Politics, policy and payment – facilitators or barriers to person-centred rehabilitation?

Politics, policy and payment – facilitators or barriers to person-centredrehabilitation?

LYNNE TURNER-STOKES

Regional Rehabilitation Unit, Northwick Park Hospital, Department of Palliative Care, Policy and Rehabilitation, and King’s

College London School of Medicine, London, UK

AbstractAims. This paper explores the tensions between politics and payment in providing affordable services that satisfy the publicdemand for patient-centred care.Key findings and implications. The two main approaches taken by the UK Government to curtail the spiralling costs ofhealthcare have been to focus development in priority areas and to cap spending through the introduction of a fixed-tariffepisode-based funding system. The National Service Framework for Long Term Neurological Conditions embraces manylaudable principles of person-centred management, but the ‘one-size-fits all’ approach to reimbursement potentially cutsright across these. A series of tools have been developed to determine complexity of rehabilitation needs that will support thedevelopment of banded tariffs. A practical approach is also offered to demonstrate the cost-efficiency of rehabilitationservices for people with complex needs, and help to ensure that they are not excluded from treatment because of their highertreatment costs.Conclusions. Whilst responding to public demand for person-centred care, we must recognize the current financial pressureon healthcare systems. Clinicians will have greater credibility if they routinely collect and share outcomes that demonstratethe economic benefits of intervention, as well the impact on health, function and quality of life.

Keywords: Rehabilitation, complex neurological disability, cost-efficiency

Introduction

Whilst the treatment of patients lies at the heart of

any healthcare system it is by no means the only core

function of a healthcare service. In the UK,

successive governments have been elected on the

promise of a better NHS, and then battled with the

challenge of providing a comprehensive healthcare

service which is free at the point of delivery for all

UK residents, entirely paid for by tax, at a relatively

small proportion (currently about 8.5%) of the Gross

Domestic Profit.

Primary Care Trusts are currently the frontline

custodians of the NHS purchasing power, respon-

sible for commissioning services to achieve ‘value for

money’ in healthcare provision. ‘Value for money’,

however, can mean different things to different

people.

. For service commissioners, it means maximiz-

ing cost-efficiency to ensure a higher through-

put of cases for less cost.

. For clinicians focused on the needs of their

patients, it tends to mean striking a balance

between maintaining throughput and ensuring

the best possible outcomes for individuals

under their care.

. For patients and their families struggling to

come to terms with newly acquired disability, it

can be hard to think of the ‘cost’ part – the key

for them is generally to achieve the best possible

outcome, whatever the cost. Moreover, the

experience of living with a disabling condition is

often limited more by external factors (trans-

port, housing, employment etc) than by factors

within the health service. Nevertheless, since

rehabilitation professionals are frequently the

Correspondence: Prof Lynne Turner-Stokes, DM FRCP, Regional Rehabilitation Unit, Northwick Park Hospital, Watford Road, Harrow, Middlesex,

HA1 3UJ, UK. Tel: þ44 208 869 2800. Fax: þ44 208 869 2803. E-mail: [email protected]

Disability and Rehabilitation, October – November 2007; 29(20 – 21): 1575 – 1582

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd.

DOI: 10.1080/09638280701618851

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only available intermediaries, patients often

look to them for support in problem-solving

outside the realms of healthcare.

By definition, ‘patient-centred outcomes’ reflect the

individuals’ experience of healthcare and beyond.

Purchasers and politicians are constrained to spread

scarce services ever more thinly, and rehabilitation

professionals find themselves caught between the

need to serve their patients on the one hand, and

those who hold the purse-strings on the other. In

order to function effectively, it becomes important to

be able demonstrate the cost-efficiency of rehabilita-

tion at the same time as addressing the person-

centred goals that we know to be important. If we

cannot convince purchasers that rehabilitation is a

cost-efficient option – they quite simply will not buy

services.

This paper will explore the tensions between

politics and payment in terms of providing affordable

services that satisfy the public demand for patient-

centred care. It will address some practical solutions

to ensure that patients with more complex needs are

not excluded from services under the new NHS

financial reforms; and it provides a practical

approach to demonstrating cost-efficiency of rehabi-

litation for patients with profound and complex

disabilities who have little potential for achieving

independence, but who represent a substantial and

ongoing cost burden for the NHS if not appropriately

managed.

Politics and payment – how do we afford the

NHS?

Faced with the challenge of demonstrating contin-

uous improvement in healthcare, whilst containing

the costs of NHS healthcare provision, the current

UK Government has employed two main ap-

proaches:

(1) Limiting the areas of healthcare development

and investing within those areas to meet

predefined targets, as laid down in a series of

National Service Frameworks.

(2) Capping spending to encourage a competi-

tive market in healthcare provision through

financial reforms which introduce a fixed-

tariff episode-based funding system.

Limiting healthcare development to priority

areas

National Service Frameworks (NSFs) were intro-

duced in 2000 as the tools for defining limited health

targets and focussing funding to ensure that those

targets were met. NSFs set national evidence-based

standards with ‘must-do’ targets against which NHS

providers and purchasers were required to demon-

strate performance. Latterly, targets went out of

favour [1] and subsequently ‘new-style’ NSFs have

set softer standards or ‘quality requirements’, but

without ear-marked funding to ensure that they

are met.

The NSF for Long Term Neurological Conditions

[2] was the first of the ‘new-style’ NSFs published in

April 2005 to be implemented over 10 years. The

11 NSF Quality Requirements embraced many

laudable principles of person-centred management

(see Figure 1). The main central theme is integrated

care-planning to support and enable the individual to

live as they would wish. Other key principles are

‘joined up inter-agency service provision’ and ‘con-

tinuity of care’, with support for carers and family

members as well as the patient, throughout their lives

(see also Cott et al. [3] in this issue).

It was accepted from the outset that providing this

life-long continuity of care from a very low starting

level of service provision would be a major challenge

without ear-marked funding or mandated targets. At

the same time, though, it was recognized that care of

chronic conditions, particularly in the community,

had lost out in recent years to preferential investment

in acute and front-line services. This appeared to be

a genuine attempt, on the part of Government to

redress the balance.

Capping spending

However, cutting right across that came the Govern-

ment’s second approach to cost-efficiency, Payment

by Results [4] – a fixed-tariff episode-based funding

system which is designed to drive up the throughput

of patients and introduce a market economy by

inviting independent providers into the healthcare

arena. Payment by Results represents the most

significant change in financial flows in the history

of the NHS. Under these reforms, the previous

block-contracting arrangements are replaced by cost-

volume contracts, where providers are reimbursed

on the basis of each case episode, according to a

standard national tariff. Episode-based funding is

proffered as a means to ensure cost-efficiency by not

rewarding providers for longer stay patients, thus

providing financial incentives to boost throughput

regardless of outcome. This ‘one-size-fits-all’ ap-

proach to healthcare provision, however, is the

absolute antithesis of individualized person-centred

management – let alone life-long care.

Case-mix classification

Case-mix classification was first pioneered in the

USA 20 years ago, through the development of

1576 L. Turner-Stokes

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Diagnostic Related Groups (DRGs). These are tools

designed to measure and classify healthcare activity

in a way that takes account of the mix and complexity

of patients treated, based on their diagnosis, the

procedures carried out and the care and resources

involved. Each DRG is assigned a fixed tariff

payment, since patients within each category are

similar clinically and are expected to use the same

level of hospital resources. Other countries that

have followed on similar lines to introduce DRG-

equivalent systems include Australia, Canada,

Nordic Countries, France and Austria. In the UK,

a trial application of the US DRGs was undertaken

based on analysis of 14 million hospital episode

records, but demonstrated that DRGs did not

accurately fit the casemix of the National Health

Service [5]. An alternative case-mix system of

Healthcare Resource Groups (HRGs) is therefore

currently under development to support a national

schedule of reference costs, from which standard

national tariffs will be introduced under the Payment

by Results programme.

Many casemix systems have identified that the

long-term nature of rehabilitation has signficant

resource implications which require a somewhat

different approach to episode-based reimbursment.

The US DRGs excluded medical rehabilitation

because it was recognized that rehabilitation in-

patients could not be classified reliably by diagnosis

alone [6]. The level of functional dependency was

considered to be a better cost-determinator, and in

the 1990s a classification system based on func-

tion (referred to as ‘FIM-function-related groups’1)

(FRGs) was developed instead [7]. The system was

subsequently re-derived to predict total rehabilitation

costs and re-named ‘case-mix groups (CMGs) in a

further effort to contain costs. FRG/CMGs, along

with a 3-tier co-morbidity measure, form the current

basis for reimbursement for in-patient rehabilitation

in the US [8]. In Australia, two separate function-

related case-mix systems have been developed to

classify patient episodes for different levels of

reimbursement for rehabilitation [9,10]. Similarly

in the UK, rehabilitation is to be ‘unbundled’ from

other treatment costs in the casemix classification,

but the precise structure of rehabilitation HRGs has

yet to be fully determined.

Unwanted effects of episode-based funding

The philosophy behind these case-mix systems is to

reward efficiency by directly linking income to

throughput of cases. Since hospitals bear the cost

of any complications, there is added impetus to clean

up their act. At first sight, this new system is

advantageous all round. However, there are also

some obvious problems which are illustrated in

Figure 2a. There is wide variation in complexity

within the group of patients requiring rehabilitation.

The large majority of patients can be managed at

fairly low cost with modest input from their local

general rehabilitation services. Some require more

Figure 1. The ‘Fish Diagram’ depicts the NSF for Long Term Neurological Conditions care pathway and its 11 Quality Requirements. In

this pictorial representation of the NSF quality requirements, the 11 quality requirements span the full care pathway from diagnosis to death,

with QR1 ‘person-centred information and care planning’ running as a key central theme or ‘backbone’ throughout the remainder of the

person’s life.

Politics, policy and payment 1577

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intensive or expert management in a specialist

rehabilitation unit, and a small number of patients

with very complex needs will require the highly

specialized skills and facilities of a tertiary centre,

often for longer periods at significantly higher cost. If

a single average cost tariff is applied across all these

different levels of service a number of unintended

consequences emerge.

First there may be a natural tendency for private

sector providers to ‘cream-skim’, or select the easier

patients [5] and so enhance their profits, fulfilling

responsibilities to their share-holders. The distribu-

tion curve of episode costs is skewed with a small

‘tail’ of very high-cost patients. Inclusion of these in

calculation of ‘average reference costs’ will inflate the

standard tariff, offering even bigger profit margins for

the cases at the simple end of the spectrum. As much

of rehabilitation is ‘elective’, hospitals will under-

standably put pressure on clinicians either not to

accept complex cases or to discharge them, ready or

not, at the end of the funded period. This has already

been reported in the US system [11]. The notion of

averaging costs assumes that all services have a

similar caseload. However, tertiary services specifi-

cally select the most complex cases, and these

services are likely to be financially de-stabilized,

since income will no longer meet the higher cost of

managing their complex case-load.

Therefore, unless there is sufficient sensitivity

within the system to identify and reimburse the

additional cost of treating this more complex group

of patients, there are three major consequences:

(1) The most vulnerable and needy group of

patients will be discriminated against, and are

likely to receive sub-standard care.

(2) Specialist services, which offer a unique role

within the NHS by taking on the most

Figure 2. Complexity and cost-banding in rehabilitation services. (a) The different levels of complexity and service provision in

rehabilitation. Within the group of patients requiring rehabilitation there is wide variation in complexity. The majority can be managed at

fairly low cost by their local general rehabilitation services, but others required more specialist input, and a small number of very complex

cases require the special skills and facilities of a ‘complex specialized service’. Simply applying a single average reference cost would lead to

financial destabilization of complex specialized services. (b) Different tools may be used to identify patients with more complex rehabilitation

needs for the purpose of cost-banding. The Rehabilitation Complexity Scale (RCS) provides a simple rating of complexity for local and

district level services, but banding in more complex services will require detailed costing tools such as the Northwick Park nursing (NPDS)

and therapy (NPTDA) dependency assessments.


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complex cases and by supporting their long-

term management, will be destabilized and

will disappear.

(3) The standard of care will fall because

generalist services not only lack the experi-

ence and resources to manage this complex

group of patients, but also the skills to fulfil

the vital training and professional develop-

ment roles which are currently provided by

specialist services.

In recognition of this problem ‘complex specialized’

rehabilitation is excluded from the current version of

HRGs, and may be subject to alternative commis-

sioning currencies, which have yet to be defined. In

the meantime, mechanisms for the development of

banded tariffs to support the additional costs of

managing more complex cases in the lower level

services are also under exploration.

Some possible solutions

The current focus of HRG development in rehabi-

litation is on in-patient services, and the principal

factors that determine the cost of providing in-

patient rehabilitation are listed in Table I.

Systems developed in the US and Australia have

focussed on physical dependency for basic care needs

as the primary determinant of cost, as measured by

the Barthel Index or the FIM. Whilst this may work

reasonably well in the generality of post acute

rehabilitation, in the UK we have attempted to take

a broader perspective to include the other factors

listed in Table I in a simple banding measure – the

Rehabilitation Complexity Scale (RCS) [12].

The RCS is a 15-point measure made up of four

different subscales:

. C: Basic care and support needs (range 0 – 3)

. N: Nursing interventions (range 0 – 3)

. T: Intensity of total therapy intervention

(range 0 – 6)

. M: Medical intervention (range 0 – 3).

It should be reported in a manner analogous to the

Glasgow Coma Scale, e.g., RCS 7 (C2 N1 T3 M1).

For further details see Appendix.

Pilot testing of the RCS in a diverse range of

rehabilitation services including neurological, ortho-

paedic, cardio-pulmonary and burns rehabilitation

suggests that it has broad applicability. In a

preliminary cross-sectional application of the RCS

across 45 specialist rehabilitation units (25 district

specialist services and 20 ‘complex specialized’ or

tertiary units) clinicians reported that it was easy to

collect, and it appeared to be useful for distinguish-

ing these two levels of service on the basis of

complexity of their case load [12]. However, some

tertiary services reported a ceiling effect with lack of

sensitivity in the most complex cases. More detailed

tools – the Northwick Park nursing Dependency

Scale (NPDS) [13] and the Northwick Park Therapy

Dependency Assessment (NPTDA) [14] have been

developed to provide this greater level of detail.

These three measures are currently being put

forward as the tools for categorizing different levels

of input in rehabilitation services, against which

different cost bands may be developed in the future

(see Figure 2b) (see also Tennant’s paper [15] in this

issue).

Demonstrating cost-efficiency

It is not sufficient, however, simply to measure

inputs. If purchasers and Government are to be

Table I. The principal factors that determine the cost of providing neurorehabilitation. Whilst the FIM and BI provide an ordinal assessment

of independence in self-care, they do not provide the direct information on the number of carers needed or time taken to complete a task that

is provided by the NPDS, nor do they assess the need for qualified nursing input. The NPTDA provides equivalent information on medical

and therapy needs. The RCS provides a simpler crude evaluation across all four areas.

Measures

Basic care and nursing needs Basic self care

number of carers and time taken to help with washing, dressing etc.

Special nursing needs

requirement for skilled nursing input

FIM, BI

NPDS, RCS

NPDS, RCS

Therapy needs Number of different disciplines involved

Intensity of input – (hours per week per discipline)

Special facilities or equipment needed

NPTDA, RCS

Additional medical needs Special investigations

Procedures

Intercurrent medical/surgical events

NPTDA, RCS

Length of programme Bed-days or category

e.g., short, medium and long-term programmes

LOS

BI, Barthel Index; FIM, Functional Independence MeasureTM; LOS, Length of Stay; NPDS, Northwick Park nursing Dependency Scale;

NPTDA, Northwick Park Therapy Dependency Assessment; RCS, Rehabilitation Complexity Scale.


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persuaded that costly rehabilitation should be pro-

vided for patients with complex needs, they need to

be convinced that these actually represent value for

money.

A cost ‘effective’ service is one that is ‘economical

in terms of the goods or services received for the

money spent’ [16]. A cost ‘efficient’ service is one

that is ‘effective without wasting time or effort or

expense’ [16]. The cost of providing rehabilitation

is largely determined by time (length of stay) and

effort (intensity) on the part of the rehabilitation

team, so that ‘Cost-efficiency’ is an appropriate

term to describe value for money in rehabilitation

services.

There are several possible approaches to demon-

strating cost-efficiency in rehabilitation. In the USA,

Uniform Data Systems have promoted the calcula-

tion of FIM-efficiency as a surrogate marker for

cost-efficiency. FIM efficiency is calculated by ‘FIM

Gain/Length of stay’ and is used to compare different

programmes and services in terms of value for

money. However, the FIM has well-recognized

floor and ceiling effects, and the application of

FIM-efficiency is really only of value in the middle

part of the scale. Further, FIM efficiency can provide

an indication of relative value for money. It does not

give any indication of the actual sums saved through

more efficient practice.

Alternatively, if it can be shown that rehabilitation

increases independence and reduces the need for

continued care, then the cost of rehabilitation may

be offset by savings in on-going care in the

community. The cost-efficiency of a programme

may therefore be calculated in terms of the time

taken to recoup the initial cost of rehabilitation

through savings in the weekly cost of care. The

Northwick Park Dependency Scale and Care Needs

Assessment [17] was developed as a directly

costable outcome measure for rehabilitation for this

very purpose. It provides not only an ordinal

measure of dependency, but calculates the care

hours required to support the individual in the

community, and provides a generic estimation of

the weekly cost of care. Taking for example, the

case of an individual who is admitted with a level of

dependency that would require two live-in carers at

a cost of £2000/week, but by discharge they only

need one live-in carer at a cost of £1000 week. If

the cost of the initial rehabilitation programme was

£50,000, this would be offset within approximately

1 year by the weekly savings in care, even though

their dependency may not have changed much on

standard dependency scales such as the FIM or the

Barthel Index.

Using this approach, we have recently published

an analysis of cost-efficiency in a 6-year consecu-

tive cohort sample admitted to our specialist

in-patient rehabilitation unit in London [18].

Out of 320 patients with acquired brain injury,

full data were available for 297cases. These were

divided into three groups, based on their depen-

dency on admission. All three groups showed

significant reduction in dependency and on-going

care costs between admission and discharge.

However, the mean reduction in weekly cost of

care was greatest in the high-dependency group at

£639 per week, as compared with the medium-

(£323/week) and low- (£111/week) dependency

groups. Despite their longer length of stay (and

therefore higher treatment costs), the time taken to

offset the initial cost of rehabilitation was only 16.3

months in the high-dependency group, compared

with 21.5 months (medium dependency) and 38.8

months (low dependency). FIM-efficiency (FIM-

gain/length of stay) however, was low in this high

dependency group (0.16) compared with the

medium-dependency group (0.25), and the mean

total FIM score on admission was only 48/126

(SD23) confirming that many of these high

dependency patients fell below the floor at which

the FIM was a useful measure of outcome for

rehabilitation.

These findings confirm that the additional invest-

ment in rehabilitation for patients with complex

needs can indeed represent cost-efficient manage-

ment, despite their apparent failure to progress on

some of the more commonly applied outcome

measures. They serve to underline the problems in

relying solely on global measures of physical depen-

dency to assess cost-efficiency in rehabilitation.

Unfortunately, it is often the case that savings in

on-going care accrue to a different purse from that

which funded the rehabilitation, so that the

argument for cost-efficiency has to be made in the

wider political arena, rather than at local service

level. This is probably the largest single reason for

failure to recognize the true value of rehabilitation in

society.

Conclusion

As we respond to the public demand for person-

centred care, we must recognize the current financial

pressure on healthcare systems and the need to share

a scarce resource equitably amongst a large group of

patients. At the same time it is important to work

with Government and purchasers of healthcare to

demonstrate that cheaper time-limited programmes

do not always represent cost-efficient management.

Clinicians will have greater credibility if they

routinely collect and share outcomes that demon-

strate the economic benefits of intervention, as

well as the impact on health, function and quality

of life.


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Acknowledgements

I am grateful to my clinical team and research

colleagues on the Regional Rehabilitation Unit at

Northwick Park, without whom none of the various

developments described in this paper would have

been possible. In particular, I would like to thank

research staff Heather Williams and Rebecca Disler

and my consultant colleagues Dr Charlie Nyein and

Dr Aung Thu. Financial support for preparation of

this manuscript was kindly provided by the Luff

Foundation and the Dunhill Medical Trust.

Note

1. FIM¼Functional Independence Measure. FIMTM is a trade-

mark of the Uniform Data System for Medical Rehabilitation, a

division of UB Foundation Activities, Inc.

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Patient identification

Name: Hospital No: Date of score: . . . . . / . . . . . / . . . . . . .

For each subscale, circle highest level applicable

Basic care and support needs

Describes the approximate level of intervention for basic self-care

C 0 Largely independent in basic care activities

C 1 Requires help from 1 person for most basic care needs

C 2 Requires help from 2 people for most basic care needs

C 3 Requires help from 42 people for basic care needs

or Requires constant 1:1 supervision

Skilled nursing needs

Describes the level of intervention from qualified or skilled rehab nursing staff

N 0 No needs for skilled nursing

N 1 Requires intervention from a qualified nurse (e.g., for monitoring, medication, dressings etc)

N 2 Requires intervention from trained rehabilitation nursing staff

N 3 Requires highly specialist nursing care (e.g., for tracheostomy, behavioural management etc)

Therapy intervention

Describes the approximate level of input that is given from therapy disciplines

State number of different therapy disciplines involved: �2 3 4 �5 (Circle)

T 0 No therapy intervention (e.g., awaiting discharge)

T 1 Total therapy intervention �4 hours per week (or 51 h/day)

T 2 Total therapy intervention 4 – 9 hours per week (or approx 1 – 2 h/day)




T 6 Total therapy intervention 425 hours per week (or 45 h/day)

Medical intervention

Describes the approximate level of medical care environment required for medical/surgical management

M 0 No active medical intervention

(Could be managed by GP on basis of occasional visits)

M 1 Basic investigation/monitoring/treatment

(Requiring non-acute hospital care,

Could be delivered in a community hospital with day time medical cover)

M 2 Specialist medical intervention

(Requiring in-patient hospital care in DGH or specialist hospital setting)

M 3 Acutely sick or potentially unstable medical condition

(Requiring 24 hour on-site acute medical cover)

Total C: N: T: M: Summed score: /15

Appendix

The Rehabilitation Complexity Scale


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Documents

Politics, policy and payment – facilitators or barriers to person-centred rehabilitation?