Robert J. Bell – Chief Executive Royal Brompton & Harefield NHS Trust London, UK

Patient-Focused Funding Patient-Focused Funding & Payment by Results & Payment by Results

The UK ExperienceThe UK Experience

CEO Forum, Kananaskis, AlbertaCEO Forum, Kananaskis, AlbertaFebruary 16, 2009February 16, 2009

Robert J. Bell – Chief ExecutiveRobert J. Bell – Chief Executive

Royal Brompton & Harefield NHS TrustRoyal Brompton & Harefield NHS Trust

London, UKLondon, UK

[email protected]@rbht.nhs.uk

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The NHS (2008)The NHS (2008)

DEPARTMENT OF HEALTH

STRATEGIC HEALTH AUTHORITIES

PRIMARY CARE TRUSTS

Manage and provide Medical and Surgical care in Teaching and

District General Hospitals, Specialist Hospitals and DTCs

Contract with PCTs for services to patients on a

local/regional basis

ACUTE CARE TRUSTS

THE LOCAL HEALTH ECONOMY

Contract for (commission)

hospital care, locally

Manage and integrate primary care for medical,

dental, pharmaceutical and

optical services

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10 STRATEGIC HEALTH AUTHORITIES 10 STRATEGIC HEALTH AUTHORITIES

(SHAs)(SHAs) For a population of 51 millionFor a population of 51 million

152 PRIMARY CARE TRUSTS (PCTs)152 PRIMARY CARE TRUSTS (PCTs) Average population of 330,000 Average population of 330,000

230 NHS TRUSTS230 NHS TRUSTS Acute, Mental Health, Ambulance Acute, Mental Health, Ambulance

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The NHS (2008)The NHS (2008)MAJOR REFORMS : THE PAST DECADE ……MAJOR REFORMS : THE PAST DECADE ……

Key FunctionsKey Functions Examples of discrete reformsExamples of discrete reforms

Standard-setting and monitoring National Institute for Health and Clinical Excellence (NICE)National Service Frameworks (NSF)Core and development standards (set by the Department of Health)Clinical Audit

Target-setting Public Service Agreements, NHS contract

Clinical governance Legislation

Regulation Institutional

Individual

Healthcare Commission (HCC)MonitorAudit CommissionNational Clinical Assessment AuthorityGeneral Medical Council (GMC)Appraisal and Revalidation

Patient/Public engagement Patient choice of providersExpert Patient ProgrammePatient and Public Involvement (PPI), LinKSPatient Advice and Liaison Services (PALS)

Payment and IncentivesPayment and Incentives Payment by Results (PbR)Payment by Results (PbR)GP ContractConsultants’ contractAgenda for Change

Public Reporting Dr FosterLeague TablesStar ratings (now superseded by the annual health check)

Commissioning NICE Commissioning guides, Practice Based Commissioning

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Payment by ResultsPayment by Results

THE NEW WAY OF DOING BUSINESS

PbRBLOCK

FUNDING

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Payment by Results Payment by Results (PbR) (PbR)

KEY ELEMENTS(Payment by Activity)

HRGs

Activity

Health

reso

urc

e

groups

National Tariff

Payment to provider by PCT

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Payment by Results Payment by Results (PbR) (PbR)

TO FACILITATE DECENTRALISED WAITING TIME TO FACILITATE DECENTRALISED WAITING TIME

REDUCTION (TARGETS)REDUCTION (TARGETS) TO REWARD EFFICIENCY AND QUALITYTO REWARD EFFICIENCY AND QUALITY TO SUPPORT PATIENT CHOICE (MONEY FOLLOWS THE TO SUPPORT PATIENT CHOICE (MONEY FOLLOWS THE

PATIENT)PATIENT) TO PROVIDE A TRANSPARENT AND FAIR WAY TO PAY TO PROVIDE A TRANSPARENT AND FAIR WAY TO PAY

PROVIDERSPROVIDERS TO REDUCE TRANSACTION COSTS AND NEGOTIATION TO REDUCE TRANSACTION COSTS AND NEGOTIATION

DISPUTESDISPUTES

WHY WAS IT INTRODUCED?

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PCT’s and Commissioning

PCT’s

PRACTICE BASEDCommissioning

• GP’s

18 WEEK PATHWAYS

• Integrated Care

PATIENT CHOICE

“Choose & Book” PLURALITY

PbR(Payment by Results)

• National Tariff• Patient Level Costing

• Foundation Trusts• ISTC’s• NHS Trusts• Etc.

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Payment by Results Payment by Results (PbR)(PbR)

THE KEY ELEMENTS

FINISHED CONSULTANT EPISODES (FCEs)• HRG’s counted by FCEs

HEALTH RESOURCE GROUPS (HRGs)

• Developed in Australia

• Implemented in the UK (1992)

• Standard Grouping

• Clinically similar patients

• Consume similar level of Healthcare

• Used to set a National Tariff (Price/HRG)

NATIONAL TARIFF

• Based on average reference costs

• Separate Tariff (Elective vs Emergency)

• Tariff paid according to actual work

• Trusts compensated through national contracts/local SLA

BASELINE ACTIVITY

SPELLS

• Agreed level of work between PCT and Trust

• Adjustments subject to SLA and risk sharing

• Providers paid for a “spell” that may include several FCE’s

SPECIALIST TOP UPS

• Complex rules/algoritism

• Specific uplifts for certain combination codes

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Has it really worked?Has it really worked?

Did the UK get the Balance right Did the UK get the Balance right for the NHS and the Taxpayers?for the NHS and the Taxpayers?

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The The CombinationCombination of PbR and National of PbR and National Targets has Targets has markedlymarkedly decreased Wait decreased Wait Time for Admission to hospitalTime for Admission to hospital

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Lower Hospitalisation has been Lower Hospitalisation has been experiencedexperienced

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And: Short stay activity has increasedAnd: Short stay activity has increased

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• Increasing efficiency

• Rewarding and increasing quality

“THE JURY IS STILL OUT”

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However,

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Data Quality has substantially improved ….

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So what does the future look like? PbR is here to stay PbR is here to stay

current HRG version 3.5 to be replaced by version current HRG version 3.5 to be replaced by version 4.04.0

PbR has been extended to Mental HealthPbR has been extended to Mental Health HRG unbundling to support PCTs in shifting local HRG unbundling to support PCTs in shifting local

commissioning to community settings and GP’scommissioning to community settings and GP’s Pay for Performance may be next (linking Quality Pay for Performance may be next (linking Quality

and Outcomes)and Outcomes) PbR may be applied to community and home based PbR may be applied to community and home based

servicesservices

Robert J. Bell – Chief Executive Royal Brompton & Harefield NHS Trust London, UK

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