the independent sector and the nhs - quality and …/media/confederation/files/public...the...

The Independent Sector and the NHS -pQuality and Outcome Data BriefingMarch 2013

NHSPN - who are we?• The NHS Partners Network (NHSPN) is the trade association

representing independent sector providers of NHS services ranging through acute diagnostic primary and community carethrough acute, diagnostic, primary and community care.

• Members are drawn from both the “for profit” and “not for profit” p psectors and range from large international hospital groups to small specialist providers. They deliver care ranging from primary to acute elective provision as well as out of hours and home-based services.

• All our members are committed to working in partnership with the• All our members are committed to working in partnership with the NHS and to the values set out in the NHS Constitution.

• NHSPN is one of the networks of the NHS Confederation and works in partnership with the rest of the NHS.

Elective care in the independent sector• The independent sector is increasingly treating more NHS patients

across a range of elective procedures both in private hospitals and i d d t t t t t (ISTC )independent treatment centres (ISTCs).

• The independent sector now carries out nearly a fifth (19%) of allThe independent sector now carries out nearly a fifth (19%) of all elective hip and knee replacement surgery in the NHS

• Although the sector is only permitted to undertake certain types of cases, usually excluding the most complex, the data is adjusted for k t f i b lkey aspects of case mix – see below.

• However the data suggests that the case mix differences are not asHowever, the data suggests that the case mix differences are not as significant as is sometimes claimed.

The Data • The data in this presentation has been compiled by the NHSPN fromThe data in this presentation has been compiled by the NHSPN from

a number of independent sources – see later slides.

• It gives a comprehensive overview of many different aspects of care and compares NHS and independent sector providers of NHS care to enable patients and GPs make informed decisions about careenable patients and GPs make informed decisions about care.

• It specifically highlights comparisons between independent sector andIt specifically highlights comparisons between independent sector and NHS providers of elective primary hip and knee replacement surgery and looks at PROMS data and rates for readmission within 28 days

• The pack also includes CQC data on reported compliance rates for lit t f 2011 12 t h l i i f ll thcore quality outcomes for 2011-12 to help give an overview of all the

criteria that patients consider when exercising choice.

The data sourcesThe electi e hip and knee s rger data in this pack as commissioned fromThe elective hip and knee surgery data in this pack was commissioned fromthe Private Healthcare Information Network (PHIN) and compiled by Northgate Public Services in November 2012.Northgate Public Services in November 2012.

Northgate Public Services (NPS) is one of the Country’s largestproviders of Business Process Outsourcing (BPO) Information services andsoftware to the UK public sector. They are contracted by the Department ofH lth t th ti l PROMSHealth to run the national PROMS programme.

The Private Healthcare Information Network (PHIN) is a not-forThe Private Healthcare Information Network (PHIN) is a not forprofit organisation established in 2012 to collate and publish comparativeclinical performance data on UK private and independent healthcare to help, inform patient choice. It is funded through subscriptions from the privatehospital operators.

The data sources• This data pack also collates information already in the public domain p y p

relating to elective hip and knee replacement procedures for NHS patients. The data specifically compares performance between independent and NHS providers. Sources include:• NHS Patient Reported Outcome Measures (PROMs)• The National Joint Registry (NJR)• The National Joint Registry (NJR)• NHS Hospital Episode Statistics (HES).

• Figures on readmission rates have been adjusted using underlying HES data.

• The comparative reported compliance rates are from The Care Quality Commission (CQC) State of health care and adult social care inCommission (CQC) State of health care and adult social care in England 2012.

“Health gain” from elective hip and knee surgeryg y

Patient reported outcome measures (PROMS)(PROMS)

What are patient reported outcome measuresWhat are patient reported outcome measures (PROMS)?

A ti t t d t (PROM) i i f ti• A patient-reported outcome measure (PROM) is a series of questions that patients undergoing certain procedures, including hip and knee replacements, are asked in order to gauge their views on their ownreplacements, are asked in order to gauge their views on their own health.

• Patients are asked the same questions before and after treatment in order to assess the ‘health gain’ from treatment

• All providers of NHS care collect this data which is co-ordinated by the Department of Health The Health and Social Care Information Centre isDepartment of Health. The Health and Social Care Information Centre is responsible for scoring and publishing the data.

The Oxford orthopaedic scores

• The Oxford hip and knee scores are a set of joint-specific outcome measure questions, used by orthopaedic surgeons, designed to assess symptoms and function in patients undergoing joint replacement surgery.

• The scores comprise of 12 multiple choice questions relating to the• The scores comprise of 12 multiple choice questions relating to the patient’s experience of pain, ease of joint movement and ease of undertaking normal domestic activities such as walking or climbing stairs.g g g

• Each of the 12 questions on the Oxford Hip Score and Oxford Knee Score is scored in the same way with all questions laid out similarly and response categories decreasing from four (least or no symptoms) to zero (most severe symptoms)(most severe symptoms).

Case-mix adjustment

• Well established statistical techniques have been used to produce a model for each procedure and scoring combination.

• Variables taken from the PROMs returns and linked HES records that significantly influenced the patients score were included in the modelsignificantly influenced the patients score were included in the model.

• Only factors that were deemed outside of the organisation's control O y gwere included in the model. The model was then used to adjust the organisation's post-operative scores.

• A full description of the methodology can be found at http://www dh gov uk/en/Publicationsandstatistics/Publicatiohttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_133445

PROMS d tPROMS dataNHS funded care, April 2011 – March 2012

Hip and knee replacement – summary of results• Independent sector organisations who carry out elective primary (first)

hip and knee replacement surgery for the NHS dominate the top10 id f i i ti t ' lit f lif f ll i th dproviders for improving patients' quality of life following the procedure.

• Of the top ten providers for hip replacement surgery seven are from theOf the top ten providers for hip replacement surgery, seven are from the independent sector. In the top five, four are independent sector providers.

• Of the top ten providers of knee replacement surgery eight of the top ten i d d t t id I th t fi th i d d tare independent sector providers. In the top five, three are independent

sector providers.

Hip and knee replacement – summary of results• More than 70,000 hip replacements and 70,000 knee replacements are

carried out in the NHS in England every year. They are two of the most l f d th di d d i ifi tlcommonly performed orthopaedic procedures and can significantly

improve patient quality of life.

• The independent sector now carries out almost a fifth (19%) of all elective hip and knee replacement surgery done in the NHS in England.

• The independent sector can thus be seen to deliver some of the highest lit th di f NHS t t d t i d b ti tquality orthopaedic care for NHS patents as determined by patients

themselves.

Patient Reported Outcome Measures (PROMS)(PROMS)

Elective hip replacement surgery

Hip replacement – PROMS health gainIndependent Hospitals Specialist Orthopaedic Hospitals NHS Hospitals

Primary hip replacement:Top 50 hospitals* ranked by mean adjusted Oxford Hip Health Gain Score

(NHS funded care Apr '11–Mar '12)

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Source: Hospital Episode Statistics (HES) / PROMs, The NHS Information Centre for health and social care.

* Hospitals treating at least 50 patients during the selected period


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Patient Reported Outcome Measures (PROMS)(PROMS)

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Knee replacement – PROMS health gainIndependent Hospitals Specialist Orthopaedic Hospitals NHS Hospitals

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Elective hip and knee replacementReadmission rates

Readmission rates – the data

• Data for this analysis is taken from NHS Hospital Episode Statistics (HES) for patients admitted to hospital between 1 April 2011 and 31 March 2012 having been discharged from a prior admission for hip or knee replacement surgery within the preceding 28 days.

• A readmission is identified within HES as an admission within 28 days of a prior discharge for that patient where the admission method is p g pcoded as ‘emergency’ rather than ‘elective’.

• In this context, emergency means clinically urgent, but not necessarily life threatening. This definition will capture most readmissions arising from complications following treatment but inevitably also capturesfrom complications following treatment, but inevitably also captures some unrelated admissions.

Readmissions rates – the dataDetailed anal sis of HES data and disc ssion ith independent• Detailed analysis of HES data and discussion with independent providers suggests that, historically, they have not always been consistent in the use of the ‘emergency’ Coding of Admission Methodconsistent in the use of the emergency Coding of Admission Method possibly leading to under-reporting of readmissions in HES. The independent providers are now working to correct it this issue.

• For the purposes of this analysis, the requirement of ‘emergency’ has b d d f d t t d b th i d d t t h th tbeen dropped from data reported by the independent sector, such that any admission within 28 days of a prior discharge is recorded as a readmission (see adjustment methodology on following slide).readmission (see adjustment methodology on following slide).

• This slightly inflates the readmissions rates for independent hospitals, when compared to HES figures but we believe it is a better reflection of reality.

Hip and knee readmissions - adjusted

For this updated analysis the following adjusted criteria have been applied: • For readmissions where the index admission occurred in the NHS:

• All readmissions to the same or a different NHS hospital must have an Admission Method = Emergencyhave an Admission Method = Emergency

• All readmissions to an independent hospital can haveany Admission Method y

• For readmissions where the index admission occurred in the independent sector • All readmissions to an NHS hospital must have an Admission

Method = Emergency • All readmissions to the same or a different independent sector• All readmissions to the same or a different independent sector

hospital can have any Admission Method.

Hip and knee readmission - standardisation

• All readmissions data has been indirectly standardised for differences between hospitals with respect to age and sex.

• Indirect standardisation involves the calculation of the ratio of an i i ’ b d b f d h b forganisation’s observed number of events and the number of

events that would be expected if it had experienced the same event rates as those of patients in England given the mix of age and sexrates as those of patients in England, given the mix of age and sex of its patients.

• This standardised ratio is then converted into a rate by multiplying it by the overall event rate of patients in England.

Hip and knee readmissions – confidence intervals

• Confidence intervals of 95% and 98% provide a measure of the statistical precision of the readmission rate for an organisation.

• It indicates two ranges which, with 95% and 98% probability, will contain the true value of the indicatorcontain the true value of the indicator.

• If the confidence intervals for two rates overlap, in most cases the p,difference between the rates would not be considered statistically significant.

• The method used to calculate confidence intervals is the same as that used by the National Centre for Health Outcomes Developmentused by the National Centre for Health Outcomes Development (NCHOD): http://www.nchod.nhs.uk/

Elective hip and knee replacement readmission p prates – summary of results

• Activity volumes confirm that nearly a fifth of NHS procedures are done by the independent sector.

• For both hips and knees readmission rates the independent sector rate is well below the general NHS rate and clearly comparable to g y pNHS specialist orthopaedic hospital rates.

Primary Hip Replacement – activity volumesIndependent Hospitals Specialist Orthopaedic Hospitals NHS HospitalsIndependent Hospitals Specialist Orthopaedic Hospitals NHS Hospitals

Source data Hospital Episode Statistics: August 2011 – July 2012

Hip Readmission RateLOWER CI = Lower Confidence Interval UPPER CI = Upper Confidence IntervalLOWER_CI = Lower Confidence Interval UPPER_CI = Upper Confidence Interval


Knee Replacement – activity volumesIndependent Hospitals Specialist Orthopaedic Hospitals NHS HospitalsIndependent Hospitals Specialist Orthopaedic Hospitals NHS Hospitals


Knee Readmission RateLOWER_CI = Lower Confidence Interval UPPER_CI = Upper Confidence Interval


National Joint Registryg yAnnual report 2011

NJR Measures• Patient Consent Rate: This is the rate at which patients have agreed• Patient Consent Rate: This is the rate at which patients have agreed

to have their data added into the NJR.

• Average ASA Grade: The ASA physical status classification system is a system for assessing the fitness of patients before surgery. It was introduced by The American Society of Anesthesiologists (ASA) who adopted adopted the five-category physical status classification system; a sixth category was later added These are:system; a sixth category was later added. These are:

1) A normal healthy patient.2) A patient with mild systemic disease.3) A patient with severe systemic disease.) p y4) A patient with severe systemic disease that is a constant threat to life.5) A moribund patient who is not expected to survive without the operation.6) A declared brain-dead patient whose organs are being removed for donor purposes.

• Average Age: The average age of patients on the NJR

NJR summary of results• Patient consent rates (the rate at which patients have

agreed to have their data added into the NJR) in the NHS g )and independent sector are clearly comparable as is average patient age.

• Average ASA grade is also closely comparable between the two sectors – and far more so than had beenthe two sectors – and far more so than had been supposed.

Patient Consent RatePatient Consent Rate: This is the rate at which patients have agreed to have their data p gadded into the NJR.

Summary charts source data from pages 179 - 193 from NJR 2011 9th Annual Report

Average ASA Grade



Average Age


CQC compliance rates for hospitals andp p

community healthcare 2011–12

CQC compliance rates - summary of results

• The Care Quality Commission’s(CQC) reported compliance rates for core quality outcomes covers all CQC outcomes where there is both NHS and independent sector data available and where there were at least 25 providers inspected in each category during the inspection period.

• The data shows that in many of the areas that we know matter most to patients the compliance rates for the independent sector are higher thanpatients the compliance rates for the independent sector are higher than the NHS.

• One of the key areas that patents are concerned about is dignity and respect . Almost all independent providers (98% in hospitals and 96% in community are meeting the required standard on dignity and respect.

CQC compliance rates: hospitals 2011–12

80%90%

100%

CQC compliance rates*: hospitals 2011-12Independent Hospitals NHS Hospitals

40%50%60%70%80%

0%10%20%30%

R C C M C S C M S S R S S A CRespecting and invo

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CQC compliance rates: community healthcare 2011–12CQC compliance rates* comm nit healthcare 2011 12

80%

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CQC compliance rates*: community healthcare 2011-12Independent Hospitals NHS Hospitals

40%

50%

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0%

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* covers all CQC outcomes where there is both NHS and IS data available and where there were at least 25 providers inspected in each category during the inspection period

For more information on any of the data contained inFor more information on any of the data contained inthis pack, or to source a case study, please contactCatherine Steele at: [email protected]@ gor on 020 7799 8678

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