Patient-level costing mandated for community services

The decision will see the move to patient-level costing completed across all parts of the secondary care sector. As part of the Costing Transformation Programme (CTP), acute trusts have been required to submit patient-level costs since 2018/19, with mental health and ambulance service trusts joining in 2019/20.

A consultation on the proposals, undertaken at the end of last year, received 39 responses including 35 from trusts – nine community-only providers and 26 integrated service providers. Of these, 23 trusts (66% of respondents) agreed with the mandation proposal, with 25 trusts also agreeing that the collection of reference costs should stop from 2020/21.

All trusts that provide community services, (whether it is their main service or not) will be required to record and report costs at the patient level, using the national costing standards, from 2021/22 – with a first mandatory submission in 2022. NHS England and NHS Improvement’s response document clarified that some services, including cancer multi-disciplinary team meetings, community midwifery, home births and maternity ultrasound scans and renal dialysis, will continue to be collected via workbook until collection issues and currencies are agreed.

The costing bodies acknowledged concerns about the underlying availability, completeness and accuracy of community activity data. Not all organisations have the necessary collection systems in place and some data sets required for the costing process are either not mandated or organisations are not yet complying with them.

However, they said that underlying data issues had already led to the mandation being delayed by a year and that voluntary submission of patient-level costing data had led to an improvement in data accuracy. They promised to work with the sector to ‘support the underlying national dataset requirements for electronic clinical data’.

Trusts had also flagged concerns with the complexity and volume of costing standards. NHS England and NHS Improvement said they did not expect that all trusts would be able to comply with the standards for the first few years. ‘There will be a transition pathway document (over a three-year period), which has been updated for the 2021 publication of the approved costing guidance, in advance of the costed year (2021/22),’ the response document said.

The national bodies rejected calls for a further delay or for a phased approach. With the first collection in 2022, they suggested there would be ‘ample time’ for trusts to prepare for the submission. They underlined the importance of understanding community services’ contribution to ‘cradle to grave’ costs and argued that better understanding of these costs would be fundamental to the move to integrated care systems.

A phased introduction was ruled out as being too complex.

The response document also promised further work on how to cost and treat indirect patient contacts such as safeguarding work and on the development of community currencies in general.

HFMA head of costing and value Catherine Mitchell (pictured) backed the adoption of patient-level costing across the whole service, but said that the challenges facing community service providers were significant.  ‘Practitioners tell us that data completeness and quality are huge issues for community services, with some services still using paper records,’ she said, adding that investment in informatic infrastructure had historically been low.

‘Not all activity carried out is captured, and where it is, the quality does not always reflect what the teams actually do,’ she said. ‘While the association agrees that the implementation of patient-level costing and the use of cost data by clinical teams will drive improvements in the quality of non-financial data, the very poor quality of the current data should not be underestimated.

‘Until data quality improves substantially, some of the benefits of implementing patient-level costing in community services are unlikely to be delivered,’ she added, ‘for example, understanding the use of healthcare resources across patient pathways and multiple organisations.’