British Geriatrics Society

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Best Practice Tariff for Hip Fracture - Making Ends Meet

A plethora of guidelines advocating timely and co-ordinated multi-disciplinary care to improve outcomes for patients with hip fracture has been published over the past few years.

However, their implementation has been patchy throughout the UK.

The best practice tariff (BPT) for hip fracture came into effect in April this year, meeting the commitment to High Quality Care for All, Lord Darzi’s NHS Next Stage Review report.  This financial incentive to improve care will initially involve four areas; fracture neck of femur, cataracts, cholecystectomy (gall bladder removal), and stroke, conditions chosen as high volume areas with significant unexplained variation in quality of clinical practice and clear evidence of what constitutes best practice.

The BPT indicators for hip fracture care are:
(a) time to surgery within 36 hours from arrival in an emergency department, or time of  diagnosis if an inpatient, to the start of anaesthesia

(b) involvement of an (ortho) geriatrician:
i) admitted under the joint care of a consultant geriatrician and a consultant  orthopaedic surgeon
ii) admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia
iii) assessed by a geriatrician (as defined by a consultant, non-consultant career grade (NCCG), or specialist trainee ST3+) in the perioperative period (defined as within 72 hours of admission)
iv) postoperative geriatrician-directed
a. multi-professional rehabilitation team
b. fracture prevention assessments (falls
and bone health).

To qualify for the best practice tariff, all the characteristics in (a) and (b) (i) to (iv)above must be achieved.

Compliance will be monitored through the National Hip Fracture Database (NHFD). The tariff will be paid in 2 parts with the top-up payment for best practice paid quarterly (figure 1).

The 'base tariff' (that is the payment a provider receives for not doing best practice) has been adjusted such that it is £110 lower than the 'conventional tariff' (what the tariff 'would be' if we didn't have best practice tariffs). This is to ensure that if current best practice provision is maintained, then the policy will be cost neutral.

The 'best practice tariff' is £335 higher than the 'conventional tariff' i.e. £445 higher than the 'base tariff'. In other words, this year, if you do best practice, you will receive £445 more per case than if you don't.

An average unit treating 350 hip fractures / year with 90% meeting the BPT requirements will result in just over £140,000 of additional income (0.9 x 350 x 455). This extra income will be “real” money over the next 2-3 years and then this standard of quality will be expected within the base tariff.  In practice this means that if a poor to average performing hospital  does nothing to improve quality over the next two years they will miss out on this additional income and will be affected by reducing national average tariffs brought about by increased efficiency in other units.  However, there are only a few Trusts with Orthogeriatricians around the country and appointing to new posts will be challenging over the next 12 months. Trust and PCT units will need to be creative and sensible in providing joint medical care for these patients.

An estimate of two direct clinical care sessions per week for each 100 hip fracture patients per year of senior Orthogeriatrician time is required to provide a basic service. This includes the peri-operative assessment, review of falls and bone health and involvement in the multi-disciplinary team to facilitate appropriate rehabilitation or discharge. Much of this can be performed by a geriatric medicine ST3 and above or a NCCG doctor with the appropriate training. It is unlikely that the on-call medical registrar will have this experience but on occasions they will be required to be involved in patients out of hours to manage acute medical problems requiring immediate attention.  

However, it is essential that there is a Consultant Geriatrician involved in the day to day running of the service to provide continuity of care, in making difficult decisions regarding fitness for theatre, in complex discharge planning and in end of life decision making. The involvement of two Orthogeriatricians sharing the workload along with their other commitments should be considered and would provide a balanced job plan and ensure adequate cross cover when necessary.

The NHFD now asks for the GMC number of the Orthopaedic Surgeon and the Orthogeriatrician responsible for the fractured neck of femur pathway. This Geriatrician may not be involved directly with all patients but should provide leadership and be involved in reviewing the pathway and responding to any issues identified by those patients not meeting BPT.

The fractured neck of femur pathway will vary in different settings with variability in A&E departments, orthopaedic on call arrangements, elective and trauma set ups and availability of intermediate care teams and in-patient rehabilitation facilities. Setting up a service requires a review of the current patient pathway and comparison with an ideal patient pathway to establish what changes need to be made. This review should look at the whole patient journey from the point of admission right through to discharge back into the community and should involve motivated representatives from all departments working as a team. The process may be streamlined and achieved more effectively by employing a project manager with experience in lean methodology.

There are many examples of good practice available through the National Hip Fracture Database Website (www.nhfd.co.uk) which can aid Trusts in getting started, including business cases for Consultants and  Staff Grades in Orthogeriatrics, clerking proformas / Integrated Care Pathways and Handbooks of the Medical Management of patients with Fractured Neck of Femur. These are freely available to download, adjust, agree and implement by local teams.

There are several Trusts who have been through this process over the last few years, some supported by the National Institute of Innovation and Improvement, demonstrating that joined up care with the involvement of an orthogeriatrician can significantly reduce length of stay, reduce mortality and provide cost savings.  The concept of the Best Practice Tariff is to provide an initial financial incentive to encourage all Trusts to take the first step to improve the quality of care of this vulnerable group of patients.

Helen Wilson, Guildford
Karen Harding, Bristol
Opinder Sahota, Nottingham

on behalf of the Falls and Bone Health Section, British Geriatrics Society

Published in the June 2010 issue of the BGS Newsletter

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