Published: 24/02/2005, Volume II5, No. 5944 Page 9 11 13

An increasing need for accurate data monitoring means clinical coding is no longer seen as a back-room job. Steve Mathieson looks at the training and career options on offer

NHS organisations, particularly in England, increasingly rely on the data they generate on their activities. 'Payment by results requires much more accurate monitoring of what's going on, ' says York University professor of health economics Professor Alan Maynard. 'That will determine your reimbursement as a hospital.' Providing this data is the job of clinical coding staff. 'These people have been buried in the bowels of a hospital, not well trained or paid, ' says Professor Maynard.

But that will need to change. 'In future, they will have to work closely with doctors. There are two sets of people: those who collect data and those who analyse it. The analysts will look at problems with readmission and mortality rates.

They will probably require good masters-level training, ' he says. This means being skilled in statistical techniques, and with the analytical abilities to ask the right questions.

Practitioners agree that, in the past, clinical coding suffered from low status. 'Unless you worked in a records office or hospital, you never really knew about clinical coding, ' says Institute of Health Record and Information Management director of education Moira McLaughlin.

However, 'over the years, it has become more and more important'.

Fully qualified IHRIM, along with the health services of each of the four home nations, recognised the increase in importance, creating the national clinical coding qualification, for which the first examinations were held in May 1999.

Those passing both the theory paper, which requires a 60 per cent pass mark, and the clinical paper, with a demanding 90 per cent pass mark, can use the suffix ACC (accredited clinical coder).

'You do not have much room for error, ' says Ms McLaughlin of the clinical paper, adding that one 2004 candidate managed a perfect 100 per cent.

The numbers taking the qualification have grown from 'a handful' to around 200 in 2004.

'They are rising. A lot of it is to do with Agenda for Change, ' she says. Under this, 'it helps to have a qualification. It gives [clinical coders] a hierarchy of posts, somewhere to go'.

Ms McLaughlin, who also works for NHS Scotland, says demand for the examination has been strongest from England. 'Last year, Scotland only had two people sitting the exam. Wales and Northern Ireland are a bit like Scotland; We have only had a few people from them. I think That is partly because the NHS Information Authority runs refresher courses for coders, whereas NHS Scotland's information and statistics division hasn't.' Another possible reason is the introduction of payment by results for hospitals in England, but not Scotland. 'From a hospital's point of view [in England], It is important to get coders through for that reason.' She says the qualification seems to attract a range of ages, not just young people looking for a quick start to their career. At the awards ceremony held near Chester last October, the majority were over 30. This is being accepted as a standard: 'If you look at the HSJ job ads, some are asking for the ACC qualification.' Furthermore, a real career path is emerging, with the potential for a qualified clinical coder to apply for jobs in internal and external auditing.

There will be something of a pause next year, however. Since 2001, the examination has been held once a year. In 2005, it will be offered in May and November, but not at all in 2006, due to the introduction of the National Intervention Classification project, which will affect what is studied to gain the qualification. 'It wouldn't be fair to examine people on it when It is new, ' says Ms McLaughlin.

In England, clinical coding has been managed by the NHS Information Authority, and will be transferred to the national programme for IT on NHSIA's abolition on 1 April. 'This recognises the importance of the clinical coding function as a key quality assurance role in supporting the care records service, ' said the NHSIA in a statement.

'To date the national clinical classifications service of NHSIA has developed and delivered a very successful training service with a portfolio of courses and materials to support clinical coding from foundation courses to specialist and audit workshops, ' it says. 'Making Information Count, the human resources strategy for health informatics staff, has recognised clinical coders as being a specialist group of professionals sitting under information management.

'NHSIA...has also secured recognition of clinical coding skills through Agenda for Change which has resulted in a range of band levels from entry level to manager level. Early implementer sites highlighted that this urgently needed to be done to retain staff. Agenda for Change has recognised this fact by adding the recruitment and retention premium.' Problems with recruiting and retaining staff are not restricted to England. 'Staff levels in some trusts are lower than they would like them to be in coding, ' says Tony Couch, head of information products for Health Solutions Wales, part of Velindre trust, which runs clinical coding training in Wales. 'The basic training courses are, in the main, oversubscribed. There are some who are turned away, or rescheduled for a later course.' In Northern Ireland, Mark Ruck, GP audit and information officer for the Eastern health and social services board, says the demand for clinical coding training from primary care has increased as a result of the general medical services contract. 'It would have been patchy before that, and for the majority of practices it was poor to average. It has got better, because of the new contract and GPs getting new computer equipment.' The Eastern board, which is the largest of Northern Ireland's four, has been providing increased training for general practice staff with courses that take in IT, governance and audit, with some training provided by GP software firms.

Raised status In England, clinical coding training is run by a variety of bodies, although using the NHSIA's national standards. In the Cheshire and Merseyside strategic health authority area, training for all organisations is provided by the area's data quality and clinical coding team.

Team manager Janet Kempson says increasing numbers are going through its training programme, which aims to ready trainees for the ACC qualification in two years through 14 days of initial training and follow-up work after six and 12 months.

'It is raising the professional status of clinical coders. It is the acknowledgement that it is a complex job, and it needs training, skills and a good knowledge base.' She echoes the point that Agenda for Change is making it worthwhile for staff to show their competence.

But Miss Kempson says the increased training for clinical coders benefits English trusts too.

'Good coding means securing income for the [acute] trusts, certainly in the payment by results era. If trusts haven't got their data coded by the submission dates, they will get no money - It is as simple as that. From the primary care trust commissioning angle, knowing that coders are trained to national standards gives them some assurance that the information the trusts are giving them is correct.' Some trusts have used innovative methods to fill vacancies. Morecambe Bay Hospitals trust has recruited three clinical coders through its use of the modern apprenticeship scheme, which since 2002 has helped it recruit in jobs from electricians to pathology lab staff.

Trust learning development manager Carl Hunter says it either employs modern apprentices directly, or takes placements from a training organisation. For clinical coders, it has employed them directly.

Of the three, he says: 'One left the department, but stayed within the organisation, working in medical records - a slightly better-paid job.' The apprenticeship qualification is in business administration, so those coming through can easily choose to move away from clinical coding itself.

'Another completed the [apprenticeship] qualification, and is now studying to be a qualified clinical coder, and We are supporting that. The other is on maternity leave, and we hope she'll come back to become a clinical coder as well.'

Off the street King's College Hospital trust in London has also tackled a shortage by training people from scratch. Last year, with£15,000 funding from the Learning and Skills Council, it looked for unemployed and first-job-seekers to undertake basic training in the subject, a technique the trust has used successfully in other areas including patient record clerks and medical secretaries.

Using local jobcentres, the scheme attracted 30 applications, and gave 12 people places on the course. 'We took people off the street who had no knowledge of the NHS, except as users, ' says head of patient records Chris White. 'Some dropped out during the course, but it proved we could find another way to recruit.' Of the 12, two are working as trainee clinical coders at King's, one is working for a different trust in that post and another is now a trainee medical secretary.

Ms White and her colleague Shirley Freeman considered using the modern apprenticeship scheme, but decided it was 'a bit mechanistic, and very heavy on the paperwork, ' particularly as they were organising the programme in addition to their normal work.

'There is a lot of competition, ' says Ms White.

'Coding doesn't seem to be an attractive field - It is something people do towards the end of their career. Ward clerks are not attracted to it, medical secretaries would see it as a step down. It is very hard work, very meticulous and probably not as financially rewarding as it could be. Our coders could pick up£150 a day through an agency.' However, she says she is aware bidding wars have taken place between trusts over coding staff.

Trainees are on the A&C3 grade, starting at around£14,500 in London, progressing to A&C4 for a full clinical coder, on a salary of up to£20,000.

'We started out from a chronic need to recruit, ' says Ms White. 'If we couldn't recruit, we would train our own.' The trust still has a couple of vacancies, and is planning to rerun the basic course using the remainder of the£15,000 grant.


Ipswich Hospital trust has focused on training its existing employees: of 11 clinical coding staff, two are in trainee posts and the other nine have taken and passed the national clinical coding qualification.

The staff took the examination in two batches, and all can now use the ACC suffix.

Clinical coding trainer and auditor Ann Sanderson says that Agenda for Change was part of the motivation: 'We encouraged each other to take it. Some hospitals have had a financial incentive, but our management didn't agree with that. It was the satisfaction in passing.' It has had a positive effect, she says. 'Some of us have been coding for a long time, and getting the ACC doesn't make that much difference, but it has helped the younger ones who maybe lacked confidence.' Getting the second batch of five candidates through the examination did present difficulties, not through lack of skill - all passed - but because the trust didn't send in the entry form.

Ms Sanderson says: 'IHRIM wasn't going to be flexible, but at the last minute it said there would be space in Southampton. It took a lot of phone calls to get an agreement.' The trainees' job description now includes them taking the ACC qualification, something Ms Sanderson believes is relatively unusual, but should be standard.


Some universities include material on clinical coding within their courses.

Central Lancashire University started a twoyear foundation course in health informatics in January, including modules in clinical coding, and such content is within its health informatics courses at BSc, postgraduate certificate, diploma and MSc courses.

The university is now working on a bespoke training course for coding and the general medical services contract, which it hopes to start in April and is aimed at GPs.

'We have had a good level of interest, ' says MSc course leader in health informatics Beverley Ellis.

Those on the courses are able to take NHS information management and technology professional awards, alongside their university qualifications.

However, similar programmes, such as Derby University's information management and technology in health and community care courses, do not include specific modules on clinical coding.

'We tend to have it quite a lot in the certificate, but running through the whole programme, as It is an integral part of how you manage information, ' says Derby degree programme leader Jean Gilbert.

Find out more

NHS Information Authority www. nhsia. nhs. uk/clinicalcoding

Institute of Health Record and Information Management www. ihrim. co. uk/qualifications. php

Key points

The advent of payment by results has seen the role of the clinical coder pushed to the fore in England.

Examinations for a clinical coding qualification began in 1999. In 2004, approximately 200 people took the qualification.

Trusts are attracting people to the role by offering training from scratch or through modern apprenticeships.