A business critical briefing from HSJ’s Payment by Results conference
- Noel Plumridge, financial columnist
- Bob Alexander, director of NHS finance, Department of Health. Download Mr Alexander’s presentation.
- Stephen Piper, assistant director of information and performance, Ealing Hospitals Trust
- Jonathan Storey, portfolio manager and payment by results lead, North East Strategic Health Authority
- Howard Davis, payment by results benchmarking manager, the Audit Commission
- Paula Monteith, information design consultant within the casemix team, Information Centre
- Carole Greene, project director, Care Pathways and Packages Project
- Alex Brookes, currency and pricing development, Transforming Community Services, Directorate of Commissioning and System Management
- Richard Russell, RSR Consultants
- Dr Di Bilton, consultant physician, Royal Brompton Hospital
- Joanne Osmond, clinical care and commissioning manager, the Cystic Fibrosis Trust
Keynote address, Bob Alexander, director of NHS finance, Department of Health
- The aim for 2010-11 with regard to payment by results is to consolidate any known issues from 2009-10 and to introduce currencies, but not a tariff, for adult mental health.
- Another aim is to implement best practice tariffs, which will incentivise best clinical practice and produce efficiencies. They will challenge commissioners and providers to work together to ensure appropriate incentives are in place to improve efficiency and clinical practice while not rewarding less than best practice.
- There are wide variations in clinical practice that can be addressed by payment by results (e.g. for cholecystectomy the day case rate should be 70 per cent, whereas it is 30 per cent in practice).
- Challenges for the future include expanding the remit of payment by results into other areas, ensuring there are appropriate rewards and improving data quality.
Using patient level information and costing to better understand the cost of care and measure success, Stephen Piper, assistant director of information and performance, Ealing Hospitals Trust
- The benefits of patient level information and costing will include clinical engagement, quality, efficiency, productivity and performance because of the level of detail considered and discussed within organisations.
- Organisations must be clear on the reasons for implementing patient level information and costing and have their vision accepted by clinicians and managers.
- Good quality data is essential. With appropriate information, it is possible to change behaviour. For example, presenting data on the number of diagnostic tests per patient demonstrates to consultants that junior staff are requesting too many tests.
- A quality dashboard is being considered along with patient level information costing.
Examining the current and future development of payment by results, Jonathan Storey, portfolio manager and payment by results lead, North East Strategic Health Authority
- Payment by results was developed in a period of growth to improve access to services and develop contracts on a transactional level.
- For 2010-11 there are no major changes planned and it will be used as a sense check on payment by results.
- The future will include tariffs for mental health, ambulance services, specific projects such as critical care and payment for procedure irrespective of the setting (day case or outpatient).
- The best practice tariffs will include all the aspects of care, such as outpatient attendances and procedures.
Driving improvements in data quality to ensure accurate financial reporting, Howard Davis, payment by results benchmarking manager, the Audit Commission
- All the dimensions of data quality, accuracy, validity, reliability, timeliness, relevance and completeness must be in place and are equally important. Organisations should monitor all these dimensions and strive to improve data quality.
- Good data quality is essential for payment in HRG4, performance management and monitoring of care quality. Eight per cent of payments are wrong. There is no evidence of upcoding; this is more to do with errors.
- The quality of source documents is not good, with one trust having 16 per cent of its records described as unsafe to audit. The development of standards for the structure and content of medical records will help to address the poor quality of source documents.
- The main factors needed to improve coding and data quality are the involvement of clinicians in the coding process and the training and development of coders.
Understanding resource use with HRG4, Paula Monteith, information design consultant within the casemix team, Information Centre
- HRG4 has 1,400 types of episodes.
- For some episodes, there are different tariffs depending on the complexity and type of complication.
- There are very different prices for the same procedure carried out as an outpatient, day case or inpatient.
- The HRG chapters do not map to specialties; for example, general surgery procedures can fall across all the chapters.
Developing payment by results in mental health services, Carole Greene, project director, Care Pathways and Packages Project
- The plan is to develop national currencies and local tariffs, which need consistency for benchmarking and to provide cost effective services.
- There will be more incentives to finalise tariffs and currencies because of the current fiscal environment.
- There is a need to create groups or pathways that are resource homogeneous.
- There is a need to improve recording, especially start and end dates of treatments.
- Patients do not often fit neatly into a specific cluster and may also move between groups.
- There are 21 clusters identified, booklets and definitions will be produced by December.
- Ongoing training and development is essential.
- The quality of data sets is currently not good, and will present challenges for all organisations.
Current development in community services, Alex Brookes, currency and pricing development, Transforming Community Services, Directorate of Commissioning and System Management
- There is no national dataset for community services, which limits capacity to develop currencies and tariffs.
- There is a need to understand community service spending and develop pathways that consider outcomes.
- There is a need to consider what data is available, and then with professional engagement clarify what the service should look like and then develop feasible currency.
- Some areas such as end of life care are complex, but the currency needs to incentivise community activity and consider resources used in providing care.
- When setting the currencies and tariffs for services, the aim is to avoid perverse incentives. The components of the pathways need to be clear and understood by providers and commissioners, with agreement on outcomes of individual parts of the pathways.
- There is always a need to challenge currencies: are they realistic, measurable, can they be performance managed and linked to outcomes and pathways?
- The development of patient level information and costing will enable more meaningful discussions to take place with clinicians, professionals and commissioners.
Derek Miller is an independent consultant, currently working at South West London Acute Commissioning Unit.
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