The Care Quality Commission (CQC) should use a ratings system like the Ofsted system for schools, according to a Government-commissioned expert report.

The new ratings system could be applied to GP practices and social care services within two years, and later to hospital services.

Think tank the Nuffield Trust emphasised that the system should be “sector-led” and allow input from patients, making it a key facilitator of patient choice.

This would not be a revival of the previous government’s ‘star ratings’ for hospitals, which were abolished in 2004 as being narrowly target-driven.

The BMA has praised the report’s commitment to appraisal of hospital services rather than entire hospitals.

The Nuffield Trust review, commissioned by Health Secretary Jeremy Hunt, said the CQC could develop the new ratings system given “stability from disruption over a period of time”.

There is “a clear gap” in the existing NHS performance appraisal system, the report said: no process exists to give patients clear information about the quality of available care providers.

Presenting the report, Nuffield Trust Chief Executive Jennifer Dixon (pictured) said ratings systems for GP practices and social care could be introduced within two years – but for hospital services, which would require individual department and clinical service ratings, more time would be needed.

The previous ‘star rating’ system for hospitals, used to help them qualify for Foundation Trust status, did not accurately reflect care quality, Dixon said.

The report emphasised that the new “sector-led” ratings system needed to be integrated with existing appraisal systems, and that the CQC would need support from other NHS stakeholders to develop and implement it.

Sources for the ratings could include QOF indicators (for general practice), hospital records, patient and staff surveys and inspections.

The UK medical professions have worked together to develop a strategy to address the national obesity crisis – the worst in Europe.

Two thirds of adults in the UK are now overweight and a quarter are clinically obese, the Academy of Medical Royal Colleges (AoMRC) has warned.

Professional training, weight management services, nutritional education and changes to the built environment are among the measures it recommends.

Obesity is a strong risk factor for diabetes, heart disease, musculoskeletal disorders and mental health problems.

The UK’s national health services should collectively invest £100m in weight management services modelled on the existing smoking cessation services, the AoMRC argues.

These should range from early intervention to bariatric surgery, with QOF incentives for GPs to refer patients to the relevant services.

Healthcare professionals should seek to “make every contact count” in influencing patient behaviour.

While most of the recommendations are related to patient lifestyles and the “obesogenic environment”, many medicines can impact on weight management – and vice versa.

While some measures, such as a ban on the advertising of junk food to children, are unlikely to be adopted by the Government, the prioritising of the obesity crisis within the NHS will influence many aspects of medical care.

Linda Hindle, Chairman of the Dietitians in Obesity Management group, said: “Obesity in the UK is an absolute epidemic, there is no question that the recommendations in this report are essential.”

The UK’s Quality and Outcomes Framework (QOF) has achieved slight improvements in the quality of primary care, according to a systematic review.

Introduced in 2004, QOF has reduced health inequalities and hospital admissions but made primary care less patient-centred.

The review recommended research into how to make such schemes effective across a wider range of medical domains affordably without negative effects.

Surveying 94 studies, the authors found that QOF accelerated improvements in quality of care for incentivised conditions during the first year – but there was a return to previous rates after that.

QOF was also found to have reduced the gap in medical outcomes between deprived and affluent areas, and to have driven slight reductions in mortality and hospital admissions for some conditions.

There was also evidence of improved data recording and clinical teamwork, and improved specialist nursing skills, due to QOF.

However, doctors and nurses agreed that patient-centred care was negatively affected by the QOF agenda.

The review concluded that similar pay-for-performance schemes should be introduced with caution in the future.

The new public health system must address the ‘clustering’ of risk behaviours in order to prevent health inequalities widening, according to the King’s Fund.

While the overall prevalence of ‘unhealthy behaviours’ in terms of smoking, drinking, diet and exercise has fallen, their coincidence has increased in more deprived populations.

The think tank recommends that ‘multiple lifestyle risks’ should be added to the public health outcomes and QOF frameworks.

The study focused on the prevalence of four ‘unhealthy behaviours’ stated by the WHO to be responsible for nearly half of disease incidence in developed countries: smoking, alcohol abuse, poor diet and lack of exercise.

It found that the overall proportion of the English population that engaged in three or four risk behaviours declined from 33% in 2003 to 25% in 2008.

However, people with no educational qualifications were five times as likely to engage in all four behaviours as those with higher education in 2008, compared with only three times as likely in 2003.

The study argued that public health policies which had benefited the population as a whole had increased health inequalities, due to a ‘silo’ approach that had not linked public health initiatives to measures targeting health inequalities. It noted that the current Government has pursued a similar approach.

Public health policy, it argued, needs to recognise that the combinations of health risks affecting people differ systematically between social groups.

The authors recommended the DH “should seriously consider” adding “multiple lifestyle risks” to the public health outcomes framework as an indicator.

This could be reinforced, they said, by using the QOF to reward GPs for successful interventions where patients have multiple lifestyle risks; and this principle could be carried into the tariff for commissioning.

Financial performance related schemes do not motivate GPs and result in a drop in standards of primary care, researchers claim.

Professor Steffie Wollhandler from the New York School of Public Health warns that financially related systems are based on “flawed assumptions” about medicine, measurement and motivation.

She added that providing financial rewards for hitting set targets “changes the mindset needed for good doctoring”.

The DH’s Quality Outcomes Framework currently rewards doctors who hit set targets. But Professor Wollhandler said that while more “straightforward manual tasks” are completed, complex cognitive tasks are overlooked.

“A growing body of evidence from behavioural economics and social psychology indicates that rewards can undermine motivation and worsen performance on complex cognitive tasks, especially when motivation is high to begin with,” said Professor Wollhandler in an editorial with the BMJ.

“Highly detailed prescriptive contracts may be perceived as controlling and may undermine the intrinsic motivation crucial to maintaining quality when nobody is looking.

“Offering financial incentives to doctors, rather than enhancing their intrinsic motivation, may reduce their desire to perform an activity for its inherent rewards (such as pride in excellent work, empathy with patients).”

The General Practitioners Committee (GPC) has questioned the move to create a composite indicator for diabetes believing it may have an adverse affect on patient care.

Measures to conduct nine separate checks in each diabetes patient will demotivate doctors, lead to increased referral rates and infringe on rights to refuse treatment, the GPC warns.

Dr Laurence Buckman, GPC chair, said in a letter to NHS Medical Director Sir Bruce Keogh that a single indicator may lead to “unintended consequences”.

The Department of Health recently asked NICE to consider a composite indicator for inclusion in the Quality Outcomes Framework (QOF) after an investigation found only half of patients received the nine existing separate checks.

But the GPC argues that if the new indicator were to be introduced it would “have consequences”, especially where patients did not wish to engage in specific checks or attend altogether.

“A composite indicator that defunded practices of the whole quantum of diabetic QOF funding – designed to fund the process, not just the outcomes – risks demotivating practices completely and would almost certainly have the unintended consequence of increasing diabetic referrals,” said Dr Buckman.

He added that a “regimented tick-box check” would be “extremely counterproductive”.

But Sir Bruce responded by defending the switch. “The QOF is currently not incentivising practices to increase the number of their patients who receive all nine care processes that are the hallmark of good diabetic care delivered to patients,” he said. “If one or two are missed, patients are not getting the care they should receive.”

NICE has proposed 16 new indicators for inclusion in the 2013/14 Quality and Outcomes Framework (QOF) and rheumatoid arthritis (RA) as a new clinical area.

The recommendations include four for RA, two for men with diabetes, plus indicators for COPD rehabilitation and hypertension.

Dr Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said the potential indicators “can make a real difference” to improve standards of care.

QOF is a voluntary incentive scheme that rewards GPs for implementing systematic improvements in care for patients. It operates through a points system which rewards doctors for their performance against the indicators.

Indicators for RA include GP practices creating a register of patients aged over 16, and patients being assessed for cardiovascular risk and fracture risk.

In men with diabetes, indicators focus on offering advice on erectile dysfunction and on available treatment options.

The final ‘menu’ of indicators will be decided by NHS Employers and the British Medical Association later this year.

Children’s healthcare in England needs to be more integrated, timely and focused on individual needs, the Children and Young People’s Health Outcomes Forum has said.

The Forum’s recommendations, proposed as the basis of a national strategy, include a strong emphasis on pharmacovigilance and avoiding the use of off-label medications.

Other key recommendations relate to the goal of “joined up” care, seeking to address gaps in the consistency and continuity of children’s healthcare.

The report describes the view that children in England are well cared for as “sentimental and complacent”, and states: “the UK is worse than other countries in Europe for many outcomes that could be improved through better healthcare and preventative interventions”.

To address this situation, the report argues, it is vital for children and young people to be more involved in decisions about their care; for GPs and other clinical staff to have better training in paediatric care; and for healthcare to meet the changing needs of the young individual over time.

Four new outcome indicators are proposed:

• time from first NHS presentation to diagnosis or start of treatment

• integrated care – developing a new composite measure

• effective transition from children’s to adult services

• age-appropriate services, with particular reference to teenagers.

More generally, the report recommends that all NHS organisations “should take a life-course approach, coherently addressing the different stages in life and the key transitions instead of tackling individual risk factors in isolation”.

It also calls for better systems to allow sharing of information between care providers in different sectors, with “sentinel conditions and pathways” being selected to help identify “gaps in services, including prevention”.

The report notes high levels of medication error and use of off-label or unlicensed medications with children, and calls on the MHRA to prioritise these issues “in line with the new EU legislation effective in July 2012”.

To improve the evidence base for healthcare, it recommends breaking down health data for the first two decades of life into five-year age bands.

To improve clinical leadership, it says, the NHS Commissioning Board should appoint a National Clinical Director and CCGs should appoint a senior clinical lead in this area.

Finally, it recommends that the QOF and PbR systems for child healthcare should be developed and improved.

A single diabetes indicator will be created for the Quality Outcomes Framework (QOF) by the DH after an investigation found only half of patients received the nine existing separate checks.

Findings from the National Diabetes Audit for 2010/11 suggest that suspected diabetes patients are not being thoroughly checked for the condition by GPs.

Sir Bruce Keogh (pictured), NHS Medical Director, has written to NICE asking it to replace the current QOF indicators with a “composite indicator measuring the proportion of patients who received all nine of the processes”.

In the letter, Sir Bruce also called for the Institute to review the range of “target measurements and associated payment thresholds”.

“We hope to work together (with NICE) and with the BMA and other stakeholders to improve the QOF and support ongoing improvements in quality and outcomes for patients,” said a DH spokesperson.

The new indicator – which would be worth more than £5,000 – could be included in the 2015 framework.

The General Practitioners Committee (GPC) filed a complaint over the data used in the audit. The DH has now launched an investigation into the complaint with the outcome expected in September.

A local information strategy is key to successful account management. The data is out there. Rhiannon Thomason explains how turning information into insight is all about context.

Despite reforms that appear to encourage decision-making and accountability at a local level, the UK health service remains a national one. The Health & Social Care Act actually strengthens the centralised power-base and, via the NHS Commissioning Board, issues a series of top-down directives that will cascade to a local level for implementation. Rumours of the death of the ‘N’ in our NHS are grossly exaggerated. But for Key Account Managers across the UK pharma industry, what happens at a local level is perhaps the prime focus. There is much talk of the need for ‘local health intelligence’. It is indeed a vital commodity. But it is important to draw the distinction between information and insight. The former is readily available. The latter is hard won and impossible to achieve in isolation. In the battle for local health intelligence, context is King.

The NHS is awash with data. Nowadays there is much more information available and the health service itself is increasingly placing useful data into the public domain. Examples such as QOF data, Joint Strategic Needs Assessments, HES (Hospital Episode Statistics) data, the Atlas of Variation and Public Health observatories provide a rich seam of information from which sales and marketing professionals can develop appropriate local messages. They combine to form a complex matrix of information. The challenge for KAMs is interpreting it and understanding what it means in their disease area and in their locality. There is variation right across the system.

In primary care, QOF data has become increasingly important. NHS customers are being tasked to reduce unnecessary hospital admissions, and the financial incentives from a local practice perspective are significant. But as the transition towards Clinical Commissioning Groups continues, practices know that they cannot work in isolation and that they must prove to the wider organisation that they are achieving their targets.

For the industry, QOF indicators have become a catalyst for improved customer engagement. Proactive sales professionals are no longer targeting GPs with messages based only on the clinical benefits of their products. They are instead identifying key local decision-makers and attempting to demonstrate how their product can impact a service, reduce hospital admissions, save a locality money and improve patient care.

Clearly, QOF data has become a strong lever for account managers to understand how their product can help customers meet their targets. In isolation however, the data can only take you so far.

When used in combination with other available information, a much more powerful package of metrics can emerge.

Sales professionals need to build the bigger picture of what is going on at a local level, to understand how their products can make a difference. This depends upon drawing together all the various strands of information, and developing value propositions based on the local context as a whole.

• How is each local health economy constructed? Which organizations are operating within each locality? What are the roles/responsibilities of each and how do they engage with one another? Who are the key stakeholders?
• What is the community profile? How many patients are there? What are the deprivation and ethnicity breakdowns?
• What is the patient pathway? What services are provided, by whom and how are patients managed?
• What is the cost of hospital activity? How much does each group of patients cost each locality?
• What are the outcomes? How much is each locality spending and how well are they managing each group of patients? How can the outcomes be measured?

The trick for pharma is to be able to use all of this information intelligently, in combination. Much of it is publically available, but without the knowledge and understanding of how it translates into what you are trying to achieve, it could, in a worse case scenario, send the sales professional in the wrong direction.

Variation in care
In a complex environment where context is everything, it is important not to lose sight of the bigger picture on a national scale. Many of the challenges being faced by local commissioners on the ground are around the treatment of diseases identified as national priorities. The implementation of commissioning plans at a local level largely cascades down from the key domains laid out in the NHS Outcomes Framework. The challenges manifest themselves in the local variations in care that are widely highlighted as being in need of redress. Once again, these local variations – if intelligently assessed – provide pharmaceutical companies with a powerful market access opportunity. Companies that can demonstrate that their products, not just their messaging, are aligned with local need will significantly increase their chances of uptake.
A good example of how the national agenda is driven by addressing variation in care at local level, is the treatment of diabetes.

Diabetes – a mini case study
The national picture
An estimated 3.8 million people in England have diabetes, with 2.45 million QOF registered patients. This is forecast to rise to 4.6 million by 2030. Diabetes and its complications costs the NHS around 10% of its annual spend. £725 million a year is spent on diabetes medication (8.4% of NHS drugs spend), and an additional £600 million is spent on diabetes-related hospital activity. An estimated 80% of the NHS’s £9.8 billion UK diabetes bill is spent on treating diabetes complications. It is predicted that diabetes will cost the NHS £16.8 billion by 2035.

National and local initiatives
As part of QOF, practices are to be encouraged to provide lifestyle advice and annual glucose checks to everyone judged as high risk from the age of 25 – even those with normal HbA1c levels. NICE is piloting new QOF indicators that promote tight cholesterol control in diabetes.
The introduction of insulin pumps instead of injections, as well as educational programmes such as the DAFNE (Dose Adjustment For Normal Eating) course are good examples of local initiatives to combat diabetes.

Local variation
NHS Hampshire has the highest number of diabetes patients on the QOF register (54, 761). Hospital admissions (inpatient, outpatient and emergency attendances) are costing NHS Hampshire £3.7 million each year – one of the highest of all PCTs. However, its cost per thousand patients is low – ranking 113 of all PCTs. It also has the lowest death rates from diabetes. Therefore, although it has the highest number of diabetes patients, NHS Hampshire appears to be managing its patients well.

NHS Kingston has one of the highest diabetes spend per thousand patients in England. Compared to other PCTs in its SHA, it also has a higher number of Finished Consultant Episodes, longer lengths of stay, higher emergency admissions and the lowest elective admissions. Compared to NHS Hampshire, this suggests  that NHS Kingston could be managing its diabetes patients more optimally.

Lessons for pharma
The diabetes example outlined above provides a clear indication that a one-size-fits-all approach to pharmaceutical sales and marketing will no longer work. The apparent variation in care between two diverse PCTs highlights that every local health economy has different needs. A diabetes KAM working in Hampshire could not relocate to Kingston and challenge stakeholders there in the same way, with the same proposition. The situation, and the opportunity, in each PCT/CCG is totally different. The ensuing approach must be similarly distinct.

A local information strategy is critical for Key Account Managers engaging with today’s NHS. Understanding local dynamics is critical, and the information to facilitate this is increasingly within reach. The key is joining it all together and placing everything in context. It’s a mixture of local and national. Top-down directives issued at national level are providing important indicators by which local commissioners are measured, and are in turn are becoming powerful levers to help pharma develop value propositions that align with local need.

The data is out there. But success is in understanding the difference between information and insight. After all, context is King.

Rhiannon Thomason is Business Development Manager, Cegedim Relationship Management.