The Commissioning for Quality and Innovation (CQUIN) indicators for 2022/23 were recently published by NHS England and for the first time include a vascular indicator, 
the “Achievement of revascularisation standards for lower limb ischaemia”. This is great news and will drive quality improvement for patients with chronic limb-threatening ischaemia (CLTI). 
In this editorial we describe what this means for English NHS organisations providing vascular services, vascular clinicians and patients.

The Prescribed Specialised Services (PSS) CQUIN framework is a pay-for-performance scheme for English NHS Trusts. 
It supports improvements in quality of care by linking a proportion of the healthcare providers’ income to the achievement of quality improvement goals in clinical priority areas. 
It was launched in the NHS in England in 2013 but was suspended during the pandemic. This year there are five PSS CQUIN indicators that acute Trusts must adopt. 
The baseline value for the CQUIN equates to 1.25% of the fixed element of the expected annual contract value, with each of the five indicators worth 0.25%. If the CQUIN target is not met, 
the CQUIN value will be deducted and reimbursed. For an arterial centre, this penalty is estimated at approximately £500,000 or more depending on Trust size.

The “Achievement of revascularisation standards for lower limb ischaemia” CQUIN indicator is based on the Vascular Society of Great Britain and Ireland Peripheral Arterial Disease Quality 
Improvement Framework (PAD-QIF) published in March 2019, which recommends a timeframe of 5 days from referral to the vascular team to revascularisation for patients admitted urgently with CLTI. 
This indicator evaluates quality by measuring the proportion of patients with CLTI that undergo open, endovascular or hybrid revascularisation within 5 days from non-elective admission to vascular 
provider units.4 Payment is determined by reference to two thresholds (upper threshold 60%, lower threshold 40%). NHS organisations will receive the full CQUIN value if 60% or more  of CLTI patients 
who are deemed suitable for revascularisation are revascularised within 5 days from admission and no payment will be earned if this proportion is below 40%. Deductions will be graduated if performance 
falls between the two thresholds. Regional Specialised Commissioning teams will monitor performance of providers using Hospital Episode Statistics (HES) data and data entry to the National Vascular 
Registry (NVR).

The CQUIN aims to drive improved levels of data entry to NVR, which will be used to quality assure the timeliness of revascularisation and patient outcomes. 
This supports the Getting It Right First Time (GIRFT) recommendation that case ascertainment rates for lower limb procedures should exceed 85%.6 Therefore, 
if comparison between NVR and HES data demonstrates significant under-reporting, there is the potential for commissioners, at their discretion, to withhold or reduce payment. 
This should ensure providers identify sufficient resources (including administrative support) for vascular services (both surgical and radiological) to meet this target level 
of case ascertainment to the NVR.

There has been conflicting evidence about the effectiveness of pay-for-performance schemes to improve processes and patient outcomes.6-8 The CQUIN aims 
to improve quality of care by measuring clinical processes, and assumes that improvement in these metrics will result in improvement in patient outcomes and a more positive 
patient experience due to fewer delays. Patients treated within 5 days have been demonstrated to have shorter postoperative and overall hospital stays in the recent NVR report,
9 and may experience fewer complications. The positive effect of interventions such as dedicated limb salvage clinics on patient outcomes such as amputation-free survival 
has also been demonstrated.10 Additionally, having a vascular CQUIN indicator focuses the attention of NHS providers of vascular services and provides an opportunity for clinicians 
to seek resources and support from their organisational leadership, by highlighting the potential financial gains thanks to the reduced length of stay and subsequent increased bed capacity, 
as well as the financial incentive of the CQUIN itself.

Vascular units may need to reconfigure their pathways to prioritise patients with CLTI and expedite patient review, imaging and treatment in order to achieve the target. In this effort, 
they may benefit from the experience of the early adopters participating in the PAD-QIF, who have introduced a number of innovative solutions that can serve as examples for other units.
11 Vascular units are able to identify their baseline performance, published in the 2021 NVR report.9

The PAD-QIF timeframes are challenging and achieving them is likely to require additional resources and a change in the delivery of vascular services. However, 
we hope that the inclusion of the CLTI indicator in the CQUIN framework will raise the profile of peripheral arterial disease with NHS Executive teams. Furthermore, 
by highlighting CLTI as a clinical priority, the CQUIN will encourage the adoption of the 5-day target into clinical practice and lead to improved patient outcomes and reduced amputation rates.


1. NHS England and NHS Improvement. Commissioning for Quality and Innovation (CQUIN): 2022/23 Guidance. January 2022. Available from:

2. Feng Y, Kristensen SR, Lorgelly P, et al. Pay for performance for specialised care in England: strengths and weaknesses. Health Policy 2019;123(11): 1036–41.

3. Vascular Society of Great Britain and Ireland. A Best Practice Clinical Care Pathway for Peripheral Arterial Disease. Available by clicking here.

4. NHS England and NHS Improvement. Commissioning for Quality and Innovation (CQUIN) 2022/23 Annex: Indicator specifications. January 2022. Available from:

5. Horrocks M. Vascular Surgery GIRFT Programme National Specialty Report. Available from:

6. Mendelson A, Kondo K, Damberg C, et al. The effects of pay-for-performance programs on health, health care use, and processes of care. Ann Intern Med 2017;166(5):341–53.

7. Milstein R, Schreyoegg J. Pay for performance in the inpatient sector: a review of 34 P4P programs in 14 OECD countries. Health Policy 2016;120(10): 1125–40.

8. Ogundeji YK, Bland JM, Sheldon TA. The effectiveness of payment for performance in health care: a meta-analysis and exploration of variation in outcomes. Health Policy 2016;120(10):1141–50. j.healthpol.2016.09.002

9. Waton S, Johal A, Birmpili P, et al. National Vascular Registry: 2021 Annual Report. London: The Royal College of Surgeons of England, November 2021. Available by clicking here.

10. Nickinson ATO, Dimitrova J, Houghton JSM, et al. Does the introduction of a vascular limb salvage service improve one year amputation outcomes for patients with chronic limb-threatening ischaemia? Eur J Vasc Endovasc Surg 2021;61(4):612–19.

11. Peripheral Arterial Disease Quality Improvement Programme. Lessons learnt from the PAD QIP early adopters. August 2021. Available by clicking here


Conflict of Interest: PB, KB, ADP, JRB and RDS contributed to the development of the vascular CQUIN application. RDS, JRB and ADP are members of the National Clinical Reference Group for Vascular Services. JRB and ADP are members of the VSGBI Executive Council and RDS is the VSGBI representative at the RCS England Council.

Funding: EA is supported by a Royal College of Surgeons/Circulation Foundation clinical research fellowship. PB is supported by a VSGBI/BSIR/Circulation Foundation clinical research fellowship.

Acknowledgments: We would like to acknowledge the contribution of the NVR team, and especially Professor David Cromwell and Mr Sam Waton, in the development of the vascular CQUIN. We would also like to thank Mr Michael Wilson, Programme Director for Specialised Commissioning in NHS England, for his input and support in the development of this CQUIN.

Birmpili P,1,2 Atkins E,1,2 Boyle JR,3 Sayers RD,4,5 Blacker K,6 Williams R,7 Pherwani AD8

Author Affiliations:

  1. Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
  2. Hull York Medical School, Hull, UK
  3. Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
  4. Department of Cardiovascular Sciences, University of Leicester British Heart Foundation Cardiovascular Research Centre, Leicester, UK
  5. National Clinical Reference Group for Vascular Services, NHS England and Improvement, UK
  6. National Specialised Commissioning Team, NHS England and Improvement, UK
  7. Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, UK
  8. Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK

Article DOI:

Journal Reference: J.Vasc.Soc.G.B.Irel. 2022;1(3):63-64

Publication date: March 29, 2022