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CCGs begin 2013 with diagnostics challenge

Plans to unbundle outpatient tariffs which will allow hospitals to charge separately for diagnostic imaging could have far reaching effects on commissioning budgets and GP workload, warn GP commissioners.

Until now diagnostics have been included in the outpatient tariff but from April this year the Department of Health plans to unbundle the tariff, creating a separate charge for diagnostic imaging carried out when a patient attends a hospital outpatient appointment.

GP commissioners fear the move could prove to be a big challenge for their commissioning budgets if the unbundling results in a large diagnostics bill and could result in GPs being asked to do more diagnostics in primary care.

The rationale for the decision to unbundle the tariff was outlined in a letter from deputy NHS chief executive, David Flory, back in September where he inferred hospitals were rationing diagnostics to keep costs down or leaving providers out of pocket for specialised care which can involve more diagnostic imaging.

In the letter, Mr Flory said: ‘Concerns have been raised that the current reimbursement arrangements may act as a disincentive for scans to be carried out which will benefit the patient and may not appropriately reflect the cost of imaging associated with specialised care.’

Shortly before Christmas, draft guidance for Payment by Results for 2013/14 was published,which again acknowledged the financial risks the unbundling could pose.

To counter the risk, the Department  of Health is proposing a marginal tariff rate of 50 per cent for any diagnostic imaging which exceeds a baseline agreed between providers and commissioners. If a baseline cannot be agreed it suggests using 2012/13 levels as a baseline marker of growth.

The guidance says:

‘The main change to the tariffs for outpatient care for 2013-14 is that we are making diagnostic imaging associated with outpatient attendances subject to separate tariffs, rather than ‘bundling’ the costs into the attendance tariffs. This change does not apply where the outpatient activity is paid by mandatory tariff against a procedure-driven HRG. We are making this change to support early diagnosis and efficient pathways for patients.’

Dr Jagan John, clinical director of NHS Barking and Dagenham CCG  said: ‘It´s difficult to predict but I think it will add a lot more cost in the system. I have concerns this will start changing the way hospitals and GPs interact, for example in terms of how things are followed up. We´ll see hospitals asking GPs to do further tests/ follow up patients rather than doing it themselves. It could potentially increase the workload on GPs.

You´d hope that all tests carried out would be in the interests of patients but with diagnostics unbundled it could potentially generate more income for hospitals and we will have to start addressing the whole duplication issue and start checking to make sure tests aren´t duplicated.

‘This really is far-reaching. Pathways will need to be more explicit too. This will also interact with shifting more care into the primary sector. I think we underestimate diagnostics. They are fundamental to the way we practice medicine in the UK. This will change the way things are done, without a doubt.’

Dr Charles Alessi, interim chair of NHS Clinical Commissioners said CCGs were likely to suggest GPs take on more diagnostics in-house: ‘It is up to tactics to rise to the challenge. I suggest quite a few of them will as it makes the journey the patient has to update much easier if care is delivered close to home.’

But Dr Alessi said he did not expect CCGs to have to ration diagnostics: ‘I do not envisage this, but I do think we need to be more mindful of the downside to investigations if done indiscriminately. This means we could see a world where one had to justify what one was proposing to do, but that is no bad thing if handled sensitively .’

Professor Andrew Street, professor of health economics and director of the health policy team at the Centre for Health Economics, University of York said: ‘In future with unbundling, there may be a risk of overprovision, with more tests conducted than currently, thereby inflating overall costs for commissioners.

‘Careful setting of the tariff for diagnostic imaging is probably the only way to contain this risk. It will be very difficult for commissioners simply to refuse to pay for tests or to impose volume controls.’

Diagnostic imaging procedures to be unbundled from the outpatient tariff includes:

-       Magnetic resonance imaging scans

-       Computerised tomography scans

-       Dexa scans

-       Contrast fluoroscopy procedures

-       Non-obstetric ultrasounds

-       Nuclear medicine

-       Simple echocardiograms