Should pay-for-performance schemes be locally designed? evidence from the commissioning for quality and innovation (CQUIN) framework.

Objectives: It is increasingly recognized that the design characteristics of pay-for-performance schemes are importantin determining their impact. One important but under-studied design aspect is the extent to which pay-for-performanceschemes reflect local priorities. The English Department of Health White Paper High Quality Care for All introduced aCommissioning for Quality and Innovation (CQUIN) Framework from April 2009, under which local commissioners andproviders were required to negotiate and implement an annual pay-for-performance scheme. In 2010/2011, theseschemes covered 1.5% (£1.0bn) of NHS expenditure. Local design was intended to offer flexibility to local prioritiesand generate local enthusiasm, while retaining good design properties of focusing on outcomes and processes witha clear link to quality, using established indicators where possible, and covering three key domains of quality (safety;effectiveness; patient experience) and innovation. We assess the extent to which local design achieved these objectives.Methods: Quantitative analysis of 337 locally negotiated CQUIN schemes in 2010/2011, along with qualitative analysisof 373 meetings (comprising 800 hours of observation) and 230 formal interviews (audio-recorded and transcribedverbatim) with NHS staff in 12 case study sites.Results: The local development process was successful in identifying variation in local needs and priorities for qualityimprovement but the involvement of frontline clinical staff was insufficient to generate local enthusiasm around theschemes. The schemes did not in general live up to the requirements set by the Department of Health to ensure thatlocal schemes addressed the original objectives for the CQUIN framework.Conclusions: While there is clearly an important case for local strategic and clinical input into the design of pay-forperformanceschemes, this should be kept separate from the technical design process, which involves defining indicators,agreeing thresholds, and setting prices. These tasks require expertise that is unlikely to exist in each locality. The CQUINframework potentially offered an opportunity to learn how technical design influenced outcome but due to the highdegree of local experimentation and little systematic collection of key variables, it is difficult to derive lessons from thisunstructured experiment about the impact and importance of different technical design factors on the effectiveness ofpay-for-performance. Balancing the policy goal of localism with the objective of improving patient outcomes leads us toconclude that a somewhat firmer national framework would be preferable to a fully locally designed framework. [ABSTRACT FROM AUTHOR]