Dr Gillian Leng explains how submissions to the QIPP collection are assessed for inclusion and highlights other NHS Evidence resources for use in improving patient care

The Quality, Innovation, Productivity and Prevention (QIPP) challenge for the NHS is to improve quality of care in the most efficient way possible while delivering the best possible outcomes for patients.

The QIPP collection on NHS Evidence (www.evidence.nhs.uk/QIPP) provides quality assured examples of how staff across the NHS are rising to the QIPP challenge. This resource includes evidence-based examples, which have been shown to:

  • improve quality
  • save money
  • help ensure that patients are referred to the right service at the right time
  • highlight areas of potential disinvestment from NICE guidance and Cochrane reviews.

In the changing NHS, GP consortia will be focusing their attention strategically to where real improvements to care and cost savings can be made—this is where the QIPP collection can help.


Quality assurance

All applications that are submitted to the NHS Evidence QIPP collection are scored according to a set of evaluation criteria or ‘gates’ to ensure that they meet the following standards:

  • Savings
  • Quality
  • Evidence
  • Implementability.

Savings
This gate addresses the level of costs and amounts and types of savings involved in the initiative. Organisations are requested to provide information on any costs relating to making the change (such as investment in new computer software or additional staff training). It is not always necessary for an initiative to deliver significant cost savings to be considered for inclusion in the QIPP collection; for example, a GP surgery might implement a training initiative locally—this would not necessarily make direct cost savings, but productivity could benefit through increased levels of staff confidence.

Quality
The outcome of the initiative on quality is assessed to determine if a significant improvement in clinical quality occurs, such as improved management of a long-term condition to reduce hospital admission. Other areas that are assessed include whether there is any known expected impact on patient and carer experiences and if the initiative supports the call for greater choice and patient-centred care as set out in the recent White Paper.1

Evidence

Information that describes the evidence base for the initiative and evidence of the outcome or results delivered by implementing the initiative is assessed by this criterion. If the initiative is underpinned by NHS Evidence-accredited guidance such as NICE or SIGN, a higher score will be awarded. In some cases, the initiative may be based on local opinion—a theoretical improvement that has yet to be tested in an organisation. While this commands a lower score, it may still be a valid reason for implementation.

Implementability
The final gate addresses the effort required to implement the initiative and describes the ease and timescales involved, such as:

  • the likely speed of implementation
  • the ease of organising the change
  • the level of support required to implement the change
  • any organisational or financial barriers to implementation that were addressed.

The time taken to implement initiatives can vary; so far, most initiatives delivered have taken between 3 months and 1 year to implement; others have been put into practice in just 6 weeks. Initiatives delivered in social care or mental healthcare may take up to 3 years to implement.

Specialist review
Prior to appearing on the QIPP collection, all submissions are reviewed by at least two external advisers with a specialist interest in the respective clinical area to validate the assessment of the submission.

For example, an initiative on renal health in primary care may be reviewed by Dr Donal O’Donoghue, National Clinical Director for Kidney Care and Dr David Colin-Thome, National Clinical Director for Primary Care.

Recommended examples
A combined overall score is used to identify the top 10% of case study examples—these are denoted as ‘recommended’ and can be found on the NHS Evidence—QIPP homepage (www.library.nhs.uk/qipp/).

Updating submissions
After appearing on the collection for 12 months, organisations are contacted to provide any additional information about how their respective initiative has changed since the submission was first assessed. This helps to ensure that case study examples remain relevant and fit for purpose in case there are other organisations that want to implement them.

QIPP evidence: showcasing best practice

Around 100 best practice examples currently appear in the QIPP collection some of which have been delivered in primary care. The examples have been evaluated and range from one-off studies in single organisations to large-scale changes that have been replicated in multiple organisations, with the outcomes published in academic journals.

Fostering innovation

Electronic consultations in the management of chronic kidney disease
A recent addition to the QIPP collection showcases how a primary care team in Bradford explored the use of electronic consultation (e-consultation) to support the management of patients with mild-to-moderate chronic kidney disease (CKD) in primary care.2

A centralised primary care IT system was used to share individual electronic health records (EHRs) with a renal specialist after obtaining and recording patient consent. The specialist was able to review important clinical details (including co-morbidities, medication history, communications from other specialists, reports of previous imaging, and numerical pathology data in tabular and graphical formats) and make a timely decision as to whether a patient should be referred to clinic, undergo preliminary tests or interventions, or continue to be monitored by the primary care team. Responses are saved in the patient’s EHR and sent as tasks to alert the primary care team.2

As a result of the e-consultation initiative, GPs are more confident in managing uncomplicated CKD in the community. Other outcomes include:2

  • efficient use of NHS resources
  • improvements in patient experience
  • environmental benefits through a reduction in unnecessary hospital visits.

No significant costs have been identified for introducing the e-consultation scheme, but savings have been estimated at up to £94 per e-consultation. Although the impact in direct monetary terms is relatively small, high levels of improved productivity are expected through a reduction in inappropriate referrals.2

Telemedicine for electrocardiogram interpretation
An initiative implemented in Cumbria and Lancashire has been supporting GPs to access reliable and accurate support in the interpretation of electrocardiograms (ECG). By establishing a telemedicine system, ECGs undertaken in primary care can be sent for interpretation to a centre staffed by clinical specialists and returned within 30 minutes.3

Evaluation of the initial pilot demonstrated that GPs referred 16% fewer patients to accident and emergency and 7% of admissions were avoided. This amounted to a saving of approximately £4000 per GP practice, which when extrapolated across the NHS, has the potential to save £46 million a year.3 Since this initiative was piloted, 130,000 ECGs have been successfully interpreted.

Cochrane evidence for disinvestment

In addition to showcasing positive changes that can be made, the QIPP collection highlights potential areas for disinvestment. Each month, the UK Cochrane Centre provides NICE with details of newly published systematic reviews that indicate if an intervention is harmful, ineffective, or not supported by sufficient good-quality evidence and therefore should not be used outside of research.

The Cochrane QIPP topics available on NHS Evidence include the following examples in which evidence indicates that the intervention is ineffective:

  • Light physical conditioning programmes for workers with back pain4
  • Symptomatic treatment of the cough in whooping cough5
  • Routine chest physiotherapy for pneumonia in adults.6

The Cochrane topics on NHS Evidence come from the ‘implications for practice’, which are written by healthcare professionals working internationally, and can be found in all Cochrane systematic reviews. These topics may inform local initiatives and address the quality and productivity challenge by indicating areas of care that commissioners may wish to consider when making local disinvestment decisions, thus reducing patients’ exposure to treatments of unproven benefit.

NICE ‘do not do’ recommendations

The NICE ‘do not do’ database can be viewed via a link on the QIPP page.7 During the process of guidance development, NICE’s independent advisory bodies often identify examples of routine clinical practice that they recommend should be discontinued completely or not used routinely.
Two such examples of these ‘do not do’ recommendations relevant to primary care are:7

  • danazol should not be used routinely for the treatment of heavy menstrual bleeding
  • oral antibiotics should not be prescribed to children with fever without apparent source.

NICE referral advice

The NICE referral advice recommendations database contains current primary-to-secondary referral advice from NICE clinical guidelines, cancer service guidance, and public health guidance. It highlights recommendations that clearly identify where patients might benefit from secondary care or specialist services (and, by implication, those where patients would not benefit from these services). Apart from ensuring value for money, the NHS, by following the recommendations in this database, will help to improve clinical outcomes and patient experience.

Inappropriate referral to secondary care places a large financial burden on the NHS. Implementing NICE guidance can provide a way for GPs and commissioners to ensure that patients receive treatment that is proven to be both clinically and cost effective including appropriate referral of a patient to hospital.

Get involved!

The volume of information on the QIPP collection illustrates clearly that there is no shortage of innovative ideas in the NHS. And many are yielding unexpected results—an initiative developed by the Chartered Society of Physiotherapy to enable patients to refer themselves to outpatient musculoskeletal NHS physiotherapy services, led to a decrease in referrals, while still providing greater choice and control for patients.8

If you have good examples that have been shown to work and which can help the NHS nationally meet its challenge, NHS Evidence wants to hear from you. Your organisation could become a beacon of best practice in primary care for others to learn from.

For your QIPP initiative to be considered for inclusion on NHS Evidence, you will need to complete an online form, which you can find at www.evidence.nhs.uk/QIPP/default.aspx together with a
user guide9 outlining what types of supporting information the assessment team is looking for.

I would strongly encourage you to access the QIPP collection on NHS Evidence to find out how your colleagues are contributing to the quality and productivity challenge. As a primary care professional, you know that delivering efficiencies is not something that can ‘wait until tomorrow’—it requires focus, drive, and innovation now.

NHS Evidence is changing in May 2011

From May 2011, we will be broadening the types of information available on NHS Evidence and signposting GPs more clearly to the very best resources:

  • A new focus on medicines information—allowing users to search key sources simultaneously, including the British National Formulary, National electronic Library for Medicine, and National Prescribing Centre
  • New clinical topic areas, bringing together the latest guidelines, high-quality patient information, ongoing trials, and other selected information
  • Access to NICE pathways—allowing users to easily visualise and browse associated NICE products (e.g. technology appraisals, interventional procedures, clinical guidelines, medical technology and diagnostics guidance, public health and social care advice, quality standards, and accompanying tools produced by NICE to support implementation) online and be guided through supporting documents
  • Summaries of recently published evidence in the form of evidence updates
  • Notifications of the latest significant research in speciality areas.

Further information on the changes to NHS Evidence will be included in the May issue of Guidelines in Practice.


  1. Department of Health. Equality and excellence: liberating the NHS. London: DH, 2010.
    Available at: www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm
  2. Bradford Teaching Hospitals NHS Foundation Trust. Chronic kidney disease:
    electronic consultation
    . Available at: www.library.nhs.uk/qipp/ViewResource.aspx?resID=406809&tabID=289 (accessed 29 March 2011).
  3. NHS Improvement. Telemedicine for primary care ECG (electrocardiogram) interpretation. Available at: www.library.nhs.uk/qipp/ViewResource.aspx?resID=330720&tabID=289 (accessed 29 March 2011).
  4. The UK Cochrane Centre and NICE. Light physical conditioning programmes for workers with back pain. Available at: www.library.nhs.uk/qipp/ViewResource.aspx?resID=383206&tabID=289&catID=15418 (accessed 29 March 2011).
  5. The UK Cochrane Centre and NICE. Symptomatic treatment of the cough in whooping cough. Available at: www.library.nhs.uk/qipp/ViewResource.aspx?resID=383290&tabID=289&catID=15418 (accessed 29 March 2011).
  6. The UK Cochrane Centre and NICE. Routine chest physiotherapy for pneumonia in adults. Available at: www.library.nhs.uk/qipp/ViewResource.aspx?resID=383132&tabID=289&catID=15418 (accessed 29 March 2011).
  7. National Institute for Health and Care Excellence. Search the NICE ‘do not do’ recommendations database. Available at: www.nice.org.uk/usingguidance/donotdorecommendations/search.jsp
  8. Chartered Society of Physiotherapy. Musculoskeletal physiotherapy: patient self-referral. Available at: www.library.nhs.uk/qipp/ViewResource.aspx?resID=406806&tabID=289 (accessed 1 April 2011).
  9. National Institute for Health and Care Excellence, NHS Evidence. A user guide for quality, innovation, productivity and prevention (QIPP) case study submissions to NHS Evidence. Available at: www.evidence.nhs.uk/Accreditation/Documents/QIPP_User_Guide_v1.9.pdf G