Examination of Witnesses (Questions 200
- 219)
THURSDAY 14 JANUARY 2010
PROFESSOR ANDREW
STREET AND
DR PETER
BRAMBLEBY
Q200 Dr Stoate:
Can you explain up-coding to us and how much of a problem it is
in your experience?
Dr Brambleby: To give a simple
illustration, a different tariff is paid for someone who has an
operation to replace a faulty hip and an individual who has it
done with complications. The difference in price can be in the
order of £1,000. If you were a clinical coder in a hospital
with an incentive to protect your income, possibly for very laudable
purposes, you would scrutinise very carefully to see whether there
was any mention of diabetes, in which case you could add it as
a second diagnostic field. The price will then go up. But the
reality may be that the additional cost of that episode from the
patient's diabetes is not commensurate with the amount of money
the trust has just attracted. That is up-coding. If it was deliberately
exploited to the maximum allowed by the rules that would be gaming,
but if there was a deliberate attempt to add codes that did not
exist that would be fraud.
Q201 Dr Stoate:
Do you have much evidence that gaming is going on?
Dr Brambleby: The longitudinal
trends we observe would suggest that trusts use the maximum flexibility
available to them to attract the greatest possible cost for each
episode, so if that is gaming perhaps. Prices were set on the
basis of the typical experience of a typical patient and that
is why different bands and healthcare-related groups were put
in place. However, once the price has been set there is an incentive
to move the goal posts and to reclassify people for the maximum
income.
Q202 Dr Stoate:
Do you have much evidence of cost shifting where a hospital sends
someone back to the GP with a long list of things which effectively
that GP pays for subsequently? I have seen examples of it.
Dr Brambleby: We do not see as
much of it now as we did in the old days. There is now a developing
sense of common purpose. At the end of the day there is one NHS
budget and not much point in cost shifting, but there is competition
and so if anything there is reluctance to move people around the
system because then you lose your tariff-paying customers.
Q203 Dr Stoate:
Can you explain what tariff granularity is?
Dr Brambleby: I believe it means
the degree of specification within the tariff. If you had a tariff
for an orthopaedic episode it would have very low granularity.
If you could break your orthopaedic episodes into hips, knees,
carpel tunnels and so forth that would increase the granularity;
you would have smaller grains. I think that is what it means,
but it is an ugly term.
Q204 Charlotte Atkins:
What impact has payment by results had on the quality of care
for patients?
Dr Brambleby: It is definitely
mixed. There is an upside and very definite downside. On the upside
one of the rationales, such as there are, behind payment by results
is to encourage different providers to compete on the basis of
quality because the price is fixed. It harks back to the question
about fixed prices put by Mr Scott. In that regard it has been
a stimulus to improve quality. On the downside it has not encouraged
us to look at, or indeed commission, whole pathways or patterns
of care and that can have a negative impact. To illustrate that,
in my patch we had evidence recently from a general practitioner
who said he wished a patient could have ended his days in his
own home but because of the disinvestment in the community nursing
set-up that community support was not available. Therefore, the
person died in a place not of his or her choice, and at greater
expense. That is an example of an anomaly in the system that adversely
impacts on the patient's quality of care.
Q205 Charlotte Atkins:
In a hospital context there is no incentive for the hospital to
discharge the patient as quickly as possible. The patient may
be lying on the bed waiting for a doctor or consultant to come
along to do whatever has to be done. Very often there does not
appear to be very much urgency in terms of co-ordinating all the
tests and consultations that a patient needs once in hospital.
Payment by results does not really help us achieve a more co-ordinated
and focused pathway of care.
Dr Brambleby: Yes and no. That
takes us into a technical area of trim points. For example, a
patient may be an emergency admission for a chronic obstructive
pulmonary disease that has flared up. Whether the patient stays
for three days or 17 days we pay the same tariff. In that case
there will be a very strong incentive on the hospital for the
stay to be a shorter space of time because it is not getting any
added income, but it becomes difficult at the trim points. The
gap between two and three days is very substantial; it is more
than £1,000. Therefore, there is a disincentive to keep the
patient for a shorter time because one loses money potentially.
At the other end, once the 15 or 17 days are up thereafter it
is a daily rate, so there are mixed incentives for either keeping
or discharging the patient. To amplify that just a little, imagine
a system where chronic obstructive pulmonary disease patients
stay on average a week but the trust wants to get it down nearer
to four or five days and quite sensibly improve efficiency. If
it does that simply by referring the patient to a community provider
who will pick up the rest of the patient's recuperation and a
new tariff and cost begins one can end up adding more cost to
the system. That takes us from trim points to "bundling"
and "unbundling" tariffs. Those of us who work at the
sharp end of commissioning would like to see much more commissioning
of patterns and pathways rather than simply episodes of care.
Q206 Charlotte Atkins:
Can you identify any benefits from payment by results?
Dr Brambleby: There have been
some. I am not by any means alone as a clinician working in the
NHS to be deeply ambivalent about payment by results. We feel
that it was a sincere and partially successful attempt to address
the wrong question. What we see as the mission, which is hidden
or imbedded in "co-mission-ing", is to improve the health
of the population, not just secure healthcare for the population
and not necessarily make the hospitals the pivot or the main gravitational
attraction for that care. It is the overall health of the patient
for which we want to commission. To that end payment by results
has been a distraction and distortion and is tangibly counter-productive
in some cases.
Q207 Sandra Gidley:
You suggested that payment by results is "too blunt"
a tool for many clinical pathways and that "purchasers have
to pay the tariff whether the patient is better or worse, alive
or dead." What system would you have instead?
Dr Brambleby: To set some reference
or normative costs for a typical admission would be very helpful.
Had payment by results stopped at a guide price or a starter for
negotiating—maybe a maximum price—it would have taken
us some way. Where it fell down was that, first, it was far too
late; we needed it right at the beginning of the internal market
and long before we started to talk to external providers. I should
like to come back to the point about the rationale for payment
by results. A lot of it was to bring the external independent
sector into the market on a level playing field. The major flaw
in it was that it did not apply right across the health system;
it did not even apply right across the hospital system. In the
early years it was set just for planned operations and procedures
in the hospital context, not the rest. Therefore, for it to be
successful and achieve what we hoped it would and reach its considerable
potential tariffs should have been set right across the board
for mental health episodes and community episodes. A quick check
should have been made that if we multiplied the current volume
of activity by the tariffs set for that activity did it come close
to the money available so it did not break the system? Did we
have the IT in place to monitor all of this? It should have been
piloted in one or two areas to check that it worked and then launched.
That would have made a lot of sense. It could then have achieved
its full potential. If I give an analogy which I think is helpful,
it is a bit like changing from driving on the left to driving
on the right. If you are to do it you do not simply say it should
be introduced for buses and lorries for the first six months to
see how it goes. I do not believe that is a ridiculous analogy
because that is what it has felt like. It has not been gaming
per se. I do not believe there has been a lot of deliberate manipulation
of the system for ulterior or narrow ends but the system has led
to people bumping into one another.
Q208 Sandra Gidley:
You wanted to come back to external providers.
Dr Brambleby: I think I managed
to slip it in. Having said that, it was explained to us that one
of the principal rationales for introducing payment by results
and to fix the tariff and make it non-negotiable was to give new
entrants into the healthcare field the security of income for,
say, a three-year period which would justify their investment
in capital and staff to enter the market in the hope that contestability
and competition would drive up quality. In the end it had an adverse
impact to a degree; it got in the way of quality, flexibility
and choice.
Q209 Dr Naysmith:
When you answer Charlotte Atkins' question earlier I got the impression
that your ambivalence about the PbR system was more to do with
the fact that you hoped we would move into the community and more
into public health and this system really was not doing that.
Is that a fair summary of what you said?
Dr Brambleby: It is a very fair
summary. They key word in your question is "hoped".
We had hopes and expectations.
Q210 Dr Naysmith:
It is the government's stated aim to shift more care out of hospitals
and into the community and yet it seems PbR is having exactly
the opposite effect. Is that how you see it?
Dr Brambleby: It is a question
of degree, but generally that is how I see it. There are some
unnecessary impediments to the development of community services
and the community setting has suffered hitherto and is now in
a weaker position; it starts from a poorer base than it might
have done, say, five, seven, 10 or 12 years ago.
Q211 Dr Naysmith:
How do you believe PbR sits with other recent reforms such as
practice-based commissioning and foundation trust hospitals?
Dr Brambleby: Those are two very
different questions. I am a fan of practice-based comissioning.
It would add another clinical voice to the discussion which should
be about "co-mission-ing". It takes us back to the "mission2.
I do not suggest for a moment that the clinical voice should be
the dominant one. There should be a partnership between the patient
voice, the policymaker who holds the purse strings and the clinician.
But what it does is address, to a degree, the secondary/primary
imbalance. GPs are ideally placed to assess the need of their
practice population, to do something about it by prescribing,
referring or whatever, to assess the quality in real time because
they see their patients afterwards, and, as an addition to that
mix, to have some knowledge and control over the budget. I do
not go as far as to say they have to own the budget but they certainly
have to see it, recognise it and own the opportunity cost, to
use the jargon. As to foundation trusts, I think that if a local
hospital has a good connection with its local population—it
is often a major feature of local population, and there are friends
of local hospitals up and down the country—that can only
be a good thing. If the freedoms that they enjoy are used responsibly
and there is a sense of common purpose about meeting local health
needs within the available budget, fine.
Q212 Dr Naysmith:
Do you believe that PbR facilitates the standards of commissioning
that world-class commissioning now calls for, or is it an obstacle?
Dr Brambleby: Perhaps I should
declare an interest in that I was invited by Mark Britnell and
Gary Belfield to have some input into defining the World-Class
Commissioning values and competencies.
Q213 Dr Naysmith:
That makes you more of an expert, so we are glad to hear it.
Dr Brambleby: I do not know about
"expert". But it started very well with defining some
of the values in World-Class Commissioning. As I have seen from
the evidence of Mr Britnell to your Committee, it was about adding
life to people's years as well as years to people's lives. That
takes us into education, housing, leisure opportunities, having
a job and being all you can be. It is an awful lot more than simply
the delivery of caring services when you are ill. Therefore, the
values were good. Commissioning competencies made a helpful attempt
to define, belatedly, the syllabus. If you wanted to be a commissioner
and learn your craft here were the competencies which as an individual
or organisation you needed to cover to be good at what you did.
I believe that has been sidetracked into an understanding of commissioning
as the procurement of secondary healthcare services. It has lost
its way slightly in overemphasis on the transactional side of
commissioning and has not sufficiently emphasised the partnership
approach and a much wider health improvement agenda rather than
a healthcare delivery agenda.
Q214 Charlotte Atkins:
Senior officials of the Department of Health have told us that
commissioning did not really start to work until two years ago.
Is that a fair assessment?
Dr Brambleby: Yes; it had not
begun to realise anything like its true potential until two years
ago.
Q215 Charlotte Atkins:
Why do you think that was?
Dr Brambleby: That is a key question.
I think it would be interesting to ask people to define what they
mean by "commissioning" because many see it as the procurement
of secondary healthcare. They use it synonymously with purchasing
and payment but it is different. It was explained to me by one
of my trainers when I came into this area. Think of the difference
between commissioning a painting and purchasing it. There is a
totally different relationship between the artist and the person
who holds the funds. As someone who has committed his career to
the commissioning function I have been waiting eagerly for it
to start for the past 19 years.
Q216 Charlotte Atkins:
Is that because people are just not skilled enough in commissioning
the right things, or do you think the levers are not right?
Dr Brambleby: The skills are abundant.
The NHS is blessed with innovative people with good ideas and
commissioning could fly. What has happened is that we have not
managed between ourselves either to construct a system that really
liberates that creativity and local accountability, shaping local
pathways to local needs within a finite budget—we could
go a long way but the system sometimes gets in our way—or
have sufficient ambition to go for the available levers. It is
a very rich question and a very mixed answer. It has left us with
very mixed patterns across the country.
Q217 Charlotte Atkins:
Presumably, it varies around the country; it is not uniquely good
or bad. In different parts of the country different commissioners
do a better or worse job?
Dr Brambleby: Exactly so. If I
may venture an opinion to illustrate how asking new questions
leads to new answers, there is an approach to commissioning practised
in other countries round the world, some parts of Canada being
a good example. It is called "programme budgeting" which
is sometimes linked to "marginal analysis". Here the
proposition is a very simple one. Instead of a PCT asking how
much is spent on this or that hospital, prescribing general practice
and community services, the question is how much is spent on mental
health, cancer and maternity services, etc, across the board.
That should not be a difficult question but at the moment people
struggle to answer it. On the principle that it is better to light
a candle than curse the darkness there are some enthusiasts, of
whom I claim to be one, who say we should see if we can construct
that debate. It is timely to raise it because today on the Department
of Health's website the 2008-09 returns from every PCT in the
country have just been posted. Every PCT in the country has declared
where it estimates it has spent its resources in that year on
mental health, maternity and so on, that is, the 20 chapters of
the international classification of diseases. If we could correlate
the programme objectives and the providers' objectives we would
be an awfully long way down the road of being able to account
for where the money was going and do more good with it. For example,
I should not look at Scarborough Hospital simply as a £100
million-plus trust near the coast; I should think of it as 6%
of our cancer programme, 20% of our maternity programme and so
on. Every year we should have a discussion at the PCT about what
we want to do for mental health and maternity and therefore what
we want our various hospitals to contribute, or our GPs and community
services to contribute. "Is everybody happy with that? Do
patients agree with that?" If so, we let the contracts and
then on a monthly or annual basis we ask: "How are mental
health and maternity are getting on? Is it costing what we thought?
What will we do if it is going adrift? Is it delivering the outcomes
we hoped for?" There is a better way.
Q218 Charlotte Atkins:
Do you believe World-Class Commissioning has improved patient
care?
Dr Brambleby: To a degree, yes,
but it is nowhere near its full potential. Is it sufficiently
complete and finished as an exercise? No.
Q219 Charlotte Atkins:
What needs to happen to take it to completion?
Dr Brambleby: I believe there
needs to be a re-attunement and re-engagement in what the mission
for commissioning is, to get everybody on the same page. "Are
we a national health service or a national healthcare procurement
business?" "What is the dominant theme and therefore
what is the model?" If we are a health improvement business
it takes us into the realms of practice-based commissioning and
much closer partnership working with local authorities which can
have a very significant impact on how well and how long people
live. Take for example educational attainment. It takes one to
a different model from the one being pursued fairly aggressively
with an entire competency based on whether the market is being
stimulated. It is a very market-oriented approach, whereas one
could develop some of the earlier competencies such as: "Are
you showing leadership? Are you engaging with your local community?
Are you truly accountable and delivering what local people need?"
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