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Demystifying the quality agenda

Lord Darzi outlined his plans for the quality agenda in his report last year and some of his initiatives are already under way – at least in pilot form. Emma Wilkinson takes a look at the developments that will have an effect on PBC

Lord Darzi outlined his plans for the quality agenda in his report last year and some of his initiatives are already under way – at least in pilot form. Emma Wilkinson takes a look at the developments that will have an effect on PBC.

Quality must be at the heart of everything the NHS does, Lord Darzi proclaimed in the final report of his Next Stage Review published last summer. There are three key facets to his vision – patient safety, patient experience and effectiveness of care.

World Class Commissioning is at the centre of this drive for quality – ensuring high standards in clinical service provision.

So how does PBC fit into all of this?

Providers' pay will be linked to quality

Since April, PCTs have been expected to push ahead with the Commissioning for Quality and Innovation (CQUIN) payment framework.

As outlined by Lord Darzi in his Next Stage Review, the idea is to improve services locally by linking a small proportion of providers' payments with the quality of service delivered.

Under the scheme for 2009/10, PCTs must make 0.5% of contract value dependent on achievement of these goals by providers of acute, ambulance, community and mental health services. This proportion is expected to grow over time.

Local CQUIN schemes should be an agreement between the provider and commissioner – not just set down by the PCT – and specify quality indicators, the improvement or threshold expected, how that achievement is to be measured and how payments are made.

The only nationally set requirement is that there should be at least one goal in each of four areas: safety, effectiveness, patient experience and innovation.

For example, if a hospital is doing poorly on infection, commissioners may choose to look at audit standards that have to be met for payment to be made. Other examples are discharge summaries (see box) or readmission rates.

It is thought that in the first year, use of CQUIN will be limited and may be mainly about getting data with which to benchmark services but will expand as commissioners get to grips with its use.

However, there is a ‘clear expectation' this year that PCTs should be making provision for the use of CQUIN payments, says Dr David Jenner, NHS Alliance's PBC lead.

‘My understanding is that my own PCT cannot afford to invest in CQUIN this year for the local acute trust measures.

‘If I was in a commissioning group that had a good relationship with my PCT, CQUIN would give me a really good opportunity to start commissioning for quality rather than volume. Some groups are pushing quite far ahead with it.'

He admits there is a fair bit of confusion in the PBC world about getting started with CQUIN but, even in these early stages, he advises that it is worth one person from every commissioning group getting up to speed on the issue.

Patient questionnaires will benchmark providers' performance

Patient-reported outcome measures (PROMs) are initially being collected for four interventions – hip and knee replacements (both primary surgery and revisions) and groin hernia and varicose vein surgery. All NHS providers will be expected to invite patients to complete a questionnaire prior to undergoing these procedures from April 2009. The questionnaires measure patients' health status or health-related quality of life and are carried out before and three to six months after the procedure (depending on the procedure).

The hip replacement questionnaire, for example, compares patients' self-reported assessments of their mobility and pain before and after a hip operation, creating a measure of clinical success for commissioners to work with.

It is envisaged that the information collected through the PROM questionnaires will be used for a variety of purposes. Commissioners will be able to use the data to benchmark providers' performance in elective procedures, compare different technical approaches to a procedure, look into the appropriateness of referrals and improve quality of services.

NAPC president Dr James Kingsland says it is about realising the importance of the patient experience.

‘In our integrated care programme, we expect 500 patients to go through facilitated discharge and each one will have an in-depth interview with a researcher. That's taking it to extremes but PROMs are just another facet of a patient-centred NHS.

‘Commissioners need to ask questions about how PROMs are going to measure patient experience and not just be markers of efficiency.'

Dr Nick Goodwin, research fellow at the King's Fund, adds that PROMs are at a very early stage and the initial rollout is little more than a pilot.

‘There are pros and cons to how you use this information so there are issues yet to be resolved.'

Quality accounts to influence commissioning decisions

At the end of 2009/10, healthcare providers working for the NHS will by law have to publish their first quality accounts.

The accounts will be reports to the public outlining the quality of services in terms of safety, experience and outcomes, just as trusts must currently publish financial accounts. It marks a move away from the recent years' focus on financial balance.

A consultation last year resulted in 140 good measures of quality being identified, and these have formed part of the assured menu of Indicators for Quality Improvement (IQI) published by the NHS Improvement team on 15 May this year.

Providers can pick from this menu of indicators for their quality accounts. The legislation on quality accounts will define their content to include a national set and a much bigger set of local priorities for improvement.

There is still some debate over whether PCTs will pick and choose indicators that make them look good and there is likely to be much scrutiny of how the process has worked.

Ultimately it is likely that this system will throw up services that are not meeting required standards and failing to improve.

However, there are also concerns that quality accounts will be nothing more than a box-ticking exercise.

In its response to the Department of Health consultation on quality accounts, the King's Fund said trusts should be tracking quality month by month, not just annually, and if the accounts are to be transparent and meaningful they also need to be subject to external scrutiny and audit.

Dr Goodwin says there are plans to eventually introduce quality accounts for primary care: ‘It is a very transparent way to benchmark the quality of service and the idea is they are used by patients and GPs to make decisions about which services they want to go to.‘

The commissioner can also use it as a way of looking at the quality being provided and initiate conversations to improve that quality.'

Dr Kingsland adds: ‘We're not just saying we've saved money or achieved financial balance, but that we have a provider population that is healthier than it was.'

Increased focus on commissioning for outcomes

Lord Darzi signalled a move away from national tariffs to best-practice tariffs that are structured and adequately reimburse the cost of high-quality care. It was proposed that these tariffs would start in 2010/11 for some procedures.

The debate currently centres on how this could and should work, and whether this kind of incentive will be set nationally or by individual PCTs has yet to be decided.

Dr Jenner says that how proposals around best-practice tariffs move forward could well depend on the political climate over the next 18 months. A Conservative government, he says, could bring even stronger moves to commission to clinical outcomes.

‘I haven't seen people really moving away from the national tariff as yet but certainly in time that will bring in competition on price.

‘Who knows what will happen next year? But there is a consistent political message about the need to commission to outcomes and we'll see increasing payment and contract value being placed on quality payments or even a whole contract itself based on quality standards.'

He does, however, point out that the credit crunch may affect how quickly commissioning for outcomes rather than cost becomes a reality, despite the drivers being put in place.

‘In time hopefully the move will be to quality but financial balance is going to become pre-eminent in the short term.'

Dr Kingsland says local flexibilities on tariffs are being built in but with trusts already struggling with the new HRG4 tariff and with a significant proportion of hospital services that still do not have a tariff, a best practice tariff is very much an ‘aspirational' idea rather than an imminent reality.

‘However, if we can demonstrate that a particular new care pathway can produce more efficient and better healthcare, that might be the basis on which we start to develop new tariffs.'

Emma Wilkinson is a freelance journalist

Commissioners need to ask how PROMs are going to measure patient experience and not just be markers of efficiency Commissioners need to ask how PROMs are going to measure patient experience and not just be markers of efficiency CQUIN in action

There are many different areas of quality improvement which can be slotted into CQUIN.
David Jenner explains one proposal they are working on for discharge summaries.
‘Within our local trust, the quality of services is very good but the communication lets it down. The key thing we wanted to do in year one was to look at discharge summaries,' he says.
‘The plan is to trace discharge summaries in several practices and audit the time taken for the summaries to arrive. Those results will be published and the trust challenged if necessary.
‘If there's no improvement, those results will be the subject of a PCT board report.
If there's still no improvement, penalties will be invoked.'

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