Consultation on mandating patient-level costing in the ambulance sector

Transcription

1 Consultation on mandating patient-level costing in the ambulance sector August 2018

2 We support providers to give patients safe, high quality, compassionate care within local health systems that are financially sustainable.

3 Contents About this document... 2 Scope of the consultation... 3 What are we proposing?... 6 Future direction of travel Annex 1: Patient-level costing consultation: glossary Annex 2: Trusts covered by the proposal Consultation on mandating patient-level costing in the ambulance sector

4 About this document 1. This consultation proposes changes to the requirements on ambulance NHS foundation trusts and NHS trusts 1 to record and report the costs of 999 activity. We propose that from 2019/20 the costs should be reported at a proxy patient/incident patient level, in line with the methodologies and approaches in the Healthcare Costing Standards for England (the standards). The changes would apply from the 2019/20 financial year, with the first mandated collection in Since 1 April 2016, Monitor and the NHS Trust Development Authority have operated as a single organisation known as NHS Improvement. This document is issued in accordance with the duty to consult imposed on Monitor by section 69(7) of the Health and Social Care Act In this document NHS Improvement means Monitor, unless the context requires otherwise. 3. The document covers: what we propose to change options reviewed how we engaged with the sector in developing these proposals. 4. It should be read with the annexes and the supporting documents, especially the impact assessment. 3 The document has been set up as a PDF form to allow you to enter your feedback directly into the document. Questions are highlighted in boxes. You can also provide your feedback through an online survey. 4 To use the PDF form, you will need to use Acrobat Reader. If this is not already installed, speak to your IT team or you can download it for free from: 1 See Annex 2 for the current list of relevant trusts. 2 The duty to consult applies where section 69 requires Monitor to carry out an impact assessment of proposals which are, among other things, likely to have a significant impact on providers of NHS services Consultation on mandating patient-level costing in the ambulance sector

5 Scope of the consultation 5. This is a statutory consultation in relation to the following proposal: For the financial year 2019/20 onwards, it would be mandatory for the NHS providers of 999 ambulance services to record and report patient-level costs for 999 activity in line with the Healthcare Costing Standards for England (the standards). The collection of reference costs in relation to this activity would cease, with 2018/19 being the last year of the submission of the reference cost return. This would reduce the burden to the ambulance sector and allow the ambulance providers to focus on implementing patient-level costs. 6. Collecting patient-level cost data is key to achieving the vision in the Five Year Forward View (5YFV) and improving patient outcomes and efficiency. We described the role of costing in supporting these wider objectives in our 2016 report, Patient-level costing: case for change. 5 The plan for the transition to costing at a patient level was set out in Improving the costing of NHS services: proposals for 2015 to As part of this process, from 2018/19 the submission of patient-level cost data has been mandated in the acute sector (for designated trusts). 7. There has been a good level of engagement with the ambulance sector in this process. For 2017/18, seven of the 10 trusts are planning to submit patientlevel cost data alongside the mandated reference cost return. At the time of the impact assessment, there were only two trusts without a patient-level cost and information system (PLICS) and in both instances systems are currently being implemented. 8. Our impact assessment indicates that mandating recording and submission of patient-level cost data using the standards would have significant benefits to trusts, commissioners and other users of the data: It would enable trusts to compare their data with peers at a detailed job-cycle level covering both performance and cost information to Consultation on mandating patient-level costing in the ambulance sector

6 The improved granularity of patient-level cost data will support engagement with the acute and other sectors by allowing the full pathway of non-elective patients to be identified and mapped. This in turn will help providers and commissioners identify changes to improve the flow of patient across the health system. Better cost data will improve currency design and support more accurate local tariffs. Although this mandation proposal only covers 999 services, many ambulance providers have indicated they will be able to use the same costing methodologies to support bids for commercial activities, such as 111 call centres and patient transport services (PTS). 9. This consultation invites you to feed back on the proposal to make patient-level costing mandatory for 999 activities from 2019/20. We plan to publish our response to the issues you raise and expect to make a final decision on the proposal in the autumn of We will publish our decision on our website. 10. If you want to keep up to date with this work, please see our costing newsletters 7 and the mandation page on our website 8. Responding to this consultation 11. The proposal for the mandatory submission of patient-level costs for 999 activity from 2019/20 is subject to a statutory impact assessment and consultation process, as required by Section 69 of the Health and Social Care Act 2012 (the 2012 Act). These processes offer stakeholders the opportunity to be informed of the likely impact of the proposals and to tell NHS Improvement what they think about them. 12. The consultation period begins on 20 August 2018 and ends on 1 October We welcome feedback on the proposals and will consider your responses before making a final decision on whether to mandate patient-level cost for 999 ambulance activity. 14. You can submit your feedback in two ways: Consultation on mandating patient-level costing in the ambulance sector

7 completing the online survey: answering the questions in this PDF, starting with the information about you requested below, then saving the document and sending it to 15. Both surveys contain the same questions. 16. Please contact if you need any more information. About you Name Role Organisation Organisation type (If other) 5 Consultation on mandating patient-level costing in the ambulance sector

8 What are we proposing? Mandation We propose that from the financial year 2019/20 onwards it will be mandatory for NHS providers of 999 services to record and report costs at a patient level for 999 activity 9 in line with the Healthcare Costing Standards for England. The mandation of reference costs will cease, with the final year of collection being 2018/ Trusts currently submitting reference costs using the agreed ambulance data would be required to record and report costs at a patient level. 10 The methods and basis for costing would follow the rules set out in the standards 11 published as part of the Approved Costing Guidance 12. Data would be submitted to NHS Improvement after the end of the financial year. 18. This data would be recorded and reported by the relevant ambulance NHS trusts and NHS foundation trusts (currently those noted in Annex 2) from the financial year 2019/20. The collection would take place after the end of the financial year currently planned for summer Currently cost data is collected on an average basis as part of reference costs, and the methods for calculating costs 13 have been on a comply-or-explain 14 basis rather than required. This has led to issues and differences in how costs are calculated, reducing the benefits for users from benchmarking their costs and pathways. Inconsistencies and poor methods of apportionment caused about half the inaccurate costing audit results over the last three years. 20. The result is that this reference cost data, using average costs and differing methods of apportionment, cannot easily be linked to an individual patient and can often hide errors in how resources are allocated. Because of this, the data The proposal only includes 999 related activities. Those services let under commercial contract 111 and PTS are excluded from this process Previously the Healthcare Financial Management Association Costing Standards, recently the Healthcare Standards for England. 14 A regulatory approach used in the UK and other countries in corporate governance and financial supervision. Rather than setting out binding laws, regulators set out a code, which listed companies may either comply with, or if they do not comply, explain publicly why they do not. 6 Consultation on mandating patient-level costing in the ambulance sector

9 does not allow ambulance providers to review and benchmark job cycles internally or with other providers. In addition, costing processes vary across organisations, meaning there is no consistency in costing processes or methodologies, affecting the usefulness of data for comparison, both between trusts and within organisations. 21. Our impact assessment indicates that, across trust who have implemented patient-level costing, more accurate costing will bring a range of benefits, including the following: Supporting the provision of care in the best environment for patients, as envisaged in the 5YFV. Patient-level costing would allow providers and commissioners to use anonymised activity to identify patient pathways across all types of providers from ambulance to community settings. This could support plans for integrated care across providers and contribute to a more joined-up and preventive approach across NHS and other service providers. Improving comparison between peers internally and with other providers. Production of consistently costed activity will allow more accurate benchmarking internally and with other providers, enabling identification of cost variations across providers. Better engagement with clinicians. Because patient-level costing is at a patient level and can be regularly produced, providers can share patient pathway and cost data with staff outside finance departments. This will not only improve the accuracy of the data, but will also allow ambulance trusts to understand what happens to patients transported to emergency departments and help identify other treatment options. Allowing providers and sustainability and transformation partnerships to assess the impact of changes in service provision. Many providers are already using patient-level data to model the impact on cost and pathway of changes to service provision. For example, a group of providers is looking at how to provide services across a variety of sites, allowing the creation of centres of excellence while maintaining quick access to emergency services. Providing more accurate data for agreeing local prices and local variations to national prices. In the past, prices have often been based on a provider s average costs. However, detailed costs at a patient level, which have been validated by clinicians and commissioners, would give a more accurate basis for discussing prices. 7 Consultation on mandating patient-level costing in the ambulance sector

10 22. We have estimated the costs of implementing and running PLICS as part of our impact assessment. The benefits to ambulance providers are not as clear-cut as for the acute sector, as patient-level costing has not been fully implemented in the sector. However, feedback from ambulance trusts that have recently implemented PLICS indicate there are other benefits they anticipate benefiting from, including: being able to cost across all services in a consistent manner (even where the service is a commercially let contract and cost information is not collected). This will reduce time spent on business cases and bidding for contracts as cost information will be readily available producing more accurate information to identify cost or savings improvements, or business cases for service changes. 23. By mandating the methods and approaches for costing set out in the standards we can ensure consistent costing, which will support benchmarking of costs and job cycles. How would patient-level cost recording and reporting be made mandatory? 24. The standard conditions of the NHS provider licence 15 contain provisions relating to pricing, including requirements on recording and reporting information about costs see conditions P1 and P2. The licence applies to NHS foundation trusts; NHS trusts are required to comply with equivalent conditions, including the requirements relating to pricing and costs. 25. The conditions require trusts to: record cost information in accordance with cost allocation methodologies published by NHS Improvement in its Approved Costing Guidance (condition P1) provide such information, documents and reports relating to costs as NHS Improvement may require for its pricing functions (condition P2). 26. These requirements apply if the relevant providers are notified in writing we notify providers by publishing the relevant requirements in our costing guidance Consultation on mandating patient-level costing in the ambulance sector

11 27. The proposal to mandate patient-level cost recording and reporting would be implemented by including the applicable requirements, methodology and standards in guidance published by NHS Improvement in advance of the financial year 2019/20 (likely to be January 2019). 28. This would mean that trusts would have duties to record and report costs in accordance with the standards. Failure to comply with those duties would be a breach of the relevant conditions, which might result in regulatory action by NHS Improvement, including, in appropriate cases, use of its statutory enforcement powers. Issues and risks of the proposal 29. This proposal is a significant change in how costs are recorded and reported across trusts. Implementing patient-level costing raises several issues. Table 1 summarises these issues and sets out the mitigation or rationale for our decision. Table 1: Obstacles to implementing patient-level costing Issue There are differences in the proposed currencies between reference costs and patientlevel costs. The new standards are very detailed, and some trusts are concerned they do not currently have all the expected information to fully implement the new approaches. Mitigation or rationale We believe that it will be possible to recreate reference costs from patient-level cost data should it be needed. However, moving straight to patient-level costing will reduce the burden on the small finance departments in ambulance providers, while also making patient-level costs the key source of costing and activity data for 999 services. Seven of the 10 ambulance trusts are planning to submit patient-level cost data for 2017/18 and we expect all providers to be able to be involved in a voluntary collection for 2018/19. We will continue to work with the Ambulance Technical Focus Group to identify trusts that need additional support and identify whether a transition pathway, like that for acute, is required for those trusts that are not as advanced as others. 9 Consultation on mandating patient-level costing in the ambulance sector

12 Issue The accuracy of underlying data has not been verified, and the cost of introducing patient-level costing may not lead to sufficient benefits to recoup the costs. Mitigation or rationale We believe that patient-level costing will improve the accuracy of data collected by providers and will allow trusts to compare aspects of job cycles both internally and externally to identify where processes can be improved. It will also allow ambulance providers to link in and be part of conversations about plans on how to access emergency and urgent care resources. Question To what extent do you agree with mandating patient-level data from 2019/20 for all incidents going through 999 call centres or dispatch centres at a proxy patient/ incident level, in line with the methodologies and approaches in the Healthcare Costing Standards for England? Strongly agree Agree Neither agree or disagree Disagree Strongly disagree What is the reason for your answer? Ceasing the collection of reference costs To support the implementation of patient-level costing, we propose ceasing the collection of reference costs, with the last year being 2018/ We believe that ceasing the collection of average reference cost data will not only reduce the burden on the small finance teams in ambulance trusts, but will also hasten the implementation and use of patient-level costs as the single version of cost data by providers, commissioners and other data users. 31. Because there are only four currencies for ambulance services, we are satisfied that we can stop, even though there are some differences between the currencies used for patient-level costs and reference costs. We believe that having a single consistent method of recording activity (and associated costs) 10 Consultation on mandating patient-level costing in the ambulance sector

13 will be beneficial, given there is currently no ambulance national dataset. We are also confident that, should it be required, we would be able to recreate reference cost data from patient-level costs. 32. The proposal does involve some risks and issues. We have included these, and the mitigation or rationale for our decision, in Table 2: Table 2: Dual collection issues Issue Reference cost data is used as the basis for local prices and moving to patient-level costs may impact on agreeing prices with commissioners. Mitigation or rationale This was noted during the impact assessment work. Those trusts not on block contracts have been using sophisticated costing processes to calculate and agree local prices. There is a risk that cross subsidisation of services could be an issue. However, ambulances work across very large geographical areas and will move between various commissioners patches as required. We will be making data from the voluntary patient-level costs collections for 2017/18 and 2018/19 available to ambulance trusts as part of the PLICS portal, and we are working with NHS England and the Ambulance Technical Focus Group to support the move away from reference costs for pricing purposes. Questions Do you agree with the proposal to cease collection of reference costs for 999 activity, with the last year being 2018/19? Yes No If you disagree, please explain why Is there an alternative? Please provide details of what you propose. 11 Consultation on mandating patient-level costing in the ambulance sector

14 Assessment of likely costs 33. Because of how each organisation has structured its internal finance process, we have only included an estimated cost of producing the required cost return whether reference costs or patient-level costs. For example, some providers include the cost of producing service-line reporting and other cost data as part of their costing function and others exclude this. Therefore, we have estimated the cost of producing a costing return (including collecting the relevant data and calculating the costs) based on information collected from previous reference costs surveys and onsite visits and data provided by trusts. We have excluded the costs of internal financial functions. Question Do you have any comments on our assessment of the likely costs? 12 Consultation on mandating patient-level costing in the ambulance sector

15 Future direction of travel 34. This section covers three topics where we would like to start collecting information on possible the future direction of travel. These are: frequency of collection move to full patient-level costing inclusion of other services (such as 111 and patient transport). Frequency of patient-level cost data collection 35. Although we are not currently recommending collection of patient-level cost data more frequently than annually, we would like to use this opportunity to invite comments from trusts and other users of reference cost data. 36. Currently, costing data is collected annually. However, in trusts, financial data is produced more frequently often quarterly. Producing and collecting cost data on a more regular basis would, initially, increase the burden on trusts. However, this would be spread over the year and we believe the overall increase would be limited. 37. Feedback from the acute consultation 16 indicated that more regular cost collections would be beneficial, but that issues such as how to account for yearend changes would need to be addressed before rolling this out. 38. We believe collecting patient-level cost data more frequently would benefit all providers and other users. For all trusts these benefits include: identifying issues with costing during the year rather than after the year-end, allowing correction and more accurate costs to be submitted supporting the financial management process as cost and activity information is available more frequently. More regular collection of data will enable trusts to identify and address issues on a timelier basis Consultation on mandating patient-level costing in the ambulance sector

16 39. For other users, we believe: it would further the work of, for example, the Model Hospital as metrics could be run more frequently, allowing them to support providers in a timelier manner it may reduce information collected by NHS Improvement for instance, data on costs and activity could reduce the information trusts must collect as part of quarterly reporting, and it would help in agreeing financial targets and cost improvement plans. Issues and risks of the proposal 40. As with our other proposals, we have identified issues and risks. Table 3 summarises these and explains the mitigation or rationale for the proposal. Table 3: Frequency of collection issues Issue Moving to quarterly collection would increase the burden on providers costing and finance staff and reduce the time available to investigate and review patient-level costing within trusts. Mitigation or rationale The burden would increase initially but much of the validation and investigation that currently happens at the year-end would be spread throughout the year so spreading out the time to review issues. We also believe that: more frequent collection of cost data would link better with trusts internal reporting arrangements and therefore better support internal financial monitoring the data can be used to support commissioning and reduce time spent investigating queries it will help identify cost saving plans and costs that differ from expectations more quickly. What would quarterly data be used for? We could regularly publish data validation reports and outlier information, to help trusts improve the accuracy of their data during the year. It could also be used to assess the impact of activity changes during the year. 14 Consultation on mandating patient-level costing in the ambulance sector

17 Questions Do you agree patient-level costing returns for the ambulance sector should, in time, be submitted quarterly? Strongly agree Agree Neither agree or disagree Disagree Strongly disagree What is the reason for your answer? If you agree, when would it be realistic to make this a requirement? 2021/ / /24 or later Please give details of any other risks or issues you feel need to be addressed to support the move towards quarterly collection of patient-level cost data Do you have any other views or comments to make on this proposal? Move to full patient-level costing 41. Under the current costing standards, detailed cost information is calculated at an incident rather than patient level. This is because ambulance trusts plan, manage and report their activity at incident level and the systems and processes for capturing information relating to specific patients are not sufficiently developed or widely used by the sector. 42. Ambulance trusts submit their information at an incident level to NHS Improvement along with NHS number where identified. Where this is not available or there are multiple patients treated at one incident, then NHS Improvement use an agreed methodology 17 to calculate this proxy patient cost. 17 The methodology will split costs by number of patients - assumes one patient per vehicle or, where more than one vehicle attends the number of vehicles is used as a proxy. 15 Consultation on mandating patient-level costing in the ambulance sector

18 43. To be consistent with other sectors, in the future we are considering how we move from this incident/estimated patient cost level reporting to actual patientlevel reporting. We would like invite ambulance providers, the sector and other interested parties to provide feedback on this proposal. 44. For ambulance providers, moving to patient-level costing would mean that the detailed cost of delivering care is calculated and collected for each patient, as opposed to each incident. For all users, it will provide information on patient pathways which can be used to identify improvements in services to reduce the burden on emergency departments as well as supporting wider system changes. Issues and risks of the proposal 45. As with our other proposals, we have identified issues and risks. Table 4 summarises these and explains the mitigation or rationale for the proposal. Table 4: Move to full patient-level costing Issue Ambulance providers plan, manage and report their activity at an incident level. There is no requirement to cost or report at a patient level. In several instances, patients are unable to provide details which would allow them to be identified (ie patient is unconscious, not registered, etc). This data is not currently collected by ambulance staff and requiring its collection, when it is not used except for costing, would be a burden to providers and front-line staff. Mitigation or rationale We would look to ensure that the burden to collect this information would be as minimal as possible. Part of this invitation will ask, not only whether we should move to patient-level costing, but to start identifying methods which, if agreed, could be used. We will work with ambulance and acute providers to agree a process to identify patient-level information for patients conveyed by ambulance to healthcare providers. As part of this information request, we are asking ambulance providers to estimate the percentage of their activity this would affect this will enable us to quantify and assess the burden in implementing this proposal. 16 Consultation on mandating patient-level costing in the ambulance sector

19 Questions Do you agree with the plan to move to from incident costing to patient-specific costing at some point in the future? Strongly agree Agree Neither agree or disagree Disagree Strongly disagree What is the reason for your answer? If you agree, when would it be realistic to make this a requirement? 2021/ / /24 or later Are you able to estimate, for your provider, the percentage of activity where the incident is not coterminous with a patient? (ie those where more than one patient is conveyed in an incident) Do you have any suggestions that would support moving to real patient-level cost collection? Please give details of any other risks or issues you feel need to be addressed to support the move towards collection of patient-level data at a real patient level Do you have any other views or comments to make on this proposal? 17 Consultation on mandating patient-level costing in the ambulance sector

20 Inclusion of other services 46. This impact assessment and the current costing standards only cover 999 activity that is to record and report the costs of all incidents going through 999 call centres or dispatch centres. However, ambulance providers undertake other activities for which cost data has not been collected in the past. This includes: NHS 111 is the free number to call when you have an urgent healthcare need which is not an emergency and can include GP out of hours services; and Patient transport services (PTS) to and from healthcare facilities. 47. These types of activities are usually tendered by NHS commissioners and let under commercial contracting arrangements. Discussion with trusts providing these services indicate that that across different commissioners, there are often variations which may impact on consistency of costing. 48. For 111 services, the benefits of collecting this data include: allowing providers and commissioners to better understand and manage the services contracted allow benchmarked between providers and when linked to outcomes, will allow providers and commissioners to review and improve other services to reduce the burden on emergency departments 49. Collecting PTS data will allow providers and commissioners to work across settings to obtain the best value for such contracts. 50. For NHS Improvement, collecting this data will support the work of Model Hospital, to provide detailed benchmarking to support providers and commissioners to ensure the most optimum services are provided for patients. 18 Consultation on mandating patient-level costing in the ambulance sector

21 Issues and risks of the proposal 51. Table 5 summarises the risks and mitigation for the proposal. Table 5: Inclusion of other services Issue Contracts for non-999 activities such as 111 services and PTS are let under commercial contacts. If collection and publication of such data was only for NHS providers, this could breach the rights of those NHS providers submitting cost information and damage their commercial position in relation to their market competitors Mitigation or rationale We are currently working with the independent sector to identify how patient-level costing could be rolled out across the services they provide, including 111 and PTS services. The issue of commercial sensitivity of data has been noted and collection of such data and uses would be discussed with NHS Improvements legal services as part of scoping any future collection. The lack of standardisation of commercial contracts for non- 999 activity may affect the ability to accurately and consistently cost and benchmark services these services. The impact of differences in contract arrangements should not affect the costing if the currency used (unit of cost) is consistent across all providers. As part of any development of costing standards we would consider how to manage any differences between contracts could be costed and recorded in any data collection. 19 Consultation on mandating patient-level costing in the ambulance sector

22 Questions Do you agree with the proposal to collect patient-level information for non 999 services in the future? Strongly agree Agree Neither agree or disagree Disagree Strongly disagree What is the reason for your answer? If you agree, when would it be realistic to make this a requirement? 2021/ / /24 or later Are there services which you believe should not be collected at a patient level? Please give details of any other risks or issues you feel need to be addressed as part of extension of collection of costs to non 999 activity Do you have any other views or comments to make on this proposal? 20 Consultation on mandating patient-level costing in the ambulance sector

23 Annex 1: Patient-level costing consultation: glossary Term Description 2012 Act The Health and Social Care Act activity This is activity for all incidents going through 999 call centres or dispatch centres. 111 services The NHS service provides urgent health advice out of hours, when the GP practice or dentist is closed. It's sometimes referred to as 'unscheduled care services'. This means that the service is there in the out of hours period when other sources of support such as the GP or dentist are closed. Approved costing guidance Costing transformation programme (CTP) Getting It Right First Time (GIRFT) Healthcare Costing Standards for England (the standards) Model Hospital The Approved Costing Guidance is provides essential information that trusts will be required to comply on costing in the NHS, including the costing principles Aims to improve the quality and use of costing information in the NHS, with patient-level costing and a single, national annual cost collection. A programme is helping to improve the quality of care within the NHS by reducing unwarranted variations The approved approaches and methodologies for calculating costs, published in the Approved Costing Guidance: A digital information service designed to help NHS providers improve their productivity and efficiency. 21 Annex 1: Patient-level costing consultation: glossary

24 Term Patient-level costing Patient-level information and costing system Patient Transport Services (PTS) Reference costs Description Calculating and collecting data at an individual patient level. The system used to record and report costs at a patient level. Known as PLICS. This service provides pre-planned non-emergency transport for patients who have a medical condition that would prevent them from travelling to a treatment centre by any other means, or who require the skills of an ambulance care assistant during the journey. The average unit cost to the NHS of providing 999 activities to NHS patients. 22 Annex 1: Patient-level costing consultation: glossary

25 Annex 2: Trusts covered by the proposal Org code RX9 RYC R1F RRU RX6 Trust East Midlands Ambulance Service NHS Trust East of England Ambulance Service NHS Trust Isle of Wight NHS Trust London Ambulance Service NHS Trust North East Ambulance Service NHS Foundation Trust RX7 RYE RYD North West Ambulance Service NHS Trust South Central Ambulance Service NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust RYF RYA South Western Ambulance Service NHS Foundation Trust West Midlands Ambulance Service NHS Foundation Trust RX8 Yorkshire Ambulance Service NHS Trust 23 Annex 2: Trusts covered by the proposal

26 Contact us: NHS Improvement Wellington House Waterloo Road London SE1 8UG improvement.nhs.uk Follow us on This publication can be made available in a number of other formats on request. NHS Improvement 2018 Publication code: C 14/18