NHS England published its final version of the CQUIN 2017-19 on Friday. Why is this big news? For those that aren’t familiar with it, CQUIN (which stands for commissioning for quality and innovation) allows Trusts and other healthcare providers to receive income for taking actions to improve patient care. If your Trust ticks the boxes set out in the CQUIN, it gets paid up to 2.5% of its annual contract value. This can be a large sum of money. The reason we’re writing about it is that Advice & Guidance for non-urgent GP referrals is included in the CQUIN 2017-19. Providers can receive up to 0.25% of their annual contract value for offering it.
Consultant Connect is specifically cited in the document as the only example of “synchronous” (immediate) Advice & Guidance. This means that, for example, a Trust with an annual contract value of £300 million that implements Advice & Guidance will be eligible for £750,000. So far so good, but how achievable is it? As you would expect, there are conditions and milestones to be met over the 2 year period together with reporting obligations. Our summary is:
- The CQUIN is very achievable, we would go so far as to say it is “easily” achievable;
- For telephone Advice & Guidance it allows standards to be agreed locally, which is fair;
- For written Advice & Guidance, standards are arguably onerous and less flexible;
- Required reporting is straightforward and unambiguous.
If you’d like to discuss any of this with us, please call us on 01865 261467 or email us on email@example.com. We’ve set out a more detailed look at the scheme below. CQUIN 2017-19 ADVICE & GUIDANCE INDICATOR REVIEW
What Is Required?
- “The scheme requires providers to set up and operate A&G services for non-urgent GP referrals, allowing GPs to access consultant advice prior to referring patients in to secondary care”
- “A&G in the context of this CQUIN refers to structured, non-urgent, electronic A&G provided via telephone, email, or an online system. CCGs may agree with trusts how the local programme of A&G will operate”
The key elements to note here are that the A&G is for elective care only and that access must be “structured”: we interpret this as meaning that access across specialties must be standardised. This may exclude ad-hoc arrangements that vary from specialty to specialty within providers, but the wording gives scope for CCGs to specifically agree local approaches. Our experience is that a standardised “access point” for Advice & Guidance results in increased usage of the service across all specialties.
What Will Be Measured?
- “75% of GP referrals are made to elective outpatient specialties which provide access to A&G services”
- “Are there rules for any agreed in-year milestones that result in payment? Payment will be made quarterly over the 2 year scheme, on evidence of milestones”
- “Are there any rules for partial achievement of the indicator at the final indicator period/date? Yes”
If a Trust is to receive the full amount on offer under the CQUIN, the A&G offered will have to cover the highest volume elective specialties by Q4 2019. This may on the face of it sound challenging and NHS England agree – the original figure proposed in the engagement draft was 90%. In our experience, though, this is very achievable – although it is dependent on a couple of key factors. The first is clinician engagement. If leaders at the Trust are committed to achieving the CQUIN and communicate the rationale and their enthusiasm for it to the relevant specialties, this will enable clinical teams to engage with and progress the project. The second is that, whatever approach is implemented, it needs to be simple enough to enable rollout, adoption and usage in time for the milestone dates – which means as little training, systems integration work and hardware as possible. It is worth noting, the CQUIN is (reasonably in our opinion) NOT all or nothing – there is provision in it for Trusts that offer Advice & Guidance but do not achieve the full 75% specialties-by-volume target. A sliding scale allows Trusts a significant percentage of the CQUIN reward for achieving a lower coverage of specialties, and this should reassure those with resourcing issues in some areas. It is worth doing even if you can’t do all of it. What Standards Will Apply to the Service?
- “Agree local quality standard for provision of A&G, including that 80% of asynchronous responses are provided within 2 working days”
- Quarterly milestones require “quality standards for provision of A&G met”
NHS England are, quite correctly, insisting that, where Advice & Guidance is offered, the service is timely and reliable. For synchronous (immediate) Advice & Guidance (such as Consultant Connect) there is flexibility as to what the quality standards should be – and this is as it should be, since every area is different.
For example, in localities where there isn’t a great deal of consultant cover, determining an achievable answer rate or limiting the hours the service is offered are both options for ensuring that the system meets local demand despite resource limitations. We have good experience of working with commissioners and Trusts to agree standards that are both acceptable to GPs and achievable for consultants. The question is whether the standard for asynchronous (written) A&G is achievable. Our concern is that a one-size-fits-all approach, with no flexibility for commissioners to account for local conditions, is not ideal. We feel that the requirement for 80% of responses to be provided within 2 working days is high, especially for specialties with limited resources – the example given in the CQUIN only achieved 74%. We would expect Trusts thinking of including elements of asynchronous A&G in their CQUIN work to negotiate with commissioners and NHSE for some flexibility prior to committing to this approach.
So, is the CQUIN Achievable?
In a word, yes. Speaking for ourselves, we feel that the milestones are very achievable and the flexibility to agree appropriate service standards for a telephone-based approach should give Trusts and commissioners comfort that they won’t be tripped up. Those Trusts that are unable to reach the target of Advice & Guidance for specialties covering 75% of patient volume by the end of Q4 2019 can still qualify for significant CQUIN rewards – it’s not all or nothing, which makes it fairer for Trusts with constraints. I
f you would like to discuss the CQUIN or the practical steps required to roll out telephone Advice & Guidance in your area, please contact us on 01865 261467 or email us on firstname.lastname@example.org.