecard.
Thisshouldbedonebothatanindividualpracticelevelandenmassetoinformprimary caredevelopment.
ConsiderbenchmarkinginformationacrosstootherlocalpracticesoracrossotherPCT areas(refertothe‘Howto’guide,‘How to develop a Taxonomy of General Medical Practices to support and encourage performance development’).
ThefollowingtablesetsoutwaysBalancedScorecardscanbeusedandhighlightsissues forconsiderationiftheyareusedintheseways.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Howtouse theresults
Considerations Examplesofpractice
Banding ABalancedScorecardscores NHSHaringeydetermineslevelof scheme practicesonlyonbroad
categories.Thebandsarethe foundationofinvestmentsand sanctions.
performancelocallyfordifferent priorities,withspecificlevels expectedbypoorlyperforming practices.
NHSStokesetsinitiallowerlevels ofcareforpoorlyperforming practices.
NHSNorthamptonshirehas producedascoringsystemwhich allowsbothasnapshotofapractice’s overalllevelandalsogroupsof metrics.Itdemonstratesmovement withinthatleveleveniftheoverall levelhasnotchanged.Thetrust alsohastwo-yeartrenddata.
Support for Performingpracticeswillwish AchievementinTowerHamlets delivery totakepartbutalsoexpect
toreceivedevelopment support;practicesneeding developmentmaynotsee themerit,especiallyifthey scorebadly.Goodsupportand developmentmechanismsto achieveimprovedlevelsofcare needtobeseenasincentives forthisgroup.
leadsto‘earnedautonomy’which meansalightertouchbythePCT.
InStoke,practiceshadtomeet anumberofprerequisitesbefore beingabletojoinadevelopment programme.Thisincludesaset ofexemplarylevelsofcareover andabovetheQOFindicators requirementsasameansof achievingbestpossible,rather thanaverage,practice.Funding hasbeenallocatedtosupport theprogramme,whichincludesa supportprogrammeforpractices.
Sanctions Remedialactionmaybe TowerHamletshasclearsanctions against poor requiredforcontractual, andusestheBalancedScorecardin performance specifiedlevelsofcare;
theBalancedScorecard schemeshouldneatlyfitinto performancemanagement.
newservicecontractspecifications. Theserequirepracticestomeet BalancedScorecardrequirements beforetheyareabletocontractfor newservices.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Howtouse theresults
Considerations Examplesofpractice
Publication Thisdependsonconfidence NHSWestminsterpublishes80%of of results intheresults,thequalityof
thedataandconfidencein practices,althoughnoneof thedatashouldbepatient specificornotinsomeway inthepublicdomainalready. Itisthewayitistreatedthat makesthedifference.The publicalsoneedtounderstand thecontextwithinwhichthe practiceisoperatinginorderto fullyappreciatetheoutcomes oftheScorecard.
Severallevelsofpublication arepossible,forexampleas anaggregatedresulttothe PCTboardandpractices,or asseparatepracticeresultsto thePCTboardandown-results toeachpractice.Ingeneral, publicationmightbelimitedin thefirstyearofthescheme. BalancedScorecardsmaybe usefultofulfiltherequirement forpracticestodevelopquality accountsbytheCareQuality Commissionin2012.14
itsScorecardresultstohelppatients makedecisionsonwheretoaccess primarycareservices. Seeitswebsite: www.westminster-pct.nhs.ukand followthe‘FindaGP’link.
NHSWestminsterusedits communicationsandpatientand publicinvolvement(PPi)leadsto ensurethecommentaryonthe comparatorsisuserfriendly.There isalsoafeedbacksectiononthe websiteforuserstoinformof improvements.
Investment Dependingonresults,thePCT NHSNorthamptonshireusesthe for change mightfindthatthereneedsto
beinvestmentacrosstheboard (ieinotherservicesaswell asGPpractices)in,for example,access,childhood immunisations,improving thepatientexperience andprescribing,aswellas investmentinpracticesthat requiredevelopment.
BalancedScorecardasawayof understandingandstimulatingthe marketinordertoidentifyareasfor furtherinvestment.
BalancedScorecardsareused inNHSSuffolktoreviewand renegotiatePMScontracts.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
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Step 10:DecideontheinfrastructuretostandardiseoperationsoftheScorecardsystem.
Administration Thescorecardapproachdemandsgoodcommunicationand timetabling,timelyresponsesandclearaccountability.
Data Collectionshouldbeelectronicwherepossible,usingexisting channels,e.g.QMAS,butwithconsiderationofnoveldata extractsasintheQOFAssessorToolkit.
Documents Detailing,forexample,oflocalaudits,shouldbemanaged electronicallywherepossible,usingstandardtemplates.
Analysis The‘translation’intoscoresshouldbeagreedandautomated wherepossible.Itiscrucialthattheinformationisproducedwithacleardescriptionofmeaningandcontext.
Step 11:Decideonaframeworkfortheobjectivemeasuresandindicators.
Itisimportanttoensuretheframeworkemploystherightindicators.
Appendix1providesthesuggestednationalindicatorset,andAppendix3providesexamplesofthedomainsusedbyasampleofPCTs.
Step 12:Decidewhentoreporttheoutcomesandwhen/iftodiscussthefindingswith boardmembers.
Thisisprobablyonlyoncethedevelopmentteamisconfidentintheshapeofthepolicy, intheScorecarditselfandhasagreedtheoutcomesthattheteamwantstosee.
Step 13:DevelopacollaborativeapproachwiththeLMCandlocalclinicians.
Whentheelementsofthepolicyandtheshapeoftheframeworkareclear,itneeds tobesharedwiththeProfessionalExecutiveCommittee(PEC)andtheLMCassoon aspossible.
DevelopingagoodrelationshipwithLMCissightedbyallareaswithaneffective BalancedScorecardascrucialtotakingthisworkforward.Togainsupport, commissionersneedtobeabletodescribethebenefitsforpatients,butmore importantlythebenefitsforpracticesandthesupportavailabletoimprovepractice performance.ThemeetingswiththeLMCarelikelytobeaprinciplednegotiation–one whereyouhaverealisticbutstretchingobjectivesandclearbottomlines.
TheBMAadvocatesthatLMCsneedtomakecontactwithPCTsonbehalfoftheir practicesassoonasthePCTbeginstoundertaketheBalancedScorecarddevelopment. ThiswillenabletheLMCtoadviseonhowthecollecteddatawillbeused,toensurethat indicatorsareexpressedwithclearreferencetothecontextinwhichthecareisprovided, andthattheyarerobustandbalanced.
HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Step 14:Takestock.
Step9canbeverytime-consuming.Itisnotasinglemeeting.Frameworkdevelopment, ietheearliersteps,shouldproceedinparallel.
Step 15:DevelopajointimplementationgroupwiththeLMC.
Thisisrecommendedonanongoingbasistoensureconsultationoneachstageof developmentandreview.
examples of practice
TowerHamletshasajointLMC/PCTimplementationgrouptoworkonindicatorsand otheraspectsoftheScorecard.FinalreportsaresenttotheLMCforratification.
Thisgroupwouldbevaluableinagreeingwhenresultswillbepublishedinthepublic domain.Beforethishappens,practicescouldbesentalettershowingtheirresults comparedwithothers.
Step 16:PresentatapublicsessionofthePCTboard.
Thiswillensureabsolutesignupandonwardcommitment.
Step 17: Organisealauncheventwiththepurposeofengagingpartners,including localauthorityofficersandoverviewandscrutinycommitteemembers,forexample.
Thiswillprovidefurtherdemonstrationofcommitment.Detailofferedattheevent shouldincludefirmdatesforeachstageandtheconsequencesforpracticesandthe PCTifXorYhappens.
Step 18:Runtheprocess.
Theremustbecontinuousmonitoringandreviewoftheprocesswithswiftresponses fromtheprojectteam/owner.Theteamshouldbepreparedtoactatanytimeifvery poorordangerousperformanceshowsunexpectedly.Theimplementationgroupwillbe invaluableintakingthisstepforward.
Step 19:Actontheyear-endresultsandactionplan.
ThebroadoutlineoftheBalancedScorecardwillalreadyhavebeenagreedwiththe boardandLMC.
Theactionplanneedstobeagreedoverallandwitheachpractice.
Thereshouldbeanopportunitytocelebratesuccess.
Step 20:Reviewandchangetheframeworkonanannualbasis,ifrequired.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
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AppeNdIx 1: mAppINg THe BASelINe (TAkeN From prImAry CAre & CommuNITy ServICeS: ImprovINggp ServICeS5)
National indicator set
Capacity,including:
• numberofGPandnurseconsultationsper1,000weightedpopulation
• lengthandqualityofallprimarycareconsultations
• averagepatientlistsizeperGPpractice
• numberofwhole-timeequivalentGPsandotherclinicalstaff(e.g.practicenurse, nursepractitioner,healthcareassistant)per1,000weightedpopulation.
Quality,mappedacrossthreeareas:
• organisationalquality(includingsafety)
– practiceaccreditation
– premises
• effectiveness
– achievementintheclinicaldomainoftheQOFindicators
– exceptionratesandcomparisonsbetweenreportedprevalenceandexpected prevalenceoflong-termconditions
– localdata,e.g.prescribing,referralsandclinicalgovernance
• patientexperience:GPs,practicenurses,receptionstaff,communicationssystems, parking,qualityofpremises,etc,combinedtomakeuptheoverallexperience. PCTsmayusethenewGPpatientsurvey,orotherformsofpatientfeedbackoran analysisofcomplaintsreceivedtomeasurethis.
Access and responsiveness,asdescribedbythespecificDHguideonthisissue, tobepublishedsoon.Measurementswillinclude:
• patientsatisfactionwithaccess
• practiceopeninghoursforclinicalappointments
• disabilityaccess
• consultationlanguages
• choiceofmaleandfemaleGPs
• uptakeofextendedopeninghours
• useofpremiumratetelephonenumber
• attendanceatA&Eorwalk-incentresasaproportionoflistsize.
HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Patient choice,includingchoiceofhospital,choiceofpracticeandpersonalised careplanning.
Value for money,includingGMSandPMSspendperhead,referraland prescribingdata.
Premises,includingcompliancewithnationalstandards.10
Demand,including:
• emergencyreferrals/spellsper1,000weightedpopulation
• A&Eactivityper1,000weightedpopulation
• activitywithinout-of-hourssettings,particularlyforroutineorplannedcare
• BetterCare,BetterValueindicatorsforambulatorycaresensitiveemergency admissions
• BetterCare,BetterValueindicatoronsurgicalthresholds
• BetterCare,BetterValueindicatoronout-patientreferrals.
Enhanced services,includingaccessanduptakeoftheseservices.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
AppeNdIx 2: exAmple TImeTABle When What Outcome
Jan–Feb Negotiateobjectivesanddevelopment planforthenextyear,ensuringthatthere isanappropriateblendofqualitativeand quantitativeobjectives.Agreeanycontract variations.ObjectiveslinkedtoPCT’s strategy,suchasincentivestotacklehigh priorityareaslikecoronaryheartdisease,will becommontoallproviders.Otherswillbe specifictoindividualpractices(e.g.extend openinghoursfromXtoY,orincrease patientsatisfactionbyX%).
Draftagreementfor eachpractice.
By Mar 31 Signoffagreement/contractvariationswith eachpractice.
Writtenplan/contract variation,signedby bothparties.
May Formal,senior-levelaccountabilityreview witheverypractice,assessingperformance overprevious12months.
Ensurethatanybalancingpayments/claw-backsrelatingtothepreviousyearare agreed.
Annuallettertopractice, tobesharedatPCT publicboardmeeting. Thiscouldinclude anoverall‘traffic light’assessmentof performance.
Practicetoreceive clearstatementof performance.
July PublishQ1keyperformancemetricsfor eachpractice.
Datapublishedon PCTwebsite.
Oct Formalmid-yearreviewwitheverypractice. PublishQ2keyperformancemetrics.
Letteroutliningmain pointsofreviewmeeting. Datapublishedon PCTwebsite.
Nov–Dec Reviewofperformanceframework andmetrics.
Revisedframework(if appropriate)published.
Jan PublishQ3keyperformancemetrics. Datapublishedon PCTwebsite.
April PublishQ4keyperformancemetrics. Datapublishedon PCTwebsite.
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
AppeNdIx 3: exAmpleS oF THe dIFFereNT domAINS uSed By prImAry CAre TruSTS (pCTS) Doncaster PCT
Clinicalperformance
Safety
Organisationalprocesses
Quality
NHS Knowsley
Listsize/GPwhole-timeequivalent
Lifeexpectancy
GPaccess
PartnershipsinHealth
Clinicalquality
Expectedprevalence
unplannedcare
Education
PatientandPublicInvolvement
Coventry PCT
Activities
Diseaseandneed
Administrativeprocesses
Prescribing
Teamwork,training,employment
Additionalpossibilities:
Numbersremovedfromlistandwhy
Systemtoalertout-of-hoursservicetopatientsdyingathome
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
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NHS Haringey
Existingcommitment
Nationalrequirements:
Waitingtimes
Hospitalacquiredinfections
Nationalpriorities:
Allageallcausemortality
Cardiovasculardiseasemortality
Cancermortality
Suicideandundeterminedinjury
Smoking
Obesity
Immunisation
Breatfeeding
Childrenandadolescentmentalhealthservices
Chlamydiascreening
Accesstodrugmisuseservices
Self-reportedexperienceofNHS
NHSstaffsatisfaction
Primarydentalservices
Tower Hamlets PCT
Section A – Contractual and statutory requirements and compliance
Contractualcompliance
Businesscontinuityplanning
Healthcarecommissionstandards
ResponsetoCentalAlertingSystemalerts
Section B – Key indicators
Patientsabletogetanappointmentwithin48hoursiftheywish
Cervicalscreening
Childhoodimmunisations
Pre-schoolboosters
Pneumococcalimmunisationforover-65s
HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Section C – Developmental/quality indicators
Access:
Rangeofenhancedservices
Patientprofilinglocalenhancedservices–ethnicityrecording
Patientprofilinglocalenhancedservices–languagerecording
patient experience:
CompositeIpsos/MORIscore
public health:
Influenzaimmunisationsforover-65s
Breastscreening
Bodymassindexrecording–aged16yearsandoverinprevious15months
prescribing
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
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AppeNdIx 4: SpeCIFIC meTrICS THAT provIde A HeAlTH INequAlITy perSpeCTIve ABalancedScorecardisagenericscorecardbalancingdifferentmetricsanddomainsfora practice,butthesewouldbetheonesparticularlyofinterestforaddressinghealthinequalities:
Capacity and accessibility
• Numberofface-to-faceGPappointmentsperyearperpatient
• Numberoftrainednurseappointmentsperyearperpatient
• Extendedhoursoffered(outsidecorehours)
• Patientexperience–usingpatientsurveys
• Disabilityaccess
• Consultationlanguages
• Culturalsensitivities
• uptakeofenhancedservicestomapavailabilityanduptakebypopulationto ensureaccessibility
Prescribing
• useofstatins
• RatioofACEinhibitorstoangiotensin-IIantagonists>75%(excludingcombination products)
Public health targets
• Percentagesachievedforcervicalscreening,childhoodimmunisations,breastscreening
• Fluvaccineuptake
• Coronaryheartdisease,cancerandinfantmortality
• Allageallcauseandlifeexpectancylevel(maleandfemale)
Value for money
• Valueformoneyprescribingindicators–prescribingcostsversusoutcomesfor diabetes;hypertensionmanagement;status
• urgentandelectivereferralsper1,000weightpopulationcomparedacrosspractice SuperOutputAreas(SOAs)
HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
Quality and Outcomes Framework indicators
• Prevalence–actualidentifiedagainstpredicted
• Exceptionreporting–reasonswhy
• WorkbeingdonetotreatthoseabovetheQOFindicatorstarget
• Diabetes–HbA1cachievement
• Cardiovasculardiseasemanagement–bloodpressurecontrol,treatmentand distribution
• Chronicpulmonaryobstructivediseasemanagement
• Cancerreferrals–earlydiagnosis,urgentversusnon-urgent,two-weekreferrals (anddiagnosisratio)
Local targets
• Smokingcessation–effectiveness
Local context
• IndicesofMultipleDeprivationscore(IMD)
• Demographics:populationagedover75years
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HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
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reFereNCeS 1 DH(2009)Primary Care & Community Services: Improving quality in primary care,
DH,www.dh.gov.uk/prod_consum_dh/groups/dh.../dh_106575.pdf 2 NHSPrimaryCareContracting(2008)Quality Development Methodology Using a
Balanced Scorecard,commissioningpaperPCC/C/QDM/WB/0508,www.pcc.nhs.uk 3 DH(2008)High Quality Care For All: NHS Next Stage Review final report,DH,
www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_085825
4 DH(2009)Primary Care & Community Services: Improving GP services,DH, www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_093830
5 DH(2009)Primary Care & Community Services: Improving GP services,DH, www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_093830
6 BritishMedicalAssociation(2009),Focus on the Department of Health’s ‘Improving GP Services’ Guidance,GPCguidanceforLMCsandGPs(Englandonly),BMA, www.bma.org.uk/images/focusimproveGPservices_tcm41-189138.pdf
7 www.towerhamlets.nhs.uk/publications/corporate-publications/?entryid4=29504&q= 0%c2%acimproving+health+and+well-being%c2%ac
8 www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp 9 DH(2009)Primary Care & Community Services: Improving quality in primary care,
DH,www.dh.gov.uk/prod_consum_dh/groups/dh.../dh_106575.pdf 10www.nhsestates.gov.uk/primary_care/index.asp
HowtodevelopandimplementaBalancedScorecardtotacklehealthinequalities
AuTHor ANd ACkNowledgemeNTS Written by:
JaneLeaman,AssociateDeliveryManager HealthInequalitiesNationalSupportTeam [email protected]
Acknowledgements:
editing Board BevNorton,HealthInequalitiesLead,NHSPrimaryCareCommissioning
PhilipLeech,PrimaryCareLeads,NHSPrimaryCareCommissioning
RebeccaThornton,AssociateDirector,NHSPrimaryCareCommissioning
Contributors AndrewRidley,DeputyChiefExecutive,TowerHamletsPCT
DrChrisMimnagh,MedicalDirector,NHSKnowsley
DavidHill,Acting,GPCommissioningManagerforNorthWestlocality, CommissioningManagerforCommunityHealthServices,TowerHamletsPCT
HeatherMarsh,DeputyDirectorofPrimaryCare,NHSDoncaster
Jo-AnnSheldon,GPCommissioningManager,TowerHamletsPCT
KristianSmith,HeadofContractingandPerformance,NHSNorthamptonshire
MabliJones,AssociateDirector,PrimaryCareCommissioning,TowerHamletsPCT
MelanieCraig,DeputyDirectorofPerformance,NHSSuffolk
DrPeterBarker,ConsultantinPublicHealth,CoventryPCT
SophieRuiz,CommissioningManager–ContractManagement,WestminsterPCT
StephenDietch,AssociateDirectorofPerformance,NHSHaringeyPCT
Stakeholders CatherineJenkins,HeadofQualityTeam,PrimaryMedicalCareBranch, CommissioningandSystemManagementDirectorate,DH
HemlataFletcher,Equality&DiversityLead,TransformingCommunityServices,DH
JillMatthews,Director–PrimaryCareandCommunityServicesStrategy, PrimaryCare–CommissioningandSystemManagement,DH
ZawarPatel,PolicyAdvisor,EqualityandInclusion,DH
Ifyouwantmoreinformationontheexamplescontainedinthisguide,pleasecontact [email protected]
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