1. Creating incentives for better quality: Lessons from the English NHS Jennifer Field, Associate Director National Institute for Health and Clinical Excellence

2. Overview Background to the English NHS and NICE Defining and identifying quality –Developing Quality Standards –Potential use of QS within the English NHS Payment by Results - Best Practice Tariffs –System overview –Emergency hip fracture –Elective hip and knee replacements Conclusions

3. English NHS Structure (as at 2010/11) Parliament Department of HealthMonitor Arms length bodies Strategic Health Authorities Primary Care: Commissioning services from secondary care and: General Practitioners Dentists Opticians Pharmacists Secondary Care: Acute Trusts Mental Health Trusts Ambulance Trusts Care Trusts (Community) Foundation Trusts

4. NICE has become a unique platform Optimal use of new and existing treatments Clinical guidelines and quality standards Health promotion and disease prevention Comprehensiv e evidence service NICE and NHS Evidence Evidence – guidance – shared learning

5. How does NICE develop its guidance? Guidance Legislation (Equality & Diversity ) Legislation (Equality & Diversity ) Other factors Social Value Judgements Uncertainty Cost- effectiveness Clinical- effectiveness Patient experts Clinical experts Clinical experts Consultation Comments

6. Quality Standards Evidence Clinical guidelines Quality standards QOF CQUIN COF BPT The starting point is the evidence base. This is distilled down to produce clinical guidelines and other guidance Quality standards and statements are derived from NICE clinical guidelines and other guidance The QS include indicators and measures that can inform a variety of quality initiatives – and be linked to financial incentives Quality measures

7. Example quality statement for stroke In a high quality service for patients with stroke... Patients with acute stroke receive brain imaging within 1 hour of admission if they meet any of the indications for immediate imaging (QS2) Relevant CG recommendation –Brain imaging should be performed immediately (within 1 hour) for people with acute stroke if any of the following apply …

8. Example of quality measure for stroke Structure: Evidence of local arrangements to ensure patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. Process: Proportion of patients with acute stroke who meet any of the indications for immediate imaging who have had brain imaging within 1 hour of arrival at the hospital. [Numerator & Denominator defined]

9. Data Source Structure: Local data collection. Process: Trusts can collect data via the Sentinel Stroke Audit, Hospital Episode Statistics (HES) data and through local data collection.Sentinel Stroke AuditHospital Episode Statistics There exist existing quality assured indicators Sentinel Stroke Audit CV02 –Proportion of stroke patients given a brain scan within 24 hours of stroke DH WCC Assurance Framework Acute 36 –Percentage of stroke admissions given a brain scan within 24 hours

10. Best practice tariffs Criteria for potential areas for a BPT: –High volume / cost area –Variation in practice –Strong evidence base and consensus on what is best practice Various methods of rewarding BPT: –Price differential to incentivise delivery of care – day case / outpatient relatively higher than inpatient –Additional payment on top of base tariff where best practice is delivered –Incentivise best clinical management through reducing tariff within range of savings expected

11. BPT example 1: Hip Fracture Best practice criteria: –Time to surgery within 36 hours –Admitted using agreed assessment protocol –Assessed by geriatrician in the perioperative period –Multi-professional rehabilitation –Fracture prevention assessments

12. BPT example 1: Hip Fracture The tariff is paid in two-parts: Base tariff per patient Best practice premium Base tariff per patient National average cost Reduction in base tariff for national compliance rates. National Hip Fracture Database captures compliance with best practice criteria Additional premiums monitored and paid quarterly

13. BPT example 2: stroke Applies to emergency admissions (excluding maternity related) with a diagnosis of stroke Non-transient stroke Haemorrhagic Cerebrovascular Disorders Base tariff£3,712£3,579 Adjustment if rapid brain imaging£286 Adjustment if direct admission and 90% of stay in an acute stroke unit £684 Subtotal£4,682£4,549 Adjustment if thrombolysed using alteplase where indicated £828

14. Conclusions It is possible to create incentives to improve quality Incentives can be both positive or negative Need to have clear link between what is measured and incentivised and improved outcomes Need to consider the administrative burden and what can easily be measured Care needs to be taken to avoid incentives being abused Need to consider impact on both the provider of care and the commissioner (payer)