Using Payment by Results to commission better quality clinical care

1. Using Payment by Results to commission better quality clinical care Eileen Robertson Payment by Results (PbR) Development Team

2. Outline • What is Payment by Results? • Using PbR to commission better quality care • Supporting best practice: Fragility hip fractures

3. What is Payment by Results? The aim of PbR is to provide a transparent rules-based system for paying providers in England • a system in which PCTs pay hospitals for the number and complexity of patients treated, using a price list – the national tariff – for all activity within the scope of PbR • covers admitted patients, outpatients and A&E • new way of funding NHS activity introduced in 2003-04 • replaced block contracts based on historic costs • part of a group of payment systems known internationally as casemix funding Price x Activity = Income

4. Tariff At a basic level the tariff is… Priced at national average cost A fixed price Paid per patient Published annually At spell level Per HRG

5. Using PbR to commission better quality care • PbR focuses negotiations between commissioners and providers away from price and towards quality • Introduction of best practice tariff to better support improved quality • Is better quality clinical care more efficient? • Reduce length of stay • Reduce re-admissions • Improved outcomes • Wider health and social care impact

6. Supporting better quality care: Fragility Hip Fracture From April 2010 PbR will be introducing a “Best Practice Tariff” for fragility hip fractures. • High Quality Care for All (HQCFA) report • Highvolume service area • Significant variation in clinical practice • Improve bothquality and value • Excellent source of clinicaldata (NHFD) • Support existing work on fragility hip fracture care

7. The best practice tariff aims to… Reduce unexplained variation in quality and universalise best practice. • Key clinical characteristics: Involvement of an (ortho)-geriatrician Surgery within 36 hours AND • Characteristics are best practice – they go beyond the standard

8. Definition of characteristics • Time to surgery • Arrival in A&E or diagnosis if an inpatient to start of anaesthesia • Involvement of an (ortho)-geriatrician:All 4 required • Admitted under the joint care of a Consultant Geriatrician and a Consultant Orthopaedic Surgeon • Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia • Assessed by a Geriatrician * in the perioperative period ** • * Geriatrician defined as Consultant, NCCG, or ST3+ • ** Perioperative period defined as within 72 hours of admission • Postoperative Geriatrician-directed: • Multiprofessional rehabilitation team • Fracture prevention assessments (falls and bone health)

9. Cost profile of meeting best practice unit cost Tariff to reflect this profile over time time Best practice care costs less… “Looking after hip fracture patients well is a lot cheaper than looking after them badly.” The ‘Blue Book’ (p. 10) invest save

10. The tariff will be paid in two-parts… • National Hip Fracture Database captures compliance with clinical practice • PCTs to monitor and make additional payments quarterly Payment per patient Reduction in base tariff for national compliance rate National average cost Additional payment for best practice Base tariff for each HRG

11. Summary of best practice tariff • Aim is to universalise best practice around two key characteristics with hip fracture care • Payment to be a 2-part tariff with compliance to be monitored through NHFD • Additional funding to providers of best practice care • PCTs reap financial benefits through savings in super-spell and future reductions in tariff • 2010/11 is an opportunity to change practice