Feature / PROMs date

The quality agenda is about to take a step forward with the routine collection of patient reported outcome measures. But what are they and how will they be linked to payments under the CQUIN initiative? Seamus Ward reports

One of the oft-repeated criticisms of payment by results is that it is a misnomer, paying providers for activity rather than results or outcomes. However, this is about to change because from April a small proportion of providers’ potential income will be based on meeting quality measures, including how patients feel their treatment has improved the quality of their lives.

In a move that breaks new ground for the NHS, patient reported outcome measures or PROMs will play an important role in measuring the effectiveness of care and contribute to the commissioning for quality and innovation (CQUIN) incentive payment framework.

Together with clinical outcomes, PROMs make up the effectiveness element of CQUIN – the other two being safety (including cleanliness and infection rates) and patient experience (which addresses issues such as dignity, respect and ease of access to services).

Historically, the NHS measured the success of surgery on how well (or badly) the procedure went on the day. It was a purely technical assessment. However, the patient’s view of how the surgery had affected their lives – whether they could now walk or climb stairs free from pain, for example – was rarely heard. The introduction of PROMs, multiple choice questionnaires that assess patients’ health and quality of life, will change this.

In 2009/10 PROMs will be collected in four elective procedures – hip and knee replacements, varicose vein and groin hernia surgery – and over the year the Department of Health believes around 250,000 patients will be asked to fill in the questionnaires.

Launching the scheme, health minister Lord Darzi, who announced the idea in his High quality care for all report, said: ‘While a surgeon may judge a hip replacement successful because the procedure has been performed perfectly on the day, the patient will rightly disagree if they are still in pain and continue to have a poor quality of life six months down the line.

‘The beauty of PROMs is that they measure the success of operations as reported by patients themselves,’ he said. ‘This programme is the first of its kind in the world and the information collected will empower patients to choose a hospital that achieves the best results for the operation they need.’

Patients answer the same set of questions before and after their surgery (six months later for hips and knees, three months for the others). The questionnaires focus on the patient’s degree of pain and mobility, together with generic measures of their health. The post-operative PROMs include questions about complications, readmissions to hospital and operations that had to be performed again, as well as questions about rehabilitation services, where appropriate.

Pioneering work by the Royal College of Surgeons and the London School of Hygiene and Tropical Medicine has influenced Lord Darzi’s ideas on PROMs. Their 2007 study found PROMs in the four surgical areas were a valid approach.  ‘I think PROMs are valuable as a tool to improve outcomes for patients in elective surgery. Outcomes can be made available to inform patient choice, provided they are properly explained,’ says Jan van der Meulen, director of the Royal College’s clinical effectiveness unit.

Monitor policy director Robert Harris, who has been working with foundations on the adoption of PROMs, also backs the initiative. ‘I think it’s a significant step in the right direction because for the first time we are trying to measure efficacy and are endeavouring to build a framework that measures both generic and disease-specific quality of care,’ he says. ‘We are trying to get to the heart of how effective we are in terms of the care we give and, more importantly, how the patient benefits from it.

‘It is right to acknowledge organisations that provide better care. If we are serious about choice it is right to draw the public’s attention to organisations’ performance so they can make an informed choice.’

The professionalism of staff and their organisation’s responsibility to provide the best quality care will drive quality improvements, he adds, while the link to providers’ income and commissioners’ spending will focus minds.

‘There is a real consequential financial benefit for doing it well,’ says Professor Harris. ‘Providers will start to push hard on the data to demonstrate quality and benchmark their performance.’

But he adds that better quality rather than higher income should be the driving force behind PROMs. ‘In itself, with money following the patient, that could lead to more income but the payment mechanism is a means to an end. Organisations should stretch themselves notwithstanding the reward. They must constantly stretch to improve, re-evaluate and reinvent.’

Dr van der Meulen is concerned about the link between PROMs and income, even though the amounts involved are relatively small. ‘I am a public health doctor and I have been impressed by how strongly the surgeons have welcomed this initiative focusing on outcomes, especially as expressed by patients.

‘But the Department of Health and the Darzi report also give PROMs a role in payment by results through the CQUIN initiative and I believe that might be taking it one step too far.’

He continues: ‘It’s good to give the health service feedback on patients’ views on how it can serve them better. But I am not sure to what extent they should be used in performance management. I am not sure the collection and interpretation system is robust enough to do that. The interpretation of the data is quite difficult, especially if you start to link it to payment.’

He adds that data quality has to be addressed – making sure that the number of patients recruited to complete the questionnaires is comparable across all trusts. ‘People in the US who work on incentives say the UK is doing something amazing but it is trying to run before it can walk.’

Incentive payments will be controversial but some feel they should be taken further. One manager asks whether penalties should cut deeper, with under performance attracting under-tariff payments. ‘If we are paying more for better quality should we not be paying less for lower quality?’ he asks

NHS North West is well advanced in its PROMs implementation, in part through its Advancing Quality (AQ) incentive payment scheme. AQ programme director Alan Horne, who is leading on PROMs, says it has worked closely with the Department to ensure its scheme will fit as closely as possible with the national programme.

The Royal College of Surgeons in England has been appointed to manage the collection of PROMs and the college and the AQ team have worked together to raise awareness in trusts and PCTs through conferences and workshops.

Initially, the AQ scheme will use two PROMs – for hip and knee replacements. The other two clinical areas – varicose veins and hernia repair – will be implemented in the North West as part of the CQUIN scheme.

Mr Horne says some hospitals in the region are further advanced, using PROMs for colorectal and cardiothoracic surgery. AQ may also introduce PROMs for coronary artery bypass surgery (CABG) in the future.

‘We are also looking at a pilot with the Department and the London PCTs on long-term conditions, including asthma, chronic obstructive pulmonary disease, diabetes, epilepsy, heart failure and stroke,’ says Mr Horne. ‘But we will be expanding only where there is a solid evidence base.

‘We are looking to extend along the care pathway by using PROMs in hospital, primary and community care. We are quite excited by that.’

The AQ PROMs reward budget for 2009/10 for hip and knee has been set at £500,000, though a decision on how this will be distributed will be thrashed out at a meeting this month.

‘When you break down the questionnaire, some questions are generic and could be related to any area of clinical focus and then there are some more specific questions. You could reward on one of these or in a composite way. We are working with the Royal College on this,’ Mr Horne says.

‘Incentive payments could be made on an absolute or relative basis – so you could pay only the top performers, those that have achieved a given target or the most improved.’

Although discussions on how AQ will align with CQUIN are ongoing, providers will only be rewarded once for hip and knee PROMs improvement – they will not receive payments under both AQ and the CQUIN scheme.

There are questions over the robustness of PROMs data – the Department has acknowledged scores must be adjusted to reflect risk (inequality, sex, age and morbidity, for example).

There is also a question over how patient expectation will affect PROMs scores – they may have an unrealistic expectation of their life after surgery when their condition or wider health may indicate the best possible outcome is being largely pain-free or having much-improved, though not full, mobility.

The PROMs questions will seek to avoid such problems by asking about specific situations – whether or not the patient can do the household shopping on their own or is able to put on a pair of socks without any difficulty, for example. But their judgement could be clouded if expectations are not met.

Dr van der Meulen says some clinicians believe they should have input into the post-operative PROMs assessment. For example, they could X-ray a joint replacement after six months to ensure it is still in place, giving commissioners, providers, clinicians and patients assurance that the operation has been performed properly.

Mr Harris believes the solution lies in the NHS educating patients to think in a ‘more precise and accurate’ way when assessing their own condition.

He adds that by doing this PROMs could even have public health benefits by prompting patients to be more aware of their general health and the role they can play in keeping themselves healthy.

The implementation of PROMs and the quality agenda in general has sparked a lot of interest, not least because of the link to providers’ income. But even though the amounts involved are relatively small, providers are keen to ensure they maximise their income by increasing quality.

As one finance director comments: ‘We are very interested in PROMs and the CQUIN initiative. Although it is 0.5% of our contract income, we know we are entering an uncertain period where growth will be limited. In that context 0.5% or even more could be very useful indeed.’

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