Services for people with chronic obstructive pulmonary disease

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg43

5 Service specification for COPD services

In order to meet local needs, commissioners should collaborate with clinicians, local stakeholders, and service users when determining what is needed from services for people with COPD. The care pathway should be person/patient-centred and integrated with other elements of care for people/patients with COPD.

Commissioners may wish to consider commissioning services for people with COPD 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, and other statutory partners, private or third sectors.

Commissioners must 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 standard for COPD.

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 for COPD when commissioning services and should include quality statements and measures in 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 patients' views and those of other stakeholders when making commissioning decisions.

Table 5 includes considerations for commissioners when developing a contract specification for COPD services.

Table 5 Considerations for contract specification

Heading	Section	To be described in service specification
Purpose	Policy context	National policy drivers for COPD, 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 COPD and smoking 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 COPD-related hospital admissions, bed days and readmissions Number of people currently being treated in community-based COPD services and other relevant services, such as stop-smoking services Number of people who see their GP and have a recorded incidence of respiratory related ill health Population groups that will be targeted for brief interventions such as smoking cessation support Population groups that will be targeted for pulmonary rehabilitation and assisted discharge schemes
	Exclusion criteria	Define exclusion criteria for assisted discharge and pulmonary rehabilitation 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 COPD. Commissioning of core service components (case finding and spirometry, brief advice and interventions such as stop-smoking, assessment, home oxygen, pulmonary rehabilitation, structured discharge planning, 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, defining accessibility requirements and discreet location(s) Integration with other services for people with COPD 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 patients 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 COPD Management of 'unable to attends' (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 COPD, 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 or level of experience and competency and expected skill mix Skill mix and competencies of staff for specific areas of care – for example, spirometry, pulmonary rehabilitation and assisted discharge
	Information sharing	Define information sharing, confidentiality and audit requirements, including IT support and infrastructure Raising awareness of services for people with COPD. Do patients 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 COPD services in order to develop and monitor services 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 compliments and how used to inform service
	Quality indicators	Use NICE quality standards to define high-quality care Patient satisfaction surveys on COPD services and access to treatment Define outcomes and (proxy) measures including outcomes provided within the quality standard on COPD
	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, starters and completers for pulmonary rehabilitation (to be determined locally using best evidence as national guidance not available)
	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 in 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 Skills 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 needs. See Skills for health for examples, including a respiratory disease competence framework 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 for NICE clinical guideline 101 on COPD, audit criteria for NICE public health guidance 1 on brief interventions and referral for smoking cessation, NICE audit support for smoking cessation services, NICE audit support for 91 on depression with a chronic physical health problem and the Royal College of Physicians national COPD audit
	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 pulmonary rehabilitation on referrals to other services, hospital admissions and bed days Long term impact of improved diagnosis of COPD on referrals to other services and hospital admissions 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 patients receiving the most appropriate services for COPD? Cost of facilities, for example venue hire for pulmonary rehabilitation Cost of staff travel to services and patients' homes. QIPP See the Commissioning and benchmarking tool for further information