As NHS England reviews incentives, how do we ensure the right ones are in place for improving quality of care, asks Richard Sloggett

The health sector is currently undergoing a large − and some would say top-down − reorganisation amid cash strapped purchasers, care scandals and displaced staff. This is not the easiest environment in which to improve the quality of care in the NHS and, as the new system beds down, it is important that operational levers and incentives in the new structures are used effectively to do just that.

The big question currently being considered by NHS England as part of its incentives review, is how?

‘Why would a commissioner add additional areas of care to an already bloated list of metrics on which it has to currently report?’

There is no doubt the new service seeks to balance the needs of the health service nationally with local decision making. 

While some clinical commissioning groups might dismiss the idea that they have been “liberated”, the new system does provide a great opportunity for them to prioritise and improve important local health issues and − most importantly − be financially rewarded for doing so. The mechanism for this is the quality premium.

MHP Health’s analysis of the quality premium measures selected by the first set of commissioners who went through the clinical commissioning group authorisation process last year, reveals ways in which commissioners are rising to this challenge and the importance of system design in this decision-making process.

Analysis of priorities

The analysis reveals areas being prioritised are closely aligned with the new NHS performance management framework. Areas of care where outcome strategies, quality standards and outcome indicators exist are heavily favoured over those where such measures and guidance is minimal or non-existent. 

For example, while improving dementia, mental health and reducing emergency admissions all feature regularly in local priorities, attempts by commissioners to use quality payments to improve care for people with musculoskeletal conditions, neurological conditions or learning disabilities are far less common. 

This is perhaps not surprising and some would argue savvy; after all, why would a commissioner add additional areas of care to an already bloated list of metrics on which it has to currently report?

Such an approach demonstrates the continuing importance of the national system in assisting local decision makers in developing plans and tools to deliver local services. In particular, it shows the need for healthcare campaigners to continue to make the case at a national level for appropriate service prioritisation, through the development of quality standards and outcome metrics for particular condition areas.

Robust framework

While it is clear the performance management framework is feeding through to local service prioritisation, it is also important that the framework itself is robust and actually rewards higher quality services, rather than the mere meeting of minimum standards.

Last year, MHP Health published the first ever assessment of the commissioning for quality and innovation in a single health economy. The report, Paying for Quality, analysed the effectiveness of the scheme in London in 2010-11, including which areas of care trusts were prioritising for improvement, the measures used to assess such improvement and the performance of individual trusts against such measures.

‘The use of levers and incentives clearly needs to be joined up closely across the system’

While the report found that national CQUIN indicators did appear to be having a positive impact with improvements in clinical practice, at a local level there appeared to be variation in the measures trusts had to achieve to secure their payments.

Indeed, some indicators appeared to be incredibly easy to achieve such as implementing the Institute for Healthcare Improvement “trigger tool” to monitor patient safety, which was achieved by all but one trust that returned data.

Such findings reflect concerns that the introduction of such incentives is not a quality payment at all, but merely a payment for providers to do things they really should be doing in the first place. This will draw parallels with the long debated flaws of the quality and outcomes framework in paying GPs to complete activities rather than really driving up care quality.

System-wide coordination

The use of levers and incentives clearly needs to be joined up closely across the system (you will notice that I have deliberately avoided the overused and heavily abused term “integration” here). Such coordination is critical to ensuring all parts of the system are working to deliver improved outcomes and quality care for patients.

Sadly, and as demonstrated by recent research from HSJ, such coordination remains elusive, with new clinical commissioning groups and health and wellbeing boards selecting differing areas of focus for their priorities. Such discord is unlikely to bring transformational improvement in results.

The increasing use of transfer funds from health to local authorities to encourage more joint working and collaboration may help, but again our research, as evidenced in the Atlas of variations in social care report, indicates the jury is still out on the effectiveness of this.

As NHS England grapples with its incentives review it should ensure that it plots a course of direction that does three things:

  • reviews the effectiveness of current quality measures and develops more robust measures for local implementation;
  • empowers commissioners to introduce such measures and be properly rewarded for delivering against them; and
  • encourages a more coordinated approach to incentives across health and social care to ensure a whole system approach to care improvement.

Do these and this will be one review that delivers tangible and long term results.

Richard Sloggett is an account director at MHP Health