News / Local reviews to set thresholds for avoidable readmissions

The rules on non-payment for readmissions will be simplified and the marginal rate emergency tariff amended, NHS deputy chief executive David Flory said as he confirmed details of the 2012/13 payment by results (PBR) package.

Mr Flory said there would now be no distinction between readmissions following elective and non-elective initial admissions. In the current year non-payment applies to most readmissions following an elective admission, and to a locally agreed proportion of readmissions following non-elective admissions.

In a covering letter, he said the draft guidance published for the road test had acknowledged that both commissioners and providers had found the policy on emergency readmissions difficult to operate. The final PBR guidance went further, saying it had led to unacceptable variation in implementation.

However, Mr Flory said pilot reviews of emergency readmissions had demonstrated a way of giving the policy a firmer clinical basis.

In 2012/13, commissioners and providers will carry out local clinical reviews to determine the proportion of readmissions not paid for. These will give providers and commissioners a greater understanding of the reasons for readmissions and provide a basis for agreeing the proportion of eligible readmissions that were avoidable through action by the whole health economy – provider, primary care team, community health services or social services.

The reviews should take place over a set period and will use a standard reporting format and methodology. They should be led by a clinician who is not employed by the provider and set a threshold for all avoidable readmissions.

Following the review, providers should not be reimbursed for the proportion of readmissions judged to have been avoidable through the actions of any agency. If agreed, separate proportions can be set for readmissions following elective and non-elective admissions.

There had been some concern about the use of the savings generated by the policy. ‘I should like to stress that the savings arising must be reinvested in rehabilitation and reablement services to help avoid readmissions, with providers  involved in this process. PCTs must account for how this money is spent,’ Mr Flory said.

While unhappy that the Department was penalising acute providers for readmissions that are outside their control, the Foundation Trust Network (FTN) said the changes were an improvement. It would give much greater focus on holding commissioners responsible for how they spend savings and ensure providers are consulted on where to focus this spend. The use of clinical review also provides a stronger evidence base on where this investment would be needed to prevent readmissions.

FTN chief executive Sue Slipman said a thorough review of the policy was still necessary. ‘We would like… to ensure that avoidable readmissions are actually being reduced and acute trusts are not being fined for outcomes beyond their control,’ she said.

A provider finance manager contacted by Healthcare Finance echoed the FTN’s views, adding that the revision was a step in the right direction.

The Department has also amended the marginal rate emergency tariff to help providers that have emergency admissions below the 2008/09 baseline but continue to have funds deducted because of fluctuations in small-volume contracts. Mr Flory said contracts worth 5% or less of the 2008/09 baseline should not attract the marginal rate where the overall value of emergency admissions is below the 2008/09 baseline.

The final PBR arrangements revealed a small number of changes to prices published at road test.