Technical / Monitor plans change to investigation triggers

As part of the RAF, Monitor currently assesses foundation trusts’ financial risk using a continuity of services risk rating. This considers two aspects of financial robustness – liquidity and capital servicing capacity. (Liquidity is measured as the days of operating costs held in cash or cash-equivalent form, including wholly committed lines of credit available for drawdown; capital servicing capacity is the degree to which the organisation’s generated income covers its financing obligations.)

Each metric is scored on a 1 (high risk) to 4 (low risk) scale and the scores combined (averaged and rounded up) to give an overall continuity of services (COS) rating. The RAF requires Monitor to consider an investigation when a trust has a COS rating of 1 or 2.

Each foundation trust’s quarterly rating is initially calculated based on its submitted annual plan. This is then adjusted through the year based on actual financial performance.

However, Monitor is consulting on changes to the threshold that would trigger further investigation. Its framework update consultation (closes mid-February) points to ‘significant pressure on foundation trusts’ and ‘increasing numbers of providers that may be at risk of breaching the COS requirements now and in the near future’. ‘At times it may be appropriate for Monitor to investigate a potential issue earlier, especially where earlier intervention could prevent further deterioration or help resolve issues more easily,’ it says.

The current trigger for investigation – COS rating of 1 or 2 – would stay in place. But Monitor is concerned that a strong position on liquidity may mask significant risk in capital servicing – or vice versa. For example, a foundation trust with a rating of 4 on liquidity and 1 on capital service would be rated as 3 overall, avoiding further investigation. So it proposes an override, with a foundation trust scoring a 1 in either liquidity or capital servicing capacity facing potential further investigation.

Monitor says an investigation will not be an automatic consequence of scoring 1 in either metric, but it does mean an investigation will be considered and could be taken forward.

Monitor also has plans for stress-testing foundation trusts’ submitted forward plans. This recognises a poor-quality plan may not adequately reflect the potential future risk to continuity of services, it says, masking concerns that may otherwise have led to earlier investigation. To counter this, Monitor proposes testing plans against different scenarios and assumptions. If a plan is considered poor after this testing, the regulator may investigate.

In brief

Changed sections of the 2014/15 foundation trust manual include: annual reports and accounts in FTs’ final period of operation; and transfers of public dividend capital in transactions accounted for under absorption accounting.

The final version of the Department of Health group manual for accounts 2014/15 – formerly the NHS manual for accounts – is now available, accompanied by mandatory guidance on changes in discount rates as from 31 March 2015.

The Department of Health and Department for Communities and Local Government have set the policy framework for the better care fund in 2015/16. Issues include payment for performance metrics, the legal and financial basis of the fund, access conditions and assurance and approval processes.

The Department of Health has amendedthe main schedule of its national reference costs schedule for 2013/14 to correct discrepancies relating to cystic fibrosis.

NICE update: Upfront testing could improve pneumonia treatment

Pneumonia is an infection of the lung tissue. Diagnosis is based on symptoms and signs of an acute lower respiratory tract infection, and can be confirmed by a chest X-ray showing new shadowing. It is usually bacterial in origin and can be a severe illness, so it is usual to prescribe an antibiotic. More severe cases may need hospital admission.

Between 220,000 and 484,000 people have community-acquired pneumonia every year in England and there were about 175,000 hospital admissions in 2013/14. Between 1.2% and 10% of admitted adults are managed in intensive care. At any time, 1.5% of hospital inpatients in England have hospital-acquired respiratory infection – said to increase hospital stay by about eight days.

A new guideline from NICE, CG191 Pneumonia: diagnosis and management of community- and hospital-acquired pneumonia in adults, includes several recommendations. It suggests that, for people presenting with symptoms of a lower respiratory tract infection in primary care, a point-of-care C-reactive protein test should be considered if a diagnosis of pneumonia has not been made. The results should guide prescription of antibiotics (yes, no or delayed).

C-reactive protein tests are rarely used in primary care for this purpose. Some 5,500 GP practices would need to invest in analysers to carry out the point-of-care testing, though they can be used for other tests too. This would be a one-off cost of £700 to the GP practice – £3.8m in England. There are recurrent costs of £13.50 per test.

Better targeting of antibiotics supports the Department of Health’s Start smart, then focus antimicrobial stewardship guidance to help reduce the threat of antibiotic resistance.

Improvement in identifying appropriate treatment regimens could lead to a reduced use of antibiotics. Appropriate use of delayed antibiotic prescriptions may also reduce the number of repeat appointments.

The guidance also recommends the consideration of pneumococcal and legionella urinary antigen tests for people with moderate or high severity community-acquired pneumonia.

These tests are performed by pathology departments in hospitals and cost about £40. The current level of urinary antigen testing is not known. Performing the tests may lead to more timely and appropriate treatment with antibiotics that target the specific cause of the pneumonia. This should improve outcomes for people, help reduce length of stay and support the antimicrobial stewardship targets.

Reduced length of stay beyond the national tariff trim point may represent savings for commissioners. There could be more efficient use of beds for providers, depending on local circumstances. The saving for each bed day avoided could be £192 – or more for critical care.

By Nicola Bodey, senior costing analyst at NICE