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Can efficiency and quality co-exist?

More than just a management mantra, QIPP – shorthand for ‘quality, innovation, productivity and prevention’ – has become something of an article of faith for the NHS. According to NHS Improvement, QIPP ‘is all about ensuring each pound spent is used to bring maximum benefit and quality of care to patients’.

In a less challenging financial climate, QIPP might have served as a worthy, open-ended aspiration. But, under the circumstances, it has become inseparable from another challenge, also laid down under the previous government, the so-called Nicholson challenge – after NHS chief executive Sir David – to make £20bn efficiency savings by 2014/15. 

Quality, quality, quality

QIPP has its roots in Lord Ara Darzi’s 2008 Next Stage Review, ‘High Quality Care for All’. It said patients’ views on the quality of care they receive should affect funding for hospitals and GPs, and that information on the quality of an NHS body’s service should be published, including quality accounts.

The incoming coalition government seized on QIPP in its July 2010 white paper Equity and Excellence: liberating the NHS, which paved the way for the Health and Social Care Bill, calling for it to continue with ‘even greater urgency’ and putting GPs in charge. Three years on, CCGs are set to take on the challenges, spurred by both carrot and stick – the threat to their authorisation should they fail to deliver and the carrot of a GP quality payment of up to £5 per head if their CCG is within budget. In plain numbers, the Nicholson challenge translates to finding an average of 4% productivity gains each year until 2015.

The QIPP theory is backed by a library of case studies amassed by NHS Improvement and Cochrane Collaboration systematic reviews of quality and productivity topics.

According to DH figures, the NHS met its plan and saved £1.9bn in the final quarter of 2011/12, bringing the total for the year to the forecast level of £5.8bn. But there have been media reports, based on tracking of DH data, that so far this year some local QIPP initiatives are slipping behind schedule.

Question mark

And as ever with orthodoxy, there are experts lining up to question it.

Professor David Kerr, professor of cancer medicine at Oxford University and a former adviser to Tony Blair and Prime Minister David Cameron, is the most recent to weigh into the debate. Writing in the Guardian last month, he warned that the current round of efficiency savings was being driven by ‘knee-jerk short-termism’ rather than value for patients.

He wrote: ‘The NHS could lead the world by making value the central component of its reforms … but it is grappling with unnecessary structural change.’

Professor Martin Marshall, professor of health improvement at University College London, is realistic about how much QIPP can deliver – in contrast to the evangelism of some of his fellow improvement advocates. His qualms centre upon QIPP’s national ‘scalability’. An article he published in the BMJ last year drew conclusions from research by the Karolinska Institute in Sweden and suggested there is ‘great potential’ for making savings by addressing deficiencies in quality. But, while these changes can be made, there are questions over whether the savings can be realised in the short term, without major changes to the ways healthcare is financed, structured and delivered.

How does he feel a year on? ‘QIPP is trying. There are some great examples of how quality and efficiency can work together – and it’s a good initiative. Our critique was not that it can’t be done at
a small scale but that scaling up is difficult.’

Claire Henry, national lead for the end-of-life care QIPP workstream, would beg to differ. She believes the evidence for the national scalability of QIPP is already there – at least in her workstream. ‘We’ve been working with local teams, testing initiatives and moving them out nationally. For example, we’ve been working with GPs on identifying the 1% of patients who are going to die within the next year. We’ve exceeded our target of getting 1,000 GPs signed up nationally and are starting to get them involved in assessment of patients. We’ve also launched a commissioning resource tool to identify the main elements in the commissioning process, explain the commissioning cycle in practical terms and offer a four-stage approach across all sectors.’

Dr Johnny Marshall, interim partnership development director with NHS Clinical Commissioners and an NAPC executive member, believes local QIPP initiatives can work on the national stage, though there will be major challenges.

‘Scaling up is a much more difficult task – it entails a different model of service delivery. You need care to be better integrated and need to understand the cost impact on other areas of the NHS. It’s not something a CCG can do on its own, so the commissioning board has an important role. It means CCGs talking to each other, to secondary care, to their local area teams –
a national conversation. And it’s something the new commissioning assembly could certainly have a role in.’

Is scalability enough?

Stephen Dorrell, chair of the House of Commons health select committee and
a former Tory health secretary, is another QIPP-sceptic. His concern is that the NHS is fiddling around the edges of a major problem and that, even if QIPP is nationally scalable, anyone who thinks 4% savings can be made without anyone noticing just doesn’t ‘get’ the QIPP agenda.

He told a conference this year: ‘The only way you can meet the Nicholson challenge is to recognise it is a system-wide challenge that should include areas like housing and social care. That is how we need to respond.’

Professor Martin Marshall shares the concern: ‘What I see happening through QIPP is some superb local work but in fact I don’t think QIPP alone is going to make much difference. I think it’s easy in theory to demonstrate potential savings across the board but you have to make structural change and that brings political difficulties. The big stuff – redundancies, shutting services – is going on regardless.’ And he believes a separate savings agenda alongside QIPP will necessarily involve a tight leash on CCGs.

‘The DH already knows where the big savings lie. That’s why it is retaining strong central control of commissioners. I’m not saying this will be draconian – it recognises clinician engagement is good – but also that purse strings have to be centrally managed.’ 

Quality for quality’s sake

What the experts do agree on is that QIPP is a good idea – even if it won’t meet the Nicholson challenge on its own.

Professor Martin Marshall says: ‘As long as we know there is waste, we should do something about it. We’re under-using prevention. Safety issues are preventable.

‘For example, we know tens of thousands of pounds can be added to the costs of procedures by avoidable central line infections. We know some other health systems are much more efficient – Kaiser [Permanente] works at something like 20% less cost. There’s a lot of waste in our system – and we have to tackle it.’

Claire Henry agrees: ‘Quality comes first. In end-of-life care, you only have one chance to get it right. QIPP has helped us focus on costs and look further upstream about how to deliver the quality patients want.

‘We’ve made QIPP work for us rather than us work for QIPP, based on what we already do. But will there come a point when the pursuit of quality ends up costing more? There will come a point when we can’t make any more savings without it affecting quality. Then quality must still come first.’

Dr Johnny Marshall believes the pursuit of quality through QIPP ‘won’t save the NHS’. And he warns that commissioners will have to adopt a practical approach: ‘It depends on how you measure quality. It may be that a gold standard diabetes system and a bronze standard stroke system is better than a silver standard in both.

‘That’s the reality – how to get the best for the population. It means CCGs have to think about commissioning outcomes. And that may meaning defining quality on what’s good enough.’

Alisdair Stirling is a freelance journalist