Is QIPP really about ‘doing more with less’?

The NHS Quality, Innovation, Productivity and Prevention (QIPP) Challenge was launched in March 2010 as a strategy to facilitate major cost savings within the NHS, in response to the impact of the global recession. The principle of QIPP was that given the need for austerity budgeting, serious planning and rethinking were needed to ensure ‘smart’ cost-cutting that did not harm patient outcomes. The QIPP agenda was about identifying solutions that held together the four key principles, reducing overall costs by making interventions more timely, efficient and effective.

The new Government’s NHS reforms promised to facilitate QIPP by empowering local providers and commissioners to develop the best solutions for their communities. However, the economic pressures on CCGs and Foundation Trusts within the new system, combined with the ‘Nicholson challenge’ of cutting £5 billion out of the NHS budget in each of four successive years, have meant that the dominant theme of QIPP at a local level is cost reduction.

The first full year of QIPP (2011–12) delivered savings of £5.8 billion against a target of $5 billion. However, reports of NHS rationing and ‘postcode prescribing’ have proliferated. QIPP was devised as a strategy to combine two goals: the shift towards community-based healthcare and the urgent drive towards NHS cost-cutting. Is that still the agenda, or have the pressures of NHS reform reduced its four principles to one: reducing expenditure? Is QIPP really about “doing more with less”, as Andrew Lansley claimed, or is it just about doing with less?

A new healthcare paradigm
The DH booklet introducing the QIPP challenge in March 2010 set the context: “The NHS needs to identify £15–20 billion of efficiency savings by the end of 2013/14 that can be reinvested in the service to continue to deliver year on year quality improvements.” The booklet placed emphasis on improving quality while reducing overall costs through strategies such as early intervention, improved infection control and home-based care. Its authors included Jim Easton, then National Director for Improvement and Efficiency. The DH described a series of QIPP ‘workstreams’ it was setting up to help clinical teams and NHS organisations “improve quality and productivity across care pathways”. The first of these related to care of long-term conditions, urgent care and end-of-life care. Further workstreams would examine safety challenges, such as pressure ulcers (bedsores), and ‘right care’ issues such as referral management and identifying “low-value treatments” (later to become controversial issues).

The authors called for “a collective response at local, regional and national level” to address the QIPP priorities. These included early diagnosis, primary and secondary prevention and patient self-management. The need for “better partnerships between primary, community and secondary care to support people with long-term conditions” was emphasised. QIPP extended from the “daily clinical practice” of individual HCPs to “the wider care pathway”, the booklet said. Each SHA had its own QIPP lead and innovation lead, and was establishing an online regional ‘quality observatory’ and Innovation Fund to help clinical teams improve quality and productivity.

These ideas were illustrated by case studies where local NHS organisations had developed better and more affordable healthcare solutions. These included the use of an electronic system to ‘re-engineer’ blood transfusion, reducing waste and improving safety; and systematic guidance on antibiotic prescribing to reduce rates of C. difficile infection. These solutions all involved using teamwork and sharing information to make the best use of available resources.

The booklet ended on a warning note: “If we do not respond to this challenge there is a real risk that the need to cut costs will overtake our best intentions to improve care for our patients.” More than two years later, the crucial question is: has QIPP averted that outcome or brought it closer?

Innovation is ‘core activity’
In June 2012, Nicholson’s annual report claimed 2011/12 had been “a remarkable year” for the NHS. He highlighted the contribution of local initiatives to maintaining service quality while cutting costs. Austerity would dominate the NHS “for the foreseeable future”, he said. However, the innovation agenda promoted by the previous Government’s Office for Life Science and revived by the current Government in December 2011 would engage dynamically with that challenge: “Innovation has to... become the core activity of the NHS.”

His report went through the elements of QIPP, noting achievements in each area. Quality achievements highlighted included: in cancer care, the achievement of key treatment standards across all eight performance measures, as well as improved early detection figures; and in stroke care, better access to specialist stroke units and faster treatment of people with transient ischaemic attacks. Community-based asthma services in South East Essex were used as an example of a successful local initiative.

The brief section on innovation focused largely on the use of technologies in the community, including telehealth and home dialysis. The preventative care section emphasised the growing role of health visitors, and drew attention to the success of a national screening campaign for risk of venous thromboembolism (VTE) with prophylactic drug treatment given where needed.

In the productivity section, Nicholson noted QIPP savings of £5.8bn and praised the “modest reduction in activity levels” across the NHS – placing these in the context of the QIPP Long-term Condition Workstream, which aims to reduce unscheduled hospital admissions by 20%, reduce hospital stay length by 25%, and maximise the role of “supported care planning” in helping people to manage their own health. However, no reference was made to the rationing of procedures or the cuts in hospital nurse staffing.

Milestones or millstones?
A recent Health Service Journal report on the DH’s QIPP tracker indicates that the PCTs (soon to be abolished) plan savings worth £13bn nationwide between now and 2015, with £4.5bn of this to be achieved through the 53 local QIPP plans. The planned savings are front-loaded: £3.8bn this year and £3.6bn, £2.9bn and £2.6bn in the next three years. However, only £2bn of the planned QIPP savings are currently being achieved on schedule, and only six local QIPP plans are on track with all of their workstreams.

According to the tracker, productivity gains are the main objective of most local initiatives. Common features include the redesign of care pathways for long-term conditions, including diabetes and COPD, and the development of integrated care teams for dementia patients. However, many local plans have the single goal of reducing the cost of services – for example, South of Tyne and Wear PCT notes as an objective: “reduce price paid for Gateshead Health Foundation Trust older people’s mental health service”.

John Appleby, chief economist of the King’s Fund, commented that this emphasis on savings denied the original point of QIPP: “to improve value to patients”. He also said there was no evidence of the money saved being reinvested in future services, which was a key principle of the original QIPP agenda. The Audit Commission has since reported that the NHS has £4bn in “uncommitted finances”: cash reserves created by aggressive cost-cutting. Mike Farrar, Chief Executive of the NHS Confederation, has argued that this money needs to be invested in community and primary care.

Jim Easton, the NHS Commissioning Board’s Director of Improvement and Transformation, warned in July that too many NHS organisations were relying on spending cuts without any element of service redesign. The “deeper change” of shifting healthcare to the community was not being undertaken, he said, and
QIPP was becoming a “label” for “cost improvement plans”. As a result, the QIPP savings of the past year would be very difficult to repeat. Instead of building a new healthcare model, the NHS was just cutting
parts of the old one.

Easton has since announced that the Board will fund a new innovation body to deliver a “system-wide” response to the QIPP challenge. From April 2013, the new organisation will replace all existing NHS innovation and technology adoption bodies. He anticipates that it will “provide hands-on support for great models of care” developed within and beyond the healthcare sector. However, his resignation has cast a shadow over these plans.

According to the King’s Fund, 27 of 42 NHS finance directors it surveyed believe there is a high risk that the NHS will fail to meet the ‘Nicholson challenge’. A key question for industry, and for patients, is whether QIPP can help the NHS deliver on the more important challenge of transforming healthcare to meet the
changing needs of the population.

The end to the ‘postcode lottery’ will have to wait a little longer. Hopes were raised earlier this year when the Department of Health unveiled plans to introduce an ‘innovation scorecard’. The scheme would prevent hospitals blacklisting expensive drugs recommended by NICE. Patients, regardless of their location, would be able to receive the latest treatments without delay.

The DH initially planned to have the scorecard “fully implemented by the Autumn.” But, after discussions with the NHS and the pharmaceutical industry, it now looks likely that the scorecard will not be in place until the end of the year.

Speaking exclusively to Pharmaceutical Field, a DH spokesperson said talks were still ongoing between the health service and pharma to “collect all the data and information needed to ensure the scheme is accurate and effective. It will be launched in the coming months.”

The new scheme is expected to work in three different ways:

1. The innovation scorecard will allow patients and the public to see which NHS organisations have adopted the latest NICE guidance on recommended drugs and treatments.
2. The NHS will no longer have an excuse not to provide patients with NICE recommended products. Treatments recommended by the Institute will now be automatically added on to local formularies, allowing doctors to prescribe more expensive treatments if they wish.
3. A new group will be established to help the NHS overcome any barriers when implementing NICE guidance. The introduction of new medication or treatment may mean big changes in the
   way services are delivered. The group aims to spread best practice across the health service.

The DH added that NHS Trusts receive funding for each new NICE appraisal, so financial issues should not be used as a barrier to the uptake of innovative new treatments.

Speaking when the details were first announced in late August, then Health Minister Paul Burstow said the “new regime” would be a “catalyst for change”. He added that the DH is “determined to eradicate variation” across the uptake of NICE approved drugs. “NHS organisations must make sure the latest NICE approved treatments are available in their area, and if they are not, then they will now be responsible for explaining why not,” he said. “Being transparent with data like this is the hallmark of a 21st century NHS. It is
a fundamental tool to help healthcare professionals improve patient care.”

The introduction of the scorecard has been backed by the ABPI. Stephen Whitehead, ABPI Chief Executive, said it would be a “valuable tool” to support the latest NICE recommendations. “There is still a great deal of variation across the country on which treatments patients are able to access and so I am hopeful the scorecard will help highlight discrepancies which can then be addressed,” he said.

Whitehead called the scorecard a “definite step forward” in ensuring patients receive the latest treatments as quickly as their European counterparts. He said the existing system was bad news for the health of the nation which resulted in a lost opportunity to “drive efficiency savings through the use of medicines”.

The NHS Confederation was equally receptive to the introduction of the scorecard. But former Deputy Chief
Executive David Stout warned its implementation may cause “unnecessary bureaucracy” and stretch NHS finances even further. “It is also important to remember that the NHS is facing an unprecedented financial challenge and organisations must live within their means while providing high quality care,” he said. “The reality is we can only afford to provide new drugs or treatments where they are cost effective and demonstrably add real patient benefits. In a health system with no financial growth, any new costs have to be offset by savings elsewhere.”

Stout added that the introduction of the scorecard will only be a success if the NHS engages with local communities and clinicians to decide what local priorities are.

Jim Easton, one of the most senior people in the NHS, looks set to resign from his roles at the NHS Commissioning Board and the Department of Health.

It’s believed that Easton will quit the public sector and take over as the managing director at Care UK, an independent private provider of health and social care.

The NHS CB confirmed that Mr Easton has “been approached” about a new role but could not comment further until the move has been approved in line with DH business rules.

Easton currently serves as the Director of Transition at the NHS Commissioning Board and as the DH’s National Director for Improvement and Efficiency.

In recent years Easton has played a pivotal role within the NHS. He has led the Quality, Improvement, Productivity and Prevention (QIPP) agenda since 2009. QIPP aims to help the NHS makes huge efficiency savings as part of the Nicholson Challenge. However, he recently criticised certain NHS organisations for using the QIPP agenda as a means of cutting costs without incorporating service redesign.

Before the move can be completed there is expected to be a series of negotiations and discussions around the timing of Easton’s departure. The switch also has to be formally agreed in line with rules governing the transfer of public sector staff to private companies.

“Because this would be an outside appointment, it is subject to approval in line with the business appointment rules for senior Department of Health staff moving to new roles in the independent sector,” said a Commissioning Board spokesperson.

“In Jim’s role at the Department of Health, as National Director for Improvement and Efficiency, the rules apply for a two year period after leaving. Therefore, we cannot say any more before an application to take up an outside appointment has been considered under those rules.”

Care UK were in negotiations earlier this year about a potential takeover at George Eliot Hospital in Nuneaton.

The NHS needs to involve the general public in making important decisions when managing their care and encourage greater interaction in their health and wellbeing, the NHS Confederation has said.

Mike Farrar, Chief Executive of the Confederation, said the NHS needs to go further to meet statements in its constitution to combat future challenges.

Farrar, writing in an editorial in The Guardian, said “NHS organisations need to do more to involve patients and the public” in how services are run.

The NHS Confed leader referred to the statement in the NHS Constitution that: the NHS belongs to the people.

But he admitted that the “daily reality for patients and the public” is somewhat different – and highlighted poor clinical practice and senior NHS leaders ignoring public opinion when making difficult decisions.

He said: “Take all this into account and you sense the NHS is a ‘public service’ with a long way to go.” Farrar added that the solution must change rapidly if the “NHS is to survive its next decade of challenges.”

Farrar pointed towards greater patient engagement in the future to obtain “faster and more sustainable results.” He said this was “business critical” if the NHS is to provide better standards of care and outcomes “for less money as healthcare demands grow”.

“There is no doubt that healthcare issues are complex,” he said. “But NHS managers and doctors do themselves no favours by their attitude of ‘arms around their work, no peeking’. We have to change.

“There is a huge need for more transparency, honesty and openness about why we need to modernise health services. There is an even bigger need for revealing to the public information about the economics, finances, and costs of health and social care.”

The NHS has billions of pounds which is being unused, according to a new report by the Audit Commission.

Research into the NHS’ financial year 2011/12 discovered there was nearly £4bn in ‘uncommitted finances” after PCTs, SHAs and NHS trusts restricted spending.

The NHS Confederation said the money should be given to CCGs across England to help transform local health services.

The report revealed NHS organisations had a combined under-spend and surplus of £1.6bn. However, the number of NHS trusts and foundation trusts in deficit increased from 13 in 2010/11 to 31 in 2011/12. A small number of trusts did report improved finances during the same period.

It also highlighted the financial difficulties NHS trusts have in different parts of the country. The majority of NHS trusts in deficit were either in London or around the south east.

Andy McKeon, Managing Director of Health at the Audit Commission, said the findings show there is “financial room for manoeuvre in the future.”

“The NHS has also delivered the first tranche of its £20bn savings required by 2014/15,” he said. “While nationally the NHS appears to be managing well financially, and preparing itself for the changes and challenges ahead, a number of PCTs and trusts are facing severe financial problems.

“The Department of Health and other relevant national authorities need to focus their attention on the minority of organisations whose financial position is deteriorating, and on their geographical distribution and service standards.”

Mike Farrar, NHS Confederation Chief Executive, said the funds should be used for “big investment in community and primary care” to ensure services can meet demand in the future.

“Fundamental changes to the way we provide care are necessary if the NHS is to maintain financial balance and become more responsive to patients’ needs,” he said. “Doing this will require some difficult decisions and in some cases will require changing or closing down some services, but this can only happen if we build up the capacity in the community and in primary care to enable people to be treated at home.”

New organisations formed as a result of the NHS reforms may cause conflicting policies and bundles of red-tape for the health service, Mike Farrar, NHS Confederation CEO, has warned.

Mr Farrar said the reforms would lead to several new bodies interfering with the day to day operation of the health service and result in a “tsunami of new bureaucracy”.

He added that new organisations will need to “minimise the burdens their policies place” on the NHS in order for it to “stay focused on patient care” and not on “repeatedly providing information in different formats to multiple bodies.”

Writing in an editorial for the Health Service Journal, the NHS Confed chief executive was responding to a survey of NHS chairs and CEOs. The survey found widespread concerns by NHS leaders as a result of the reforms.

Managers warned that widespread structural changes will result in a lack of senior experience and that savings targets are causing serious financial pressures.

Mr Farrar argued that the reforms are not a magic wand to improve performance and that expectations must be realistic. “Performance in many parts of the system will be patchy at first,” he said.

“Those leading the change need to be open-minded and flexible to improve policy and practice as we go. We are losing many experienced leaders.

“We need to ensure that as new ones emerge, taking on these challenges, they are given the support and cover they need to succeed, even if that means tolerating some difficulty along the way.”

The former SHA leader added that for new organisations to be successful they must listen to NHS leaders and focus on “critical overarching concerns that will matter most in the end”.

“It’s essential that national bodies ensure they are driving towards the same goals, not subjecting the NHS to a myriad of conflicting policies,” he said. “Otherwise the NHS will be pulled in different directions and unable to make progress.”

Health Minister Simon Burns insists the reforms remove layers of administration and will actually result in less bureaucracy for the NHS. “Our reforms mean that doctors and nurses will be in charge of the NHS, not managers,” he said. “It makes sense for the people that know their patients best, doctors and nurses, to take responsibility for driving up standards in their local NHS, free from bureaucratic interference.

“Careful work is underway now to ensure that new NHS bodies are prepared, but this is not affecting patient care. Waiting times are low, infection rates are down and patient satisfaction remains high.”

The NHS Confederation has called for greater levels of transparency in order to stop patients taking cash-strapped trusts to court over prescribing decisions.

David Stout, NHS Confed Chief Executive, said trusts need to be honest about the financial challenges they are facing to help patients understand why certain treatments approved by NICE are not prescribed.

He was responding to comments made by NICE chair Sir Michael Rawlins who claimed that patients should take trusts to court if they were being denied recommended medicines.

Mr Stout agreed that trusts should be providing treatments to patients they are “legally entitled to”. But he added that “every NHS organisation has a finite amount of money available” and that funding for new treatments means “fewer resources for other treatments”.

“NHS organisations are faced with the difficult challenge of achieving the best outcomes and highest quality care for patients while balancing their budgets,” he said.

“The issue raised by Sir Michael Rawlins leads us on to the wider debate that we need to have about the fact that the NHS is facing an unprecedented financial challenge. All NHS organisations are facing budgetary pressures while striving to maintain high quality care.

“We need to be open and honest with the public about what the consequences of this financial challenge are, and the fact that trade-offs will be required if we are to improve standards of care while keeping the NHS affordable.”

Labour plans to scrap the Government’s controversial NHS reforms if they win the next general election, Shadow Health Secretary Andy Burnham (pictured) has said.

Speaking in Parliament during a debate opposing the reforms, Mr Burnham insisted the changes open the door to privatisation within the NHS and undermine the health service in general.

He said that Labour will “repeal the bill” if elected claiming it to be a “defective, sub-optimal piece of legislation” that has left the NHS with a “complicated mess”.

The Shadow Health Secretary added that it would be “irresponsible” to leave the Health Act in place if Labour were elected and added that the “gap between ministers’ complacent statements and people’s real experience of the NHS gets wider every week”.

“They are in denial about the effects of their reorganisation in the real world, it is dangerous complacency and it can’t be allowed to continue.”

Health Minister Simon Burns countered Mr Burnham’s claims by reminding the Leigh MP that Labour leader Ed Miliband had previously said he would keep clinical commissioning in place if elected as prime minister.

But the former Health Secretary insisted “it’s not about the organisations, it’s about the services they provide”.

“The existing organisations can be asked to work differently, as I would ask them to work differently,” he said.

“I don’t want those NHS organisations in outright competition, hospital versus hospital. I want them working collaboratively.”

The NHS operating framework provides the blueprint for the NHS in England. Pf examines its objectives around quality and reform.

The Operating Framework for the NHS in England 2012/13 is an important document for UK medical sales professionals. It outlines the national priorities, system levers and mechanisms that the NHS in England must focus on to improve patient care. The strategic framework details expectations for the NHS’ ongoing efficiency challenge and the transition to the new commissioning and management system. It sets out the planning, performance and financial requirements for NHS organisations and the basis on which they will be held to account. With QIPP imperatives at the heart of the strategy, proactive pharmaceutical companies that can demonstrate an ability to help NHS customers deliver efficiencies and improve qualities in areas of national priority will be best placed to succeed.

The Framework identifies four key themes for NHS organisations in 2012/13:

1. Putting patients at the centre of decision making in preparing for an outcomes approach to service delivery
2. Completing the final year of transition to the new system
3. Accelerating the delivery of the QIPP challenge
4. Maintaining a strong grip on services and financial performance.

Quality - a focus on outcomes

The Operating Framework says that the NHS’ model of delivery must be overhauled in 2012/13 to become a system driven by quality and outcomes. It identifies the Outcomes Framework as the catalyst for this – with its focus on clinical outcomes and the reduction of health inequalities driving changes in culture, behaviour and service delivery. The Outcomes Framework sets out the improvements against which the NHS
Commissioning Board will be held to account from 2013/14.

These measurements are set out within 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 recover from episodes of ill health or following injury.

Domain 4: ensuring people have a positive experience of care.

Domain 5: treating and caring for people in a safe environment and protecting them from avoidable harm.

The Operating Framework details a range of indicators for each domain, all of which are explored in the NHS Outcomes Framework. These will be supported by NICE quality standards, which provide definitions of what high-quality care should look like for a particular pathway of care. The document also advises NHS organisations to meet the service specific outcomes strategies that have already been published in areas such as mental health, cancer, COPD, asthma and long-term conditions.

Each domain in the NHS Outcomes Framework has a strong relevance to pharma, whether through the development of medicines to treat disease in priority areas, or via collaborative service design to move care closer to patients’ homes and reduce hospital admissions. Organisations that are able to show how their innovations can improve a care pathway or be used as part of a redesigned service will enjoy
more positive NHS engagement.

The Operating Framework identifies dementia and care of older people as a key priority, and sets clear goals to integrate health and social care. It also highlights examples of initiatives where NHS organisations have successfully improved services in line with each of the four key elements of QIPP; quality, innovation, productivity and prevention.

Reform - the transition blueprint

The Operating Framework outlines the key milestones for the reorganisation of the NHS. Whilst the headlines are widely known, it is interesting to track current progress against a timetable that was set out many months before the Health & Social Care Act was passed. The Framework notes that by
the end of 2012/13:

“The NHS will have transformed the commissioning landscape into one focused on local clinical decision
making, with the development and authorisation of CCGs, assisted by commissioning support vehicles and overseen by the NHS Commissioning Board. Local authorities will take the lead role in public health, alongside the new Public Health England. Central to the new system will be the establishment of Health & Wellbeing Boards (HWB), who will provide local systems leadership across health, social care and public health. Alongside this, developments will continue to the provider landscape, through the extension of Any Qualified Provider (AQP), progress with the NHS Foundation Trust (FT) pipeline and the establishment of the new NHS Trust Development Authority.”

Key 2012/13 objectives in the transition are as follows:

• PCTs and SHAs will remain statutory organisations until April 2013. They will be held to account on delivering performance and support the development of new organisations for clinical leadership. Clinical Senates and networks will be established
• PCTs will support CCG authorisation and the transition of power before March 2013
• HWBs will be established in shadow format, becoming statutorily operational from April 2013. They will act as the local system leader through JSNA and HWB Strategies
• CCGs must be coterminous with a single HWB ‘as far as possible’
• CCGs must: play an active role in planning and budgeting, develop relationships with local partners
  including social care, deliver their share of the QIPP agenda and identify how to secure commissioning support services in line with their running cost allowance
• Public Health England will become a statutory executive agency from April 2013
• NHS Trusts are expected to achieve FT status by April 2014
• PCT clusters should start to offer patients choice of AQP in at least three services that are local priorities. There should be a presumption of choice for most services from 2013/14.

South London Healthcare may become the first NHS hospital trust to be declared bankrupt after accumulating debts of £69m.

Health Secretary Andrew Lansley has warned the trust that an administrator may be brought in to sort out its finances. The trust could also be dissolved and certain services closed as a result.

Mr Lansley said in a letter that he realises not all of the debts are the trust’s fault. However, he added that problems must be “tackled” and that “we are almost at this point”.

The trust merged three London hospitals in 2009: Princess Royal University Hospital in Orpington, Queen Mary’s Hospital in Sidcup, and the Queen Elizabeth Hospital in Woolwich.

When the three joined to form one organisation, the trust inherited a large debt through a private finance initiative (PFI) that had been used for the buildings at Orpington and Woolwich.

If the Health Secretary decides to disband the trust, it would not necessarily mean that all services would close as another NHS organisation or a private provider could take over responsibilities.

Government ministers are thought to be considering a deal which would see taxpayers taking over responsibility for the £2.5bn PFI contract.

But the option of emergency funding to reduce the deficit is not being considered in a move which ministers believe would allow other trusts to assume similar bailouts.

Mike Farrar, Chief Executive at the NHS Confederation, welcomed the move by the Health Secretary. “The NHS can’t go on with short-term fixes to financial problems,” he said. “That might mean some tough decisions, but hopefully will deliver financial sustainability in the long term.”

Chris Streather, Chief Executive of South London Healthcare, said talks were now ongoing with the Department of Health and NHS London to decide the “best future” for the trust.

“The most important thing is that the health needs of the local population are sorted out,” he said. “Over the last three and a half years since we have merged we have made an enormous amount of progress on quality of care.

“There is a huge gap in our financial plan in order for us to become viable in the long term and this intervention if it solves that problem which it is designed to do is absolutely welcome and will be helpful.”

A decision is expected on the future of South London Healthcare in the middle of July.