Peter Bullivant discusses how primary care has a vital role in identifying local priorities and achieving the Clinical Commissioning Group Outcomes Indicator Set

  • The CCGOIS:
    • provides transparent and comparative information on quality and outcomes
    • reflects the five domains in the NHS Outcomes Framework
    • supports CCGs and their local partners to determine local priorities for improving outcomes based on national indicators
  • The quality premium is a potential source of non-recurrent additional resource for the local community
  • Qualifying for the quality premium requires achievement against a range of measures that combine national outcome measures from the CCGOIS, locally agreed measures, and a requirement to continue to meet key pledges within the NHS Constitution
  • General practice and wider primary care services are key to the delivery of improvements in quality and outcomes measures through the CCGOIS.

The Clinical Commissioning Group Outcomes Indicator Set (CCGOIS)1 is designed to enable commissioners to use outcomes as a way of comparing the quality of the services they commission. The indicator set reflects the duty that the Health and Social Care Act 20122 places on commissioners to improve quality and outcomes. A quick reference guide to the CCGOIS is available here.

The indicators in the CCGOIS are derived from domains within the NHS Outcomes Framework.3 This framework contains the range of outcomes and indicators that define the accountability of the Secretary of State and NHS England, formerly the NHS Commissioning Board (NHS CB), to the taxpayer for improving health outcomes.

The outcomes and indicators of the NHS Outcomes Framework are published and updated annually to refine the indicator set, and to reflect progress.3 The indicators are grouped into the five domains that describe the main areas where the NHS should be seeking to improve (see Box 1).3

The CCGOIS follows the domain structure in the NHS Outcomes Framework but has additional indicators that support the delivery of improvement in quality across the five domains. These additional indicators have been developed with NICE and the Health and Social Care Information Centre.

The CCGOIS is designed to enable clinical commissioning groups (CCGs) and their stakeholders to set improvements in areas that are appropriate for the local population as well as key national areas. This supports one of the key aims of the Health and Social Care Act 2012:2 to ensure services are planned locally, based on local needs.

Box 1: NHS Outcomes Framework ‘five domains’

  • Domain 1—preventing people from dying prematurely
  • Domain 2—enhancing quality of life for people with long-term conditions
  • Domain 3—helping people to recover from episodes of ill health, or following injury
  • Domain 4—ensuring that people have a positive experience of care
  • Domain 5—treating and caring for people in a safe environment; and protecting them from avoidable harm.

Local priorities

The CCGOIS does not prescribe levels of achievement, but is intended to enable CCGs to set their own thresholds and aims for improvement with health and wellbeing boards.4

This approach of locally determined aims and ambitions is detailed in the NHS CB commissioning guidance for CCGs, Everyone counts: planning for patients 2013/14.4 While the NHS Constitution5 and the NHS Outcomes Framework3 describe clear requirements for commissioners, there is an expectation that the way these are to be delivered will vary locally.

Clinical commissioning groups have been given the freedom to drive local improvements, but with this freedom comes responsibility. Specifically, CCGs must show that they have worked with other local agencies to set priorities, and that these are based on a sound understanding of the demographics of the local population and its health needs. Relationships with the local health and wellbeing board, the main forum for developing and agreeing local healthcare and social care priorities, are key. Once these priorities have been agreed, CCGs and health and wellbeing boards should use the CCGOIS to determine local priorities for quality improvement.

Outcomes versus process measures

The range of indicators contained within the CCGOIS demonstrate the change in emphasis as a direct impact of the implementation of the Health and Social Care Act 2012.2 There is a shift away from process measures around factors such as waiting times, to outcome measures such as ‘ensuring people feel supported to manage their condition.’1 This outcome is determined by measuring the health status score of all adults with a long-term condition.

While there is a shift away from process-based targets, CCGs still have to consider the delivery of pledges enshrined in the NHS Constitution,5 including:6

  • patients on incomplete non-emergency pathways (yet to start treatment) should wait no more than 18 weeks from referral
  • patients should be admitted, transferred, or discharged, within 4 hours of their arrival at an A&E department
  • there should be a maximum 2-month (62-day) wait from urgent GP referral to first definitive treatment for cancer.

Incentives and levers for improving services

In order to achieve improvements in care, CCGs must lead the transformation needed. The NHS has fixed resources and must make better use of these as the demand for services increases. So changes need to be made to make the commissioning and provision of services as effective as possible, ensuring that quality, innovation, productivity, and prevention (QIPP) are at the heart of this transformation. Each CCG will have a QIPP plan, which will describe how it will transform services to deliver the improvement in outcomes defined by the CCGOIS.

A range of financial incentives and levers has been made available to commissioners to drive the improvement of quality and outcomes for patients:

  • NHS standard contract
  • Commissioning for Quality and Innovation (CQUIN)
  • quality premium.

Some of these are part of the contractual relationship between CCGs and their providers, and some are fundamental to the success of the CCG.

NHS standard contract

The NHS standard contract:

  • is the primary contractual mechanism by which CCGs will ensure that services are secured in a way that delivers their QIPP programme.7
  • is to be used for all contracting of NHS health services, including those delivered in primary care beyond the core primary medical services contracts.
  • has been enhanced to make it a more effective tool for enabling quality services. Commissioners should be looking at the way they contract for and measure services, so that they promote the delivery of quality improvement and innovation.

Commissioning for Quality and Innovation

Commissioning for Quality and Innovation was designed to allow providers to be paid for achieving quality improvements in their services according to local and national requirements. The national areas for improvement include:8

  • friends and family test
  • NHS safety thermometer
  • venous thromboembolism
  • dementia care.

Quality premium

NHS England will also reward CCGs that improve or reach high standards of quality in key areas. This will be realised through the awarding of the quality premium in 2014/15 to improve services for patients.9 To earn the quality premium, the CCG must achieve the thresholds set out in four nationally agreed indicators, and three locally agreed indicators. The level of the payment will be determined by success in each of the indicators.9 These indicators are a subset of the CCGOIS, see Table 1 (above).9

The award of the quality premium will not just be based on achievement against these indicators. There are other conditions that must be met. The first of these are linked to pledges in the NHS Constitution, namely the 18 weeks, 2-hour A&E wait, and cancer diagnosis to referral targets (as above), plus the target for responding to category A Red 1 ambulance calls within 8 minutes.7

Where a CCG does not deliver the identified patient rights and pledges on waiting times, a reduction of 25% for each relevant NHS Constitution measure will be made to the quality premium payment.9

Finally, in order to earn any quality premium, a CCG must have managed within its own resources, as well as ensuring there are no serious quality failures for providers from which it commissions services. The value of the quality premium has not been published but is likely to be significant.9

Table 1: National measures for the quality premium9*
Domain of NHS Outcomes Framework% value of quality premiumMeasure definition
Domain 1 12.5 A 3.2% or more reduction in potential years of life lost (adjusted for sex and age) from amenable mortality for a CCG population between 2013 and 2014
Domains 2 and 3 25 Reduction or no change in emergency admissions for a combined set of conditions for a CCG population between 2013/14 and 2014/15
Domain 4 12.5
  1. Assurance that all relevant local providers of services commissioned by a CCG have delivered the nationally agreed roll-out plan to the national timetable
  2. An improvement in average friends and family scores for acute inpatient care and A&E services between Q1 2013/14 and Q1 2014/15 for acute hospitals that serve a CCG’s population
Domain 5 12.5 No cases of MRSA bacteraemia for the CCG’s population, and Clostridium difficile cases at or below defined thresholds for CCGs.
  • * Other conditions will need to be met for CCGs to qualify for the quality premium including achievement of three local measures based on local priorities such as those identified in joint health and wellbeing strategies. (NB These three local measures total 37.5% of the quality premium [i.e. 12.5% each].)
  • Combined indicators:
    • emergency admissions for acute conditions that should not usually require hospital admission (adults)
    • unplanned hospitalisation for asthma, diabetes, and epilepsy in children
    • unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)
    • emergency admissions for children with lower respiratory tract infection.
  • CCG=clinical commissioning group; MRSA=methicillin-resistant Staphylococcus aureus

Role of primary care

The NHS Outcomes Framework,3 CCGOIS,1 and quality premium9 have been designed to help commissioners focus on the improvement of outcomes and quality for patients.

As members of CCGs, general practices should be involved in determining local priorities, as well as shaping the aims and ambitions of the CCG. They will have locally agreed roles and responsibilities, as set out in the NHS Constitution. Practices have an interest both as providers of healthcare for the population they serve, and as independent businesses. The interests of patients should be at the forefront of their individual and collective decision-making.

The indicators in the CCGOIS are designed to reflect the success of the whole system, including primary care. All parts of primary care, not just general practice, contribute in some way to the indicators. Each practice needs to understand that it can contribute to achievement of the indicator set as a member of the CCG. One example is domain 2: some of the indicators relate directly to how patients are managed in primary care, and the corresponding data will be collected through primary care; for example, the indicator C2.2—supporting people with long-term conditions—will be sourced through the GP patient survey.10

Where CCGs do not demonstrate success against indicators, their freedoms are likely to be curtailed, and rewards withheld. Forward-thinking practices will identify and take advantage of the opportunities that the CCG plans for transforming services will create. General practice could be the basis for many of the community focused services that are integral to the delivery of better outcomes for patients, especially in provision of services for people with long-term conditions, for example:

  • near-patient testing for anticoagulant monitoring
  • management of patients with diabetes (or even providing the integrated diabetes care for the CCG population).

General practice is key to supporting the achievement of the quality premium. If successful, this will bring significant funding to the local system, benefiting local patients and the practices from which they access services.

If general practice wants to secure future funds outside of its primary medical services contracts, the CCGOIS is a potentially significant source of new income to the local population through the award of the quality premium. However, member practices need to support the CCG in achieving the CCGOIS, and work with them to ensure that the quality premium is secured to support the investment in patient care; this in turn will provide business opportunities for the member practices.

Conclusion

The CCGOIS is derived from the NHS Outcomes Framework. It allows CCGs the opportunity to work with practices and other agencies, including the health and wellbeing board, to initially prioritise and then measure improvement in the health of the local population. The CCGOIS will be used alongside the local indicators to determine the requirements for which the quality premium will be awarded. It is important that practices work together within the CCG to make best use of the resources available to them. This will not only support the achievement of the quality premium but also, through the effective use and re-commissioning of the resources, enable practices to grow and develop into the community providers of the future.

  1. NHS England. The CCG outcomes indicator set 2013/2014. NHS England, 2012. Available at: www.england.nhs.uk/wp-content/uploads/2012/12/ois-ataglance.pdf
  2. Legislation.gov.uk website. Health and Social Care Act 2012. www.legislation.gov.uk/ukpga/2012/7/contents/enacted (accessed 17 May 2013).
  3. Department of Health. The NHS outcomes framework 2013/14. London: DH, 2012. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/127106/121109-NHS-Outcomes-Framework-2013-14.pdf.pdf
  4. NHS England. Everyone counts: planning for patients 2013/2014. NHS England. Available at: www.commissioningboard.nhs.uk/files/2012/12/everyonecounts-planning.pdf
  5. NHS Commissioning Board. The NHS Constitution: the NHS belongs to us all. London: DH, 2013. Available at: www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/the-nhs-constitution-for-england-2013.pdf
  6. NHS.The handbook to the NHS constitution. London: DH, 2012. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/152200/dh_132959.pdf.pdf
  7. NHS England website. 2013/14 NHS standard contract. www.england.nhs.uk/nhs-standard-contract/ (accessed 17 May 2013).
  8. NHS Institute for Innovation and Improvement website. Commissioning for quality and innovation (CQUIN) payment framework. www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html (accessed 17 May 2013).
  9. NHS England. Quality premium: 2013/14 guidance for CCGs. NHS England, 2013. Available at: www.england.nhs.uk/wp-content/uploads/2013/05/qual-premium.pdf
  10. NHS England. CCG outcomes indicator set 2013/2014: technical guidance. NHS England. Available at: www.england.nhs.uk/wp-content/uploads/2012/12/ccg-ois-tech-guide.pdf  G