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

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

3. Payment by Results 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

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

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

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

8. Payment by Results 8 Definition of characteristics 1. Time to surgery  Arrival in A&E or diagnosis if an inpatient to start of anaesthesia 2. Involvement of an (ortho)-geriatrician: All 4 required a) Admitted under the joint care of a Consultant Geriatrician and a Consultant Orthopaedic Surgeon b) Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia c) Assessed by a Geriatrician * in the perioperative period **  * Geriatrician defined as Consultant, NCCG, or ST3+  ** Perioperative period defined as within 72 hours of admission d) Postoperative Geriatrician-directed:  Multiprofessional rehabilitation team  Fracture prevention assessments (falls and bone health)

9. Payment by Results 9 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 time unit cost Cost profile of meeting best practice Tariff to reflect this profile over time

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

11. Payment by Results 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