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Background: A Pay-for-Performance (P4P) programme, known as Prescribed Specialised Services Commissioning for Quality and Innovation (PSS CQUIN), was introduced for specialised services in the English NHS in 2013/2014. These services treat patients with rare and complex conditions. We evaluate the implementation of PSS CQUIN contracts between 2016/2017 and 2018/2019. Methods: We used a mixed methods evaluative approach. In the quantitative analysis, we used a difference-in-differences design to evaluate the effectiveness of ten PSS CQUIN schemes across a range of targeted outcomes. Potential selection bias was addressed using propensity score matching. We also estimated impacts on costs by scheme and financial year. In the qualitative analysis, we conducted semi-structured interviews and focus group discussions to gain insights into the complexities of contract design and programme implementation. Qualitative data analysis was based on the constant comparative method, inductively generating themes. Results: The ten PSS CQUIN schemes had limited impact on the targeted outcomes. A statistically significant improvement was found for only one scheme: in the clinical area of trauma, the incentive scheme increased the probability of being discharged from Adult Critical Care within four hours of being clinically ready by 7%. The limited impact may be due to the size of the incentive payments, the complexity of the schemes' design, and issues around ownership, contracting and flexibility. Conclusion: The PSS CQUIN schemes had little or no impact on quality improvements in specialised services. Future P4P programmes in healthcare could benefit from lessons learnt from this study on incentive design and programme implementation. [ABSTRACT FROM AUTHOR]

Introduction: Individuals with Long Covid represent a new and growing patient population. In England, fewer than 90 Long Covid clinics deliver assessment and treatment informed by NICE guidelines. However, a paucity of clinical trials or longitudinal cohort studies means that the epidemiology, clinical trajectory, healthcare utilisation and effectiveness of current Long Covid care are poorly documented, and that neither evidence-based treatments nor rehabilitation strategies exist. In addition, and in part due to pre-pandemic health inequalities, access to referral and care varies, and patient experience of the Long Covid care pathways can be poor. In a mixed methods study, we therefore aim to: (1) describe the usual healthcare, outcomes and resource utilisation of individuals with Long Covid; (2) assess the extent of inequalities in access to Long Covid care, and specifically to understand Long Covid patients' experiences of stigma and discrimination. Methods and analysis: A mixed methods study will address our aims. Qualitative data collection from patients and health professionals will be achieved through surveys, interviews and focus group discussions, to understand their experience and document the function of clinics. A patient cohort study will provide an understanding of outcomes and costs of care. Accessible data will be further analysed to understand the nature of Long Covid, and the care received. Ethics and dissemination: Ethical approval was obtained from South Central—Berkshire Research Ethics Committee (reference 303958). The dissemination plan will be decided by the patient and public involvement and engagement (PPIE) group members and study Co-Is, but will target 1) policy makers, and those responsible for commissioning and delivering Long Covid services, 2) patients and the public, and 3) academics. [ABSTRACT FROM AUTHOR]

Background Several countries paused their rollouts of the Oxford-AstraZeneca coronavirus disease-19 (COVID-19) vaccine in mid-March 2021 due to concerns about vaccine-induced thrombosis and thrombocytopenia. Many warned that this risked damaging public confidence during a critical period of pandemic response. This study investigated whether the pause in the use of the Oxford-AstraZeneca vaccine had an impact on subsequent vaccine uptake in European countries. Methods We used a difference-in-differences approach capitalizing on the fact that some countries halted their rollouts whilst others did not. A longitudinal panel was constructed for European Economic Area countries spanning 15 weeks in early 2021. Media reports were used to identify countries that paused the Oxford-AstraZeneca vaccine and the timing of this. Data on vaccine uptake were available through the European Centre for Disease Control and Prevention COVID-19 Vaccine Tracker. Difference-in-differences linear regression models controlled for key confounders that could influence vaccine uptake, and country and week fixed effects. Further models and robustness checks were performed. Results The panel included 28 countries, with 19 in the intervention group and 9 in the control group. Pausing the Oxford-AstraZeneca vaccine was associated with a 0.52% decrease in uptake for the first dose of a COVID-19 vaccine and a 1.49% decrease in the uptake for both doses, comparing countries that paused to those that did not. These estimates are not statistically significant (P  = 0.86 and 0.39, respectively). For the Oxford-AstraZeneca vaccine only, the pause was associated with a 0.56% increase in uptake for the first dose and a 0.07% decrease in uptake for both doses. These estimates are also not statistically significant (P  = 0.56 and 0.51, respectively). All our findings are robust to sensitivity analyses. Conclusions As new COVID-19 vaccines emerge, regulators should be cautious to deviate from usual protocols if further investigation on clinical or epidemiological grounds is warranted. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the impact of offering a free nicotine replacement therapy (NRT) and different levels to telephone support via an English national telephone quitline on the smokking cessation rates. The study has conducted a parallel randomised controlled trial involving 2591 non-pregnant smokers aged 16 and above. It is found out that 17.7% of those provided with NRT have stopped smoking while 18.2% of those offered counselling have reported smoking cessation.

Background: Uncertainty about the benefits new cancer medicines will deliver in clinical practice risks delaying patient access to new treatment options in countries such as England, where the cost effectiveness of new medicines affects reimbursement decisions. Outcome-based payment (OBP) schemes, whereby the price paid for the drug is linked to patients' real-world treatment outcome(s) has been put forward as a mechanism to accelerate access. Although OBP schemes have generally focused on clinical outcomes to determine reimbursement, the degree to which these represent the outcomes that are important to patients is unclear., Objective: To advance the application of OBP we ask, what outcomes do patients with cancer value (most) that might form a practical basis for OBP?, Methods: A review of the literature on outcomes in cancer produced a long list of candidates. These were evaluated in a focus group with patients with cancer and were then, in a second focus group, distilled to a shortlist of ten outcomes using a card sort method. The ten outcomes were included in an online survey of patients with cancer and carers, who were asked to rank the importance of each outcome., Results: The focus groups identified a range of both clinical and functional outcomes that are important to patients. Analyses of the 164 survey responses suggested that the four most important outcomes to patients and carers are survival; progression, relapse or recurrence; post-treatment side effects; and return to normal activities of daily life., Conclusion: Commissioners of cancer services wishing to instigate an OBP scheme should prioritise collecting data on these outcomes as they are important to patients. Of these, only mortality data are routinely collected within the national health service (NHS). Progression and some morbidity data exist but are not currently linked, creating a challenge for OBP.

Pay-for-Performance (P4P) schemes have become increasingly common internationally, yet evidence of their effectiveness remains ambiguous. P4P has been widely used in England for over a decade both in primary and secondary care. A prominent P4P programme in secondary care is the Commissioning for Quality and Innovation (CQUIN) framework. The most recent addition to this framework is Prescribed Specialised Services (PSS) CQUIN, introduced into the NHS in England in 2013. This study offers a review and critique of the PSS CQUIN scheme for specialised care. A key feature of PSS CQUIN is that whilst it is centrally developed, performance targets are agreed locally. This means that there is variation across providers in the schemes selected from the national menu, the achievement level needed to earn payment, and the proportion of the overall payment attached to each scheme. Specific schemes vary in terms of what is incentivised - structure, process and/or outcome - and how they are incentivised. Centralised versus decentralised decision making, the nature of the performance measures, the tiered payment structure and the dynamic nature of the schemes have created a sophisticated but complex P4P programme which requires evaluation to understand the effect of such incentives on specialised care., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To compare the effects of free nicotine replacement therapy or proactive telephone counselling in addition to standard smoking cessation support offered through a telephone quitline., Design: Parallel group, 2 × 2 factorial, randomised controlled trial., Setting: National quitline, England., Participants: 2591 non-pregnant smokers aged 16 or more residing in England who called the quitline between February 2009 and February 2010 and agreed to set a quit date: 648 were each randomised to standard support, proactive support, or proactive support with nicotine replacement therapy, and 647 were randomised to standard support with nicotine replacement therapy., Interventions: Two interventions were offered in addition to standard support: six weeks' nicotine replacement therapy, provided free, and proactive counselling sessions (repeat telephone calls from, and interaction with, cessation advisors)., Main Outcome Measures: The primary outcome was self reported smoking cessation for six or more months after the quit date. The secondary outcome was cessation validated by exhaled carbon monoxide measured at six or more months., Results: At six months, 17.7% (n = 229) of those offered nicotine replacement therapy reported smoking cessation compared with 20.1% (n = 261) not offered such therapy (odds ratio 0.85, 95% confidence interval 0.70 to 1.04), and 18.2% (n = 236) offered proactive counselling reported smoking cessation compared with 19.6% (n = 254) offered standard support (0.91, 0.75 to 1.11). Data validated by carbon monoxide readings changed the findings for nicotine replacement therapy only, with smoking cessation validated in 6.6% (85/1295) of those offered nicotine replacement therapy compared with 9.4% (122/1296) not offered such therapy (0.67, 0.50 to 0.90)., Conclusions: Offering free nicotine replacement therapy or additional (proactive) counselling to standard helpline support had no additional effect on smoking cessation., Trial Registration: ClinicalTrials.gov NCT00775944.

Objectives: To describe how funds were pooled or otherwise jointly managed by National Health Service (NHS) primary care trusts and local authorities in England. To compare expenditure on local children's services by health, education and social services., Methods: We conducted a questionnaire survey of all 35 children's trust pathfinders, six months after they were launched, with a follow-up at 2.5 years. We also undertook an in-depth analysis of local authorities and primary care trusts, within eight pathfinder areas and three non-pathfinder areas, whereby we compared expenditure on children's services, interviewed managers and professionals and examined financial documents., Results: Local authorities and NHS trusts coordinated expenditure in various ways, most commonly through informal agreements and aligning budgets but also by formally pooling budgets. The latter were usually for selected services such as child and adolescent mental health services, though four children's trusts pathfinders pooled (or aligned) their budgets for all children's services. Total expenditure per child was greatest for education, lowest for social services and intermediate for health. However, it was difficult to quantify education expenditure on children with health and social care needs, and health care expenditure on children., Conclusions: Sharing money for local children's services requires shared objectives, trust, and legal and accounting expertise. Several different mechanisms are permitted and many are feasible but programme budgeting for children's services could make them more effective.

Objective: There is insufficient evidence regarding the clinical and cost-effectiveness of surgical interventions for carpal tunnel syndrome. This study evaluates the cost, effectiveness and cost-effectiveness of minimally invasive surgery compared with conventional open surgery., Patients and Methods: 194 sufferers (208 hands) of carpal tunnel syndrome were randomly assigned to each treatment option. A self-administered questionnaire assessed the severity of patients' symptoms and functional status pre- and postoperatively. Treatment costs were estimated from resource use and hospital financial data., Results: Minimally invasive carpal tunnel decompression is marginally more effective than open surgery in terms of functional status, but not significantly so. Little improvement in symptom severity was recorded for either intervention. Minimally invasive surgery was found to be significantly more costly than open surgery. The incremental cost effectiveness ratio for functional status was estimated to be 197 UK pounds, such that a one percentage point improvement in functioning costs 197 UK pounds when using the minimally invasive technique., Conclusions: Minimally invasive carpal tunnel decompression appears to be more effective but more costly. Initial analysis suggests that the additional expense for such a small improvement in function and no improvement in symptoms would not be regarded as value-for-money, such that minimally invasive carpal tunnel release is unlikely to be considered a cost-effective alternative to the traditional open surgery procedure.

A GP practice set up a new system of assessing patients, with an emphasis on appropriate immediate need. The aim is to speed up treatment and reduce inappropriate accident and emergency admissions. A new role of community paramedic on loan from the ambulance trust was a vital part of the team. The first eight months dramatically cut accident and emergency admissions and sped up category A response times.