The quality premium has been used as a particularly controversial stick to beat CCGs – and GPs – with.
The Daily Mail saw the premium – which could be worth as much as £5 per head of population for a CCG for meeting certain targets – as a ‘bonus for GPs doing their job’. But it wasn’t just the usual suspects who viewed it with suspicion – from the outset, the BMA was clear that the doctor-patient relationship would be seriously undermined if CCGs were free to distribute the quality premium among member practices as a bonus for helping to achieve targets.
Some of these concerns were dispelled in January this year, when Pulse revealed that the NHS Commissioning Board – as NHS England was back then – had put a stop to CCGs passing the quality premium payments on to GPs, confirmed by NHS England regulations issued in March. Instead, any payments made to CCGs would have to be spent on improving patient care and narrowing health inequalities.
The regulations also dispelled another worry: CCGs might find their local commissioning plans compromised by rewards for meeting national imperatives.
There were still the centrally mandated targets for CCGs, based on measures in the NHS Outcomes Framework, that were together worth 62.5% of the premium: reducing potential years of lives lost through amenable mortality; reducing avoidable emergency admissions; ensuring roll-out of the Friends and Family Test; and preventing healthcare associated infection.
But the regulations also allowed CCGs, in agreement with their local area teams and health and wellbeing boards, to formulate three local priorities, worth 37.5% of the payments and usually focused on areas where outcomes are poor compared with others. For the average CCG with a population of 226,000, this part of the quality premium could be worth around £420,000.
Now figures obtained by Pulse reveal for the first time the most popular local priorities among CCGs – with the reduction of emergency readmissions, estimated diagnosis rate of people with dementia and proportion of people feeling supported to manage their conditions coming out top (see table).
These figures offer a glimpse of what CCGs’ long-term commissioning intentions are, in a period of austerity. So how are CCGs using their local priorities to help their patient population?
There were stipulations on how CCGs could choose their local priorities. The NHS Commissioning Board guidance said: ‘Each measure should be based on robust data and the improvement needed to trigger the reward should be expressly agreed between the CCG and the NHS CB area team.’
The local measures were also not allowed to duplicate the national or NHS Constitution measures. They should reflect services that CCGs are responsible for commissioning or are commissioning jointly with other organisations.
CCGs’ local priorities
|Position||Indicator description||Frequency of selection|
|1||Emergency readmissions within 30 days of discharge from hospital||29|
|2||Estimated diagnosis rate for people with dementia||27|
|3||Proportion of people feeling supported to manage their condition||23|
|4 =||Improving functional ability for people with long-term conditions||22|
|4 =||Enabling people to die at their preferred place of death – include establishing preferences and measuring achievement of preferences||22|
|6||Reducing emergency admissions from care, nursing or residential homes||17|
|7||Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)||15|
|8 =||Patient experience of primary care i) GP services ii) GP out-of-hours services*||12|
|8 =||Risk profiling and care management scheme||12|
|8 =||(Other) Emergency Admissions attributed to alcohol||12|
Source: NHS England
But despite these restrictions, CCGs were still allowed scope to exercise a certain amount of discretion.
In South Manchester CCG – which chose the common priority of increasing the rate of dementia diagnosis, alongside identifying more cases of atrial fibrillation and increasing the number of cancer diagnoses through the two-week pathway – the priorities were formulated as a result of quarterly meetings with member practices.
Dr Naresh Kanumilli, the CCG’s GP quality and performance lead, says: ‘Manchester has a particular problem with cardiovascular disease so we chose to try to pick up AF cases by feeling more patients’ pulses opportunistically – even in flu clinics, for example. We’d also heard about a percentage of people presenting at A&E with cancer so thought we should tackle that and work out whether it was to do with our pathways or communications.’
’A lot of issues such as these come up at our quarterly meetings with member practices so we can then take them to the board and we also run them past our patient and public advisory group and get their input too. So the priorities come from grassroots GP level and we agree them with practices.’
‘The money against it focuses the mind and acts as an extra lever but we´d be doing them anyway – we´d have to.’
Dr Huw Charles-Jones
NHS Coventry and Rugby CCG looked at areas where it could change outcomes when choosing its priorities of reducing alcohol-related hospital admissions, reducing smoking in pregnancy and increasing the uptake of cervical screening in vulnerable and hard-to-reach groups.
Dr Adrian Canale-Parola says: ‘We´re in interesting position as a CCG in that we straddle two councils and so have two health and wellbeing boards and two joint strategies.’
’Luckily there’s good working between the two and we’ve worked out that these three areas will give us the most return for our investment in terms of healthcare. We’ve got the data and have done the modelling to demonstrate that we can really make a difference.’
’We’ve also got good sign-up from our practices across the localities.’
Dr Huw Charles-Jones, chair of NHS West Cheshire CCG, says his area is an outlier for childhood respiratory tract infections, so tackling these was an obvious target. As was reducing emergency admissions in the elderly and developing supported self-care.
He says: ‘These are all very much part of a wider strategy which involves hospital at home services and integrated health and social care services – what´s being referred to as “The West Cheshire Way”.’
This begs the question: are these measures in lieu of bigger transformation programmes, or do they go hand in hand?
For Dr Canale-Parola, the priorities reflect the wider strategy for Coventry and Rugby, which includes an emphasis on healthy living and lifestyle choices.
This is echoed by Dr Charles-Jones and Dr Kanumilli, who say that these priorities were on their CCG’s to-do list anyway, with the incentive of money from the quality premium being a bonus.
Dr Charles-Jones says: ‘The money against it focuses the mind and acts as an extra lever but we’d be doing them anyway – we’d have to.’
But it is not simply the incentive of the money that helps CCGs achieve better outcomes. As Dr Kanumilli puts it: ‘I think we’d do the things we’ve prioritised for the quality premium anyway, but target-setting like this is useful to give GPs a focus.’
It also helps with long-term plans, Dr Kanumilli adds: ‘When we´ve achieved these targets we´ll look at next steps. What needs doing next on AF, for example. And the quality premium might help towards buying monitors or funding some of the newer anticoagulants.’
‘Mid Staffs taught us that targets per se can be destructive as well as constructive’
Dr Nigel Watson, chair of the GPC’s commissioning and service development sub-committee
In Coventry, the local priorities have allowed the CCG to take long-term steps to tackle the areas they have identified. Dr Canale-Parola says: ‘We’ve commissioned an alcohol-related admissions liaison officer, so that patients who are admitted are targeted for their addiction as well as whatever they´ve been admitted for. This means significant cost savings in terms of future admissions.’
’These are probably things we’d be doing anyway. Having said that, we´re all financially squeezed and if we can demonstrate that we´re making savings as well as improving quality of care, that´s what it´s all about.’
Despite the positive noises coming from CCG leaders, opinions are still sharply divided over its value in the commissioning process.
Dr Steve Kell, co-chair of NHS Clinical Commissioners leadership group and chair of Bassetlaw CCG, believes it does enable commissioners to focus on local priorities.
‘CCGs have a wide range of responsibilities outlined by the outcomes framework and will use the quality premium to assist in those areas which have most impact locally.’
‘The measures identified by [these figures] highlight important areas that CCGs are tackling and it is welcome that there is a focus on areas that measures that should have a long-term impact for patients and people who care for them.’
However, he adds a rider: ‘It is important to remember that while this is part of their responsibility, it is by no means all that CCGs are actively tackling.’
But for Dr Nigel Watson, chair of the GPC’s commissioning and service development sub-committee, the ethical problem with CCGs getting paid for meeting targets still remains. He says: ‘Mid Staffs taught us that targets per se can be destructive as well as constructive. The BMA’s view is that CCGs should agree what they aiming at but should not be financially penalised if they fail to get there.’
‘The premium is not, generally speaking, worth the work. But for some CCGs, every penny they get will be welcome – especially those who have lost £50m through topslicing. It would be OK if CCGs had everything within their control, but with the system as it is, CCGs could end up being penalised just because their local hospital fails to deliver and that’s not a fair way of doing things.’