1. Best Practice Tariffs Falls and Fractures: Towards Best Practice Sam Alderson Economic Adviser – PbR Development Team

2. Best Practice Tariffs – Fragility Hip Fracture 2 Context Tariffs in 2010/11: 1. Gall bladder removal 2. Cataracts 3. Stroke 4. Fragility hip fracture High Quality Care for All (HQCFA) report High volume service area Significant variation in clinical practice Improve both quality and value Excellent source of clinical data (NHFD) Support existing work on fragility hip fracture care

3. Best Practice Tariffs – Fragility Hip Fracture 3 The tariff aims to… Reduce unexplained variation in quality and universalise best practice. Key clinical characteristics: Characteristics are best practice – they go beyond the standard Surgery within 36 hours Involvement of an (ortho)- geriatrician AND

4. Best Practice Tariffs – Fragility Hip Fracture 4 Definition of characteristics Time to surgery Arrival in A&E (or diagnosis if an inpatient) to start of anaesthesia Involvement of an (ortho)-geriatrician: All 4 required 1. Admitted under the joint care of a Consultant Geriatrician and a Consultant Orthopaedic Surgeon 2. Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia 3. Assessed by a Geriatrician * in the perioperative period ** * Geriatrician defined as Consultant, NCCG, or ST3+ ** Perioperative period defined as within 72 hours of admission 4. Postoperative Geriatrician-directed: Multiprofessional rehabilitation team Fracture prevention assessments (falls and bone health)

5. Best Practice Tariffs – Fragility Hip Fracture 5 Best practice care costs less… Looking after hip fracture patients well is a lot cheaper than looking after them badly. The Blue Book (p. 10) invest save time unit cost Cost profile of meeting best practice Tariff to reflect this profile over time

6. Best Practice Tariffs – Fragility Hip Fracture 6 The tariff will be paid in two-parts… NHFD captures compliance with clinical practice PCTs to monitor and make additional payments quarterly Base tariff for each HRG Additional payment for best practice Reduction in base tariff for current compliance rate Payment per patient Current tariff structure Best practice tariff structure 2-part tariff for best practice Current price

7. Best Practice Tariffs – Fragility Hip Fracture 7 Why pay more for best practice? Align with the Quality Framework set out in HQCFA Recognising and supporting local progress towards best practice through payment Clear benefits to patients and savings along the NHS- and super-spell Tariff to recognise cost profile Balance incentives between PCTs and providers PCTs wont pay twice for current compliance Base tariff adjusted for current compliance Overall envelope of PbR funding will not increase Impact will be re-distributive towards relevant HRGs

8. Best Practice Tariffs – Fragility Hip Fracture 8 Summary Best practice tariffs link payment to quality Aim is to universalise best practice around two key characteristics with hip fracture care Payment to be a 2-part tariff with compliance monitored through NHFD Target incentives at both providers and PCTs 2010/11 is an opportunity to change practice as future tariffs will mirror the cost profile.

9. Best Practice Tariffs – Fragility Hip Fracture 9 Next Steps Guidance and tariffs will be published as part of roadtest exercise in December Guidance on implementation to be issued alongside final tariff package in January/February 2010. Evaluation of the best practice tariff policy. First report due in June/July 2010 Develop 2011/12 tariff informed by evaluation and NICE clinical guideline. http://www.dh.gov.uk/pbr