Since the 2012 Health and Social Care Act Local Authorities in England have been responsible for the provision of open access sexual health services in their local areas. The services to be provided include:
- Preventing the spread of sexually transmitted infections (STIs)
- Testing, treating and caring for people with such infections
- Notifying sexual partners of people with such infections
- Advice on and reasonable access to a broad range of contraceptive substances and appliances and
- Advice on preventing unintended pregnancy
These services are commissioned by Public Health teams within Local Authorities. Commissioning may take the form of a block contract for the entirety of the service or parts of it or a tariff based payment mechanism. Historically, GU services predominantly addressing STIs, and contraception services were delivered by different healthcare providers, often from different clinics. GU services were commissioned under a national tariff published by the NHS prior to 2013 and contraception services were commissioned under locally agreed block contracts. This legacy persists in many areas still, even after the transition to local authority commissioning. However, a number of pressures have encouraged commissioners to re-design their commissioning arrangements.
Open Access and Cross Charging
The requirement to offer open access services has led to recognition that providers need to be able to cross-charge for the cost of care delivered to patients attending their service from beyond the local commissioners boundary. The nationally recognised guidance on cross charging1 indicates the charge raised should be based on the charge negotiated with the local host commissioner and the cross-charged commissioner is entitled to suitable backing data to substantiate that charge.
A publish tariff allows the provider to demonstrate the charges being raised to out of area commissioners for non-contracted activity are the same as those negotiated locally with the local host commissioner. Our tariff grouper also provides direct access to independently generated backing data without the need for reconciliation with invoices delivered by the provider
Service Provision
The drive for improved patient-centered services encourages the adoption of integrated services where clients can attend the same clinic and receive support contraception and GU services as part of a single attendance. Allowing a cross-over of care delivery for clients attending for GU or contraception services improves the opportunistic public health opportunities.
Return on Investment for Public Health
The pressure on local Public Health funds and the demands to demonstrate value are encouraging commissioners to adopt a tariff-based commissioning arrangement that links cost directly with the care delivered so value for money assessments can be made and more strategic commissioning decisions can be informed. Our integrated sexual health tariff dataset dataset combines commissioning charges and care.
Integrated Sexual Health Tariff data offers commissioners a detailed insight into how local funds are spent as well as the providers' public health performance through the monitoring of detailed service level agreements.
Fragmentation of Commissioning
The commissioning landscape across the broader sexual health environment is complex and fragmented, with care being commissioned and delivered by multiple actors including Local Authorities, CCGs and NHS England, if you include Sexual Assault services then add Ministry of Justice and Police Forces as well. Often the care is delivered through multiple providers over the manny channels causing disconnected service delivery and frustration and confusion to the public.
An Integrated Sexual Health Tariff allows the cost of services to be distributed as flexibly as possible in order to cope with this in-built complexity in the commissioning environment.
What is an Integrated Sexual Health Tariff (ISHT)?
Local Authorities are free to negotiate the commissioning arrangements for sexuall health care with providers as they deem fit. This can result in many different locally agreed charging arrangements. In 2011 London started to develop an integrated, tariff based charging arrangement to replace the GU 'First' and 'Follow-up' national tariffs with a set of tariffs suitable for use in GU and contraception services as part of a drive to encourage more integrated service provision.
This resulted in the establishment of a proposed Integrated Sexual Health Tariff (ISHT) for London in 2015. After a shadow period, the various London sub-regions adopted their own local versions of this tariff to meet their own needs. The London ISHT was adapted to accommodate local contractual arrangements and timings, locally agreed prices or even specific, locally commissioned activity desired for local Public Health purposes. Since then the London ISHT has moved through a number of iterations and improvements and other regions and clusters have adopted ISHTs of their own.
You can search a complete list of all Tariff Cofigurations here.
ISHTs facilitated by Pathway Analytics are represented by a Tariff Configuration made up of the following elements:
Title -- Short title identifying the Tariff Configuration
Start Date -- Submissions made by Participating Providers for data for months between the Start Date and End Date will have this Tariff Configuration applied to them
End Date -- Submissions made by Participating Providers for data for months between the Start Date and End Date will have this Tariff Configuration applied to them
Lead Commissioner -- The individual responsible for validating and making any change requests to the Tariff Configuration and requesting any data resets to submissions made by it.
Status -- This can be Draft (in planning, and un-published), Live (used for charging purposes) or Shadow (used for planning or shadow purposes).
Participating Providers, each of -- the providers whose submissions data will be processed between the Start Date and End Date by this Tariff Configuration
Provider Name -- Provider's organisation name. On occasion we add a suffix, if we need to duplicate the provider eg Blackpool Teaching Hospitals NHS Foundation Trust (Lancashire) to indicate this only relates to this providers clinics in Lancashire.
Market Forces Factor (MFF) -- a factor applied to the published Tariff Rates to accomodate local differences in costs. This used to be a nationally published rate for each provider, but now it is a rate locally agreed with the local commissioner. It is only possible to have either MFF or Geo-weighting not both.
Participating Commissioner, each of -- The list of Commissioners bears no relation to the Tariff Configuration calculation unless a Geo-Weighting is used, it is included for completeness and reference.
Commissioner Name -- organisation name as published by ONS.
Geo-Weighting Factor -- a factor applied to the published Tariff Rates to accomodate local differences in costs according to the location of the clinic delivering the care, rather than the MFF which is a factor associated with the provider. It is only possible to have either MFF or Geo-weighting not both.
Local Codes -- Certain Currencies may require Currency Triggers that use Local Codes. These are codes issued by us and used to identify a particular activity that would otherwise go undcoded. Each Local Code will be published with the Field it can be used in along with a description of the circumstances describing when it can be used.
Currencies, each of
Title -- Short and long version of a Currency Title used to identify the Currency
Primary Tariff -- The Tariff Rate used to charge the most expensive Currency charged in any patient episode or visit
Additional Tariff -- The Tariff Rate used to charge any other Currency charged in any patient episode or visit
Charge Local Host Only -- If, applied, this Currency will only and always be charged to the Commissioner hosting the clinic from which the care was delivered (ie not cross-charged).
Currency Triggers, each of: -- A Currency is triggered when a Trigger combination is present in the record data for a patient episode or visit. A patient episode or visit are any collections of records from a provider with a common Patient Id, Clinic Id and Attendance Date.
Field (subject) -- The data field
Code (object) -- The Code or data field contents
AND or AND NOT (predicate) -- a predicate indicating if the statement line is intended to be read as a negative or positive filter
Invalid Currency Combination, each of: -- This list allows us to eliminate and replace certain currency combinations
Invalid Currency Pair -- The pair of Currencies to eliminate
Replacement Currency -- The Currency to replace the eliminated pair
How is a Tariff Configuration applied?
There are a number of Meta Rules that are used in the application of a Tariff Configuration, they are as laid down below and they are all automatically applied along with the appropriate Tariff Configuration by the Grouper Service:
Data Files
A Provider can upload multiple data files in preparation for a Submission relating to a particular month.
Providers with several different contractual arrangements with different Commissioners represented by different Tariff Configurations may need to collate their data uploads into different quasi Provider organisations eg Blackpool Teaching Hospitals NHS Foundation Trust (Lancashire) to indicate this only relates to this providers clinics in Lancashire.
Data files uploaded should be in excel format and conform to the Tariff DataSet which is an amalgam of the GUMCAD and SRHAD reports.
Tariff Configurations may include the use of Local Codes
Data Submissions
A Provider makes a data Submission with a complete set of data covering the month of the Submission.
The time window after the month end to make a submission will be subject to the local service specification agreed with their local commissioner. A period of 4 to 6 weeks is generally considered appropriate.
Once the Submission is made, that month's data can only be changed by a request from the Host Commissioner and otherwise it remains locked. A Provider may make a private Sandbox calculation to test the charges raised by the data uploaded, but this is not distributed to Commissioners and remains private to the Provider.
Coding and Record Management
A record for an episode or visit is defined by a common Patient Id, Clinic Id and Attendance Date within a Provider's month of Submission.
At the point of Submission, records are merged according to our note on de-duplicting records.
Currency Tariff Rates represent the charge for either a single visit or an entire episode of care.
Currencies triggered by diagnosis codes alone, typically trigger Tariff Rates to cover the entire episode of care for that diagnosis (no matter if the care is delivered at that clinic or not), this may include any number of visits until a recurrent episode is recorded in a new record with a new Attendance Date (GUMCAD has rules about after how long a period a recurrent episode can be recorded). Diagnosis codes are typically recorded alongside the test date in the patient record, so either the test or the diagnosis currency will attract the Primary Tariff Rate.
Tariff Configuration Rules
The Primary Tariff Rate is awarded to the most expensive Currency in any one patient episode or visit. The Additional Tariff Rate is awarded to all other Currencies Triggered in an episode or visit.
A Currency may only be triggered once in any one one patient episode or visit, no matter how many Currency Triggers may be satisfied. This is because on the one hand many codes and Triggers overlap and it is not possible to differentiate between them and there is a body of activity that remains uncoded and an assumption is made that when certain Currencies are Triggered some of this uncoded activity is also being delivered and the underlying Tariff Rate has been uplifted to reflect this.
Once the appropriate Currency and Tariff Rate has been identified, either the MFF or Geo-Wighting associated with the Provider or the Commissioner hosting the clinic delivering the care is applied to the Tariff Rate.
Unless a Currency is flagged Charge Local Host Only, the Tariff Rate charge will be assigned to the Responsible Commissioner who will be defined as either in the following order of precedence: the Commissioner that hosts the LSOA reported in the Patient record as containing the patient place of residence.
Where a patient's residence residence has not been disclosed or the patient is from outside England or Wales, the charge will be assigned to the host commissioner of the clinic delivering the care.
How are Tariff Rates Calculated?
Numerous care Pathways have been compiled and costed in the case of the London ISHT they were allocated to Currencies and the weighted average costs (the weighting based on the case mix experienced across London) is used as the basis of the Currency Tariff Rates. Each Pathway has two Rates associated with it, the Primary cost, the cost of the delivering the Pathway on its own and the Additional Cost, if the Pathway was delivered alongside another more expensive Pathway. This gives us a rough and ready method to bundle Pathway or Currencies using marginal costing. The Pathways themselves are based on Time-Driven Activity Based Costing.
Commissioners are free to negotiate with Providers the Currencies and Tariff Rates they wish, they may or may not be related to underlying costs and as such they vary widely.
Candidate Service Specification Clauses