Commissioning products: What are they? How do they deliver better services for patients? Frances Flinter Chair, Medical Genetics CRG UKGTN Conference 22 November 2012

Service Specification Medical Genetics can be divided into to two main service areas both covering children and adults: Clinical Genetics and Laboratory Genetics (consisting of molecular and cytogenetic tests and, in some specified centres, specialised biochemistry tests or other specialist tests). In summary, in Clinical Genetics Departments, clinical staff will see patients affected by or at risk of a genetic condition and will provide diagnostic and genetic counselling services. The Laboratory Genetics services will provide either or both molecular and cytogenetic testing, together with advice and support to referrers and interpretation of results. SCOPE: Under this service specification, the laboratory services will only provide the Genetic tests for patients referred by the Clinical Genetics service. (They will have other contractual arrangements for other referrals which they receive).

Dashboard

Dashboard requirements 12 – 15 indicators covering the following areas: Clinical outcomes Clinical effectiveness Patient experience

Gen 01: Proportion of tests that return a positive result for affected patients who have the test to determine a diagnosis and are seen in clinical genetics Numerator: Number of tests that return a positive result ordered for symptomatic patients who have the test to determine a diagnosis and are seen in clinical genetics (exclude Fragile X) Denominator: Number of tests ordered for symptomatic patients who have the test to determine a diagnosis for patients seen in clinical genetics (exclude Fragile X) NB excludes cascade testing, carrier testing, pre-symptomatic testing

Numerator: Number of clinical genetic clinics that are part of a MDC / MDT Denominator: Total number of Genetics clinics NB Clinic is half day/4 hours GEN 02: Proportion of clinical genetic clinics that are part of a MDC / MDT

GEN 03: Proportion of clinical audits completed and action plans put in place Numerator: Number of clinical audits completed and action plans put in place (from the agreed list of audits) Denominator: Number of clinical audits that the clinical genetics department was expected to participate in NB CGS/lead clinicians to choose audits

GEN 04a: Proportion of Cytogenetics reports meeting turn round times as agreed by the professional organisations (CMGS/ACC) Numerator: Number of cytogenetics reports meeting turn round time Denominator: Number of cytogenetics reports issued by the laboratory

GEN 4b: Proportion of Molecular reports meeting turn round times as agreed by the professional organisations (CMGS/ACC) Numerator: Number of molecular reports meeting turn round time Denominator: Number of molecular reports issued by the laboratory

GEN 05: Number of educational sessions provided by clinical genetics to other specialties Supports Mainstreaming agenda One session = 1 hour

GEN 06: Rate of written complaints about the genetics department Numerator: Number of written complaints about the genetics department received during period Denominator: Average (mean) number of patient contacts per month for three months up to end of period

GEN 07: Rate of letters/ s from patients, carers or non-genetics consultants registering thanks to the genetics department Numerator: Number of letters/ s from patients, carers or non-genetics clinicians registering thanks to the genetics department received during period Denominator: Average (mean) number of patient contacts per month for three months up to end of period

GEN 08: Proportion of patients receiving test result within 5 working days after the clinic receives the laboratory report for prenatal genetic test results Numerator: Of all patients seen in clinical genetics who had prenatal diagnosis during the period, the number who received their prenatal genetic test result within 5 working days of the clinic receiving the laboratory report. Denominator: Number of patients seen in clinical genetics who had prenatal diagnosis during period

GEN 09: Proportion of appointments that are not attended Numerator: Number of DNAs within period Denominator: Total number of appointments booked during period within clinical genetics

GEN 10: Rate of patients consulted without a referral Numerator: Number of patients consulted without a referral during period Denominator: Total number of patients attending appointments during period

GEN 11a: Rate of patients consulted by a genetic counsellor during period Numerator: Number of patients seen by a genetic counsellor (including telephone appointments that replace a face to face appointment), at any point during the period Denominator: Total number patients seen (including telephone appointments that replace a face to face appointment) at any point during the period

GEN 11b: Rate of appointments consulted independently by a genetic counsellor during period Numerator: Total number of clinical genetics independent counsellor appointments during period Denominator: Total number of clinical genetics appointments of all types during period

GEN 12a and 12 b: Serious Untoward Incidents 12a Number of Serious Untoward Incidents involving patient care 12b Rate of Serious Untoward Incidents involving laboratory tests Numerator: Number of serious untoward Incidents involving lab tests Denominator: Number of lab tests during period

Gen 13: Scores from EQA schemes in which laboratory participates Numerator: Episodes of poor performance notified to the laboratory by UKNEQAS, EMQN or another EQA service provider Denominator: Number of EQA schemes in which labs participate

GEN 14: Proportion of audits participated in by the genetics laboratory (the number and type of audits to be agreed by national professional bodies) Numerator: Number of audits (from the agreed list of audits) in which genetics laboratories participate Denominator: Number of audits in which the genetics laboratory should be participating NB CMGS/ACC to determine audits

GEN 15: Proportion of test requests from clinical genetics that did not comply to UKGTN Testing Criteria (TC) where TC apply Tests included to be specified annually: list is: BWS, MEN2 and Silver Russell Numerator: Number of tests requested by clinical genetics from specified list that did not comply with UKGTN Testing Criteria Denominator: Number of tests requested from specified list

Dashboard questionnaire

CQUIN Commissioning for Quality and Innovation The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals.

Medical Genetics CQUIN Goal: To increase the proportion of appointments for patients at high risk of familial breast cancer (from referral letter) and decrease the number of genetics appointments for patients with low and medium risk of familial breast cancer. Risk is defined within the NICE guidelines for Breast Cancer Numerator: For each risk level for familial breast cancer (as established from the referral letter) the number of new patient appointments for unaffected patients in cancer genetics Denominator: For each risk level for familial breast cancer the number of new unaffected patients referred to cancer genetics

Cancer Genetics CQUIN Baseline period: first quarter of 2013/14 Final indicator value (payment threshold) To be determined once baseline established and improvement target agreed Rules: Quarterly monitoring and payment Baseline data must be submitted at end of first quarter for targets to be set. If this is not completed to time, 25% of CQUIN value will not be paid. Equally, 25% of the payment will be made for producing the baseline position. It is suggested that late submission of reports in subsequent quarter would lead to 10% of quarterly value being lost.

Other CQUINS considered Genetic counselling outcome scale: - Audit instead? Access to aCGH: - most analyses requested from outside Genetics Diagnostic success: - How to verify?

QUIPP Quality, Improvement, Productivity and Prevention Need to improve productivity and eliminate waste in order to meet tough savings requirements (£15-20bn by 2013/4) eg reduced length of stay, lower readmission rates…………what about Genetics? CQUIN results may help to derive a QUIPP proposal PolicyAndGuidance/DH_113809

New commissioning policy Preimplantation Genetic Diagnosis (PGD) Not previously commissioned: case-by-case application to PCTs CAG approved: awaiting finance and PPE sign off Strict referral criteria described to maximise clinical effectiveness of treatment and achieve equity of access

Thank you for your help CRG members Chairs of other CRGs Lead clinicians Commissioning colleagues Leaders of professional societies