Case study summary
NHS Cumbria Clinical Commissioning Group (CCG) is committed to improving the outcomes for its population, with general practice playing a vital role in achieving that. Across the practices within the CCG there are good outcomes in many areas, although a few of these are not achieved consistently by all practices, with some unwarranted clinical variation. To address this issue, in 2016 the CCG developed a Quality Improvement Scheme (QIS), which is an incentivised scheme looking to improve outcomes, reduce unwarranted variation and enable practices to work collaboratively.
Early indicators show that outcomes for patients have already improved, with levels of unwarranted variation across the CCG being addressed. The initiative has encouraged joint working and better collaboration of practices, with strong relationships across the patch being developed.
Aims and objectives
The main objective for this scheme is to improve the health outcomes of patients, reduce inequalities, enable practices to work collaboratively and ensure the most cost effective use of resources. Other principles that have been adopted in the development and design of the scheme include:
- Addressing areas of poorer outcomes for patients compared with national benchmarks.
- Targeting outcome areas that are a critical feature of the clinical strategies of the Vanguard (South Cumbria) and Success (North Cumbria) programmes aligning the focus of practices with the broader health system.
- Recognising the impact of deprivation on outcomes.
- Reducing the level of unwarranted clinical variation between practices.
- Reducing bureaucracy for practices by streamlining sources of funding and using data that is readily available.
The Quality Improvement Scheme measures improvements on a value-added basis. This involves targeted work across practices to improve outcomes for patients, whilst recognising that each practice is different and will need to focus on different parts of the overall objectives.
The scheme is incentivised with payments made to practices on an outcomes basis. This is based on them achieving metrics set out within seven specific indicators, rather than being incentivised on process.
An initial 70% of the payment was made upon completion of an action plan of improvements to cover staffing costs. The further 30% was then paid out in July 2017 as and when metrics were achieved. The seven indicators – health improvement; long term conditions; medicines optimisation; cancer; access; referral management and end of life care – were developed using the triple aim approach to ensure a balanced focus on population health, value for money and best care.
The metrics and areas identified for improvements are highlighted in the NHS Outcome Framework, CCG Outcomes indicator set and the NHS England RightCare Commissioning for Value pack.
The CCG supported practices in their endeavours to improve in the indicated areas by providing the following information:
- A rationale for each indicator.
- Information on how they should delivered and what practices will be expected to do.
- Resources available to practices and information on local initiatives.
- Metrics of measurement against performance levels (targets).
The outcomes of this scheme will be measured over its two year duration by analysing local activity data against the metrics of the seven indicators. Every practice that is signed up to the scheme within Cumbria CCG regularly has their levels of prevalence measured against these metrics, which is a collated as a QIS score.
The QIS scores are calculated for each practice by the level of standard deviation from the Cumbria mean, as seen on the graph of Atrial Fibrillation Prevalence by practice.
A full data pack is shared with each practice which highlights their performance against each metric within the indicators, as well as their performance against other practices within their locality. This allows them to identify where a bigger focus is needed in order to receive the 30% incentive payment.
Early outcomes from the scheme show that practices are achieving strong results, for example:
- Cancer – 83% of practices at Cumbria CCG are achieving the metrics set for Cancer prevalence.
- Access – 61% of practices are achieving the metrics set for unplanned hospitalisations for chronic ambulatory care sensitive conditions.
- End of Life Care – 81% practices are achieving the metrics set for patients who died who had an advanced care plan discussion or a deciding right form in place.