Department of Health Consultation Options for the Future of Payment by Results: 2008/09 to 2010/11 Consultation Response Proforma Published: 15 March 2007 Closing: 22 June 2007 Your comments must reach us by that date 1.1 As part of our reply to this consultation, we will provide an update on expressions of interest in the proposal to establish PbR Development Sites and confirm our plans. Options for the Future of Payment by Results: 2008/09 to 2010/11 Consultation Response Proforma Respondent Details (Please provide the details of a single point of coordination for your response) Title Full Name Organisation Your Role Mr / Mrs / Miss / Ms / Dr / Professor / Other Peggy Frost College of Occupational Therapists Practice Development Manager
Address (including postcode) 106-114 Borough High Street Southwark London SE1 1LB Email Address Peggy.frost@cot.co.uk Phone Contact 020 7450 2333 If you are replying on behalf of a group of respondents or a number of organisations, please complete the following information: Organisations represented within this response College of Occupational Therapists Note: We would also welcome any anonymous responses. Date of response: 18 th June 2007 Confidentiality: Information provided in response to this consultation, including personal information, may be published or disclosed in accordance with the access to information regimes (these are primarily the Freedom of Information Act 2000 (FOIA), the Data Protection Act 1998 (DPA) and the Environmental Information Regulations 2004). If you want the information that you provide to be treated as confidential, please be aware that, under the FOIA, there is a statutory Code of Practice with which public authorities must comply and which deals, amongst other things, with obligations of confidence. In view of this, it would be helpful if you could explain to us why you regard the information that you have provided to be confidential. If we receive a request for disclosure of the information we will take full account of your request, but we cannot give an assurance that confidentiality can be maintained. An automatic confidentiality disclaimer generated by your IT system will not, of itself, be regarded as binding on the Department. The Department will process your personal data in accordance with the DPA and, in the majority of circumstances, this will mean that your personal data will not be disclosed to third parties.
Chapter 2 Strengthening the building blocks of PbR Qu. 2.1 page 29 Classifications Do you agree with the strategy outlined for the development of classifications to support PbR? x Strongly agree Agree Neither agree/disagree Strongly disagree nor disagree There are concerns amongst occupational therapists that in acute settings, therapy services are disadvantaged as they may not be involved with every patient in a diagnostic group. Where therapy services do not feature in a standard tariff / classification for interventions this may result in insufficient resources to meet patients needs. Qu. 2.2 page 29 Frequency of classification updates What is a reasonable frequency for implementing updates to the classification from 2008/09 onwards; a) annual; or b) biennial? Initially, annual updates will be required until the system is robust and bedded in. Only then should less frequent updates be considered. However, we would like to see future systems that are responsive to developing and new diagnoses and interventions. Qu. 2.3 page 32 Currencies What steps should we take to ensure successful implementation of HRG4 in 2009/10? It is essential to engage with all the clinical groups, including occupational therapists, who are involved in care pathways at an early stage. Communication, widespread publicity and training about updates and application of HRG4 will be needed to ensure there is speedy and accurate uptake.
A more granular approach is a more representative system. Qu. 2.4 page 34 Costing Do you agree with our approach to implementing patient level costing? x Strongly agree Agree Neither agree/disagree Strongly disagree nor disagree The College of Occupational Therapists (COT) supports the move to make cost data representative of the services actually delivered to patients. It will be essential that the process employed allows for contributions from occupational therapists and managers at the front line. Patient level information is a key to accurate costing. It not only allows working from the bottom up, but also keeps services patient focused. The data that is collected needs to realistic and robust and all staff must fully understand the importance and application of the system to complete data accurately and in a timely manner. However, occupational therapists report that systems and accuracy of patient data remains problematic in some clinical areas. Many Trust services do not have an IT system for information collection and collation and therapists are still using paper-based systems. Furthermore, medical records are not always comprehensive. Indirect costs will need careful consideration as these may have geographical, demographic, rural and urban differences. Qu. 2.5 page 35 Timeliness of data flows How realistic is it to deliver the proposed improvement in timeliness of data flows from 2008/09 and what issues need to be considered? Given that many therapists report they are still using paper-based data collection systems and that the Integrated Care Records Service is not fully in place there is little confidence amongst occupational therapists and other
AHPs that this is progressing within the timescale indicated. As a consequence front-line staff feel isolated from the programme. Further work needs to be done on data quality given the 12% error (p 34). Clear, easily understood data definitions are essential for accurate data recording by therapists and effective tools are required to ensure accurate information is entered and that minimal time is taken away from patient care. There is a need for better training, improved information and meaningful engagement with occupational therapists and their managers. Chapter 3 Developing the national tariff Qu. 3.1 page 37 Calculating the tariff using data from a sample of providers What particular issues do we need to consider in accrediting providers data quality and in determining a representative sample? A representative sample of providers can have advantages over a national averaging system for determining tariffs, so long as it is truly representative. Selected sample organisations should include the comprehensive range of professions contributing to patient care, with reliable systems for collecting patient data from the range of professional groups. It is important the tariffs that are developed are credible and practical for commissioners and providers as well as staff and patients. Providers need to be able to evidence accuracy and ownership of data by all professional groups in their organisations. Data used in the compilation of national tariffs must be representative of actual activity, actual workforce and capital considerations. Selected providers must be able to demonstrate a high degree of understanding of all service elements within costed care pathways. This should be underpinned by evidence of clinical and front-line management engagement in the cost analysis. Care should be taken to ensure that minority specialities are included in the scope of services offered across the selected providers. Qu. 3.2 page 40 Prices that reflect quality and effectiveness
Does the approach outlined provide the right incentives for change that delivers quality care and value for money? It is not clear how judgements will be reached about quality service provision delivered by front-line clinicians. Qu. 3.3 page 43 PbR should support commissioning of care pathways Are there examples of where the tariff acts as a barrier to commissioning care pathways and, if so, what changes to the tariff structure would help overcome these problems (e.g. bundling or unbundling)? The tariff needs to be flexible so it can be unbundled to meet patients needs and choices. This is also important where a number of different clinical routes are available to reach a particular outcome for a patient. It should be clear which professional groups are involved in the price set. Unbundling will help provide clarity about the options available. It will, for example, help source occupational therapy and / or rehabilitation from a range of providers in a range of settings to meet patients needs. Where specialised services are included in the HRG, it is essential that this element of the tariff is unbundled and that the costs identified are representative. Qu. 3.4 page 44 Unbundling the tariff Given the approach outlined, what, if any, are the barriers remaining for unbundling tariffs? Finished Consultant episodes are often a different time frame from other professions episodes with individual patients.
Qu. 3.5 page 47 Applying the tariff to the same service in different settings Extending the use of HRGs to outpatient and community settings would require coding of activity in the same way as for admitted patient care where a procedure is undertaken. Is this a feasible proposition? Further detail is needed about how funding for interventions will follow the patient, through their care pathway into the community, especially for those with long term conditions. Consideration will need to be given to potential conflict of interest if PCTs become both commissioners (buyers) and commissioned providers (sellers) of services. More work will need to be undertaken if there is to be any success in securing a true care continuum for individual patients. The ability to employ PbR effectively has to be a very strong driver to success. Rehabilitation takes place in and across a range of settings, e.g. in the community, in hospitals, in specialist services. As a result, due to the complexity and / or fragmentation of care, the costs are very different for each patient. Therefore careful consideration needs to be given to how tariffs will be applied to ensure they can be unbundled to meet individual needs. See also Qu. 3.3. Qu. 3.6 page 50 Specialised services What is the best way to refine the approach to funding specialised services in 2008/09 under HRG3.5, and in the future under HRG4, in a way that funds services not institutions? There is a risk that specialist services will not be financially viable because they do not fit the norm in terms of diagnoses or interventions under PbR. Their work is often highly specialised and / or complex. The wider implications are that expertise and innovation will be lost to the country as a whole. Occupational therapists report they are unclear what will be classed as specialist services. This is a particular concern at the moment and during transition where one service, which covers the north of England, reports difficulties obtaining funding, lack of parity between PCTs and the negative effect this has on long term planning and service development.
Further information and the findings from evaluations are needed to be able to make any further comments on this point. However, as occupational therapists work in many specialised services we would welcome the opportunity for further input. Chapter 4 Future of tariff setting Qu. 4.1 page 56 Governance Do our new arrangements for tariff setting provide the transparency that stakeholders want in a way that is consistent with the Secretary of State s responsibilities to operate within a fixed cash limit? The new arrangements will provide transparency so long as the detail and rationale is made available. The new arrangements will need time to bed down so stakeholders can rebuild their confidence in the system. Qu. 4.2 page 57 Multi-year price signalling Will the proposed arrangements for multi year price signalling (2008/09 2010/11) support better service planning, and what additional information would help improve this? Occupational therapists and their managers believe this will support enhanced service planning if arrangements are cascaded in a timely way through organisations and, in particular, when the level of detail included in tariffs is in place. PbR will also need a system that effectively deals with the rapid development of new clinical and technical interventions as they emerge.
Chapter 5 Extending the scope of payment by results Qu. 5.1 page 59 Three generic models of PbR Do the three proposed models of PbR offer a sound basis for expanding the scope of PbR in the future? Strongly agree Agree Neither agree/disagree Strongly disagree nor disagree This appears to cover all the options, but it is difficult to comment at this point as PbR is not yet fully implemented across all services. Systems still need to be in place to ensure there is continued quality of care and innovative models of care are financially viable during inception. Qu. 5.2 page 62 Criteria for applying PbR to different services How could the proposed criteria for applying the three models of PbR to different services be improved? Occupational therapists and other AHPs are legitimately concerned that services seen to be at the margins of the system are currently vulnerable and that PbR does not address the problem. The criteria help clarify whether a service can be subject to national currency and pricing, but there needs to be a clear framework to govern the process of arriving at local pricing for all services that are not or cannot be nationally priced. Systems and accuracy of data collection remain a key issue. How will reasonable be defined? In order to achieve a level playing field for services there also needs to be a level playing field of data collection across disciplines.
Qu. 5.3 page 62 Priorities for developing national currencies Based on the proposed criteria, what are the priorities for developing national currencies? Again, consistent data collection and manipulation across sectors and efficiency of data flow is fundamental. Whilst the criteria appear sensible and reasonably comprehensive, there are concerns about how they will be applied in reality. We believe existing national currencies should be fit for purpose not simply acknowledged as reasonably fit for purpose. What is reasonable? (p 62) Qu. 5.4 page 67 Needs-based funding Which areas of healthcare could most benefit from a needs-based funding approach? Adults and children / young people with long term conditions People with complex and / or multiple needs People with mental health problems General Qu. G.1 Of the issues discussed in this document, which are the three most important and should therefore be prioritised? 1. Data all aspects including defining, collecting, systems, facilities, training, information, engaging with staff. 2. Clinical engagement with occupational therapists, other AHPs and their managers to further develop PbR and unbundle tariffs. 3. Avoiding a two tier system that marginalises the more difficult to cost and / or specialist services.
Qu.G.2 Do you have any ideas for developing PbR that you would wish to pilot? If so, please express your interest here to allow us to pass on to the relevant SHA or to the FT Network as appropriate. Qu.G.3 If you have any additional comments on any aspect of the consultation document, please list here. PbR is largely focused around medical models of coding and interventions. As a result it is difficult at present, identify where those services that span both physical and mental health will fit. Annex B Qu. B.1 If you have any comments on the extension of PbR to the services outlined in Annex B, please list them below, specifying which services your comments relate to. The COT hopes there will be a high level of occupational therapy involvement in the processes outlined in Annex B to ensure there is an understanding about these services to be able to arrive at appropriate tariffs. In particular, we would like to highlight the following: - Urgent and emergency care occupational therapists play an increasing role in many A&E departments, providing assessments and interventions to a range of patients, for example the older person who has fallen. - Adult mental health services occupational therapists are one of the five key professions providing a range of interventions for patients with mental health problems both in hospitals and in the community.
- Outpatient attendances where a consultant is not clinically responsible - Telephone consultations - Community based alternatives and community services occupational therapists have a wide and varied input into a range of community services to meet the needs of a variety of patients of all ages. - Long term conditions care occupational therapists work with children and adults of all ages with long term conditions. They provide a wide range of interventions both in the community and in the acute hospitals working for health trusts, and have also worked in social care for many years. Annex B describes community based alternatives to hospital care, community services and long term conditions under three sections. However, in reality these are often the same thing, not three separate services. The COT hopes you will feel free to contact us if you require any assistance sourcing experts or information in these areas. Economic, social or environmental impacts Qu. I.1 Would any of our proposals lead to economic, social or environmental impacts on you or your organisation? Equality Impact Assessment Qu.E.1 Equality Impact Assessment Please outline any ways in which the PbR policy described in this document may impinge on human rights.
Qu.E.2 Equality Impact Assessment Please outline any way in which the PbR policy described in this document may discriminate or cause inequality relating to groups covered by equality legislation: race, disability, gender, age, sexual orientation and religion and belief. Qu.E.3 Equality Impact Assessment Please outline any way in which the PbR policy described in this document may protect human rights and promote equality (within race, disability, gender, age, sexual orientation and religion and belief) and prevent inequality.
Code of Practice on Consultation All written, public consultations must follow the Cabinet Office Code of Practice on Consultation. The full text of the code of practice is on the Cabinet Office website at: www.cabinetoffice.gov.uk/regulation/consultation/code.asp. The code contains the following six criteria to be followed when undertaking consultations: 1. Consult widely throughout the process, allowing a minimum of 12 weeks for written consultation at least once during the development of the policy. 2. Be clear about what your proposals are, who may be affected, what questions are being asked and the timescale for responses. 3. Ensure that your consultation is clear, concise and widely accessible. 4. Give feedback regarding the responses received and how the consultation process influenced the policy. 5. Monitor your Department's effectiveness at consultation, including through the use of a designated Consultation Co-ordinator. 6. Ensure your consultation follows better regulation best practice, including carrying out a Regulatory Impact Assessment if appropriate. The Code also invites respondents to comment on the extent to which the criteria have been adhered to and to suggest ways of further improving the consultation process. For DH consultation, comments or complaints (but not your response to this consultation) should be directed to: Consultations Coordinator Department of Health Skipton House 80 London Road London SE1 6LH Email: Mb-dh-consultations-coordinator@dh.gsi.gov.uk Please do not send consultation responses to this address. WHERE TO SEND YOUR RESPONSE TO THE CONSULTATION Completed questionnaires, responses and comments should be sent by 22 June 2007 either by email to: futureofpbr@dh.gsi.gov.uk or by post to: Payment by Results, Department of Health, Quarry House, Quarry Hill, Leeds LS2 7UE.