England

Sustainable, Resilient, Healthy People & Places

Module: An Integrated Approach to Metrics

Sustainable | Resilient | Healthy People & Places2

Module: An Integrated Approach to Metrics

Vision: A health and care system where the progress insustainable development within organisations and as awhole can be clearly seen. Indicators and data sets enablebenchmarking without creating burdensome collectionprocesses. They also provide a firm base to identifymilestones and future development, and support theachievement of the goals of the Sustainable DevelopmentStrategy (SDS).

The measures of success by 2020 are:

The health and care system, and organisations within it, can monitor and clearly demonstrate progressagainst targets from the SDS, Climate Change Act and Public Services Act.

The monitoring of progress supports decision making throughout the system by identifying hotspots andareas for action.

Organisations are able to accurately benchmark their progress against others through systematicmonitoring, collation and reporting ensuring progress is clear to the public.

Monitoring progress towards achieving a sustainable healthand social care sector will not be possible withoutmeasurement. Although data collection and methods limitthe current measurement of sustainability a lot is possible.This document primarily focuses on what measures alreadyexist and provides a direction for further development.

Well chosen indicators can help us understand sustainabledevelopment in the health and care system, compareprogress and improve. They can also provide assurance thatthe level of ambition will be achieved by capturing theeconomic, environmental and social benefits.

The NHS Five Year Forward View1 emphasises the need tomeasure what matters and be transparent in the data wepublish in order to help make the right decisions whendeveloping and commissioning services. The ability to

accurately measure the effectiveness of sustainabilityinterventions to deliver better outcomes for people, savemoney and reduce impacts on the environment closely linksto this.

The content of this module has been developed by thenational sustainable development metrics steering group thathas representatives from across the NHS, public health andsocial care system. Further information about data sourcesand mapping processes is available in the supportingdocuments for this module.

Currently it is not possible to measure the full impacts ofsustainable development because these are not fully definedor understood yet and many of the benefits are not mapped.For instance we don’t currently know how to measure theclear health impacts of green space in a city such as

Introduction

1. NHS Five Year Forward View. Developed by NHS England with partner organisations patient groups, cliniciansand independent experts it sets out a vision for the future of the NHS.

3

Purpose

The purpose of this document is to set out proposalsand approaches that will improve the health andwellbeing of people across England. It is the product ofcollaboration with many organisations and individualsacross the system that have helped to highlight anddefine good practice in measurement and metrics.

The content of this module is not a set of instructionsor a prescriptive way of working. It shows the ways todeliver sustainable health which are neitherburdensome nor costly but improve outcomes forpeople, save money and help to protect theenvironment.

The challenges of caring for a changing populationwith limited resources and the importance of accuratelymeasuring care interventions has been highlighted inthe plans for the future of the health system.

An Integrated Approach to Metrics 3

increased exercise and wellbeing, improved social cohesionand resilience to overheating and flooding. Similarly thehealth impacts of active travel to hospital for visitors and stafflike the increases in exercise, reductions in carbon emissionsand local air pollution are difficult to quantify. This moduletherefore also advocates further development and anevolution in the measurement methods going forward.

The approach taken in this module is to start withmonitoring based around existing measurement andindicators already used in the NHS, public health and socialcare wherever possible. This helps to minimise the burden ofdata collection and avoid any duplication. It forms a soundbaseline that can be put into action immediately.

This module proposes a set of core indicators that are brief,high-level measures to demonstrate progress. These aresupported by a number of optional indicators for more

detailed measurement. These are listed in theimplementation notes for ease of reference.

Some indicators in both the core and optional sets needfurther development as they are not measured currently. Forinstance whether sustainability is embedded in thecommissioning and delivery of social care, Health andWellbeing Board strategies or the level of local publicengagement around sustainability.

Considering potential indicators helps give a sense of thedevelopment required to enable a better understanding ofprogress. In the future new methodologies may emergewhich will need to be reflected in the measurement. Inaddition organisational boundaries may change and willneed to be factored into the baselines and datasets to ensurecomparability is not distorted.

Great Ormond Street Hospital2Publishing real time data

Smart metering has enabled real-time monitoring of energy use.Great Ormond Street Hospital have taken this opportunity tobe transparent about their electricity and carbon emissions aswell as the cost.

The trust’s website shows energy use broken down by kilowatt,hours, cost and carbon emissions. Users are able to look at databy day, week and month and can also see energy use ofindividual sites as well as the trust as a whole.

Following the initial set up the system is burden free and showsreal-time information providing feedback to staff, patients and thepublic, that is clear, accessible and understandable for all.

Sustainable | Resilient | Healthy People & Places4

“Many people find this topic abstract, ok intheory but difficult to pin down in practice,so metrics are essential to be able toevaluate effectiveness and impact”

Helen Crisp - The Health Foundation

Further work is required to develop and embed the proposedindicators and to fully quantify the scale of impact of manyof the processes and actions identified across the health andcare system.

The development of metrics and measurement forsustainable development will include several phases. Thismodule proposes the first phase. Further phases are beingconsidered by the SDU and the metrics steering group toensure the ongoing development of an approach tomeasurement for sustainable development. This includes theimprovements of sustainability impact assessments and howdata capture may evolve in response to and with the supportof technology. For instance there may be a time when data isin real time so that change can be effected more rapidly.

Please do get in touch with the SDU if you are interested indeveloping this work further.

This module is divided into four parts1. Measurement approach2. Proposed set of core indicators for use across the system3. Focus on what is important4. Proposals for improving measurement

2. Real time data shown on the Great Ormond Street Hospital website homepage

An Integrated Approach to Metrics 5

This module and its supporting documents aim to ensurethat robust indicator definitions and data collections areclear in order to reduce duplication, ensure comparabilityand provide alignment between different settings. Theability to remove barriers and work across service andorganisational boundaries has been identified as a key areato help deliver health and care services in the future.3 Withthat in mind every opportunity to align indicators has beentaken to make sure that they can be used to supportdecision making across the health and care sector and thatthey are aligned with the overall vision being taken.

The proposed indicators are broken down into coreindicators which provide balanced and aligned measurementacross the system and a further set of indicators which canbe used to create scorecards tailored to local requirements.Some indicators are useable immediately whereas others willrequire further development. These are colour coded forease of reference (see table pages 6&7).

The indicators are categorised into settings to facilitateorganisational use. These are all provided in theimplementation notes, along with the drivers such as legalrequirements and assurance processes.

The core indicators are themed to support the Areas ofFocus or modules identified in the ‘Sustainable DevelopmentStrategy’.4 Each of these modules identifies success criteria,actions and processes for a more sustainable health andsocial care system. This integrated approach to the metricsmodule underpins each of these modules by providingmeasurement and indicators of progress.

Indicators are also identified for parts of the health and caresystem, to support benchmarking in these local settings.

This module is supported by further information on the SDUwebsite.

1. Measurement approach

The language of metrics

A number of terms are used throughout this documentand defined here:

Data: Information that is fed into indicators. Thisusually needs context and other data to compare withto give meaning.

Indicator: A measure, often formed with severalcomponents, that aims to describe, in a few numbersas much detail as possible about a system, to helpunderstand, compare, predict, improve, and innovate.

Metrics: Any set of data. An indicator is a particularsort of metric that identifies issues that may be worthyof further investigation.

Monitoring: The process of regular follow up forspecific indicators, with a view to action when aparticular threshold is crossed.

Outcome: A measurable change in health status,sometimes attributable to a risk factor or an earlierintervention.

Balanced (set of indicators): A set of indicatorswhich, taken together, reflect as much of a system aspossible without duplication, overlap or gaps.

Benchmark: An externally-agreed comparator tocompare performance between similar organisations orsystems.

More information about indicators is available in theGood Indicators Guide5

3. NHS Five Year Forward View - 4. Sustainable Development Strategy for NHS, public health and social care 5. Good Indicators Guide - Practical resource for those in the health system responsible for using indicators to monitor and improve

performance, systems or outcomes

2. Proposed set of core indicators for use across the system

The table below shows proposed indicators in the context of different organisational settings and mapped against the key areasof Sustainable Development Strategy supporting modules. A key explaining the colour coding and lettering can be found belowthe table

WHAT IS A CORE INDICATOR?Core indicators are indicators that can be used for standard reporting between different contexts and could beused to monitor progress across the system.

Type of setting

Example organisations

Leadership engagement anddevelopment

Commissioning and Procurement

Sustainable clinical and caremodels

Healthy, sustainable and resilientcommunities (including Adaptation)

Carbon Hotspots (andEnvironmental Impact)

Innovation

Social Value

Primary Care / Independent providers

GPs and DentistsPharmacists

Indicator to measure if sustainability isembedded (P)

Variation of pharmaceuticals use byGP/disease prevalence (L)

Variation in Meter Dose Inhalerprescription volumes (L)

Emergency admissions for acuteconditions that should not usually requirehospital admission (NHSOF 3a) (N)

Proportion of people with long termconditions feeling supported to managetheir condition (NHSOF 2.1) (N)

Evidence we provide information andadvice, and refer vulnerablehouseholders for Fuel Poverty alleviationmeasures (L)

Organisation carbon footprint (L)

Indicator gap (P)

Good Corporate Citizen AssessmentModel score (SDU) (N)

Small Providers

Small Social Care providersVoluntary and 3rd sector providers

Evidence the organisationpromotes sustainability to itsemployees (L)

Local sustainable and healthy foodavailable for staff and service userse.g. Government BuyingStandards for food and cateringe.g. Catering Mark (L)

Proportion of people with longterm conditions feeling supportedto manage their condition (NHSOF2.1) (N)

Measures recognising worktowards more sustainable carepathways (P)

Indicator of communityengagement (P)

Organisation carbon footprint (L)

Indicator gap (P)

Good Corporate CitizenAssessment Model score (SDU) (N)

Large Providers

NHS TrustsNHS Foundation TrustsLarge Social Care providers

Board approved SDMP (SDU) (N)

Proportion of procurement spendin the local community (could alsoinclude the capital programme andstaffing locally) (L)

Emergency admissions for acuteconditions that should not usuallyrequire hospital admission (NHSOF3a) (N)

Board approved plans to adapt thedelivery of activities andinfrastructure as a result of climatechange and adverse weather (SDU)(N)

Organisation carbon footprint:building energy use, procurementand travel per patient contact (L)

Organisation water use per patientcontact (ERIC) (N)

Organisation waste to landfill perpatient contact (ERIC) (N)

Indicator of adoption of innovativeeffective and sustainable medicaltechnologies (P)

Good Corporate CitizenAssessment Model score (SDU) (N)

Commissioners

Local AuthoritiesCCGsNHS England

Indicator to measure sustainabilityembedded in commissioning of SocialCare (P)

Governing body approved SDMP (SDU)(N)

Proportion of public sectororganisations with board approvedsustainable development managementplan (PHOF 3.06) (N)

Emergency admissions for acuteconditions that should not usuallyrequire hospital admission (NHSOF 3a)(N)

Proportion of people with long termconditions feeling supported to managetheir condition (NHSOF 2.1) (N)

To establish an organisational riskregister for sustainability and climatechange and continually monitor riskwith regular reporting mechanismsagreed. (L)

Carbon footprint for providerorganisations per service user/patientcontact (L)

Indicator of outcomes basedcommissioning e.g. proportion of contactspend based on "year of care" (P)

Good Corporate Citizen AssessmentModel score for providers (SDU) (N)

Community / Whole Population

Local AuthoritiesHealth and Wellbeing Boards

Health and Wellbeing Strategies with sustainability as anidentifiable component (L)

Proportion of Public sector organisations with boardapproved sustainable development management plan(PHOF 3.06) (N)

Sustainability placed onto the tendering process andsupporting guidance for suppliers (L)

Utilisation of outdoor space for exercise/health reasons(PHOF 1.16) (N)

Healthy life expectancy at birth (PHOF 0.1i) (N)

Local Joint Strategic Needs Assessments with approvedand published Adaptation chapter (L)

Implementing/ monitoring action plans for elderly andother vulnerable groups during hot and cold weather (L)

Per capita CO2 emissions (NI 186) (N)

Carbon footprint for provider organisations per head ofpopulation (L)

Indicator of improving outcomes through prevention e.g.proportion of spend on prevention compared withtreatment (P)

Local Joint Strategic Needs Assessments with approvedand published Sustainability chapter (L)

Slope index of inequality in life expectancy at birth (PHOF0.2) (N)

Overarching / National

NHS EnglandPublic Health England

Percentage of Health and Wellbeing Strategieswith sustainability as an identifiablecomponent (S)

Percentage of NHS organisations with agoverning body or executive directorsustainable development lead (SDU) (N)

Proportion of public sector organisations withboard approved sustainable developmentmanagement plan (PHOF 3.06) (N)

Emergency admissions for acute conditionsthat should not usually require hospitaladmission (NHSOF 3a) (N)

Healthy life expectancy at birth (PHOF 0.1i) (N)

Proportion of Local Joint Strategic NeedsAssessments with approved and publishedAdaptation chapter (S)

NHS, public health and social care carbonfootprint (SDU) (N)

Indicator gap (P)

Good Corporate Citizen assessmentperformed with cross-organisationalengagement (SDU) (N)

N

L

S

P

KEY: Indicator Nationally

Indicator Locally

New suggested indicators

Placeholder without indicators

Large or Small providers

Indicators published e.g. outcomes frameworks and published datasets

Monitoring and accountability can take place at local level, within organisation

Monitoring this needs a definition, metadata development and collection where appropriate

An indicator needs to be identified

Based on annual public spend (total including all contracts) being above OJEU procurement limit

(PHOF)

(NHSOF)

(NI)

(SDU)

(ERIC)

Public Health Outcomes Framework

NHS Outcomes Framework

National Indicator (current and former)

Currently collated by Sustainable Development Unit

Estates Return Information Collection

Sustainable | Resilient | Healthy People & Places6 An Integrated Approach to Metrics 7

Good measurement highlights and encourages the mosteffective actions, improves understanding and providesaccountability. Clearly some measures are more significant fordecision making, impactful or materially important and shouldbe prioritised. Effective measurement minimises the burden byfocusing on the biggest impacts and avoiding perverse incentivesas far as possible.

Measuring sustainable development often relies on a balance ofindicators because many aspects need monitoring together as aprecaution against adverse effects. These can be summarised inwhat might be termed a balanced scorecard.

In addition gradual changes such as climate change and itsimpact on health may be seen over a longer time span.

Scorecards therefore also need to capture early actions andprocess measures where outcomes will not be seen for manyyears or are not yet measurable.

In this module existing measures have been identified withineach theme or area of focus of the SDS, and considered inrelation to organisational settings across the health and caresystem. Priority has been given to indicators which are materialand important in each setting. For example GPs can have agreater long term impact through sustainability measures whichalso improve health and reduce the need for resource intensivetreatment, while building energy use is more significant in acutehospitals than in other settings and can be actioned moredirectly.

3. Focus on what is important

Sustainable | Resilient | Healthy People & Places8

Scope and materiality

Sustainability covers a broad scope of elements toconsider and often needs to capture the impacts ofdecisions made beyond traditional organisationalboundaries. It is therefore very important to be clearabout where to stop. These boundaries are based onthe relative importance and impact of each element todecide what to include. This is often referred to asmateriality.

An Integrated Approach to Metrics 9

“Reliable measurement and reportingare fundamental to understandingprogress, and to translating vision andevidence into effective actions”

Professor John Newton - Director of Knowledge andInformation, Public Health England.

Progress measurement only happens if there are definitions ofindicators which allow comparison, over time or betweenorganisations, and a collection mechanism exists which is robustenough to provide raw data.

National monitoring based on the core indicators holds a mirrorup to the system on progress, the scale of change and highlightsareas for action.

Following our assessment of current indicators and datacollections, and after alignment with the priority areas basedon materiality of impact, gaps have been identified that willneed to be addressed over time.

Some measurement can take place locally, using provisionaldefinitions while national benchmarking requires standardisedand aligned data sources.

The sustainable development (SD) metrics steering group’srecommendations are to promote:

• The ongoing work of the SD metrics steering group whichreports into the SD Cross System Group

• The need to work towards developing measurementmechanisms to minimise the gaps identified

• The voluntary uptake of core measures supported by localtailoring of optional measures The publication andtransparency of current local data

If you would like to support the work of the sustainabledevelopment metrics steering group please get in touch withthe Sustainable Development Unit using the contact details onthe back page of this document.

10 Sustainable | Resilient | Healthy People & Places10

Dashboard of independently assured indicators6

Sussex Community NHS Trust with Capita

4. Proposals for improving measurement

The trust developed a series of simple metrics to target allaspects of environmental performance and a simple dashboardto help Board level reporting. The metrics include CO2

reduction, energy and water efficiency, recycling and wastevolumes, emissions and mileage.

The complex nature of the organisation and the lack ofconsistent and reliable data was a major challenge. The Trustused climate change consultancy Ricardo-AEA to ensure that thereporting systems, data and reporting outputs are robust,credible and reliable. The Trust Board receives biannualperformance updates, which includes the reporting dashboardand associated commentary.

6. Sussex Community NHS Trust key performance indicator dashboard

1111

Voluntary adoption of aSustainability Scorecard8

Bedfordshire CCG

Through engaging with their workforce Bedford CCG learnedstaff wanted to see regular updates from the board onsustainability performance. As a result they produced asustainability scorecard including:• Carbon Footprint• Good Corporate Citizenship• Procurement 4 Carbon Reduction Tool• Key points, actions or notes and outcomes of Board papers

The scorecard supports the ‘Push it, Switch it & Sustain it!’campaign. To push the boundaries of staff knowledge andunderstanding of sustainability, to switch and adopt sustainablebehaviours in work and to maintain these new sustainable (lowcarbon) working habits so they become part of daily workingroutine and behaviour.

Spiral Health7

Social impact assessment

As a social enterprise, Spiral Health has social value at the heartof the company and central to their values. These values arecombined with business principles, enabling the organisation tobe autonomous, innovative, flexible and responsive to the needsof patients and the local community.

Spiral Health worked with the New Economics Foundation toperform a Social Value Impact Assessment to quantify the scaleof impacts. The analysis showed that 70% of the organisation’sexpenditure through supply chain was reinvested in localbusinesses and around 65% of staff ’s wages is retained in thelocal community. Spiral Health produced an infographic tovisualise this.

An Integrated Approach to Metrics

7. Spiral Health social impact assessment - infographic8. Bedfordshire CGG - Sustainability Scorecard

References

1 & 3. NHS Five Year Forward View - developed by NHS England with partner organisations patient groups, clinicians and independent experts it sets out avision for the future of the NHS.http://www.england.nhs.uk/ourwork/futurenhs/

2. Real time data shown on the Great Ormond Street Hospital websitehttps://platform.carbonculture.net/communities/great-ormond-street-hospital/4/

4. Sustainable Development Strategy for NHS, public health and social care – published by the SDU 2014www.sduhealth.org.uk/SDS

5. Good Indicators Guide - Practical resource for those in the health system responsible for using indicators to monitor and improve performance, systemsor outcomes.http://www.apho.org.uk/resource/item.aspx?RID=44584

6. Sussex Community NHS Trust key performance indicator dashboardhttp://www.sussexcommunity.nhs.uk/about-us/sustainability.htm

7. Spiral Health social impact assessmenthttp://www.spiralhealthcic.co.uk/wp-content/uploads/2013/07/spiral-health-infograph-final-version-2.pdf/

8. Bedfordshire CCG - Substitutability Scorecardwww.bedfordshireccg.nhs.uk

More detailed information about case studies and concepts can be found in the Implementation notes and Supporting documents for this module.

The Sustainable Development UnitVictoria House, Capital Park, Fulbourn, Cambridge, CB21 5XB

T: 0113 8253220 E: england.sdu@nhs.netW: www.sduhealth.org.ukFollow us on Twitter - @sduhealth

The Sustainable Development UnitVictoria House, Capital Park, Fulbourn, Cambridge, CB21 5XB

T: 0113 8253220 E: england.sdu@nhs.netW: www.sduhealth.org.ukFollow us on Twitter - @sduhealth This publication is printed on 100% recycled paper and is printed using vegetable-based inks and a water-based sealant.

Designed and produced by: MJWebb Associates Ltd

Published January 2015

This document is one of a number of modules supporting the “Sustainable, resilient, healthy people and places – asustainable development strategy” (www.sduhealth.org.uk/sds). For further information, guidance notes, tools and goodpractice to support the delivery of this module visit www.sduhealth.org.uk/focus

Document produced by the Sustainable Development Unit (SDU) which is funded by, and accountable to, NHS England and Public Health England towork across the NHS, public health and social care system. The SDU supports the NHS, Public Health and Social Care system to be sustainableenvironmentally and socially. This is done by engaging across the system to identify the frameworks, networks and mechanisms that will encourage ahealthier environment, better health and enable communities and services to be resilient to adverse weather events and climate change.

Responsibility for the content of this document lies with the Sustainable Development Unit.