Frequently asked questions

This page will be updated on a regular basis

Q. How will the audit data be used?

A. Data will be analysed by the NCAP team at the Royal College of Psychiatrists and reported on at national and Trust/Health Board level. Trusts/Health Boards will also receive local reports at an appropriate level of greater break-down of results.

Q. Will my Trust/Health Board be identified in the report?

A. Data will be provided at National and Trust/Health Board level and further appropriate levels of result's breakdown will be made available in local reports. Each Trust/Health Board has a unique identifier and these will be available in the national reports.

Q. Who will have access to the data?

A. The national reports will be made publicly available and data aggregated at Trust/Health Board level will be made available on In addition, aggregate data on key performance indicators will be provided to the Care Quality Commission (CQC) to inform visits.

Q. Can participation in NCAP be included in Quality Accounts?

A. Yes, as a NCAPOP audit, participation can be included in Quality Accounts.

Q. How will the quality of the data be assured?

A. A random number of participating services were selected for quality assurance visits in early 2018 and the same will happen in early 2019. The purpose of these visits will be to independently check a small sample of records. 

Q. Where can we view a copy of the most recent data flow chart for NCAP?

Here is a copy of our NCAP data flow chart (PDF) (last updated February 2018).

Q. When do Trusts/Health Boards receive a copy of their data?

For the spotlight audit 2018/19, copies of the final cleaned NCAP dataset and final raw data for the EIP CQUIN indicators were provided to sites 15 March 2019. In 2019/20, copies of the final cleaned NCAP dataset will be provided 14 february 2019.

Q. Where can I find data from the audit?

Case note audit results are published for participating Trusts in England. You can access the data from 2017/2018; data tables will be published for the EIP spotlight audit in summer 2019, when the national report has been published.

These data do not include any data about individual patients nor does it contain any patient identifiable information.  

Q. What is the timeline for NCAP?

A. A high-level time line for the EIP spotlight audit is available via Resources for audit.


Q. Were there service user and carer components to the core audit?

A. There were no service user or carer questionnaires in the core audit, or the EIP spotlight audit although a service user survey is taking place in Year 3 (2019/20).

Q. Will there be a contextual questionnaire like in the EIP Network self-assessment 2017/18?

A. Yes, each team is asked to complete one contextual data questionnaire, along with a copy of the case note audit tool for all patients identified in the sample.

Q. Are there differences in the tools to the EIP Network self-assessment from in 2017/18?

A. There are some minor differences. You can see a summary of the changes (PDF) in 2018/19.

Q. One patient declined to give permission to contact their family; in another case it wasn't felt appropriate that the family be involved in the patient's care. How can we reflect this in the questions about a carer-focused education and support programme?

A. Please answer 'No' to question 5 regarding whether the person has an identified family member, friend or carer who supports them. This means that you will not be required to answer question 10, which asks about a carer-focused education and support programme.

Q. What option should be chosen if a patient refused to state their ethnicity?

A. If the patient's ethnicity is not stated or not known, please choose 'not documented' when answering question 3.

Q. What would count as a ‘full package of care’ for Q11 on the contextual data questionnaire?

A. A full package of care is defined as service users receiving care which was appropriate for them at the time. It does not necessarily mean that the service user had to have received every single element of the NICE recommended care. The full package of care would refer to those service users who were discharged either after completing a 3-year pathway or those who were discharged earlier because they recovered early. This excludes service users who were discharged for non-engagement.

Q. We’re part of the South Region EIP Programme. Are we able to use data submitted for the EIP Matrix as in the self-assessment exercise in 2017/18?

A. Unfortunately, it won’t be possible for organisations to use data they'd submitted via the matrix this year. This is because the matrix used service information, whereas NCAP uses a sample and case note audit, therefore the samples are different for each.

Q. Is ethical approval or patient consent required for the audit?

A. NCAP conforms to the CCQI ethical audit  standards and does not require ethics approval nor patient consent.

Q. Our Trust participates in the annual EIP Network self-assessment – will this audit replace it, or will we be asked to participate in both?

A. NCAP will replace the EIP self-assessment exercise in 2018/19, and 2019/20.

Q. Will the sample size for our organisation be 100 patients in total or 100 patients per team?

A The sample size is 100 patients per team within the organisation. If there are less than 100 patients within a team who meet the sampling criteria, then we would just sample all of those on the caseload who do meet criteria.

Q. What time frame will we be auditing?

A. To meet the eligibility criteria, patients must have been on the team’s caseload for 6 months or more at the census date and still on the caseload when the list of patients is submitted to the NCAP team.

A. The cut-off for data collection is the 31st October and so data collected must represent the care provided prior to this date (not the census date). Physical health screening and interventions must have taken place in the 12 months prior to 31 October; for other questions, the intervention must have been delivered in accordance to the guidance.

Q. What period of the Early Intervention in Psychosis Waiting Times data will be used for Standard 1 (Service users with first episode of psychosis start treatment in early intervention in psychosis services within two weeks of referral {allocated to, and engaged with, and EIP care coordinator})?

A. Data from November 2018 – January 2019 has been used for the EIP spotlight audit. (Data from November 2019 - January 2020 will be used for the EIP audit 2019/20.)

Q. How does the NCAP data collection relate to the collection of physical health CQUIN data for EIP services in 2018?

A. In order to minimise the burden of data collection, information on the proportion of people who have been screened and had interventions for their physical health will be extracted from this year’s National Audit of Early Intervention in Psychosis for EIP services.

A. In 2018/2019, in addition to demonstrating cardio metabolic assessment and treatment for patients with psychoses, EIP services must also demonstrate positive outcomes in relation to BMI and smoking cessation for patients. To do this, we will ask for separate data on smoking status and weight for some service users identified in the CQUIN 2017/18 sample.

Q. Will patients under 18 be included in the CQUIN?

A. All patients born after 2000 will be excluded from the analysis. Please note that as we don’t have information on the month of birth, it’s not possible to exclude patients born in November and December 2000, and therefore who may still have been 17 at the end of data collection. For more information on eligibility, please see the overview of EIP CQUIN data collection.

Q. Is there any information regarding the inpatient/community CQUIN for 2018/2019?

A.Yes, please see the inpatient and community CQUIN webpages.

Q. For the EIP BMI outcome indicator, how will cases be analysed where initial baseline is “not recorded”, “documented evidence of refusal” or “person was pregnant”?

A. If either weight measurement (pre or post commencement of anti-psychotic medication) is not available, then this case would not be included in the calculations for this indicator, as both weights are required to determine a change in weight. However, we will also be reporting on the number of cases for which this information is not available to NHS England.

Q. When we received the sample for the EIP CQUIN Smoking and BMI outcome indicators, we didn’t have any patients in the smoking outcome indicator list. Is this correct?

A. Yes, smoking status will be extracted from the data submitted for the spotlight audit for all patients eligible for the indicator who are also in your NCAP sample. You will only have been asked to provide smoking status for any patients who were not in your NCAP sample. This means that some teams may not have had any patients in the sample for the EIP CQUIN smoking indicator.

Q. What happens after the CQUIN ends in 2019?

A. CQUIN is a financial lever intended to improve the quality of care over a given period of time. This CQUIN measured performance from 2014/2015 and has led to improvements in the quality of physical health screening and interventions for people with SMI who are at risk of developing a preventable disease.

2018/19 is the final year of ‘The Improving Physical Health for People with SMI’ CQUIN and providers and commissioners should work to ensure the improvements made during the CQUIN implementation are sustained and implemented.

To support this, NHS England has included a new requirement in the NHS Standard Contract which can be found here, and NHS England will continue to monitor delivery of physical health checks and interventions for people with severe mental illness through the Physical healthcare for people with SMI: Primary care data collection.

Q. In the EIPN self-assessment 2017/18 reports, the national average for the outcome indicator was reported as 1% of service users had two or more clinical outcome measurements recorded at least twice. In the NCAP EIP spotlight audit 2018/19 national report and local reports, the 2017/18 national average is reported as 9%. Why is this?

A. The national figure reported in last year’s EIPN self-assessment included all service users who were on the caseload, of whom 1% had two or more clinical outcome measurements recorded at least twice. In the NCAP EIP spotlight audit reports we provided the EIPN self-assessment figure only for those with First Episode Psychosis. This was to ensure last year’s national figure was as comparable as possible to this year’s NCAP EIP spotlight audit national figure.

Q. Why is the mean in the national report for Q4 of the contextual data (Table 12) different from the national figure in the local reports?

A. The mean in the national report is calculated based on only those teams which offer a service for these age ranges (i.e. n=123 out of n=151). The national figure in the local report is an average taking into account the number of months all teams are commissioned to provide a service for these age ranges (i.e. including those teams who do not offer this service, n=151 out of n=151).

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