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The missing link?

Commissioning for Quality and Innovation (CQUIN) can be linked to activity that can increase prescribing opportunities

Many of the barriers to the uptake of your product lie in the services set up to support patients in its disease area. Could The Commissioning for Quality and Innovation (CQUIN) provide you with the perfect opportunity to break down those barriers and align with your customers' agenda? Critically, could it encourage the NHS to generate data that may ultimately unlock market access for your brand?

What is it?
CQUIN payment framework is a national framework for locally agreed quality improvement schemes. In essence, it is a kind of performance-related pay for NHS providers – making a proportion of provider income conditional on the achievement of ambitious quality improvement goals agreed between commissioners and providers.

Designed to support the NHS' quality, innovation, prevention and productivity (QIPP) agenda, CQUIN was first introduced as part of the previous administration's High Quality Care for All blueprint, the centrepiece of the Darzi Review. It has been maintained as an important aspect of the latest NHS reforms, outlined in the recent White Paper Liberating the NHS.

The CQUIN framework is intended to reward innovation and improve quality and performance within the NHS. To earn CQUIN money, a range of providers must agree full CQUIN schemes with commissioners. Currently, CQUIN schemes cover the following providers:
•    Acute
•    Ambulatory
•    Community
•    Mental health and learning disability services.

The payment framework applies to all services covered by national standard contracts in 2010/11, which as well as the above, could also include independent sector providers and Foundation Trusts on national standard contracts.

The Department of Health (DH) defines 'quality' as 'Safety + Effectiveness + Patient Experience' – and all three elements are regarded as equally important. As such, CQUIN schemes are required to include goals in each of the three quality domains, and to reflect innovation.

A CQUIN scheme comprises the agreed package of goals and indicators. Achievement of these will enable a provider to earn its full CQUIN payment – which in 2010/11 totals 1.5 per cent of contract value. Primary Care Trusts (PCTs) are required to make the additional 1.5 per cent funding available from their 2010/11 allocations – with CQUIN payments being in addition to the contract value. Conversely, failure to meet the goals enables commissioners to 'top-slice' 1.5 per cent of the contract value – ie, claw it back – in recognition that quality indicators have not been achieved. CQUIN goals are agreed between provider and commissioner – and reflect both local and national priorities, as set out in the NHS Operating Framework. Goals must be measurable, using defined indicators. Schemes must set out clearly how and when goals will be measured, the threshold payment against each indicator and any rules for the 'partial achievement' of the indicator. Where national indicators already exist, commissioners are encouraged to consider these when setting benchmarks.

In 2010/11, CQUIN schemes for acute providers must include two specified national goals on venous thromboemolism (VTE) and improving responsiveness to personal needs of patients. Agreed goals across all schemes must be 'ambitious' and must not duplicate specific minimum expectations of providers set out in existing agreements.

CQUIN schemes can be used to address variations in provider performance – and to incentivise changes across care pathways and between organisations. The DH hopes that this will facilitate efficiencies across the health economy, generating improvements in prevention, patient focus and productivity.

Commissioners are required to align local CQUIN schemes with wider commissioning intentions and priorities, to ensure that locally agreed goals are well targeted at the areas in most need of improvement.

What does this mean for pharma?
CQUIN could provide leverage for pharma marketers to engage with customers in a manner very different from traditional methodology. If your brand fits, or could fit, in an area where a CQUIN scheme may be appropriate, there could be much mutual benefit for NHS/industry collaboration.

Successful CQUIN schemes will be dependent upon generating quality data so that the burden of disease can be understood, and efficient, innovative services that deliver high quality patient outcomes can be built. For marketers, it is often this kind of data that can remove barriers to market access for their product and unlock true market potential. The key is to present a case so that the NHS recognises the value of the data in helping it meet CQUIN objectives, and gathers and records it for you. If the data demonstrates a burden of disease in an area where your brand can make a positive difference, you will not only have helped the NHS improve its service, but will have also removed a barrier restricted market access for your product.

The CQUIN opportunity
The NHS Institute for Innovation and Improvement has a repository of all the CQUIN schemes introduced since the Framework went live in 2009/10.

The earliest CQUIN schemes centred around the acute sector, but increasingly they are now being applied to community services. This presents a major opportunity for pharma to play a role in areas where it has traditionally had strong spheres of influence.

A glance at the latest CQUIN schemes provides little evidence to suggest that drug companies are seizing the opportunity. But proactive marketers should be able to identify schemes where CQUIN can be linked to activity that can increase prescribing opportunities for products. There are at least three key areas, around community services, where pharma may be able to leverage CQUIN not only to help providers hit their targets, but also to drive competitive brand advantage.

1. Help providers meet CQUIN patient satisfaction targets
A number of current CQUIN schemes in community services set out to measure improvements in patient satisfaction. Examples include schemes for smoking cessation, continence care, mental health and contraceptive services. Can you link your product with improvements in patient satisfaction? For instance, if your drug improves outcomes in smoking cessation – ie, patients stop smoking – patients are going to rate the service highly. Likewise, in continence care or mental health, where newer drugs have fewer side effects, compliance may improve and, with it, health outcomes. As a consequence, patient satisfaction will be high – and providers are more likely to meet CQUIN targets.

2. Using an existing scheme to drive access to your product  
There are clear opportunities for pharma companies to partner with providers to help them meet existing CQUIN objectives – and in the process, increase prescribing opportunities for their drugs.

In Dudley PCT, a community services CQUIN sets out to target health visitors to record the smoking status of parents/carers, to raise awareness of its smoking cessation service. A proactive pharma company could, for instance, work with the health visitors to target young mums at drop-in centres, promote the cessation service and capture a new potential patient group. This could help increase market share and improve provider quality.

A CQUIN in Coventry sets out to develop and implement a local dementia pathway. This presents an opportunity for pharma companies working within dementia to ensure that prescribing opportunities and the evaluation of patients are considered in that pathway.

In Somerset, a community health CQUIN is tasked with developing PROMs for a musculoskeletal service. This gives pharma the chance to ensure the service reflects the patient benefits your drug might deliver; reduced constipation or reduced sedation.

3. Work with a service to amend a CQUIN where an existing scheme is not delivering quality
The NHS needs to be clever about the metrics it uses to measure quality, but doesn't always get it right. This is another area where industry can help. For example, a recent CQUIN sets out ambitious plans for a continence service whereby every home visit must occur within two working days. The local area has over 150 nursing homes, but the continence service responsible for making all the visits has not been given additional resources to carry them out. As a consequence, the number of staff available to undertake work in the clinic has reduced significantly. Visits to the clinic have reduced by 20 per cent and waiting lists have increased.

In this case, the CQUIN is actually driving poorer quality. Here, industry could work with the continence service to identify more effective and innovative ways of managing patients in nursing homes; perhaps setting up wholesale reviews of all the patients at individual nursing homes in one go, rather than reactively chasing individual patients. Industry can work with the NHS to challenge and change CQUINs when they are not working.

There are many opportunities for marketers to drive competitive advantage by leveraging CQUIN. Marketers would benefit from examining current and imminent schemes and asking:
1. Is there a general opportunity?
2. Is there a specific opportunity?
3. Is there a threat that can be turned into an opportunity?

The clues are out there. All that is required is the ability to be proactive and creative.

The NHS Institute for Innovation and Improvement has examples of CQUIN schemes in community services.

The above approach is not regarded as promotional activity – there is nothing involved that is directly about a product. Success is about understanding the environment, understanding the barriers and putting yourself in a position where you can use data to leverage a product in the future. It relies upon getting the NHS to consider that the outcomes you are interested in are the same ones that they want to deliver. It's about getting on each other's agenda. CQUIN could be a great platform for achieving just that.

A marketer's step guide to making CQUIN work

• Think beyond your product, and about the services it will sit within
• Look at the barriers along the patient pathway – how can you overcome them?
• Consider whether more data will help overcome those barriers
• If it would, how could you get that data recorded?
• Could CQUIN provide you with a lever to get the data recorded?
• Build a business case that demonstrates how what you propose will help the NHS meet a CQUIN goal
• Be prepared to present the business case to senior, executive board management within PCTs or SHAs

The Author
Andy Lee, Commissioning & NHS partnerships director, at WG Group

To comment on this article, email

2nd March 2011

From: Healthcare


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