News / CQUIN payments underpin Darzi focus on quality

The NHS is to move rapidly towards paying hospitals on the basis of quality of outcomes as a result of Lord Darzi's final report from his Next Stage Review.

In High quality care for all, published at the end of June, the health minister set out a vision for a health service focused on quality. 'The focus on prevention, improved quality and innovation will support the NHS in its drive to ensure the best possible value for money for taxpayers,' he said.

Measures include expanding access to GP services, speeding up drugs approval and increasing the measurement and publication of quality information.

The plan to link hospital payment to quality had already been flagged up by prime minister Gordon Brown in May. But the speed of the move described in the Darzi report took some finance managers by surprise with changes to payments starting in 2009/10.

The new commissioning for higher quality and innovation (CQUIN) scheme will be a 'simple overlay' to payment by results with funding created by reducing the tariff uplift. For the first year, providers will trigger payments by simply submitting data - ensuring data flows are in place. However from 'no later than 2010' payments will be linked directly to outcomes.

Reports suggested that an average district hospital with a turnover of £250m could expect up to £9m through the quality payments system. A range of quality measures covering safety (including cleanliness and infection rate), clinical outcomes and patients' views about the success of their treatment (recorded in patient-reported outcome measures or PROMs) will be used.

HFMA chairman Chris Calkin welcomed the enhanced focus on quality running through the Darzi proposals. 'We have understand- ably had a focus on activity in recent years and the results in terms of improved access and reduced waiting have been impressive,' he said. 'But it is absolutely right that we should put the focus firmly on improving the quality of care and ensuring the system and incentives underpin this quest for quality.' 

However he said that it would be important to see the detail of the proposed quality payment system. He noted that by reducing the tariff uplift to finance quality payments, there would be a danger of compounding problems in organisations with the biggest challenges.

In a further attempt to empower patients, the Department of Health is to pilot personal budgets for patients with long term conditions early in 2009.
The report also promised the expansion of payment by results to other services, with a national currency for mental health services 'available for use' by 2010/11.

The same year will also see the first moves away from using national average costs to set tariffs in four high volume areas - cataracts, fractured neck of femur, cholecystectomy and stroke care. New tariffs for these interventions will be set on the basis of best practice costs.

The report also promised to set out projections for tariff uplift and efficiency gains on a multi-year basis. Mr Calkin described this as 'logical' given the three-year comprehensive spending review cycle and the three-year pay settlement.

The Darzi report built on local Next Stage Review plans published in recent weeks by the 10 strategic health authorities, many of which map out changes in patient pathways.

Mr Calkin said that many of these changes would require strong clinical leadership in gaining clinical consensus across health economies for the shapes of services to be provided and the right pathways. He said that 'what was right for the patient' had to be at the centre of any decisions taken.

However he said that there needed to be recognition that changed pathways, perhaps involving the development of new services in different settings, could potentially carry a higher financial cost.