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 breakdown of results. Outlier analysis will also be carried out according to guidance provided by the Healthcare Quality Improvement Partnership. Details of the process can be found under Resources for audit.

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 2019 and the same will happen in early 2020. 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 are our core audit and EIP spotlight audit data flow chart (PDF) and the EIP 2019/20 audit data flow chart (PDF) (last updated September 2019).

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 2018/2019; data tables will be published for the EIP 2019/20 audit in summer 2020, when the national report has been published.

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

Q. Do you comply with the national data opt out?

Yes, NCAP complies with the national data opt-out. You can find more information on how we comply in our privacy notice, data flow and DPIA.

Q. What is the timeline for NCAP?

A. A high-level timeline for the EIP 19/20 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. Question 7 of the case note audit tool asks whether the patient has commenced Family Intervention; however, I answered ‘no’ to question 5 (does the patient have an identified carer). Will my answer to question 5 be taken into account when analysing the provision of Family Intervention?

A. Questions 5 and 7 are not linked; responses to question 5 will not be taken into account when analysing data for question 7. The standard is for all people with first episode psychosis.

Q.  There are some differences in question 7 compared to the EIP spotlight 2018/19 case note audit. Which options meet the standard for this question for EIP 2019/20?

A. The only option that will meet the standard for question 7 is ‘Took up*’ (*received at least one session). The remaining options do not meet the standard, however they do provide further contextual information.

Q. Q10 asks whether the person’s carer(s) commenced a course, or was referred to, a carer-focused education and support programme but the 2018/2019 EIP spotlight audit national report reports on the percentage of carers that took up carer focused education & programmes. Is this the same?

A. The 2019/2020 audit standard for carer-focused education and support programmes is the same as previously, ‘Carers take up or are referred to carer focused education and support programmes’. The question is intended to capture those who commenced a programme, or where they were referred elsewhere so information may not be accessible by a service as to whether it was taken up.  Please therefore only answer ‘Yes’ to this question if the carer(s) commenced a course of, or was referred elsewhere to a carer-focused education and support programme.

Q. What is the period whereby the outcome measures need to have been completed for question 6?

A. As per the Access and Waiting Times standard, as a minimum, outcome measures should be used during assessment, at six and 12 months, annually and upon discharge. Therefore, please record the most recent outcome measure which should have been within the last 12 months.

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

A. A  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 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 is because the matrix used service information, whereas NCAP uses a sample and case note audit, therefore the samples are different for each.

Q. If a team is covered by more than one CCG what should I enter on the contextual questionnaire?

A. Teams covered by more than one CCG, should enter the CCG code which covers the majority of their patients in the box on the right. This CCG  will be used to determine each team’s compliance with this standard. Any additional CCG names entered into the ‘CCG’ text box will not be incorporated in analysis for this question.

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. As we are asking Trust’s to provide identifiable data in 2019/20, we have applied for and be granted section 251 approval. You find out more about this in the patient information sheet.

Q. Is there an option for patients to opt out of the service user survey/case note audit in 2019/20?

A. Information on how we use data and how to opt out can be found on our opt out poster (PDF). 

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

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

Q. Will the case note audit 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. We have come across patients that are now deceased/have now been discharged from our service since submitting our list of eligible cases - would we still audit these patients?

A. Discharged cases would still be eligible according to the sampling criteria; however, to enable teams to have the full 12 months physical health screening and interventions, we are happy to provide replacements up until 29 November 2019. We would also replace/remove any patients who are deceased. To allow us to do this, please send the NCAP IDs to the team at

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.

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 was used for the EIP spotlight audit. Data from October 2019 - December 2019 will be used for the EIP audit 2019/20.

Q. What happens now that the CQUIN has ended?

A. CQUIN was 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 was 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, 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 was reported as 9%. Why is this?

A. The national figure reported in the 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 the NCAP EIP spotlight audit national figure.

Q. Why was the mean in the EIP spotlight audit 2018/19 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 was 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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