Guide for commissioners on end of life care for adults

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg42

5 Service specification for end of life care for adults

Commissioners should collaborate with clinicians, local stakeholders, and service users, when determining what is needed from services for people with end of life care needs. The end of life care pathway should be person -centred and integrated with other elements of clinical care.

Commissioners may wish to consider commissioning end of life care in different ways, and mixed models of provision are likely to be appropriate in a local area. Commissioners may wish to take action to stimulate the local market if shortages of providers are identified at any point in the pathway and should note that any qualified provider may include health services, local authorities, other statutory partners, private or third sectors.

Commissioners should ensure that providers implement the recommendations stipulated in the 'End of life care strategy' and that providers are taking steps to achieve the standards set out in the NICE quality standard 'End of life care for adults'.

Commissioners should ensure the services they commission represent value for money and offer the best possible outcomes for their service users. Commissioners should refer to the NICE quality standard 'End of life care for adults' when commissioning services and should include quality statements and measures in the service specification element of the standard contract if appropriate. If poor performance is identified, commissioners can discuss the level of performance with their providers and address any issues and concerns before introducing more formal contractual remedies.

Commissioners may choose to use quality standards to ensure that high-quality care is being commissioned through the contracting process, to establish key performance indicators as part of a tendering process and/or to add incentives to provider performance by using the indicators in association with incentive payments such as CQUIN.

Commissioners should ensure that they consider both the clinical and cost effectiveness of the service, and any related services, and take into account clinicians' and service users' and carers' views and those of other stakeholders when making commissioning decisions.

Table 7 includes considerations for commissioners when developing a contract specification for End of life care for adults. Commissioners may find it helpful to refer to the example service specifications provided on the National End of Life Care Programme website.

Table 7 Considerations for contract specification

Heading	Subheading	Considerations
Purpose	Policy context	National policy drivers for end of life care including the Department of Health (2008) 'End of life care strategy' Evidence base, for example NICE guidance and quality standards, NHS evidence and national strategy consultation
	Local strategic context	Local commissioning drivers (for example reducing hospital admissions and length of stay, QIPP, CQUIN) Invest to save Results of joint strategic needs assessment
	Aims and objectives of service	The expected outcomes of the services
Service scope	Define service user groups	Demographic profile of the local population (age, gender, ethnicity, socioeconomic status) Local recorded and expected need for end of life care Expected proportions of people needing end of life care services who have cancer and non-cancer diagnoses and, if appropriate, a breakdown of non-cancer diagnoses Estimated prevalence of comorbidities (for example, hypertension, stroke, heart failure, depression) Evidence of inequalities in outcomes between specific groups Number of wholly- attributable and partially-attributable end of life-related hospital admissions, bed days and readmissions Number of people currently being treated in primary care, community-based and specialist palliative end of life services and other relevant services Number of people who see their GP and are entered on the GP end of life care register Population-groups that will be targeted
	Exclusion criteria	Define exclusion criteria in accordance with NICE guidance and locally determined criteria.
	Geographical population	Proportion of people living in urban and/or rural areas. Areas of higher-than average need for example, areas with a high population of older people. Population coverage needed or geographical boundaries
	Service description / care package	Mapping existing services for people with end of life care needs Commissioning of core service components Interface with other local services including social care, residential and nursing care, hospices, intermediate care services, ambulance service, out-of-hours services, community mental health services
Service delivery	Location	Service location, defining accessibility requirements and discreet locations Integration with other services for people with end of life needs Home-based, locality-based services and centrally-based services
	Days/hours	Expected hours of operation, including days, evenings and weekends. Expected number of people for case finding, assessment, treatment, care coordination or case management, aftercare, end-of-life care, taking into account potential increased flow through the system over defined periods
	Referral processes	Referral criteria and processes for people with end of life care needs. Management of people who are 'unable to attend' and 'did not attend'
	Response times	Should be needs-based and outcomes-based Setting specific times, which may be particularly important for people identified as rapidly approaching death
	Care pathways	Agreed clinical protocols or guidelines to support decision-making in the care pathway Pathways for people with complex needs and comorbidities Use of third sector organisations Care coordination
	Discharge Processes	Process for discharge from end of life services, including aftercare and communication with other teams
	Staffing	Profile of existing health and social care workforce Staffing levels to be funded: minimum band or levels of experience and competency and expected skill mix Skill mix and competencies of staff for specific areas of care
	Information sharing	Define information-sharing, confidentiality and audit needs, including IT support and infrastructure Raising awareness of end of life care services. Do people with end of life needs and health and social care professionals know how to access services and know what services exist?
Quality assurance and clinical governance	Patient and public involvement	Processes to understand service user experience of end of life services in order to develop and monitor services. See also 'Patient experience online network' Expectations of how service user opinions, preference and experience will be used to inform service delivery for example, focus groups, representation on working groups, and surveys Monitoring of complaints and compliments and how used to inform service Views of informal carers – evaluation of services (VOICES) national survey of the bereaved may be adapted using the toolkit to develop a local survey
	Quality indicators	Use NICE quality standards to define high-quality care including NICE quality standard for end of life care for adults Satisfaction surveys and access to treatment Define outcomes and (proxy) measures including outcomes provided in the NICE quality standard for end of life care for adults
	Performance monitoring	Local need and demand for treatment, including brief interventions. Impact of services on admissions to accident and emergency, inpatient hospital care and length of stay in hospital Measurement of referrals and discharges
	Equality	Measures to ensure equality of access to services, taking into account the risks of unintentional discrimination against groups who are often under-represented, such as people who do not speak English as a first language Consider equity of access for people living in residential and nursing homes, those who are housebound, or those in prison
	Staff training and competency	Training and competencies on recruitment and for ongoing development Processes for monitoring clinical practice and competency, including professional registration and clinical supervision arrangements Skill mix and competencies required across the care pathway. See 'Skills for health' and Core competencies for end of life Staff development – appraisal and personal development plans, and mandatory training
	Audit and surveys	Specify expectations for audit, which may include assessment, intervention, prescribing practices and successful treatment outcomes It may be useful to specify that providers participate in the following audits and surveys: The National care of the dying audit – hospitals collects data on communication with primary care. National Council for Palliative Care specialist palliative care workforce survey. Views of informal carers – evaluation of services (VOICES) national survey of the bereaved may be adapted using the toolkit to develop a local survey
	Staff and patient safety	Procedures for risk assessment Formal procedures for incident reporting and monitoring Address any safeguarding concerns and promote the welfare of children and vulnerable adults
Activity Plan		Planned service development setting out any productivity improvements
Cost	Value for money	Likely cost of new or additional services Anticipated set-up costs How will pricing be set? Potential for better value for money Are people receiving most appropriate end of life services? Cost of facilities, for example venue hire Cost of staff travel to services and people's homes QIPP.