Key Performance Indicators proposed for ‘over treatment’ assurance
Rationale for this indicator / 18week assurance ? / Indicator / Measurement / Improvement path / Prevent deterioration / commentsService Delivery
Improvement in discharge planning would reduce this risk and impact to patient/commissioner / 1.Emergency Re-admissions / % of patients admitted for same or related condition within 14 days of previous discharge / 25% reduction of variation to national average in each and every subsequent year. All variations from this at 100% deduction. / 100% of amount in excess of previous year’s agreed baseline %
Improvement in health economy approach to management of ambulatory conditions. Indicator recorded and deduction reflects balance across Local Health economy / 2. Avoidable Emergency Admissions (19 Ambulatory Care Sensitive Conditions - ACS) / National Benchmark indicator for each of the 19 ACS as published within Institute for Innovation and Improvement Guidance / 10% reduction in variation to national average in each and every subsequent year / 100% deduction on growth from last year
Elective targets
Improvement in planned admissions would reduce risk to commissioner and impact on patient / YES / 3.Cancelled Operations[1] / Number of operations cancelled by the Provider for non clinical reasons / 100% on growth from last year
if rescheduled >28 days 100% deduction per case
Improvement in planned admissions would reduce risk to commissioner and impact on patient / YES / 4.Admissions for no surgical procedures / % of elective inpatients who do not receive operations / 25% reduction of variation to national average in each and every subsequent year. All variations from this at 100% deduction National benchmark of 12% / 100% deduction on growth from last year
Reduction in threshold for procedures where alternatives are available when clinically suitable.
This indicator should only be used in absence of Effective Use of Resource policy which sets out any treatment protocols and exclusions for providers / YES / 5.Elective procedures provided above expected levels (e.g 5 procedures such as tonsillectomy, D&C, hysterectomy, lower Back surgery, myringotomy ) / 5 Nationally identified standardised admission ratios / 25% reduction of variation to national average in each and every subsequent year. All variations from this at 100% deduction / 100% deduction on growth from last year, unless speciality level case can be made
Treating patients out of order on a waiting list uses higher level of activity than with treat in turn approach. Agreement on capacity required for ‘urgent’ patients is key to this indicator / YES / 6.Treat in Turn
(i.e. urgency scheduling) / Expected v actual profile / 100% deduction applied for variance between expected and actual number subject to local agreement
Efficiency
Reducing reliance on hospital for follow up’s and ensuring no incentive for recording changes
Aligns with PBC planned transfer of routine follow up to primary care settings / 7.Outpatient Follow Ups / Average New to Return Ratio’s as published within Institute for Innovation and Improvement Guidance[2] / 25% reduction of variation to national average in each and every subsequent year. All variations from this at 100% deduction / 100% deduction on growth from last year, unless speciality level case can be made
Reduce any potential incentives for inefficient internal pathways for referral, thus potentially generating over –treatment not approved as clinically necessary / 8.Provider Initiated Referrals:
a)Consultant to Consultant Referrals for the same condition
b)intra Provider Referrals
C)Tertiary Referrals / For a) and b), in the absence of national benchmarks or an agreed reduction plan, no growth from previous year’s outturn.
For c) establish hospital transfer rate / 25% reduction of variation to national average in each and every subsequent year. All variations from this at 100% deduction / For a) and b) 100% with reference to previous year’s outturn.
For c) 100% based on evidence provided on a local level. / Any referrals to be made for reasons not connected with the current referral other than urgent cancer referrals or similar urgent referrals not subject to choice must be referred back to GP, where a new first outpatient referral may be made allowing for patient choice.
Therefore we are expecting a reduction ( to be agreed ) in consultant to consultant referrals within FT
The providers recording and charging policy for any modality of care will be governed both by the clinical necessity to treat and any specification for care issued by commissioners, informed by clinical best practice / 9.National benchmarks for Modality:
Indicators are captured to determine the degree to which variation from ‘norm’. these would therefore apply in the absence of a policy issued by commissioners regarding the required setting for delivery of any service (at HRG level or above) for example / a)A&E conversion ratio’s.
b)outpatient procedures
c)classifications of Ward Attenders / a) ratio of admissions via A&E to new A&E attenders:% of 0-2 day admissions via A&E.
b)% of 9 Nationally recommended outpatient procedures charged as such
c) agreement between parties as to what constitutes ward attenders / No reduction plan . absolute / a)for variations between actual and national benchmarks, 100% deduction applied.
b)for variations between actual and national benchmarks, 100% deduction applied.
c)Determined locally / Penalties stronger here due to need for drive toward appropriate modalities for recording
Expected EBD’s above trim point established as disincentive for early discharge or increased LOS / 10.Excess bed days / Number of days above benchmarked[3] HRG Trim point. / 25% reduction of variation to national average in each and every subsequent year. All variations from this at 100% deduction. / 100% of amount in excess of previous year’s agreed baseline %
ConfidentialPage 125/01/2019
Annexe
Completed questionnaire
PURPOSE AND OBJECTIVESQ1 Do you have any KEY comments on the purpose statement below (sec 2 of this paper)?
A1
To enable PCT’s to commission services appropriate to setting, need and in accordance with specified pathways , ensuring efficient use of resources
Q2 Will a national model contract, intended to be used by PCTs, NHS Trust, NHS FTs and locally procured IS provision, be useful, and why?
A2
Yes as a expected minimum standard and fall back position from which to negotiate local agreement
18 WEEKS/DEMAND MANAGEMENT
Q3 How should the 2007-08 contract stipulate the requirement for Providers to meet 18 weeks milestone for March 2008 (with appropriate tolerances)?
A3
Joint plan with clear assumptions across CAS and Acute providers and with associated detailed scenarios.
Q4 What incentives/deductions should there be for exceeding/failing to meet this milestone? How can they be applied? At what level of granularity should they be applied (e.g., overall elective volume, split by specialty, or by HRG chapter?)
A4
See examples identified above
Q5 How should the contracting for 18 weeks cater for the potential multi-provider nature of the target?
A5
Through the scenarios on choice and across pathway CAS /Acute
Q6 Has the current model FT contract assisted the parties in managing demand? Do the Notice to Increase and Reduce provisions included within Clause 25 assist in this process?
A6
Not really. Key issue has been modality of care, aligning the contract terms for recording charging with clinical decisions and ensuring that clinicians can support this charging policy. often they are not engaged in this whilst PBC is now very engaged and the debate is moving into clinician to clinician agreement. The contract needs to reflect this.
The schedule locally developed on demand and risk has been useful in identifying the key risks and responsibilities in delivery, key enablers required and any financial impact. This ‘real demand management’ is to be distinguished against the over-treatment /inefficiency approaches identified in this paper. Both are required.
Q7 How should the contract state expected ranges of activity, and how broad? (so that the PCT has a trigger to intervene if trust exceeds this activity level for unacceptable reasons: a) clinical over-treatment via increase in OP-IP conversion rates, increase in consultant-to-consultant referrals, and b) burning through waiting lists too quickly) What planning assumptions need to be specified and how?
A7
Dependent on the cause there should be appropriate deduction made see examples
Q8 What level of granularity should this definition of activity be at (e.g., overall elective volume, split by specialty, or by HRG chapter?) – and over what period should measurement of activity being “too high” occur (e.g., over a rolling 3 month period)?
A8
At specialty as a minimum
Quarterly reconciliation with year to date position for year end agreements
Q9 How should the contract give the PCT the right to implement utilization reviews, prior approval on consultant-to-consultant referrals, new-to-follow-up ratios etc. in this case? What is the best way to prove/disprove whether a provider has over-treated?
A9
See example KPI’s
This should be complimented by strength in information schedule for verification and audit information to substantiate claims. Emphasis should shift on burden of proof for identified high risk areas is on the provider for PCT to pay as claimed
Q10 What financial deduction mechanisms should the contract stipulate should it proved that the provider has over treated?
A10
Combination of deduction for any growth and movement toward national benchmark
NON-ELECTIVE ACTIVITY (ensuring affordability for the PCT)
Q11 Should the contract include expected activity ranges for emergency attendances and admissions? Should it include sanctions for unacceptable increases in admissions %?
A11
Yes
There should be detailed activity plans with associated assumptions. Growth in ratios should be subject to deductions.
Q12 How should the contract cover finances for non-PBR activity (pricing)?
A12
As a minimum there should be recommended format for this element of the contract in terms of price, activity, benchmark and contenstibility review.
Contract should set out ability of PCT to market test these services to ensure best value and VFM and that providers should fully co-operate in provision of information for this to take place.
QUALITY, MONITORING AND PAYMENT
Q13 Should the mandatory section of the contract stipulate quality assurance/ improvement mechanisms and metrics, with associated incentives/ deductions? If so how? Or should this be left to local (transparent) negotiation?
A13
Mandatory section should focus on national targets and delivery systems /levers for this. Currently there are few penalities for missing these targets through the contract mechanism, this relies on monitor. Strengthening the performance notice system where this is in respect of national target delivery and agreement for escalation to joint meeting of PCT and Monitor would assist.
Quality : the contract should set out a recommended framework for quality measurement and reward. (see previous documentation) left for local completion at present
Q14 Do the information requirements within Clause 34 of the current FT contract adequately reflect current practice and do they assist in the regular and timely flows of information needed to govern payment and demand management?
A14
Update as required with SUS
Q15 What minimum (mandatory) information requirements and KPIs would you like to see in the contract? Within what time frame should the information be provided to the PCT?
A15
Deduction for non compliance at 2% currently release when compliance achieved.
Information schedule should set out mandatory minimum requirement and local required information flows to support PCT commissioning and demand management. These should not be with held.
Q16 What deductions mechanisms should the contract stipulate for failure to provide accurate information, on time?
A16
As above
Q17 Has contract and performance monitoring been implemented in accordance with the current FT contract? If not, do the current provisions provide a basis on which this could be achieved or how could they be improved?
A17
Performance monitoring on a monthly basis, notice given to provider by commissioner of areas disputing for Quarter reconciliation. This notice of areas of dispute should be formalised into the performance and reconciliation section of the contract.
Q18 How clear are the pricing and payment mechanisms included within Clause 8 of the current FT contract, particularly in relation to Service Prices?
A18
Clarity on uplifts and efficiency for non tariff services, exclusions to contract (e.g Drugs) should be locally determined and not anchored to national tariff uplifts. Dependent on position with regard to benchmarked performance.
Q19 What approach should be taken in the contract in case of proven and intentional up-coding and over-billing?
A19
This is difficult wording. ‘intentional’
Threat of a large fine and immediate referral to monitor for suspension of licence.
DISPUTES AND ARBITRATION
Q20 If there are disputes before a contract is signed (e.g., Provider and PCT cannot agree on acceptable activity ranges), how should these be resolved? What steps can DH/ SHAs take to ensure that contracts can be signed promptly in time for the start of the financial year?
A20
Resources at national level or regional level is lacking.
A procedure setting out key dates and milestones for economies is required and where these stages are being missed additional SUPPORT not performance management is required to assist. This must be expertise that can be deployed at both a technical, legal and executive level to make sufficient progress.
Q21 The mechanism for resolving disputes will need to be included in the contract. In case of disputes after signing, how should a dispute and arbitration scheme work? How effective is the current CEDR? Would you also like to have the option of binding adjudication?
A21
Alternative to CEDR would be useful if this could be established. At times ‘expert determination’ may be appropriate.
IMPLEMENTATION AND SUPPORT
Q22 The section of the contract on 18 weeks will be “Mandatory for local completion” (local completion because activity profiles will differ by PCT). How much support/ guidance will Provider and PCTs need to be able to complete this? Does DH need to provide some examples of this section?
A22
Yes examples and support will both be needed on this significant challenge
Q23 The proposal is that each Provider will have a contract with a lead/ co-ordinating PCT. What problems might this cause – and how could these problems be resolved?
A23
A co-ordinating PCT is a preferred term. Sufficient support and resources to provide this role is required as part of this move.
A clear description of this role and responsibilities would be helpful together with a signed PCT to PCT agreement.
Main contract co-ordinated by the lead PCT with summarised heads of terms and relevant schedules with other PCT’s.
Q24 Will PCTs and Providers be able to administer the national contract?
A24
yes
GENERAL
Q25 To what extent has the current model FT contract assisted in establishing a contractual framework between PCT's and Acute Trusts and can the provisions included within it provide a basis for the development of the National Model Contract??
A25
Has been very useful in following as a basis for clarifying roles, terms and performance arrangements.
Starting with the existing contract is a sensible way to go forward and improve key sections as outlined above.
Q26 From your current contract perspective, what are the MAIN areas that need changing and why?
A26
Ability for commissioner to set out specification for a service, modality for treatment.
Service variation section strengthened to reflect the need for providers to give notice on service changes which impact on patient experience, capacity , recording or setting of delivery. Without this commissioners are ‘caught out’ on non commissioned service changes which impact on a range of indicators and funding.
Strengthen requirement for information requests in support of PCT commissioning role, demand management and verification to be responded to without delay – penalties here would be useful.
Q27 What are your SPECIFIC proposals in this area, and how would you overcome any possible objections?
A27
See above
Q28 Do you have comments on the proposed structure of the new contract (sec 3)? Is there a better way of combining the need to distinguish between national, national/local, and local, with the need to make the contract applicable to three types of provider?
A28
National minimum with worked up local examples for completion is a helpful approach
Q29 Do you have ONE more strategic recommendation to make to the DH on the effective us of contracting arrangements?
A29
Good dispute resolution mechanisms are required
Higher support and advise to economies in particular sharing of contractual management issues – engagement of NHS Networks to support this or other similar route.
Acting Chairman: Mr J. Dunlop Chief Executive: Mr R. Popplewell
Professional Executive Committee Chair: Dr D. Dawson
[1] The items highlighted in red show the categories which will also be applicable in determining any breach of 18wks.
[2]Institute for Innovation and Improvement:Delivering quality and value.
[3]