A collection for all seasons

The specialist

Chris Marshall, finance manager (costing) 
The Royal Marsden NHS FT

A specialist cancer care trust, its income is about £260m (2019/20). It made its first mandatory PLICS submission in summer 2019 covering 2018/19, although as a roadmap partner it made voluntary submissions from 2015/16.

'One of the main issues is the time taken to produce the data, with the National Cost Collection (NCC) submission taking up to four months to produce.

'The approved costing guidance needs to be simplified, as recommended by the HFMA Healthcare Costing for Value Institute proposal (hfma.to/mar211). The guidance should also be aimed at the minimum standards required to complete the NCC and quarterly collections, with additional sections showing the superior methodologies that trusts should look to achieve over time.

'One area that particularly needs to be simplified is the general ledger to cost ledger mapping, which takes a large amount of time with little added value.

'There is an opportunity cost in the increased time being spent on annual and quarterly national patient-level cost (PLICS) collections. It means less time is spent developing and reviewing PLICS data with clinicians and service managers, which will lead to a lowering of the quality of the data being produced.

'At present, trusts have separate PLICS models for business-as-usual (BAU) and the NCC submission. Efforts should be made to bring BAU and NCC PLICS into line to avoid duplication of workload for costing practitioners. With the reduction in payment by results, perhaps we should consider removing costing of some or all unbundled activity, although this might require the development of additional healthcare resource groups to record the activity.

'Trusts do not use the NCC output because it is not compatible with how BAU PLICS is reported internally. In addition, the NCC data is not published until nearly a year after the end of the financial year being reported and the data is relatively out of date. Published data also has low volume activity redacted, which makes it unusable for benchmarking.

'Trusts pay the salaries of their costing teams, but an increase in time spent on NCCs will discourage them from investing in these teams, because it would not provide any benefit to the trust. If the centre wants quarterly PLICS for other purposes, it might consider contributing to the cost of local costing teams.

'And finally, something needs to be done to reduce the impact of annual and quarterly PLICS collections on the recruitment and retention of costing practitioners.

'This is already difficult, but will get worse if the role is just seen to be churning data for central demands.'

The mental health/community services provider

Alex Packard, finance manager 
Berkshire Healthcare NHS FT

With mental health and community income equally split, the trust made its first mandatory PLICS submission recently, covering 2019/20, and is due to submit community costs in 2022.

'Costing requirements would need to be pared back and major improvements made in the activity data collected if the service was to move to quarterly cost submissions.

'While in principle, more up-to-date costing data makes sense, the data produced and fed back continues to not be useful to providers, as we do not use the resource or activity coding in our internal presentation. And we also want the reporting to match to our ledger position.

'In general, the guidance and coding requirements are too onerous to be accurately and consistently implemented. But for community services specifically, coding of activity remains inconsistent and we don’t have a meaningful currency. So we know which service is delivering a patient contact, but very little about what interventions/therapies are actually being delivered.

'As costing practitioners, we want to be working with services to help them improve patient services. As they are currently formatted, the NCC submissions take us away from that work. They are time-consuming and they require separate costing models to be run from the ones that produce the data we use internally.

'The biggest difference is the NCC requires us to cost admitted care using spells, while for our internal data, we cost this as single days, which we believe to be much more useful.

'There also needs to be more testing with practitioners. Currently, the validations tool is too rigid. This needs to be relaxed, with the guidance then refined based on what is submitted, or they need to work with some trusts to test the rules in advance.

'For collections to be quarterly, the centre needs to move much closer to collecting what trusts produce for local use.

'The trust submitted patient-level costs for mental health services as part of the 2019/20 submission. This took a significant amount of team resource to produce a submission that would be accepted by the data validation tool (DVT). We had to make changes to our internal costing model and adjust coding in the cost ledger.

'There was also a lot of time lost on model recalculations as a result of DVT errors and costing system bugs. These have arisen because of the speed with which they are being expected to update systems in order to reflect guidance.

The acute trust

Duncan Orme, operational director of finance
Nottingham University Hospitals NHST

One of the largest teaching hospitals in England, it implemented a patient-level costing system in 2010 and made its first mandatory submission in summer 2019 covering costs for 2018/19.

'Back-office functions have changed as a result of the pandemic and this includes cost accountants. Instead of submitting returns to support tariff development and the Model Hospital, they are supporting clinicians.

'Armed with continuously improving patient-level data, the cost accountant’s work is increasingly focused on helping to identify waste and ensuring resources are used to best effect to meet patients’ needs. The growth of waiting lists and the need to maximise the available resources to reduce this backlog make this even more important.

'In this context, it may seem counterintuitive to ask teams to ‘feed the beast’ of NCC every quarter, a task many struggle to complete annually. The issues are complex, but simpler solutions have worked. We should consider:

• Nottingham developed the Wave programme using detailed analysis of patient-level data to support clinicians. Clinical heads of service and the board want additional time targeted at this programme to help achieve recovery targets. Central costing return demands, which eat into cost accountants’ time, cannot come at the expense of this programme.
• While the exceptional quarterly collection is not onerous, it provides only modest insights as it is not at patient level.  Previously, 93 trusts contributed to a patient cost benchmark club, which required a straightforward patient-level return, with modest levels of detail. Most importantly, it provided regular, meaningful reports used by clinicians.

• The NHS needs the higher quality, more granular information promised by the NCC. The pilot programme demonstrated that 68 trusts could deliver this detail for every healthcare resource group. However, we have since learned that:

º Not all trusts have software up to the task of supporting this more detailed information.

º Not all costing teams have the experience and expertise to deliver the extensive unbundling, mapping and interpretation necessary to provide a meaningful return.

º Different organisations use different methods to convert their local cost data into NCC format leading to inconsistency and making the NCC data less suitable for use in benchmarking.

'Other countries use different approaches to supply the necessary information to meet national uses. Germany, for example, provides funding for a selection of providers, operating to best practice costing standards, to meet more than minimum standards on granularity. NHSE could combine this with a more straightforward return for all.

'Up-to-date patient-level data should provide valuable insights for our clinicians to improve patient care, more rapidly recover from the pandemic, and minimise the effects of delay-related patient harm. Clearly, we must support it, but we need to find a practical way to achieve the vision.'

The supplier

Peter Lane,
lead for IQVIA UK&I Healthcare

IQVIA provides numerous solutions to over 260 NHS organisations including its patient-level costing software to more than 70 NHS trusts.

'We understand and support why NHS England and NHS Improvement want to collect patient-level cost data more frequently. But several issues need to be taken into account. First, the detail and specifications will be crucial. Each provider has its own different patient-level cost model for BAU use, and running an output for the quarterly return, which mirrors NCC requirements.

'This means a significantly different model must be processed and submitted – there is no simple ‘extract data and submit’ button. New requirements to include specialist ward care details would extend further the gap between BAU and submissions.

'As well as the time taken, there is a value consideration for local providers. Other than complying with the regulator, will further submissions be at the expense of the BAU models? Costing teams would find it difficult to run and maintain two very different outputs for different audiences simultaneously. 

'Providers that only cost quarterly may find they are working full time to create submissions for the NCC, involving contributions from IT, informatics and other colleagues. Inevitably, the work needed to provide high-quality costing output for their own organisation may become a lower priority.

'Morale of this under-resourced area of the sector is also likely to be affected by having to provide more submissions each year on top of current workloads. There is also a capacity challenge, with many costing teams struggling to carry out business-as-usual work for their provider as team members are redeployed for the pandemic response. Home working has also created difficulties for some teams.

'Unless a quarterly collection can be simplified to fall naturally out of a provider’s BAU models, it will be an unpopular collection due to the additional burden on costing teams and the value being potentially diluted.'