NHS England is consulting on proposals for the NHS Payment Scheme that will apply between 2023 and 2025, including plans to amend cataract payments. RCOphth’s response will support this change as a way to tackle the risk of “upcoding”, with the caveat that NHS England reviews the effectiveness of how the current system reflects the costs of cataract surgery and other ophthalmology services.
What is NHS England consulting on?
Launched on 23 December, this consultation covers the operation of the NHS Payment Scheme, coming into force from April 2023 and applying for two years. It replaces the National Tariff, but will similarly provide the basis for payments between commissioners and providers of NHS-funded care – both the rate of payments and the mechanism.
How could it affect ophthalmology and what is RCOphth’s response?
RCOphth’s Health Resource Group (HRG) for Ophthalmology Services Working Group, chaired by Wojciech Karwatowski, met in mid-January to discuss the implication of the proposals for ophthalmology and key points the College should highlight in its response.
One of the key changes proposed by NHS England is to equalise the payment offered to two of the cataract codes, following what NHS England describes as ‘a much larger proportion of cataract activity grouping to the BZ34A HRG than can be readily explained by changes in patient complexity’. The group agreed that this proposal made sense to tackle the risk of “upcoding” by some providers of NHS-funded cataract surgery. There was consensus however that this needed to go alongside NHS England reviewing the effectiveness of how the current system of coding reflected the actual costs of cataract surgery.
One of the other key points we plan to make in our response is to express our concern that the system from 2023 will still disproportionately incentivise new over follow-up appointments. This does not work well in ophthalmology because many ophthalmology patients will require ongoing (potentially lifelong) treatment.
The five key points we plan to make in our response are:
- RCOphth supports the proposal to tackle concerns over cataract “upcoding” by equalising BZ34A and BZ34B while creating a £156 differential between these and BZ34C, and moving the additional money created into the rest of the BZ prices. However, the RCOphth’s support is contingent on a commitment from NHS England to review the effectiveness of the current case complexity (CC) scores in reflecting the costs of care delivery in BZ34.
- Through the National Casemix Office Expert Working Group, RCOphth has previously raised concerns about the validity and working of the CC scoring process. We believe that without a significant review of this, any pricing process beyond 2025 will lack validity and credibility. There is thus an opportunity during the 23/25 payment scheme period to review and revise the CC scoring process. RCOphth is committed to engaging with and supporting such a process.
- We are concerned that the proposed payment by results structure that incentivises new over follow up appointments (e.g. ‘front loading’ by 20%) does not facilitate the best patient outcomes in ophthalmology. This is because many ophthalmology patients will require ongoing (potentially lifelong) treatment and it is these patients that are exposed to the highest risk of permanent visual damage.
- Regarding Section 8 of the proposals on the payment mechanism, we are concerned that the lack of transparency of cost data between NHS and non-NHS providers, when accompanied by differential case mix, will drive a tariff imbalance that could potentially both under and over-pay. We believe NHS England should monitor this and consider how it can be tackled.
- The ophthalmology profession, led by RCOphth, has actively supported transformational change in the way ophthalmic care is delivered. We are concerned that the coding processes which support the 2023/2025 Payment Scheme are no longer appropriate to support best practice in care delivery. In particular, we believe that the regulations behind the recording and payment for asynchronous virtual appointments, key facilitators of service improvement, are no longer appropriate. We believe this should be reviewed as soon as is practicable so that the data collected reflects true activity and cost.
What will happen next?
RCOphth will submit our response by the 27 January deadline. If you have any suggestions or comments on our proposed response, please email [email protected]
You can also respond directly to the consultation as clinicians, or raise points that you would like to be included in the response of your NHS trust (if they are responding).
NHS England will consider responses, before confirming their plans prior to April 2023. RCOphth will continue to engage with NHS England in the coming months to ensure that a commissioning framework is in place that supports the best patient outcomes in ophthalmology.