3 Using NICE quality standards to commission quality services

3.1 Background

A NICE quality standard is a concise set of statements designed to drive and measure priority quality improvements. Each NICE quality standard is informed by accredited evidence-based guidance. The Health and Social Care Act (2012) declares that the Secretary of State, in discharging their duty to improve the quality of services, 'must have regard to the quality standards prepared by NICE'. The care system should also have regard to them in planning and delivering services, as part of a general duty to secure continuous improvement in quality.

Commissioners can use NICE quality standards to support commissioning for quality improvement in a number of ways.

  • Understanding how commissioned or new services/providers compare with NICE quality standards provides an evidence-based assessment of the quality of services.

  • Comparing commissioned services and local pathways with NICE quality standards may highlight service gaps and inform local joint strategic needs assessments (JSNAs).

  • They can be used collaboratively with providers to prioritise and inform quality improvement activities.

  • They can be used as a source of evidence-based quality indicators for local quality improvement incentive schemes (for example, in health this could include the local CQUIN).

  • With the guidance on which they are based, they can contribute to the improvements outlined in local health and wellbeing strategies and the outcomes frameworks published by the Department of Health: the Adult Social Care Outcomes Framework, the NHS Outcomes Framework and the Public Health Outcomes Framework.

Quality standards consider all settings and the interface between public health, health and social care. Although some standards will be area specific, there will often be significant overlap across areas and these will be considered during development of the standard.

Quality standards for social care focus on the services and interventions to support the social care needs of service users. Using NICE quality standards to improve the quality of social care can help achieve improvements in outcomes included in the Adult Social Care Outcomes Framework.

To support local authorities in meeting their public health responsibilities, which came into effect in April 2013, the Department of Health held a public consultation to seek stakeholder views on the work programme. It then referred a library of topics to NICE, with a principal focus on public health.

Topics include: preventing healthcare-associated infections, promoting oral health, reducing tobacco use and preventing harm from smoking, preventing harmful alcohol use, and strategies to prevent obesity in adults and children.

The public health quality standards support Public Health England, local authorities and the wider public health community to improve outcomes in line with the Public Health Outcomes Framework. The Framework for England sets out objectives for the public health system in the 3 years from April 2013. It consists of 4 domains and more than 60 indicators for measuring progress. The NICE local government briefing on NICE guidance and public health outcomes provides links to NICE guidance relevant to more than 40 of these indicators and shows how it can help local authorities tackle their public health priorities.

The NHS Outcomes Framework sets out the national quality goals for the NHS and is used by the Secretary of State, through the Mandate, to hold NHS England to account. The outcomes indicator set derived from the quality standards (in part) provides clinical commissioning groups (CCGs) and health and wellbeing boards with comparative information on the quality of health services commissioned by CCGs and the associated health outcomes in support of the NHS Outcomes Framework. For more information, see NICE quality standards and NHS Outcomes Framework 2015–16.

Planning ahead

As previously discussed in this guide, it is good practice to keep up to date with NICE guidance and quality standards that are in development. By signing up for NICE news you will receive a monthly email advising you of all new NICE quality standards published that month. To find out which quality standards are currently being developed, refer to the quality standard forward planner.

Finding a quality standard to support local or regional priorities

As well as establishing a process for newly published quality standards, you may also want to check the library of published quality standards to see if any are relevant to local priorities including those identified by local Joint Strategic Needs Assessments (JSNAs) and/or detailed in Health and Wellbeing or commissioning strategies.

As well as browsing the library of published quality standards, you can also easily access all quality statements and recommendations that NICE has made on a topic by searching NICE Pathways. NICE Pathways bring together all related NICE products on a topic in a simple-to-read user-friendly interface.

3.2 Establish how commissioned services and local pathways compare with NICE quality standards

An initial assessment of how local pathways and the services you commission compare with the statements in the quality standard will help to identify any areas requiring improvement and to support local prioritisation of quality improvement activities. The nominated commissioning lead should coordinate this initial assessment, linking with provider contacts and other commissioners as appropriate.

An initial assessment should consider for each statement in the quality standard:

  • whether the statement is relevant to the commissioning portfolio

  • whether there are any local commissioning policies (for example, 'treatments of limited clinical value' policies, referral management systems or care pathways) or service specifications that would need to be reviewed in order to enable services to meet the relevant quality standards

  • which organisations are currently commissioned to provide the service

  • how services currently commissioned compare with the statement

  • an initial assessment of risk associated with not making these improvements.

It is only through linking with providers that you can establish how commissioned services compare with a quality standard. Your providers should already be planning an initial assessment of how their service compares as it will provide quality assurance to their board or flag areas requiring improvement. As risk management and quality improvement are predominantly collaborative activities, it is advisable to establish long-term processes for assessment, prioritisation, quality improvement and reporting. By agreeing the expectations as part of the contracting process, you can limit ad hoc demands for additional data, thereby enabling providers to focus data collection activities on assurance and measuring improvements.

Because the provider's initial assessment may contain detailed operational information, you as commissioner will not need to see the full detail. It is, however, reasonable to expect to be informed of any exceptions – that is, any areas where current service provision does not meet the NICE quality standard. You and your providers may negotiate a process whereby you receive a copy of the initial assessment, because this would reduce duplication of reporting and could be a way of providing assurance that services are of high quality. However, this is not the only way that such assurance can be given, and the issue needs local discussion and agreement.

As well as agreeing the process for initial assessment, there should also be agreement about timelines for the completion of each one.

3.3 Locally prioritised quality improvement

The initial assessment of how local pathways and commissioned services compare with the quality standard can help commissioners in a number of ways:

  • An assessment from providers, informed by readily available evidence, that a service meets the quality standard can provide assurance.

  • An assessment indicating areas requiring quality improvement can help inform local quality improvement programme planning and support discussions with providers about local CQUIN or local quality improvement incentive schemes.

  • The findings can also identify priority areas for audit to be included in providers' quality schedules.

  • The assessment can inform business planning discussions by identifying priority areas for improvement.

  • If the assessment identifies areas of high risk, it can help inform local risk management.

  • The assessment could contribute to local service reconfiguration or decommissioning considerations by highlighting potential for cost saving or identifying services that are of poor quality.

It may be that the assessment highlights areas where only small changes are needed to achieve the quality standard. In this case, quality improvement work led by the provider could start straightaway, with little leadership needed from the commissioner. However, you can be confident that focusing efforts on improving the service to meet the quality standard will have a positive impact on the outcomes of people using the service. Agreeing a process for the providers to periodically update you on progress may be all that is needed.

The assessment might highlight a more significant shortfall in the quality of the service provided compared with the quality standard, or service restrictions resulting from local policies or pathways. However, commissioners and providers need to be able to prioritise investment in quality improvement and service development. Points to consider when deciding whether or not to prioritise an individual NICE quality standard for quality improvement work include:

  • Are there risks associated with not improving the service so that it meets the quality standard?

  • Could savings be made (financial or efficiency)?

  • Is the topic of the quality standard already a local priority (for example, identified by the local Joint Strategic Needs Assessment and subsequent health and wellbeing strategy)?

By completing an assessment of how current services compare with the NICE quality standard, providers and commissioners are able to make well-informed collaborative decisions about how to prioritise quality improvement activities. It may be that there is local agreement to focus on some of the statements within the quality standard rather than the whole quality standard. It is likely that these discussions will take place during routine business or quality meetings between the providers and the commissioners.

If there is a collaborative decision not to prioritise the topic for improvement at the current time, this should be recorded and a date for review of this decision agreed and noted. Any significant risks associated with this decision should also be recorded on the commissioners' risk register.

3.4 Support changes in services not in line with NICE quality standard

Convene a project team

If the services you commission are not currently in line with NICE guidance and/or there is local agreement that quality improvement work should take place for a service to meet a NICE quality standard, a quality improvement project team will be needed to take the work forward.

If it is likely that major changes will be made to the service that could have an impact on referral pathways, user access or a number of providers across a pathway, it may be necessary for a commissioner to coordinate the project. If there is more than 1 commissioner of the service or pathway, integrated commissioning will be needed, and commissioning organisations may wish to nominate a lead commissioner.

The project team might be an existing group of people already working on quality improvement relating to a service or identified need (for example, a project team leading on work to address a need identified by the local Joint Strategic Needs Assessment or a team involved in a strategic clinical network). Sometimes it will be necessary to convene a new team. The team should have clear objectives and agree the project timescales at the start of the project.

Tips and resources

NHS Improving Quality gives the following advice on convening a project team:

'Having the right people involved from the beginning with the right expertise will give your project the best chance of sustainable success. If the right people are not involved from the start, it will be much harder to engage and involve these people at a later date.

A project sponsor and involvement from the top of your organisation (member of the executive team or portfolio holder) is necessary to champion your project and provide strategic direction to the project. This type of involvement also provides support to discuss issues, celebrate achievement and provide access to human resources, finance, analysts, communications, estates and IT teams when required.'

Early questions that the local project team may wish to consider are:

  • Which approach, intervention or technology will be selected and why? (Consider evidence of effectiveness in the local setting, cost effectiveness or cost comparison with alternative options, acceptability to users, patients, clinicians and organisations.)

  • How will the project be funded?

  • How can the effectiveness of the project best be measured (for example financial impact and effect on clinical, health or wellbeing outcomes)?

  • How will local metrics be identified and measured?

  • Who will be responsible for collecting data?

  • How will any necessary training and education be provided?

  • Are there any obvious challenges and how could these be met?

For larger projects, it may be advisable to have both a core team involved in the day-to-day work of the project and a wider 'stakeholder group' of people whom you can co-opt into the project as appropriate and who need to be kept informed. People in different roles will bring a range of experience, skills and ideas to the team. It is essential to involve people who will use the service because they will bring a vital perspective to the project and will often have the best ideas for quality improvement.

Tips and resources

Developing an effective communication plan

Experience shared by NHS organisations with HTAP has indicated that it is important that there is good communication between all stakeholders when implementing a significant change. This will include all those who will be affected by the planned changes.

The communication plan should include:

  • How stakeholders will be updated on progress and how frequently this will occur.

  • Barriers to change and any proposed solutions

  • How feedback from stakeholders will be received and responded to

  • How any success or useful experiences from the project are to be shared.

Identify barriers to change

Changing established behaviour of any kind is difficult. It is particularly challenging in health and social care because of the complex relationships between a wide range of organisations, professionals, services users and carers.

Certain factors may help to foster an environment that is conducive to change. An organisation where there is strong leadership and everyone is focused on improving care and outcomes is likely to develop motivated staff with a desire for continuous improvement. However, barriers to changing established practice may prevent or impede progress in all organisations, whatever the culture.

Tips and resources

The NICE guide how to change practice: understand, identify and overcome barriers to change provides practical suggestions based on evidence and experience to help get NICE guidance into practice.

The guide is split into 3 parts:

  • Part 1 discusses the types of barriers to change encountered in healthcare.

  • Part 2 offers practical suggestions for how to identify the barriers to changes in your organisation.

  • Part 3 shows how to overcome these barriers, and highlights potential levers to help people do this. Real life examples are provided illustrating how the methods described have brought about positive changes in a range of situations.

Develop an action plan (or commissioning plan)

The project team should develop an action plan (or commissioning plan) that details the steps needed to put the guidance into practice or improve services so that they meet the quality standard. As commissioner, you may be required to comment on or approve this action plan even if you are not part of the project team. This is for local agreement. There may already be some change ideas that were recorded when the initial assessment of how the service compared to the quality statements was completed. Some of these could be turned into actions. Other key sources of change ideas include:

  • The relevant NICE guidelines (a set of systematically developed recommendations to guide decisions for a particular area of care or health issue) on which the quality standard was based.

  • NICE Evidence Search (provides free open access to a unique index of selected and authoritative health and social care evidence-based information).

  • NICE local practice collection (a collection of case studies giving practical tips and detailing lessons from implementing NICE guidance and using NICE quality standards to improve services).

  • C4EO works with local areas and services (across the public, private, voluntary and community sectors) to gather examples of excellent local practice which have led to significantly improved outcomes for children, young people and their families.

  • NICE Quality, Innovation, Productivity and Prevention (provides evidence to support quality and productivity at a local level. The quality and productivity collection does not constitute NICE guidance; however, many examples are supported by NICE guidance and therefore represent practical examples of using guidance).

  • Service user surveys or interviews.

  • Focus groups.

If you are the project lead, remember to nominate leads for each action and agree timelines for completion.

Tips and resources

Spread the responsibility among interested parties to help share the workload.

Give realistic deadlines to motivate people to do it.

Keep a risk register to help manage risks associated with the project. An issues log will help capture what has been learnt from the project and may help with future improvement work.

NICE podcasts can help to increase awareness and knowledge. Opinion leaders (such as those speaking in NICE podcasts) can successfully promote evidence-based practice. They can motivate and inspire health and social care professionals to achieve the best possible care.

Effective patient and service user involvement is a fundamental part of good practice in quality improvement, and can help to ensure that services are planned and delivered with a focus on patient, service user and carer interests. Involving patients, service users and carers in clinical audit or service redesign can help improve action plans for implementing NICE guidance and ensure they are acted on.

See shared learning examples of:

Assess cost and service impact and, if needed, develop a business case

The project team should assess how much it will cost (or save) to implement the action plan. It might be possible to make some of the changes using existing resources, or it might be possible to make savings, or free up capacity for other activities.

There may be the need to consider capital needs (such as equipment), staffing and training needs, and capacity issues. These will need to be addressed by local delivery and planning processes. The project team should also explore opportunities for longer-term savings that could be made as a result of early actions to promote health and wellbeing. It is important that organisations have a process for working together with local partners to improve quality and outcomes, because it can help to even out the costs and savings. The role of the commissioner is vital here as they tend to coordinate across the whole care pathway.

To help you with building a business case, you could use the NICE costing tools or the NICE commissioning and benchmarking tools. These tools can help individual organisations and local health economies to estimate the cost impact of implementing NICE guidance based on their local population.

A resource called 'Support for commissioning' is provided alongside NICE quality standards, as appropriate, to help review the potential cost impact and commissioning implications. This resource typically:

  • highlights the key actions that commissioners should take

  • identifies opportunities for collaboration and integration at a local and regional level

  • identifies the benefits and potential costs and/or savings from implementing the changes needed to achieve quality improvement

  • directs commissioners and service providers to support tools that can help them implement NICE and NICE-accredited guidance.

3.5 Measuring quality improvement

Measurement is essential if we are to be confident that a change has resulted in an improvement. If the measurement shows that no improvement has occurred as a result of the change, we know that we need to adapt the change or try something different.

Each NICE quality standard contains a concise set of quality statements (usually 6–8 statements, up to a maximum of 15 statements in exceptional circumstances) and associated measures.

The quality statements describe key markers of high-quality, cost-effective care for a particular area of care. These statements may address prevention, as well as elements of health and social care, and will promote an integrated approach to improving quality.

Quality measures accompany each quality statement and aim to improve the structure, process and outcomes of health and social care. Quality measures are generally specified in the form of a numerator and a denominator which define a proportion (numerator/denominator). It is assumed that the numerator is a subset of the denominator population.

For instance, using the NICE quality standard on depression in children and young people as an example, the process measure is:

  • Numerator – the number of people in the denominator who have their health outcomes recorded at the beginning and end of each step in treatment.

  • Denominator – the number of children and young people receiving treatment for depression.

The proportion is the number of children and young people receiving treatment for depression who have their health outcomes recorded at the beginning and end of each step in treatment.

At present there are limited health and social care outcome measures that can be used as quality measures. Therefore, the focus of the quality measures is on improving the processes of care that are considered to be linked to health outcomes.

The quality standards also indicate where national quality assured indicators currently exist and measure the quality statement. See more information about the National Library of Assured Indicators developed by the Health and Social Care Information Centre.

Identifying local sources of data

Where national data do not exist, the project team will need to identify local sources of data to enable measurement of the impact of any changes made. The data may be available from an established source (for example, routinely collected activity data or prescribing information) or new processes may have to be established. The measures used and the methods for collecting the data need to be clear, concise and detailed so that exactly the same information is collected before and after each change. If you are not directly involved in the project team, you should agree with the provider how you would like to be kept informed of progress with the project, including which data you would like to receive and the frequency of data reporting. This will help the provider to manage their data collection and will avoid the need for ad hoc requests for additional data.

Establishing the baseline

With agreed measures and data sources in place, the project team can now establish the baseline. Depending on the availability of data during the initial assessment, this may be the first measure of the current situation – that is, before any quality improvement changes have taken place. This is the starting point.

Tips and resources

NHS Improving Quality gives the following advice:

'Ask yourself what are you trying to achieve? What would tell you that you had achieved it? What would you need to have in place to know you were making progress towards that aim? These questions should help you identify what you need to measure and therefore what data you will need.'

3.6 Deliver the action plan

Once the action plan and assessment of cost have been approved, the measures have been agreed and the data sources have been identified, the work of implementing the action plan begins. To enable effective implementation, all partner organisations should sign up to the action plan. Our guide on how to change practice: understand, identify and overcome barriers to change can help.

3.7 Evaluation, assurance and sharing success

Evaluation

As changes are implemented according to the action plan, there will need to be evaluation of how effective they have been. When implementing NICE guidance, the accompanying NICE audit tools can help review the impact of the overall implementation process and highlight any adjustments necessary to ensure sustained improvement. As commissioner of a service, you may agree with your provider a number of NICE guidelines that you would like to receive audit data on throughout the year, as a way of monitoring implementation of the recommendations.

If you are engaged in a quality improvement project with the aim of achieving the NICE quality standard for a service or pathway, it is likely that you will be implementing a series of changes and monitoring them closely for impact. By managing the implementation of change (for example, piloting each change for an agreed period of time) and monitoring the effect, the project team can effectively respond to any unforeseen consequences as a result of the change or slightly adjust the change so as to achieve the best result. It can also be easier to get people on board with a 'pilot' as they can be assured that a subsequent permanent change will be positive.

The project team will need to repeat the associated measure after each change so that it can be seen whether or not the change has had a positive impact on quality (that is, developed the service towards achieving the quality standard). It is also a good idea to repeat the measure periodically once the standard has been reached to ensure that the improvement is sustained.

The change process described is called a PDSA (Plan Do Study Act) cycle. To find out more about using this improvement method see First steps towards quality improvement: a simple guide to improving services (NHS Improvement). If you would like to read about other change models and frameworks, the C4EO change models resource may be of interest.

Assurance

NICE advises provider organisations to produce an annual report for assurance at the highest level of the organisation, detailing the use of evidence-based guidance such as NICE guidance, and how effective the organisation has been at putting it into practice. The report should also include an indication of its position against the NICE quality standards and progress with any quality improvement projects aligned to the quality standards. As commissioners of a service, it is reasonable to require assurance about the extent to which commissioned services are in line with NICE guidance and evidence of continuous quality improvement. From a provider perspective, establishing an assurance process that meets the needs of the board and commissioners can save a lot of duplicated effort and avoid ad hoc requests for data. This assurance process should be discussed and agreed as part of the contracting round.

Share success

Sharing success and failure helps everyone. Consider a joint submission to the NICE local practice collection and share your tips with other organisations. Or contact your local communications team to discuss ways of sharing your success locally through organisations' news bulletins, development days and even the local press.

Tips and resources

See shared learning examples of:

Periodically review services already in line with NICE guidance or quality standards

Review services periodically to ensure that good practice is maintained. You could prioritise what you review based on local priorities and information from other sources (such as national audits and benchmarking data).