APMS Information

Information Gathered From Attending APMS Meetings

1.  At the first APMS meeting I attended, Richard Armstrong spoke about  APMS policy.  Richard said that  APMS was a contractual vehicle to contract with any organisation and was open to PCTs (and presumably acute trusts) and was a long term policy.  In contracting through APMS it was essential to ensure that patient standards were maintained but otherwise it was a flexible contractual vehicle enabling PCTs to engage with private and voluntary organisation, patients as well as other clinicians, including GPs. It was part of the government’s plans to see a plurality of providers.  The intention of a forthcoming white paper was to grow existing service provision, including the development of new providers

2.  APMS was a useful tool to create additional capacity .  More than 50% of PCTs would use APMS contracts to deliver out-of- hours services.

3.  Essential services on Greenfield sites were protected for GPs in the first instance.  Brownfield sites were open to competition.  GPC said it expected LMCs to be involved in any decision to tender wider than general practice.

4.  Bevan and Ashford is working with the Department of Health to develop a practical regulatory framework (some chance).  It has also (or it may be the same) prepared a draft contract, which was comparable to the out of hours contract.
 
5.  Regulations relating to APMS are concerned with safety rather than clinical pathways.

6.  PASA (Purchasing Agency www.pasa.nhs.uk) is developing a toolkit on how to procure APMS.  There was mention of collaborative hooks, but no one I spoke to seemed to know what this meant but the website has details.

7.  Pfizer is working in Haringey.

8.  Lise Llewellyn chairs APMS meetings in the main.

9. Terence Higgins Trust is well developed in its thinking on APMS and I have invited the delegate attending the meeting to speak at an event I have organised for the pharmaceutical industry to stimulate interest.

10. I have some information provided from the centre which I shall circulate at our next Executive meeting for information.

Maggie Marum
27 October 2004

Consultation On Commissioning For Health And Well-Being

As a general response, we should like to say that the proposals set out in the document are sound, comprehensive and, by and large, achievable. Its implementation will be key, however, and the document is relatively short on prescription, with little new in the way of innovation. Guidance is far from enough to ensure government policy is implemented. As the document leaves a very significant degree of discretion for organisations and their partners to create a local vision, this in turn will present some significant challenges.  It is important that there is solid performance management of the implementation of this document, which, in our view, fails to give sufficient steer to PCTs.

The following sets out the Association’s response to the specific questions raised as part of the consultation process.

Q1.  In many PCTs there are inadequate data and information on which to commission clinical services and on which people can base decisions about their health.  The information does not exist in many places to support the roll-out of practice based commissioning.  Without accurate local data and information at practice level, PBC cannot take off and patients cannot make sound judgements or be given sound advice. The measures of themselves are sensible. PCTs might also be encouraged to develop local websites for patients’/populations’ views on existing or new services and changes they would like to see generally.

Q.2  It is important to identify the local groups who do not routinely use services (Asian women for instance often do not accept invitations for cervical smears) and single out their local leaders – eg, representatives from mosques, West Indian churches, community centres etc to take into account their needs and views. In doing so, it is important that their views are acted upon to ensure sustained, meaningful relationships.  Tokenism undermines engagement of hard to reach groups.  Local authorities have particular expertise in reaching socially excluded groups, which should be both drawn and built upon.

Q.3   The proposals to deal with the development of joint strategic needs assessment and difficult issues surrounding data sharing between agencies are welcome.  However, while the intentions are excellent, the fear is that the process will become increasingly bureaucratic, and patients or groups of patients will experience further delays and suffer.  The dilemma is in the process.

It is equally important to address professional and cultural issues and avoid a silo mentality, which has always been a barrier to joint working (eg Northern Ireland).  There is, therefore, in our view, a need for a significant investment in HR change management to deliver the desired objectives.

Q.4   In the view of NAPC, the way in which to have greatest impact on health and well-being through joint strategic needs assessment is to draft legislation in the Local Government Bill to provide clarity as to the respective roles.  The Bill already makes local area agreements a more significant part of planning and PCTs will be required to participate.  This should then be followed by guidance which provides the appropriate carrots and sticks for sensible implementation.

Q.5   Other providers, as well as children and parents should participate in needs assessment, for those services commissioned through children’s trusts arrangements.  We are, however, unclear how practice based commissioning works in relation to children’s trusts.

Q.6   The information requirements are sound.  It is the implementation, once again, that is challenging.  Much of the data available nationally needs cleaning up – largely through practices identifying secondary care errors and gaming.  Data needs to be both accurate and timely; in most places this is not the case.  Practices, and possibly PCTs, may also need some support in its interpretation and use.

Q.7   A more appropriate response will be obtained from local authorities and PCTs.

Q.8   The development of common IT systems across all agencies is merely speculative and unlikely, when thinking of all the potential agencies involved in the health and safety of children and young people.

Q.9   It would be helpful to underpin local agreements with a set of common principles developed at national level.

Q.10   The proposals go some way to assuring a range of high quality providers for all service, but other factors impinge on quality, such as the manner in which the proposals are implemented; the quality of the service specifications and individual performances.  Longer term contracts, with break clauses, with private providers would assist in attracting a great number into the market place.

Q.11   A centrally developed contract template would be helpful provided there is scope for local variations either in specific disease areas or service segments.

Q.12   The proposals in themselves seem sound, but successful implementation reauires the early identification of patients/clients whose health and well being would render them suitable to return to work.  Clinicians will need support and training to bring about effective implementation.

Q.13    In a recent NAPC survey, a majority of practices reported that they had neither budgets nor data to enable them commission any services. Practices need greater flexibility than currently exists in the reorganised NHS and pressure should be brought to bear on those PCTs which are demonstrably failing to deliver the PBC agenda.

It would also be helpful if a broader raft of non-health opportunities were identified in the document to assist the less imaginative.

Q.14     A move towards a ‘voucher’ type system for each patient/client would empower more fundamentally service users.

Q.15    One audit rather than two will encourage and foster improved collaboration between health and social services and should lead to economies of effort.  Audit training may need some modification to enable auditors to work competently across the sectors.  The focus should be on quality outcomes.

Q.16   For many years meetings to discuss child protection issues have taken place around the country on Monday mornings, the very worst day to encourage GPs’ attendance.  Their engagement is important yet the rigidity of organisations excludes their involvement and contribution to discussions.  Most GPs know their patients and families very well, as they develop long-term relationships with them.

It would be possible to develop a quality framework to include engagement with children’s trusts as a measure of quality in the improvement of outcomes for children.

Q 17   Insightful performance management is needed.

Q.18   We support the proposal, in theory, at least, but it would be difficult to bring about satisfactorily.

Q.20   Clean, timely data; interpreting skills; consultation techniques; modelling skills; changes in attitude to risk taking, as well as recognition of the possibility of failure within individual organisational arrangements.

Q.21   Joint Strategic Needs Assessments might be extended to include housing, police services, voluntary organisations, transport and employer organisations.

Q.23   Allow practices to challenge rogue data, save millions of pounds and improve coding skills in secondary and primary care.

Q.24   We think that joint performance management and benchmarking might be a way to ensure assessments are used effectively.

Q.25   Local discretion would be a better option

Q.26   The approach provides the opportunity to effectively define the needs of children and young people.  A will to improve services for them at a local level is also needed, along with other competing demands on commissioners’ time and resources.

We hope you find our response to the consultation document helpful.  We are of the view that PCTs require a stronger steer to allow PBC to flourish and enhance the health and well-being of local populations.

Yours sincerely

E McCullough
Chief Executive
NAPC

The Role of Information

A brief guide to the role of information

1.1 What is Payment by Results?
The aim of the financial system is to provide a transparent, rules-based system for paying trusts. It will reward efficiency, support patient choice and diversity and encourage activity for sustainable waiting time reductions. Payment will be linked to activity and adjusted for casemix. Importantly, this system will ensure a fair and consistent basis for hospital funding rather than being reliant principally on historic budgets and the negotiating skills of individual managers.
Under the reforms to NHS Financial Flows, instead of being commissioned through block agreements as previously, hospitals (and other providers) will be paid for the activity that they undertake.
Primary Care Trusts (PCTs) will commission:
• the volume of activity required to deliver service priorities, adjusted for casemix (i.e. the mix of types of patients and/or treatment episodes)
• from a plurality of providers
• on the basis of a standard national price tariff, adjusted for regional variation in wages and other costs of service delivery.

1.2 How does Payment by Results work?
Under payment by results, hospitals are paid only if an operation or treatment is carried out. The Department of Health has drawn up a long list of procedures, such as hip replacements or treatment for heart attacks, each with its own Healthcare Resource Groups (HRG) code.

There are more than 1,000 HRG codes, designed to capture all the treatments and procedures that a patient might have while in hospital for a particular condition or operation. Similar coding systems exist in many other countries. Most importantly, the price of each HRG procedure or treatment is fixed in relation to a national tariff, based on its average cost across the NHS. Hospitals that operate in parts of the country where staff costs are unavoidably high, such as London, are reimbursed directly by the Department of Health.

1.3 Impact of PbR
Payment by results means a hospital will be paid the fixed price for every treatment it undertakes. If the treatment costs more – and around half of England’s hospitals are expected to fall into this high-cost category – the hospital will have to find ways of bringing those costs down. It can either cut costs, or try to do more operations to generate extra money.

On the other hand, if it costs a hospital less than the national tariff price to perform a treatment, then it can keep the extra money, just as businesses retain their profits, to use as it sees fit. If a hospital is able to increase its volume of treatments or operations, by attracting larger numbers of patients, it can also make money.

1.4 Implementation & Timescales
Payment by results is being rolled out relatively slowly. It will not be fully implemented until 2008/9, when the target is for 90 per cent of hospital care to be covered by the system. This will allow hospitals and primary care trusts, the local NHS health bodies who hold the budgets and buy services for patients, time to adjust to the new tariffs.

1.5 Benefits of System
If payment by results works as planned, the NHS will become more efficient and productive, undertaking more operations and treatments. Evidence from other countries with similar systems points to shorter waiting times (as in Australia) and shorter lengths of stay in hospital (as in Sweden).

Other potential benefits include more transparency about the work that hospitals actually do. The national public spending watchdog, the Audit Commission, recently found a 'significant proportion' of hospital trusts with inaccurate records, or in some cases, no data at all for some of their work.

Under the new system, hospitals will not get paid for unrecorded or badly recorded ('uncoded') activity. In theory, tax payers will have a much clearer idea how their money is being spent.

1.6 Issues with the System
Payment by results rewards volume, not quality. Hospitals can make money if they bring costs down, or increase the amount of work they do. But cutting costs might be at the expense of better-quality equipment or staff numbers.

2. SECONDARY USES SERVICE (SUS)

2.1 National Reporting Infrastructure
Information technology has a key part to play in making the Payment by Results system run smoothly and efficiently. In 2006/07, NHS Connecting for Health put in place a national reporting system for Payment by Results, linked directly with patient records. This system is part of the Secondary Users Service (SUS). It collects patient level activity information from providers and makes it available to commissioners. It is a national system, which will apply the tariff to providers’ activity information, calculate the payment due and notify each commissioner. In 2006/07, SUS outputs were made the definitive source of data for transactions under Payment by Results, replacing any local systems that may have been operating in 2005/06.

2.2 Key Benefits of SUS
• Ensuring that Payment by Results rules are applied accurately, consistently and transparently.

• Reducing bureaucracy, as NHS organisations no longer need separate information flows.

• Empowering commissioners. Their analysts are free to concentrate on analysing trends in the information rather than simply trying to apply the Payment by Results rules or check that their providers have applied them correctly.

• Enabling the Department to monitor the local impacts of Payment by Results at national level.

2.3 Why is Data Quality so Important for SUS?
SUS is the main means of transmitting NHS data to all who use reports of service activity. The data needs to be comprehensive, robust and accurate to provide the information needed for delivering a high standard of health care and for planners and managers to run the business of the NHS.
Data submitted to SUS for PbR needs to be at a high standard of completeness, timeliness and reliability. Providers must send their data to reach SUS in time for processing by the 'flex' and 'freeze' dates scheduled by the Department of Health for SUS/PbR. The data must report patient activity accurately if commissioners are to have confidence in the information base on which they rely for making payments. If data are of poor quality, providers could face loss of income and payments will not reconcile with the services delivered.

2.4 Improvements to Data Quality of SUS
The following steps have been taken centrally to ensure that providers’ data quality is improved:
• The NHS has been told to use the period in which SUS is in shadow form to compare its output with that from their local systems and use this to identify and address any data quality problems.

• Since May 2005, NHS Connecting for Health has been working with individual NHS providers with specific data quality problems to ensure that the SUS system can process the data.

• The Information Centre for health and social care are leading a data quality initiative to help the NHS make improvements to their data capture.

2.5 Transfer of Data into SUS
To support PBR, every secondary care provider in England has to send a set of standard data files (Commissioning Data Sets) to the SUS system. These files are basically lists of all the patients that they have treated in a given period, along with codes that describe what the treatment was.
Providers then submit these files as EDIFACT messages to a secure Data Transfer Service (DTS) from which SUS collects the data.
The files are stored in the SUS central repository and then extracts showing each PCT how much the relevant care has cost are produced by the SUS system and published on a secure site for the PCTs to access.

3. FLEX AND FREEZE

Providers must send their data to reach SUS in time for processing by the 'flex' and 'freeze' dates scheduled by the Department of Health for SUS/PbR.

3.1 Flex and Freeze Dates
The table below outlines flex & freeze dates:

Quarter Flex Date Initial Payment Adjustment Date Freeze and Final Payment Adjustment date
1 Friday 28th July 2006 Tuesday 15th August 2006 Friday 15th September 2006
2 Friday 27th October 2006 Wednesday 15th November 2006 Friday 15th December 2006
3 Friday 26th January 2007 Thursday 15th February 2007 Thursday 15th March 2007
4 (first month) Tuesday 27th February 2007 Thursday 15th March 2007 Monday 16th April 2007
4 (final) Friday 27th April 2007 Tuesday 15th May 2007 Friday 15th June 2007

3.2 How does SUS denote Flex and Freeze Dates?
SUS flags those spells created after flex and after freeze date. These are omitted from the relevant view, though still visible on-line via the current view. The date relates to the date the spell was constructed – effectively the date the information was loaded from the SUS environment to PbR.

3.3 How much Time is available to Validate and Check the Data in SUS between Flex and Freeze Dates?
Typically 10 weeks; the actual dates for flex and freeze will be issued by the Department of Health in the near future, following discussion with HES to avoid conflicting deadlines. This reflects the 24hr Service Level Agreement for BT to load data into SUS. Where data is provided in user defined format via McKesson, this period will be reduced by five working days, reflecting the McKesson SLA to pre-process the data.

4. DATA QUALITY

4.1 What are the real Benefits of Data Quality?
• High quality data will improve the patients' experience of the NHS:
Patients will receive better, safer care from the NHS if the information held about them on the NHS Care Records Service is accurate, up-to-date and readily available. High quality data means that wherever and whenever a patient requires care, the clinicians caring for them will have access to a complete accurate and up-to-date record.
• The NHS as a whole will also benefit:
Better quality demographic and clinical information, compiled and collected to common standards means the NHS will benefit from increased efficiency of its people. The NHS will also be able to measure successfully and plan future capacity needs more effectively.
4.2 What does 'High Quality Information' mean?
High quality information is:
• accurate
• up-to-date
• quick and easy to find
• free from duplication, (for example, where two or more different records exist for the same patient)
• free from fragmentation, (where different parts of a patient's records are held in different places, possibly in different formats).
4.3 Why is it important to have Accurate, Up-to-date Information?
If patient information is not correct and up-to-date there could be consequences for patient care and safety. For example, if a patient had recently moved house, but their records contained an old address, there could be problems in contacting that patient to arrange a necessary appointment. That patient could then experience delays in receiving essential treatment.
Doctors, nurses and others need to be able to rely on the accuracy of information available in order to be able to provide timely and effective treatment for a patient.
4.4 How is NHS Connecting for Health supporting NHS organisations in Improving Data Quality?
The Information Quality Assurance Programme (IQAP) has been set up to support data quality teams across all NHS organisations. IQAP will offer guidance to NHS organisations on various elements of data quality such as good practice and procedures.

5. CODING

5.1 What is Clinical Coding?
Clinical Coding is the translation of medical terminology as written by the clinician to describe a patient's complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internatinally recognised.
5.2 What are the Code Classifications?
1. International Classification of Diseases 10th Revision, commonly known as ICD10. This classification has been devised by the Word Health Organisation and its codes cover all reasons for patients admissions to hospital. These codes are widely used internationally.
2. The Office of Population Censuses and Surveys 4th Revision, commonly known as OPCS4. This classification's codes cover all operative procedures and interventions that patients have undergone during their hospital stay. These codes are used in the United Kingdom only.
5.3 What Use is Clinical Coding?
The aforementioned codes are used to support many functions within the NHS, both Clinically and Statistically.
These functions include:
• Clinically - Clinical Governance, Clinical Audit and Outcome and Effectiveness of Patient's Care and Treatment.
• Statistically - Payment by Results, Cost Analysis, Commissioning, Aetiology Studes, Health Trends, Epidemiology Studies, Clinical Indicators and Casemix Planning
5.4 Who does the Clinical Coding within an Acute Trust?
The Trust's Clinial Coding function is carried out by fully trained Clinical Coders who are either Nationally Accredited Clinical Coders or are studying for their Accreditation Examination or have many years experience as Clinical Coders.
5.5 The Importance of Quality Coded Data

There is a wide recognition in the NHS of the importance of good quality coded clinical data and the fundamental role it plays in the management of patient care. Clinical coding, of both diagnosis and procedures, is identified as particularly important under PbR – as these provide the two main determinants of the Healthcare Resource Group (HRG) that a patient is assigned to. This, in turn, links to payment.

6. SUMMARY

6.1 Audit Commission Reports
The Audit Commission has made Payment by Results a focus of their audit work and national studies programme. For further details regarding their studies please see: http://www.audit-commission.gov.uk

6.2 Early Lessons from Payment by Results Report, October 2005
One of the predictions the report makes, based on the experience in Australia where PbR was introduced a decade ago, is that as coding directly links to payments there will be a sharp growth in number of diagnostic codes assigned to each patient. This is a trend already being seen among Foundation trusts which currently average 2.4 diagnoses. In Australia the average is about three and in the US the average is closer to six.

The Audit Commission report points to Germany as an example of a health system that has introduced a funding mechanism similar to PbR, but has first invested heavily in upgrading information systems and improving data quality.

The report says that the NHS Care Records System, due to be delivered by NHS Connecting for Health by 2010, will go some way towards achieving this. "However, trusts still need to strengthen their internal arrangements to produce timely and accurate data."

6.3 Payment by Results Assurance Framework Report, December 2006
This report outlines the results and recommendations to the Department of Health by the Audit Commission for the Payment by Results assurance framework. The main objective of this framework was to support the accuracy of payments and the underpinning data of the new financial regime in the NHS.
Within the pilot inconsistencies and ambiguities in current data definitions and standards were identified. The Audit Commission suggests that these be addressed as an immediate priority.
The report concludes that the level and nature of clinical coding error is not so high as to destabilise the PbR regime, but it does undermine it, raising concerns about the accuracy and fairness of funding flows. In addition, it has major data quality, epidemiological and clinical implications.

7. Sources

http://www.connectingforhealth.nhs.uk

http://www.dh.gov.uk

http://www.chooseandbook.nhs.uk

http://www.kingsfund.org.uk

http://www.audit-commission.gov.uk

Joanna Mooney
Churchill Medical Centre
Kingston-Upon-Thames

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