Monday, 17 December 2007

Clinicians and finance directors speaking the same language?

Paul Jennings (CEO of Walsall PCT) led on the response to the Payment by Results consultation exercise for the Renal Advisory Group that established our PbR project. If Paul had been at our recent meeting, I feel sure he would have adopted the graceful manner of Henry Morgenthau (1891-1967), the US Secretary of the Treasury who presided over the 1944 Bretton Woods Agreement.

Perhaps a grey day at Quarry House in Leeds does not compare with New England in the summer but the first meeting of the Payment by Results Group was remarkable. The finance directors and clinical directors, representing 16 Trusts across the country that provide over 30% of the specialised renal services in England, certainly had not read the recent Audit Commission’s “A prescription for partnership” (13 December 2007) that criticised clinicians and finance colleagues for not communicating. Or if they had, they were doing something about it!! I have never seen such a sight before – clinical and finance directors working together, clearly respecting each others opinions, different views of the world and experience to grapple with the complex task of developing a tariff for dialysis that will work to drive improvements in quality of kidney care. To be fair, the Audit Commission report is of course correct and we have a long way to go before the finance director asks for the quality report ahead of the income and expenditure spreadsheets but our PbR meeting was a step in that direction.

Credit goes to Bev Matthews (West Midlands’ Renal Network Manager), Chris Newton (Divisional Finance Manager, University Hospital Birmingham) and John Bradley (Consultant Renal Physician, Addenbrookes Hospital Cambridge) who have worked so hard with the DH PbR team to get us all to the same start line – well done all!

Concerns of course were expressed. We know where we want to get to – an effective translational process between the financial and clinical worlds - but we must acknowledge and manage the risks in that journey.

Donald Richardson (Consultant Renal Physician in York) was I think you would say sceptical about that whole exercise and pointed me in the direction of “competition in a publicly funded healthcare system” by Steffie Woolhandler and David Himmelstein in the BMJ 1 December whose principal thesis was that the appropriate response to the US experience with market based models for health services is quarantine not replication. Donald raised important caveats, but payment by results antecedence is of course in Australia not the USA.

One of the concerns I share is that “everything that counts can’t be counted” . I am pleased that specialised commissioning leads are part of our PbR team so they can be party to discussions and so they understand that getting robust dialysis costs are only part of the story. The year before dialysis, or as I am increasingly calling it “the year before pre-emptive transplantation if possible” and support for conservative and palliative care are essential components of a world class kidney care service. I think it is too soon to fix a tariff for these aspects of care – the definitions, data capture, models of care and performance markers are not yet in place. To introduce metrics in an effort to try to measure quality in these circumstances risks establishing arbitrary and unrealistic boundaries – judgement and commonsense could be replaced by blind reliance on numbers . The NSF standards and quality requirements in these areas of care highlight their importance and there was complete agreement in the group that we need to flag these elements of care to commissioners and providers in parallel with the PbR work on dialysis.

Roger Greenwood (Clinical Director at the Lister Hospital Stevenage) made another important observation – the risk that getting tariff right now might fossilise the service and prevent innovation in the future. Several people commented that innovation in dialysis has usually been driven by colleagues in industry. It is likely that community care will be the place for most innovation – daily haemodialysis, assisted peritoneal dialysis and the re-emergence of overnight haemodialysis spring to mind.

Having identified some of the risks, Bev Matthews has drawn up a risk management strategy. Bev is a great project manager. So we are up and running. The Project Group will meet face to face again in February to look at our various costs and their components so that we will be able to inform the reference cost submissions for 2007/08 that will be required in June 2008.
It is perhaps fanciful to liken the exercise to the Bretton Woods agreement that established the international monetary fund and the system of convertible currencies, fixed exchange rates and free trade but it was a most extraordinary meeting.

Paul Jennings couldn’t be in Leeds for the launch meeting because he was speaking about commissioning at the NHS World Class Commissioning Conference hosted by Mark Britnell (Director General of Commissioning & System Management at DH). That tells me 3 things – Paul is a well connected and respected guy, we have the right person leading our process and you can feed into things virtually.