Title: Effectiveness and Value for Money of Prescribed Specialised Services Commissioning for Quality and Innovation (CQUIN) interventions 2016/17 to 2018/19
Funder: Department of Health and Social Care

Abstract: Background Financial incentives have been widely introduced into the English NHS to improve the quality of healthcare. However, evidence of the effectiveness of those incentive programmes is limited (Mendelson et al., 2017). Furthermore, it is not clear whether these incentive programmes offer a cost-effective use of resources (Meacock et al., 2014b). PSS CQUIN was introduced in April 2016 with the aim of improving the quality of hospital services for specialised care. It is important for policy makers to understand whether the significant investment they have made is cost-effective, what determines the cost-effectiveness, and what lessons can be generalised to inform other financial incentive payment schemes. Aims The research aims of this project are twofold. First, an analysis will estimate the determinants of the effectiveness of the PSS CQUIN programme in order to inform the design of polices to incentivise the quality of care in the context of the English NHS. Second, cost-effectiveness analyses of specific CQUIN schemes will identify whether and how PSS CQUIN quality innovations should be supported. Research Plan A systematic literature review will be conducted in order to provide a synthesis of the evidence base with respect to the design (and if available the effectiveness) of incentive schemes. An economic framework will inform the empirical analysis with respect to the effectiveness of the programme and its determinants. The programme s quasi-experimental design provides an opportunity to compare the changes in performance between NHS providers that are (1) eligible for a scheme and participating in the scheme, and (2) eligible for a scheme but are not participating. Statistical analyses will be utilised to control for the non-compulsory participation. The cost-effectiveness of each scheme, measured using cost per quality-adjusted life years (QALYs) gained and/or monetary benefits, will be estimated. We will make comparisons across schemes and with other incentive programmes. The analysis will apply the analytical framework developed by Meacock et al. (2014b), based on NICE guidance for health technology assessments. The team will conduct interviews with the local NHS commissioners and healthcare providers to identify challenges and/or issues in implementation, and to explore the benefits to patients/service users. Research Team The project is a collaboration between the Office of Health Economics, the Manchester Centre for Health Economics and the Department of Economics at the University of York. The team has extensive experience in designing and evaluating financial incentives for healthcare providers. They have previously developed a methodological framework to evaluate the cost-effectiveness of financial incentives for healthcare and have significant expertise in the econometric analysis of administrative healthcare datasets. Some team members were part of the evaluation project for the original CQUIN programme. The research team will engage regularly with stakeholders: NHS England, local arms of NHS England, NHS Trusts and patients. We will produce and distribute a quarterly newsletter detailing progress to date, and each stakeholder will have a representation on the advisory group where analyses and results will be discussed in detail. Potential Impact The findings from this project will provide evidence for NHS England to understand how to operate financial quality incentive schemes in the context of commissioning specialised services, and specifically which PSS CQUIN innovations should be supported for possible mainstreaming or incorporation into service specifications. This information will be vital for NHS England in their preparations for the PSS CQUIN contracts in 2019/2020 and beyond. The comparison of the cost-effectiveness of the PSS CQUIN schemes with other quality incentive schemes, such as Best Practice Tariffs, will provide information about the efficiency of healthcare resource allocation. Additionally this project will provide generalisable knowledge about how to design financial incentives within public healthcare systems.

Lay abstract: Background NHS England introduced PSS CQUIN schemes in 2016. The primary aim of this incentive programme is to improve the healthcare quality of specialised services in NHS hospitals. NHS England intend to allocate &pound;900 million to this programme between April 2016 and March 2019. It is therefore important to understand the efficiency of this significant investment. Aims This project aims to explore: How best to operate financial quality incentive schemes such as CQUIN in the context of NHS England commissioning specialised services, and Whether, and if so how, the PSS CQUIN innovations can be supported for possible mainstreaming or incorporation into service specifications. Design and Methodology A systematic literature review will be conducted to offer insights on the design of incentive schemes in health care. A theoretical framework will be developed which incorporates the key characteristics of the PSS CQUIN. Hypotheses will be developed, e.g. how NHS providers are expected to change their performance as the result of the incentive programme; what are the possible unintended consequences of introducing these innovations. Statistical methods will be used to test the hypotheses. The statistical analyses will evaluate the effectiveness of the PSS CQUIN incentives for one scheme by comparing the changes in performance between NHS providers that are (1) eligible for a scheme and participating in the scheme and (2) eligible for a scheme but did not participate. The costs and cost-effectiveness for each PSS CQUIN scheme will be assessed. Comparisons will be made between schemes within the PSS CQUIN programme and with other quality incentive schemes for healthcare providers in the English NHS. The team will conduct interviews with the local NHS commissioners and healthcare providers to understand the various approaches to (and challenges of) implementing the schemes and the benefits to patients/service users. Patient and public involvement Patient representatives from Clinical Reference Groups under the six National Programmes of Care for the specialised services commissioned by NHS England will be invited to join our advisory group. The advisory group will be asked to offer feedback on all aspects of the study design, analysis, reporting and dissemination activities.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE