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SUS+ PbR reference manual

This document provides consolidated historical National Tariff and Payment by Results (PbR) information guidance and is amended as required to provide coverage new, developing or previously uncovered areas. It is therefore a ‘living’ document which can be updated in response to feedback from the user community. New chapters can be produced, and existing chapters enhanced, based on these requests.

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SUS+ PbR reference manual


Summary

This document provides consolidated historical National Tariff and Payment by Results (PbR) information guidance and is amended as required to provide coverage new, developing or previously uncovered areas. It is therefore a ‘living’ document which can be updated in response to feedback from the user community. New chapters can be produced, and existing chapters enhanced, based on these requests.


SUS users are therefore encouraged to provide feedback and suggestions for areas of improvement in existing guidance and new requirements for support materials. To provide feedback please email NHS Digital Enquiries and include ‘SUS Documentation Feedback' in the subject line.

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Secondary Uses Service (SUS)

The Secondary Uses Service (SUS) is the central repository which supports the flow of Commissioning Data Sets (CDS) between providers and commissioners.

When a patient or service user is treated or cared for, information is collected which supports their treatment. This information is also useful to commissioners and providers of NHS-funded care for 'secondary' purposes - purposes other than direct or 'primary' clinical care - such as:

  • healthcare planning
  • commissioning of services
  • National Tariff reimbursement
  • development of national policy

National Tariff Payment System

Following the handover of responsibility for the NHS Payment system from the Department of Health to NHS England and NHS improvement (formerly Monitor) in April 2013, PbR was effectively replaced by the National Tariff Payment System (NTPS) in April 2014. This new payment system currently retains the vast majority of PbR policy.

Due to the embedded terminology, data item and extract naming consistency, SUS continues to refer PbR in SUS. Therefore the terms 'Payment by Results', 'PbR', 'National Tariff Payment System' and 'NTPS' should be considered interchangeable when using SUS or any SUS guidance.


Payment by Results (PbR)

Payment by Results (PbR) provides a transparent, rules-based national tariff system, used to determine the reimbursement of NHS funded care in England. PbR rewards efficiency, supports patient choice and diversity and encourages activity for sustainable waiting time reductions.

Payment is linked to activity and adjusted for Casemix. This ensures a fair and consistent basis for hospital funding rather than being reliant principally on historic budgets and the negotiating skills of individual managers.

PbR is the payment system in England under which commissioners pay providers of NHS-funded healthcare for each patient seen or treated, considering the complexity of the patient’s healthcare needs.

The two fundamental features of PbR are nationally determined currencies and tariffs. Currencies are the unit of healthcare for which a payment is made and can take a number of forms covering different time periods from an outpatient attendance or a stay in hospital, to a year of care for a long-term condition. Tariffs are the set prices paid for each currency.

Coverage

PbR currently covers most of the acute healthcare in hospitals, with national tariffs for admitted patient care, outpatient attendances and accident and emergency.

This activity is submitted using Commissioning Data Sets (CDS). Current policy intends that the scope of PbR and national tariff will expand in future by introducing currencies and tariffs for mental health, community and other services.

Coding and submitting patient data

When a patient is discharged, a clinical coder translates their care into codes. Two classification systems, ICD-10 (International Classification of Diseases) for diagnoses and OPCS-4 (Office of Population Censuses and Surveys) for procedures (interventions) are used. When a patient attends an outpatient clinic, their Treatment Function Code (TFC) is similarly recorded.

For some outpatients it is appropriate to record procedures performed as these will allocate an HRG that is priced under different rules to standard outpatient attendances. This information, together with other information about the patient such as age and length of stay, is sent to SUS via CDS. Extract reports produced by SUS allow commissioners to pay providers for the work they have done or to adjust any regular monthly payments for actual activity undertaken.

Pricing

Tariff prices have traditionally been based on the average cost of services reported by NHS providers in the mandatory annual reference costs collection. In practice, various adjustments are made to the average of reference costs, so final tariff prices may not reflect published national averages. The reference costs from which the tariff is produced are three years in arrears. Therefore, an uplift is applied which reflects pay and price pressures in the NHS and includes an efficiency requirement. The introduction of best practice tariffs in 2010/11 began to introduce the policy concept that tariffs should be determined by best clinical practice rather than average cost.

The tariff received by the provider is multiplied by a nationally determined market forces factor (MFF). This is unique to each provider and reflects the fact that it is more expensive to provide services in some parts of the country than in others. There may also be other adjustments to the tariff for long or short stays, for specialised services, or to support particular policy goals.

Currency

The currency for admitted patient care, outpatients and A&E is Healthcare Resource Groups (HRG). HRGs are clinically meaningful groupings of diagnoses and interventions that consume similar levels of NHS resources. Grouping the extensive and growing number of clinical codes into HRGs allows tariffs to be set at a sensible and workable level. For Admitted Patient Care (APC), each HRG covers a spell of care, from admission to discharge.

Non-mandatory prices

For years up to and including 2018/19 SUS and SUS+ only allocated mandatory prices. In 2019/20 it became necessary to mark prices for maternity activity as non-mandatory. These are identified in APC activity as tariff types DAYNM, ELENM, NONNM and in outpatients as tariff type NONMAND. No other non-mandatory prices are assigned by SUS+.

Impact of PbR

Before PbR, it was common practice for commissioners to have block contracts with hospitals where the amount of money received by the hospital was fixed irrespective of the number of patients treated.

PbR was introduced to:

  • support patient choice by allowing the money to follow the patient to different types of provider
  • reward efficiency and quality by allowing providers to retain the difference if they could provide the required standard of care at a lower cost than the national price
  • reduce waiting times by paying providers for the volume of work done
  • re-focus discussions between commissioner and provider away from price and towards quality and innovation

PbR was introduced to support healthcare policy and the strategic aims of the NHS. As these have changed and developed over time, so has PbR. The tariff is now seen increasingly as a vital means of supporting quality outcomes for patients and delivering additional efficiency in the NHS.

PbR is not unique to England. Many other countries in Europe, North America and Australasia operate similar payment systems.

SUS PbR view

SUS PbR is a collection of rules and processes to support implementation of national tariff policy. Derivations, tariffs and business rules, agreed with NHS England and NHS Improvement, provide a common and consistent mechanism to support reconciliation of activity and payment between providers and commissioners.

Scheduled extracts of processed data are generated at two specified cut-off points to produce static snapshots.

These cut-off points are known as:

  • reconciliation - first reconciliation point
  • post-reconciliation - final reconciliation point

The system also provides a ‘current’ view which provides a view of the data held at that time. Scheduled and ad-hoc extracts can be configured and run via the portal.

Finished spells

SUS PbR supports national tariff payment and therefore only contains data for finished spells (where a patient has been discharged) because reimbursement is made at spell-level. For example, an episode-level extract will only contain episodes for completed spells.

Standard Extract Mart (SEM) view

The SEM view reflects how data would have appeared in the legacy SUS Standard Extract Mart. SEM view data contains a limited number of additional derivations and is updated by each subsequent version of activity data submitted, it reflects the position within SUS at the time the extract is taken and thus provides a changing view over time.

Data extracted using SEM view reflects the same position as PbR but is not restricted to PbR completed spells. Instead it contains all episode level information submitted to SUS up to the point at which the extract is run, regardless of whether the patient has been discharged and the spell has been completed.

PbR Data in SUS+

SUS+ supports two previous historical years plus the current financial year (currently 2015/16, 2016/17 and 2017/18).

2015/16 and 2016/17 data has been reprocessed by SUS+. Due to changes in processing (such as simplified spell creation) marginal differences in results obtained by SUS and SUS+ may occur.

Multi tariff processing

Multi tariff processing allows the user to choose the financial year for a PbR extract. Both pricing reference data and the grouper for the selected year will be applied. The extract format and column structure will be the same as that for the current financial year and users can construct their own extract.

SUS+ changes to extracts

The structure of the SUS+ extracts is very similar to its legacy SUS predecessor in order to support established user routines and processes. Expect to see development of extracts as SUS+ continues to streamline and improve.

Additional data items

New data items have been added to the appropriate extracts to support Prescribed Specialised Services (PSS) and National Programme of Care (NPoC).

Obsolete data items

Certain data items have been identified as obsolete. This means that they are either surplus to user requirements or are no longer required. In SUS+, obsolete data items continue to be available in the extract specification but will not be populated. Data items identified as obsolete are expected to be removed in future.

Format changes

A small number of minor format changes have been made to accommodate more efficient processing. These changes are not expected to impact on user routines and processes.

HRG grouping

Checks and exclusions are made based on:

  • ‘illogical data’
  • data issues and missing data

Illogical data

Such as a day case that covers three days, invalid treatment function codes or diagnosis/procedure codes which are classified as other or unspecified

Data issues and missing data

Rather than rejecting data, it is either ‘cleansed’ or ‘flagged’ as containing issues. It then continues through the process and can lead to the derivation of a UZ01Z HRG (data invalid for grouping) and assignment of a zero price.

SUS data quality dashboards

A number of dashboards have been developed by NHS Digital to support users in monitoring and driving improvements in the quality and completeness of SUS data.

The dashboards report on the coverage and quality of the APC, outpatient and A&E CDS types, as well as focussing on other key areas for improvement of data quality such as maternity and critical care.

There is no limit to the number of users within an organisation that can register for access to the SUS dashboards. YOu can find more information about how to register on the SUS guidance page.

Interchange tracking

Tracker functionality

The status of a CDS interchange submission can be monitored using the ‘Tracker’ functionality that can be accessed via the portal. It shows the live status of interchanges submitted to SUS and whether they have been processed and made available for extract.

Monthly trust statements

Tracker information is also provided in workbook format in the form of monthly trust statements, available on the operational support page.

These weekly reports track the status of all data submissions up to the date displayed in the report heading. They allow the status of all submissions for a particular organisation to be checked. Senders are encouraged to use the Tracker reports to check that data has been successfully received by SUS. This is particularly useful after any organisational or system (PAS or XML) changes have been made.

Monthly database counts

Reports are generated and published on a monthly basis to track the number of records submitted to SUS (by activity month) for the last 18 months. Activity is displayed for each CDS type on a separate worksheet and can be used to highlight where an organisation has peaks and troughs in activity submissions, has duplicated or deleted data or where an organisation has started or stopped submitting data.

Interchange notifications

Registered users will receive automatic email notifications when their interchanges have been successfully received and processed. If you wish to receive interchange notifications, please contact National Service Desk.

Interchange data quality reports

Registered users will receive automatic reports when their Interchanges have been received and processed. If you wish to receive interchange data quality reports, please contact National Service Desk.


Last edited: 5 July 2022 12:18 pm