Services for people with chronic heart failure

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg39

5 Service specification for chronic heart failure services

Commissioners should collaborate with clinicians, local stakeholders, and service users when determining what is needed from services for people with chronic heart failure in order to meet local needs. The care pathway should be person/patient-centred and integrated with other elements of care for people with long-term conditions.

Commissioners may wish to consider commissioning services for people with chronic heart failure in a number of different ways, and mixed models of provision are likely to be appropriate within a local area. Commissioners may wish to take action to stimulate the local market if there are identified shortages of providers at any point in the pathway and should note that any qualified providers may include health, local authority, other statutory partners, and private or third sectors.

Commissioners should ensure that providers implement the recommendations stipulated in NICE guidance and that providers are taking steps to achieve the standards set out in NICE quality standards for chronic heart failure and end of life care (under development).

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 standards for chronic heart failure and end of life care when commissioning services and should include quality statements and measures within the service specification element of the standard contract where 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 incentivise provider performance by using the indicators in association with incentive payments such as Commissioning for Quality and Innovation (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 individuals' and carers views and those of other stakeholders when making commissioning decisions.

Table 9 includes considerations for commissioners when developing a contract specification for heart failure services.

Table 9 Considerations for contract specification

Heading	Section	To be described in service specification
Purpose	Policy context	National policy drivers for chronic heart failure (CHF), long-term conditions and end-of-life care. 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 (JSNA).
	Aims and objectives of service	The expected outcomes of the service(s).
Service scope	Define service user groups	Demographic profile of the local population (age, gender, ethnicity, socio-economic status). Local recorded and expected prevalence of CHF. Estimated prevalence of comorbidities (for example, hypertension, stroke, COPD, depression). Evidence of inequalities in outcomes between specific groups. Number of wholly attributable and partially attributable CHF-related hospital admissions, bed days and readmissions. Number of people currently being treated in community-based heart failure services and other relevant services, such as cardiac rehabilitation. Number of people who see their GP and have a recorded incidence of chronic heart failure related ill health. 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 of deprivation and areas with a high population of older people. Population coverage required or geographical boundaries.
	Service description / care package	Mapping existing services for people with CHF. Commissioning of core service components (assessment, cardiac rehabilitation, care coordination and/or case management, aftercare, prescribing, end-of-life care). Interface with other local services including social care, residential and nursing care, hospices, intermediate care services, ambulance service, out-of-hours services, and community mental health services.
Service delivery	Location	Service location(s), defining accessibility requirements and discreet location(s). Integration with other services for people with CHF and long-term conditions. Home-based, locality-based services and centrally-based services.
	Days/hours	Expected hours of operation, including days, evenings and weekends. Expected number of individuals for case finding, assessment, treatment, care coordination or case management, 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 CHF. Management of 'unable to attend' (UTAs) and 'did not attends' (DNAs).
	Response times	This should be needs based and outcomes based. Setting specific times, particularly for assisted discharge and rapid response services for end-of-life care.
	Care pathways	Agreed clinical protocols or guidelines to support decision-making in the patient pathway. Pathways for people with complex needs and comorbidities. Use of third sector. Care coordination.
	Discharge processes	Process for discharge from services for people with CHF, 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 level 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 requirements, including IT support and infrastructure. Raising awareness of services for people with CHF. Do individuals and health and social care professionals know how to access services?
Quality assurance and clinical governance	Patient and public involvement	Processes to understand patient experience of CHF services in order to develop and monitor services. See also Patient experience online network Expectations of how patient opinion, preference and experience will be used to inform service delivery for example, focus groups, representation on working groups, and surveys. Monitoring of complaints and complements and how used to inform service. See also the NICE Quality Standard for patient experience (under development)
	Quality indicators	Use NICE quality standards to define high-quality care. Patient satisfaction surveys and access to treatment. Define outcomes and (proxy) measures including outcomes provided within the NICE Quality standard on chronic heart failure.
	Performance monitoring	Local need and demand for treatment, including brief interventions. Impact of service(s) on admissions to A&E, 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 within residential and nursing homes and those who are housebound; or people within prisons.
	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, including competencies in: assessment, behavioural change and motivational interview, personalised care planning, provision of exercise and identifying palliative care. See Skills for Health for examples. Staff development – appraisal and personal development plans, and mandatory training.
	Audit	Specify expectations for audit, which may include assessment, intervention, prescribing practices and successful treatment outcomes. See audit support and electronic audit tool for NICE clinical guideline 108 and also NICE audit support for CG91 on depression with a chronic physical health problem. Participation in national heart failure audit, including associated costs.
	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		Long-term impact of increased access to improved assessment and diagnosis of chronic heart failure on referrals to other services, hospital admissions and bed days. 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 through reduced readmissions and reduced duplication of healthcare appointments through an integrated team and improved communication between teams Are individuals receiving most appropriate services for chronic heart failure? Cost of facilities, for example venue hire. Cost of staff travel to services and individuals' homes. QIPP. See the Commissioning and benchmarking tool for further information.