Feature / Visiting rights

Development site 1
Community Health Stockport
Service area: health visiting

Community Health Stockport, the provider arm of Stockport Primary Care Trust, is initially looking at a four-tier currency to cover its health visiting service. Laura Foster, its associate director of provider finance and information, says that, as with many community services, the problem is the lack of data. Simply counting contacts – face-to-face, telephone or group contacts – provides little sophistication. A tariff constructed around a currency of crude contacts would fail to take account of the time taken in each contact, the services delivered or the circumstances or complexity of the patient involved. It would also provide the wrong incentives – rewarding more contacts or visits rather than patient convenience, efficiency and effectiveness.

To understand the detail of each patient contact better, the PCT has introduced a dedicated coding system. Health visitors are asked to add a clinical intervention code when recording each contact in the patient activity system. These codes enable health visitors to record the services delivered – distinguishing safeguarding interventions from breast feeding support, sleep management advice or post natal depression assessment, for instance.  (The codes have been selected by clinicians using SNOMED codes – the same approach being pursued for district and school nursing services.)

While clinicians are asked to record the primary reason for a visit, they can add codes if other services are delivered. This has enabled clinicians to identify four distinct activities as the basis for a tariff. First, there are the services provided to all children as part of the universal health visiting service. Then there are a range of services offered to children and parents at point of need – a problem with weaning, say, could lead to a requirement for an additional two or three visits before the child rejoins the universal pathway.

There are also services provided to children at medium risk, either in an at risk category or with a disability. These children may require more regular contacts. Finally there are services to very high risk children, delivered as part of a multi-agency response. 

The universal service tariff would be paid on a per capita basis covering a 12-month period, with separate funding for second-year-of-life care. The low-risk interventions would attract a fee per spell, while payments covering a year of care are suggested for the medium risk and high risk categories.

Mrs Foster cites the benefits. Commissioners would understand the services they are buying better, while the health visiting team (110 staff and a budget of nearly £3m) would have a budget that flexed with activity undertaken and the services delivered. There are other advantages. ‘Stockport includes areas of affluence and deprivation. We know experientially that people from the deprived areas need more services – but our systems have never been able to accurately quantify this. So for the first time on a monthly basis we know which teams are delivering what services,’  she says.

Mrs Foster believes greater sophistication could be built into the tariff, such as recognising the costs incurred in different aspects of health visitors’ core and more specialist roles – to link more closely with casemix and outcomes. But she says the four-tier tariff is a stride forward and could provide a model for the wider range of children’s 0 to fives services. ‘The key has been building this up from a knowledge of the activity being delivered – rather than a tariff created as a top-down accounting process,’ she says.

Commissioners are interested in the tariff although not yet ready to move away from the block arrangements.

Development site 2
South Birmingham Community Health
Service area: health visiting

South Birmingham Community Health (SBCH), part of South Birmingham Primary Care Trust, is one of the largest PCT provider organisations in the country. It has an annual turnover of more than £150m and is working towards being in the first wave of community foundation trusts. It is also in the vanguard of community organisations looking to develop payment mechanisms with greater links to activity and services delivered.

Underpinning the foundation application is an attempt to understand the organisation’s workload and financial position by service line (now required as part of the Monitor application process).  Better links between income and activity – and ultimately real tariffs – are seen as vital for improving the accuracy of the service line breakdown.

This began with the implementation of robust costing and contract monitoring information systems specifically tailored to community activity.

Then, linked to a productivity improvement programme, and with some assistance from external consultants, SBCH created a directory of all services, following 120 interviews with clinicians and other staff to identify clinical service lines.

Acting associate director of finance Justin Betts acknowledges it has been a challenging agenda. ‘But clinicians are enthusiastic at the prospect of finally being paid for the level and complexity of the care they provide,’ he says. ‘And we want to make the most of their experience to develop nationally transferrable currencies and tariffs.’

He says the Darzi focus on care in the community makes currencies and tariffs crucial, particularly in today’s economy.

So far 350 service lines have been identified, and with about 75% of contracts still on block arrangements, work is under way to develop tariffs for key business areas.

Internally the focus has been on health visiting, district nursing and occupied bed days as these made up roughly 30% of costs.  These developmental areas have also been incorporated into the CQUIN requirements of SBCH’s community contract for 2009/10.

South Birmingham Community Health employs 80 health visitors. Children’s services, including those delivered by health visitors, accounts for £30m of the organisation’s overall £150m income.

The project started by working with clinicians to identify three categories of activities into which all health visiting work can be organised. Category A covers all work relating to 0 to five-year-olds, including antenatal visits, visits after birth, follow-ups, immunisation promotion, health promotion activities and a development check at two to two and a half years. Category B covers services for children or mothers with a care plan, perhaps because of mental health issues. Category C relates to more severe cases, perhaps involving looked after children.

Having identified the three broad groupings South Birmingham drilled down into the activities of health visitors and district nurses to gain a better understanding of what and how care was delivered. ‘The health visitors and nurses completed a time to care plan,’ says Gurdial Mandir, acting head of costing and income at the provider organisation. ‘Over a three-week period, they recorded everything they did and how long it took. This included their travelling time, time with the patient or family, what they did, administration and training.’

This alone provided insights on how to develop currencies and tariffs. For instance, more than a quarter of district nurses’ clinical contact time was spent on wound care. For health visiting, half of staff’s time was spent dealing with patients in their homes, with 48% in clinics or health centres, while tiny proportions were in residential homes and hospital inpatient settings. Overall 56% of time went into direct patient contact or patient-related work with the rest spent on activities such as training, meetings and travel. The trust also analysed the time spent on activities by different grades of staff.

The overriding cost driver for both health visiting and district nursing is health professionals’ time. Mr Mandir says: ‘About £100m of our £150m budget is pay costs.’

And by identifying the time taken in typical interventions and visits, the organisation believes it has the necessary components for constructing a tariff. 

A shadow tariff is being used this year. Although this has started out providing a crude link to activity (total income divided by number of contacts), the aim is to improve sophistication as analysis of data enables better tariffs to be created. The initial aim is to identify a tariff for each individual activity.

This could mean visits or contacts attracting more than one tariff fee, but South Birmingham has not ruled out bundling activities together if analysis shows that costs of similar visits or interventions are similar. Having enough detail to understand and manage the service will be the key determinant in level of detail adopted.

Mr Mandir says how to structure the tariff to provide the right incentives to improve services and efficiency still needs to be determined, bearing in mind any currency will need to be nationally comparable.

One issue that needs to be resolved  is how to treat travelling time. Should the time spent travelling to a case be charged to a specific patient event or should all travel costs be apportioned evenly across the whole caseload? Or perhaps the PCT might simply pay for travel costs in a separate block contract, leaving the activity-based payments to focus solely on time spent with patients. 

The trust is looking to use existing information caught on its patient administration system to identify different patient types and the relevant tariff. It is working with nursing and health visiting staff to improve the capture of activity and exploring the use of handheld data recorders.

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