The quality premium (QP), worth up to £5 per population head, depends on CCGs meeting the new outcome indicators.
This £5 per head translates to around £1 million for an ‘average’ CCG or, for a GP practice of 6,000 patients, some £30,000.
Initially, the QP was going to be passed to CCGs to pass on to practices but the NHS Commissioning Board appears to be using its grip to prevent this. In an interview, earlier this year commissioning czar Dame Barbara Hakin ruled out CCGs being able to distribute the quality premium as a ‘bonus’ for member practices, though CCGs will be able to use it to fund incentive payments for practices to help it meet their outcome indicators.
More details on the price and regulations regarding the QP are expected from the NHS Commissioning Board shortly.
The outcome indicators themselves are based on four national priorities and three local indicators.
The national indicators are worth 62.5 per cent and the local indicators are worth 37.5 per cent of the QP.
The four national indicators that must be met are:
1 Reducing potential years of lives lost through amenable mortality
To earn this portion of the QP, the potential years of life lost (adjusted for sex and age) from amenable mortality will need to reduce by at least 3.2 per cent between 2013 and 2014.
This indicator is worth 12.5 per cent of the overall QP.
2 Reducing avoidable emergency admissions
There is no actual figure given for this indicator, but as there is a costly gradual trend in emergency admissions, the NHS Commissioning Board will accept any reduction – even a flat line 0 per cent increase is acceptable.
This indicator is the most valuable and worth 25 per cent of the QP.
3 Patient experience of hospitals
This indicator relates to the roll out of the Friends and Family test.
This is a simple test – it has come under much criticism for being too simplistic – where patients are asked the following question: ‘How likely are you to recommend our ward / department to friends and family if they needed similar care or treatment?’
To meet this indicator the friends and family test must be rolled out in their area’s hospitals by the end of March 2014. Then in the first quarter of 2014/15 the results of the Friends and Family test will be compared with first quarter of 2013/14 and the NHS Commissioning Board will be looking for some improvement in the average score.
This indicator is worth 12.5 per cent of the QP.
4 Healthcare acquired infections
To meet this indicator there must be no cases of MRSA in the area and c.difficile cases must be below a defined threshold for CCGs.
This indicator is worth 12.5 per cent of the QP
The CCG also has to select three local indicators which it has to get agreement on from the NHS Commissioning Board. CCGs are expected to consult the health and wellbeing board and local patient groups on its local indicators.
Local indicators are worth 37.5 per cent of the QP.
The thinking behind local indicators is they will promote ‘localism’ and allow CCGs to responds to local population needs.
Chris Naylor, fellow in health policy at the King’s Fund, says CCGs will have to be pragmatic about what they can achieve in 12 months when choosing their local indicators.
He told Pulse: ‘The challenge is to choose ones the CCG can realistically achieve over next year as opposed to choosing ones where prevention is beyond the CCG’s control or that take more than a year to address.’
The NHS Commissioning Board reserves the right not to pay the quality premium in the following circumstances:
– The CCG fails to achieve financial balance
– There is a serious local quality failure
– The following four patient rights or pledges in the NHS Constitution are not met:
- waiting more than 18 weeks from referral
- discharged within four hours at A&E
- two-month wait (62 days) maximum from urgent GP referral referral for definitive treatment for cancer
- category A red 1 ambulance calls responded to by crew within eight minutes
For each patients’ right/pledge not met, the CCG loses 25 per cent of its quality premium.
And here, is the interesting smallprint – if it misses all four, it will receive no QP whatsoever.
Chris Naylor, explains: ‘In effect a CCG could hit all their targets (national and local) and get nothing if they miss these four.’
The question now is how hard will CCGs work to achieve the quality premium – or whether they decide the amount of effort involved for the financial gain is not worth it.
Chris Naylor says there are also many things dependent on meeting the indicators that are not necessarily within the CCG remit.
‘Meeting all of these indicators is going to be challenging at a time when financial pressures so great.
‘A lot of these outcomes not just about the CCG body and decisions it makes, but the vision of general practice as well.
‘The objective of reducing emergency admissions is very much about managing ambulatory care sensibly in primary care.
‘CCGs are in an interesting position because they don’t hold the contract for general practice – the NHS Commissioning Board does – but the CCG is not going to be able to achieve their commissioning objectives without engaging their members.
‘CCGs don’t want to be another PCT and member engagement is a really important part of that.
‘Sensitive CCG leaders are keen not to be seen as performance-managing their member practices but also acknowledge they won’t be able to perform as a CCG if not buy-in and willingness (from GPs) to look at their clinical practice benchmarks and think about changing things locally.
‘Different CCGs will be taking different approaches. Some will be more assertive than others.’
A study in progress by the King’s Fund and Nuffield Trust is looking at six CCGs in year one and Mr Naylor said they were seeing a ‘fair amount of goodwill’ by both GPs and the CCGs themselves to achieve the indicators.
‘There’s a kind of hope that can make it work this time and do things differently tempered with a recognition that the environment that work is being done in, is very challenging.’
And while there was a loud voice of concern about the reforms from some GPs, Mr Naylor proffered that a larger group of GPs – not actively involved in the CCG- supported in principal the decisions being taken by their GP colleagues rather than PCTs.
Dr David Rooke, chair of Somerset CCG, said it would be for individual practices in his CCG to decide whether to take part and they were still waiting for the ‘devil in the detail’ on the quality premium and indicators.
‘Practices will have to see whether the income matches the workload involved’ he said.
Dr Amit Bhargava, chief clinical officer for Crawley CCG, said: ‘The CCG leads and practices have looked at the QP and see it as a positive way of creating change in the NHS.
‘But we have a number of concerns about how pay for our providers to hit the targets – as some of these changes will need pump priming – and the MRSA/c.difficile as gateways don’t seem fair.’
Sue McNulty is the outgoing editor of Practical Commissioning.