Wednesday, 20 July 2011

Q & A: Paying for value not volume

Q: Dear Donal, I thoroughly enjoyed reading your article "Paying for value, not volume" in the recent BJRM but I'd be grateful for clarification on what constitutes a multi-professional clinic. I suspect after reading your article that we have similar views on what a multi-professional clinic should be: it would included seeing the renal physician, dietician, access nurse, transplant coordinator, education nurse, pharmacist for medicine reconciliation, vascular access technician etc all at the same visit. However, the DoH definitions seem to be quite different and I've included the relevant parts below:

139. Multi-professional attendances are defined as multiple care professionals (including consultants) seeing a patient together, in the same attendance, at the same time. The TFC of the consultant clinically responsible for the patient should be applied to a multi professional clinic where two consultants are present. Where there is joint responsibility then this should be discussed and agreed between commissioner and provider.

140. Multi-disciplinary attendances are defined as multiple care professionals (including consultants) seeing a patient together, in the same attendance, at the same time when two or more of the care professionals are consultants from different national main specialties.

142. They do not apply if one professional is supporting another, clinically or otherwise, e.g. in the taking of notes, acting as a chaperone, training, professional update purposes, operating equipment and passing instruments. They also do not apply where a patient sees single professionals sequentially as part of the same clinic. Such sequential appointments count as two separate attendances, should be recorded as such in line with existing NHS Data Model and Dictionary guidance on joint consultant clinics

It seems that instead of charging for a multi-professional clinic we should code the attendance with all the other professionals supporting the renal team in outpatients as separate attendances and charge separately.

The problem is the commissioners say that this is new clinical activity and has not been agreed which puts us in a no win position. What would you advise? The other option is to see them in the same room which seems a nonsense. Kind regards, Dr Chris Dudley, Renal Unit, North Bristol NHS Trust

A: Dear Chris, thank you for your comments and for the question regarding the definition of multi-professional attendance. I am sorry for the long delay in replying. The guidance for Payment by Results is long and complex, running to 136 pages.

You have quoted the relevant paragraphs and I think the 'sticking point' is section 139 where there is reference to seeing a patient together in the same attendance at the same time. Strictly speaking multi-professional out patient tariffs only relate to situations where the care professionals are in the same room at the same time, rather than the patient going into multiple rooms to see different care professionals individually, as outlined in paragraph 142.

In many instances of multi-professional kidney care out-patients attendances, individual patients see practitioners sequentially. When that is the case however, there is more often than not a multi-professional team meeting to agree and coordinate management. As mentioned in paragraph 142 of the guidance such meetings in the absence of the patient do not count as multiprofessional or multi-disciplinary clinics either.

However, there is some scope for local flexibilities and details of what is permitted is set out in section 11 of the PbR guidance and in particular paragraphs 428 and 444 et seq. It may be worth noting that the main flexibility is, in defined circumstances, for commissioners and providers to agree to use the national multi professional tariff where this is better for the patient and the NHS.

Strictly speaking the agreed tariff should be less than the national tariff but if mutually agreed this can be by a nominal amount. I would favour such an approach rather than rearranging your clinics to meet the tariff definition at the expense of a clinically determined, and more efficient model of care. I would be guided by the recent comments by Sir David Nicholson in his transition letter of 13 April 2011.

Here he states, “in taking forward decision this year you need to ask yourself two questions:

Will it improve care for my patients?
Will it improve value for tax payers?

If the answer to both is ‘yes’, then it’s the right thing to do.” In the fullness of time I would like to see clearer specification of the services to be provided in multi-professional kidney care clinics, ongoing national clinical audit of outcomes, patient experience and processes within those clinics, and a stronger evidence base for what works to improve quality of care with people kidney disease - my hunch would be that the attitude and behaviours of the team members are likely to be as important as the skills and competencies that are brought together within the multi-professional team.

In the meantime I would advise that the entry and exit criteria for the multiprofessional kidney care clinics are discussed and agreed with commissioners so that where necessary the flexibilities within the system are used to improve the quality of care for patients and value for tax payers. Kind regards, Donal

2 August 2011, 0900am: NHS Kidney Care e-seminar presented by Dr O'Donoghue "Introducing the multi-disciplinary tariff". Register here

428. The following principles for the application of local flexibilities will ensure that we continue to protect the benefit of national tariffs and currencies, whilst allowing for local innovation and material redesign of services:
(a) the flexibility supports the provision of care that is better for the patient and the NHS – obviously, any local flexibility should be supporting better care for patients, whether it is closer to home, more convenient or of higher quality: examples include one-stop shops or see and treat services. A flexibility may also benefit the NHS as a whole, by reducing the costs to the whole health system
(b) the flexibility supports material service redesign or mutually desired outcomes – local flexibilities are not a means of simply reducing or increasing national prices without any change to how services are provided. This would negate the benefits of national pricing. They may, in exceptional circumstances, be a means of enabling the provision of services to patients which would not otherwise be provided
(c) the flexibility is the product of local agreement – with due regard to the PbR Code of Conduct, flexibilities should be agreed in advance by commissioners and providers and, where appropriate local discussions can be supported by SHAs

(d) the flexibility is clearly established and documented – an audit trail for the agreed flexibility is necessary and it should be documented as part of contract negotiations
(e) the flexibility should be time limited and reviewed as appropriate – flexibilities are not set indefinitely. For instance, innovation payments apply for three years. It may be that a local innovation becomes the national norm and the tariff changes to recognise this.

444. Tariff is a fixed price, however in exceptional circumstances, where providers and commissioners agree, they can seek approval to operate a variation to price which is lower, but not higher, than the published tariff, provided that there is no adverse impact on quality, patient choice or competition.

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