A business critical briefing from HSJ’s Payment by Results conference.

Speakers

  • Piers Ricketts, partner, KPMG
  • Bob Alexander, director of NHS finance, Department of Health
  • Professor Alan Maynard, professor of health economics and co-director, York health policy group, University of York
  • Dr Helen Wilson, consultant ortho-geriatrician, Royal Surrey County Hospital
  • Peter Saunders, head of data assurance and analysis, Audit Commission

Enabling GPs to drive future PbR, Piers Ricketts, partner, KPMG

  • The current situation is unsustainable
  • Initially there may be 300-500 GP consortia consolidating to about 100. Providers will have to deal with more commissioners and consortia will need to create networks.
  • In areas where the tariff system hinders changes, there was a move towards block contracts. 
  • GPs will most likely outsource contract management, audit, coding reviews and IT solutions.
  • The thresholds for admission will need to be agreed.

Examining the future of payment by results in 2011-12, Bob Alexander, director of NHS finance, Department of Health

  • The tariff for 2011-12 will be produced following the principles already outlined, with the only question on the size of the negative reduction.
  • The current secretary of state for health does get involved in the detail and the discussions will be long and technical. The road test tariff will be issued in December along with the operating framework.
  • The tariff for 2012-13 will continue to be developed by the DH but there will be new organisations to consider and also how the service is engaged with the testing. 

Extending PbR into mental health and community services, Stuart Bell CBE, chief executive, South London and Maudsley NHS Foundation Trust

Challenges that should be considered when implementing PbR in mental health:

  • reduce hospital admissions over a long period of time
  • large joint budgets
  • substance misuse
  • the legal status of the patient
  • expectations of society
  • It is not recommended to move straight to a tariff without developing and measuring the currencies.
  • In terms of access to services, mental health is the poor relation. Only 25% of people who need access to treatment receive the appropriate services. For psychosis, about 50% of the people receive appropriate treatment; depression is far less than 25%. This can be compared to diabetes, where 85% of people have access to the appropriate treatment.
  • Forensic care is high cost and involves a long length of stay, but because of links to the criminal justice system there are no options around treatment.

Discussion: implementing incentives to reduce avoidable readmissions, Piers Ricketts, partner, KPMG

  • There is no specific data on avoidable re-admissions. Anecdotal evidence or analysis of readmissions shows that only a small percentage, less than 5%, are avoidable because of the discharge arrangements in the acute trust.
  • The tariff structure reflects the current pattern of care; therefore, this includes re-admissions.
  • For care of the elderly and long-term conditions, an option is for the acute hospital to manage the whole pathway, including provision of services outside the hospital.
  • There is a concern that if trusts are not paid for re-admissions and the 30% marginal rate continues, then some trusts will face financial pressures.

For the policy to be fair, it will need to consider:

  • exceptions regarding self-discharge, especially for substance misuse
  • re-admission by a different trust to the one that discharged the patient
  • patients with complex co-morbidities
  • re-admissions for a different reason

Learning from PbR experience, Professor Alan Maynard, professor of health economics and co-director, York health policy group, University of York

  • The targets should be clear on activity and outcome, noting that cost cutting alone has nothing to do with efficiency if the outcome is not measured.
  • Quality is difficult to measure.
  • All doctors should participate in clinical audit.
  • Any survey on patient satisfaction needs to show the before and after data in order to be meaningful.
  • The system encourages acute trusts to admit patients to hospital.
  • Innovation is very slow (e.g. the implementation of the day case list from the audit commission).

Case study: best practice tariff for hip fracture, Dr Helen Wilson, consultant ortho-geriatrician, Royal Surrey County Hospital

  • Geriatricians and orthopaedic surgeons may have different agendas and experience.
  • Bringing a geriatrician into orthopaedics has benefits for elderly patients with trauma issues.
  • The best value tariff is based on the operation being carried out within 36 hours. However, there is no real evidence about this. The main point was that the sun should not set twice on a patient in such pain.
  • Having good quality data is key, along with a good project manager.

The future:

  • Divide the tariff between acute and rehabilitation.
  • Consider prevention.
  • Expand the list of best practice tariff.

Understanding the impact of data quality on PbR, Peter Saunders, head of data assurance and analysis, Audit Commission

The future:

  • The last few years of development have been hindered by data quality and some aspects have not been implemented due to the risk of poor data (e.g. mental health, community data not available or very variable).
  • Re-admissions on a simple basis could cost £5m to £10m per trust, but the impact by specialty and trust is very variable.

 

Derek Miller is an independent consultant and currently working at Commissioning Support for London.

 

Payment by Results