Comment / The right start

The national tariff proposals for 2016/17 recommended small changes to the maternity pathway payment system, adding six clinical factors to help clinicians assign a woman to the correct level of complexity in the antenatal phase. It also changed some of the casemix assumptions , effectively increasing the payment for more complex pathways relative to the more straightforward ones.

Nothing really to write home about – especially given that these also featured in the 2015/16 proposals and were effectively put into practice by the enhanced tariff offer that most organisations signed up to when the original tariff plans were rejected.

So, given that we appear to be at the tweaking stage, should we assume the pathway tariff system, introduced in 2013, has been a success? According to finance practitioners I’ve spoken to recently, that is not a straightforward call to make.

They say the new approach is tidier. For a start, it expanded the scope of what was paid for under the tariff, as community antenatal and postnatal care was previously paid for using local contracts. And instead of counting and billing for individual observations and investigations, providers now receive a payment for each phase of the pathway – antenatal, delivery and postnatal – with different rates depending on complexity.

It removes perverse incentives – hospitals delivering more proactive services would have been worse off under the old system. And it gets rid of a system that simply looked unfair. Depending on how hospitals recorded those individual observations and investigations – as short stay inpatient admissions or outpatients – they could be paid significantly different amounts of money, even though the care delivered was effectively the same.

But the new system is not perfect. The recharging process is clunky and time-consuming, built on as-yet imperfect data flows (using the relatively new maternity data set). And there remain concerns about what is and isn’t included in the tariff payment.

Fetal medicine is a prime example. Monitor and NHS England insist these services have been included in the costs that contribute to the maternity quantum – and so are covered by the tariff. But some providers remain unconvinced.

However, the real measure of success should be how the tariff is aiding the provision of better maternity services. Back in 2011, then health secretary Andrew Lansley said the old activity-based payment system encouraged a reactive approach that increased the chances of last-minute interventions. He wanted a payment system that facilitated more proactive services. Clinicians may not be directly influenced by how services are paid for. But the payment system should at least support any changes that services want to make.

There’s been no formal review to date, but it is hard to find examples of significant service change. This may be harsh. The financial environment is hardly conducive to developing new services, often running initially in parallel with existing services.

Maternity services are delivered in networks, so clinicians want a payment system that supports this. Paying for pathways arguably provides a better fit for this model than paying by intervention. It needs to enhance collaboration. Just because a woman has been transferred to a regional centre for an investigation doesn’t mean she should continue the rest of her antenatal care there. Can the payment system support these decisions and make such transfers easy to deal with in terms of payment?

The NHS faces significant financial pressures across all services – and perhaps maternity more than many others because of issues such as staffing guidance. So now is probably not the best time to judge. But the point of new payment systems is to support service improvement and as the NHS looks to develop better payment approaches across the board, it will be important that we check they deliver their key objectives.