Feature / An eye on quality

Last summer’s report High quality care for all set the scene for a new phase of development across the NHS, to make quality the organising principle of the NHS. From next year the Department of Health will put in place one of the key foundations to turn this into a practical reality. The national tariff – which has been based on national average costs since it was introduced – will start to move to a system that incentivises the very highest standard of care. It will do this by ensuring that the tariff targets incentives at both commissioners and providers to improve the quality of care.

Gall bladder removal, or cholecystectomy, will be in the vanguard of this move to best practice tariffs. It is seen as an important place to start in improving the quality incentives within the payment by results system. A total of 48,000 elective gall bladder removals were carried out in 2007/08, 40,000 of which were elective procedures. There is an enormous variation in the proportion of these that are carried out as a day case, ranging from close to zero in some trusts to up to 60% in others (see page 22).

Gall bladder removal will not be alone. Three other high volume service areas will also be included in the programme. In addition to being high volume activities, all four service areas share other characteristics. For instance they all exhibit significant unexplained variation in the quality of clinical practice and can draw on clear and compelling evidence of what clinical best practice constitutes. Cataract surgery will provide a second elective procedure, while stroke treatment and care for patients with fragility hip fractures add two non-elective services.

These have since been joined by renal dialysis, which is currently outside the scope of PBR and is following a slower timetable (see ‘Cleaning up on cost’, page 28).

People may question whether a policy of pushing for best practice is affordable in the current economic context. The answer should be yes, as the evidence base shows that best practice care is cost-effective care.

Tool for improvement

The best practice tariffs will be a tool to enable commissioners to deliver improved health outcomes within the limits of tightening budgets. Indeed, improving processes and procedures and prioritising the most effective treatments both reduce errors and waste, improve the quality of care, and make the health service more efficient and productive, as does keeping people healthy and independent for as long as possible.

For example, the elective procedures being investigated for best practice tariff development are both characterised by some aspects of best clinical practice being lower cost. For cataracts, a clinical pathway that is efficient and streamlined creates a better experience for patients, as they spend less time waiting for appointments and having to make trips to the hospital or clinic. But this pathway can also be delivered at a lower cost.

In addition, the majority of patients requiring removal of the gall bladder will have better clinical outcomes and a reduced risk of contracting healthcare acquired infections if they receive keyhole surgery and are able to go home on the same day. Removing the gall bladder as a day case for all patients for whom it is clinically appropriate also reduces costs by freeing up bed space.

For the non-elective procedures being investigated – stroke and fragility hip fracture care – investing in providing best clinical practice can bring substantial returns further downstream. Preoperative delays result in an increase in complications and an increase in length of postoperative stay. Stabilising patients with fragility hip fractures effectively to allow prompt transfer to theatre can therefore reduce the overall length of stay for the patient and may also allow the patient to regain more of their independence more quickly following discharge.

 Similarly, by delivering brain scans and clot-busting drugs rapidly to patients who have had a stroke, outcomes for patients can be drastically improved. In addition, providing the best quality rehabilitation care from the very start of the patient pathway improves the patient’s mobility and overall level of independence in the long term.

Finally, by quickly and effectively providing follow-up assessments to patients showing symptoms of mini-strokes or transient ischaemic attacks (TIAs), and providing clinical interventions where necessary, full strokes can actually be prevented.

Clearly, the medium- and long-term benefits to patients of receiving the best clinical care for stroke and fragility hip fracture are also invariably linked to cost savings long term.

Tariff models

There is no one model of best practice tariffs to fulfil the objectives of promoting quality and value within every service area. Rather, the approach of a best practice tariff depends on the characteristics of best clinical practice that are recommended, and on other service specific characteristics.

For some service areas, the best practice tariff aims to create savings outright, by cutting waste and unnecessary steps in the patient pathway. For others, the benefits will be delivered further downstream, in terms of encouraging fewer readmissions, avoiding interventions and reducing the need for ongoing community support.

Each approach has been developed alongside clinical experts including national clinical directors for stroke, trauma and kidney care, as well as with the involvement of the NHS Information Centre and the NHS Institute. Indeed, the NHS Institute’s series on developing best practice pathways for a range of high-volume services was a starting point for establishing the services to choose for the first set of tariffs. Views from the NHS have been taken on the price, structure and implementation of these tariffs.

For cataracts, therefore, one option would be to pay for a defined ‘pathway’ of care that only includes the number and type of appointments considered to be best practice for both patients.

For gall bladder removal, a way to incentivise best practice would be to adjust the price relativities, so that there would be an incentive to move activity into the day case setting and to provide keyhole surgery whenever clinically appropriate.

The British Association of Day Surgery suggests that as many as 60% of gall bladder removals could be performed in this way, which contrasts with a national average of 18%, demonstrating the scale of improvement that could be achieved. In addition, the tariffs correspond to new HRGs, which have been redesigned to increase the visibility of the proportion of gall bladder removals that are carried out using keyhole surgery and as a day case by their providers, allowing commissioners to monitor this activity.

For stroke the aim is to create national tariffs consistent with the new models of care that are emerging in response to the national stroke strategy. The characteristics of clinical best practice that the tariff is seeking to incentivise are: rapid and effective hyper-acute care (including brain scanning and delivering clot-busting drugs where appropriate); holistic and high-quality rehabilitation delivered well and from the start of the patient’s pathway; and timely and effective follow-up for patients presenting with symptoms of mini-stroke.

For both stroke and fragility hip fracture, the proposal being explored is to provide two tariff prices that differentiate between current and best practice. Providers that demonstrate best practice care would be eligible for best practice payment.

In addition, options are being explored in terms of how the tariff can be made flexible enough to follow the patient when the pathway moves across more than one provider.

The best practice tariff for renal dialysis will follow slightly later, as the first step is to bring renal dialysis within the scope of payment by results. This will be achieved by setting non-mandatory prices for renal dialysis for 2010/11 based on 2007/08 reference costs. Mandatory tariff prices will follow soon after, and will aim to take a best practice approach.

With all the references to quality and value, the best practice tariffs resonate with the new focus on delivering quality, innovation, productivity and prevention (QIPP). The future direction of the tariffs and how the approach will be rolled out into other service areas will rely on the impact that these first few tariffs have in incentivising improvements in practice and in delivering improved value for money. This success will be measured following an evaluation of the policy’s impact.

The first set of best practice tariffs will be available when the tariff package is road tested at the end of 2009 and released with the rest of the national tariffs, with payment beginning on activity from April 2010.

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