Feature / Assured thing

As interest in the quality of costing data increases, the reference cost submissions from 50 trusts will this year face a formal audit as part of the payment by results data assurance framework. Capita CHKS’s Howard Davis tells trusts what to expect

There is an increasing focus on cost data in the NHS. Robust data is vital for informing national tariff prices – whether payment mechanisms stay as they are or change as part of the current review by Monitor and NHS England. But cost data is also recognised as having a major role in informing local decision-making. And good-quality decision-making requires good-quality cost data.

The current annual cost collection – reference costs – covers £53bn of the NHS budget spent on hospital services – providing a breakdown by healthcare resource groups, outpatient appointments, mental health clusters and other currencies. While there are validation checks built into the collection returns themselves, the collective desire to improve costing data has led to plans for an audit programme this year.

This will involve auditing the 2012/13 reference cost submissions of 50 acute trusts as part of the ongoing payment by results (PBR) data assurance framework.

The assurance framework has in the main focused on coding quality. However, reference costs have featured once before, with an audit of all acute trusts in 2010/11. The learning from this work led to the publication of a 10-point checklist to improve the quality of reference costs – which must now be completed as part of formal board assurance alongside the cost submission.

The new audit programme will run from September 2013 to February 2014 and will be undertaken by Capita CHKS on behalf of the Department of Health. (The Audit Commission delivered the PBR data assurance framework from its outset in 2007. While it retained responsibility for the programme in 2012/13, it appointed Capita to deliver it on its behalf. Responsibility for the framework has now passed to the Department, although Capita continues in its delivery role.)

The aims of the reviews, as agreed with Monitor, the Department and the NHS Trust Development Authority, are to understand the quality of reference costs locally and nationally, to identify learning and best practice, which will improve the quality of reference costs submissions, and to highlight any data to be excluded from tariff setting (see table).

Capita is keen to undertake as many audits as possible in conjunction with reference costs experts from the NHS and we are looking for volunteers to be involved in the programme. This will support the NHS in moving toward peer review for costing and data quality – something Monitor has said it will consider using in future years for patient-level cost collections – and provide expert input into the audit, ensuring the quality of the review.

It will also offer a personal development opportunity for costing experts to improve knowledge and understanding.

This should support practitioners to improve the quality of processes and costing in their own trusts. All costs to the individual and their organisations will be covered by Capita CHKS. Each review will make a judgement on the accuracy of the overall submission under three categories:

• Admitted patient care
• Non-admitted patient care, with PBR tariff
• Non-admitted patient care, no PBR tariff.

In the 2010/11 reviews, we found that unit costs for admitted patient care were usually correct. But that accuracy decreased for non-admitted patient care covered by tariff.

The quality of reference costs for areas without a tariff were the most variable. This included specialist services, such as critical care, renal services and chemotherapy, as well as community activity and other low-cost, high-volume services.

To undertake the review, we will test the arrangements in place for ensuring accurate reference costs at a trust, identify areas of risk in the organisation and review the accuracy of costs in those areas. To do this we will:

• Review the process of sign off by the board and finance director, testing responses to the board checklist
• Check the accuracy of total costs and activity data included in the submission
• Examine outlying costs and activity identified through our benchmarking and non-mandatory validations undertaken by the Department
• Undertake deep-dive analysis in specific areas to assure the process of costing in that area, from patient to aggregate cost.

The 50 trusts to be audited will be identified through a risk assessment process. This will take into account results from the previous reference costs review at the trust, as well as audit results from other aspects of the PBR assurance framework.

For example, previous reference costs audits demonstrated that inaccuracy in reference costs was often caused by poor coding and activity reporting. We will also include benchmarking analysis of reference costs in the risk assessment, based on the information available in the PBR national benchmarker, which is freely available to the NHS as part of the assurance framework.

The final trust sample will consist of:

• 30 trusts deemed at risk of poor data quality
• 10 trusts deemed low risk to ensure we capture best practice
• 10 trusts selected at random.

The 10 low-risk and 10 randomly selected trusts will be informed of their audits in July. The at-risk trusts will be contacted at the beginning of August, once the latest reference cost submission has been completed.

 Trusts will receive a finalised report five to six weeks after their local review, and nationally we will be publishing learning and best practice from the reviews prior to the 2014/15 submission period.

The assurance framework is the only independent and comprehensive data quality review programme in the NHS and is an integral part of the PBR system. The focus of this work is to improve the quality of data

that underpins payments under PBR, but the data we review is also of wider importance to the NHS as it is used to plan and oversee healthcare provision.

Between 2007/08 and 2012/13 the assurance programme looked at the accuracy of clinical coding at all NHS trusts and foundation trusts, as well as that of independent hospitals providing treatment on behalf of the NHS. We have audited outpatient and A&E data, tested commissioners’ arrangements for ensuring good-quality data from their providers and developed an assurance programme for mental health data. We have published briefings on board assurance and data definitions, and developed the PBR national benchmarker into a tool that gives ongoing benefit to the NHS.

This year, alongside the reference costs review, we will be continuing our mental health data reviews at 25 organisations. These audits include a review of reference cost information.

We will also be undertaking clinical coding audits at 50 acute trusts viewed as being at risk from poorly coded information. At the request of NHS England, half the audit sample at each trust will focus on the coding of comorbidities and complications, the other half will be open to local choice.

For more on PBR data assurance or the PBR national benchmarker, go to http://www.chks.co.uk/Payment-by-Results-(PbR)-Assurance

Howard Davis is a senior manager at Capita CHKS and was previously with the Audit Commission, working on the assurance framework since its introduction in 2007. Contact him on [email protected]