What is the ‘payment system’?

The payment system is an umbrella term for the arrangements by which funding flows from NHS commissioners of care to the providers, who deliver front-line care for patients.

NHS England commissions specialised services. Local health care commissioners oversee funding for local acute, mental health, community and primary care providers. Commissioners’ budgets are determined by a resource allocation formula based on local population size, relative need and unavoidable cost differences (for example due to pay and building cost differentials in different locations). Under the Health and Care Bill, integrated care systems (ICSs) will take over this local commissioning role in England. Figure 1 sets out how funding flows to commissioners and onto providers.

Figure 1: How revenue funding flows from commissioners to care providers

Commissioners distribute funding to the providers of health care using a range of different payment approaches. These are set out in Box 1.

Box 1: Payment approaches by service area

The main payment method used to channel funding from the commissioners of care to NHS providers depends on the extent to which payments for services are paid for separately or grouped together – known as ‘bundling’. The second difference is whether the payment rates are set in advance or retrospectively. During the pandemic, hospitals are being reimbursed retrospectively based on actual costs incurred due to the difficultly of anticipating an appropriate price to pay for key items.

Historically, the most common payment system in the NHS was an annual block budget payment. This provides an annual spending envelope for a hospital, regardless of the number of patients treated, the type of care provided or quality of care. Block contracts are still used extensively in mental health, community and ambulance services. The advantage of block budgets is that they provide certainty of income to providers and certainty of spending to commissioners. The disadvantages include limited incentives to improve efficiency or quality and to be responsive to patient needs.

The next most bundled approach are capitation payments. These are lump sum payments to cover the services an individual needs for a period of time – they are normally annual per person payments, often ‘weighted’ to take account of the fact that some patients require additional or more costly services. They can be used to pay for a year of care for someone with a specific disease (for example cystic fibrosis or diabetes) or for a range of care services such as those provided by GPs. Capitation payments are a way of incentivising providers to focus on better prevention and early intervention to avoid high cost later. They tend to work best when the cost of care for a group of patients with specific characteristics are reasonably predictable.

Activity payments have been rolled out across the NHS over the past 15 years through the Payment by Results (PbR) tariff system. In 2016 almost 90% of NHS contracts for acute health care were paid under the PbR system. The PbR tariff provides a fixed payment for a specific episode of care (such as a hip replacement), taking into account the complexity of the patient’s health care needs. The two fundamental features of PbR are nationally determined currencies and tariffs. Currencies are the unit of health care for which a payment is made and are based on groupings of clinically similar diagnoses or procedures with a similar cost. Tariffs are the set prices for a given currency. Activity payments increase the incentive to provide services efficiently and encourage providers to deliver more care to more patients (assuming they are set at the right level). But the concern is that they can be a disincentive to collaboration, prevention and have comparatively high administrative costs.

The least bundled system of payment is fee for service where payment is made retrospectively for each unit of service provided; each activity or patient contact paid for according to a fixed price schedule, so rather than paying for a hip replacement as a whole, the commissioner would pay for the operation separately from any diagnosis tests and scans and outpatient appointments. Fee for service payment mechanisms encourage providers to be very responsive to patients’ demand and deliver comprehensive (and, under some conditions, high quality) care but have weak incentives to improve efficiency, little incentive for prevention and often lead to over-treatment.

Elements of these payment structures can be combined to try to benefit from the strengths of each while avoiding some of their weaknesses. However, there is no ‘perfect’ payment system. In the end, the health service needs to match the payment system to its main objectives, recognising there are likely to be trade-offs between them.

In addition to these core payments there are top-up or ‘withhold’ payments for quality. In primary care this is the Quality and Outcomes Framework (QoF), which is a top up payment. For hospital, mental health and community services there is a system called Commissioning for Quality and Innovation (CQUIN), where in 2019/20 1.25% of funding was held contingent on providers evidencing good practice quality care in five areas.

In recent years the NHS has overlaid ‘risk sharing’ agreements on top of the PbR tariff. These agreements set out at the start of the year how much activity is expected to occur under PbR. They then agree what will happen if activity is either significantly higher or lower than planned. The agreements specify how the cost of that variation in activity would be shared between the commissioner or provider. For example, if a hospital treats 5% more patients the risk sharing agreement might agree that the hospital should reimburse some of the PbR tariff back to the local commissioner to reduce the risk of the commissioner overspending. If the hospital treated 5% fewer patients than expected, the commissioner would agree to make an extra payment to help reduce the risk of the hospital going into deficit.

Service areas

Mental health and community health: care providers’ ‘block contracts’ predominate, where the total budget is agreed in advance with only indicative linkages to the amount and pattern of care. Some commissioners have used mental health care cluster data as a payment currency, with payment based on cluster days or episodes of care. A cluster day price is calculated by dividing the value of a provider’s mental health contract by the number of expected days of care to be provided, weighted by the relative resource intensity of the different clusters. There are 21 clusters that provide a way of capturing the presenting needs of service users coming into mental health services. They group people with similar levels of needs in the same cluster, although their specific diagnosis may be different. The clustering tool has 18 scales (eg depressed mood, problems with activities of daily living). Each scale is given a rating from 0 (no problem) to 4 (severe to very severe problem). However, in 2015 NHS England and Improvement raised concerns that payments based on cluster days would not be the best way to incentivise early intervention and recovery-focused care and was seeking to move to pay for mental health services based on either capitation or episodes of care.

Hospital care: until very recently there has been a move away from block budgets to activity-based payments based on the national average cost of providing an ‘episode’ of care. The PbR tariff has evolved over the past 15 years. Figure 2 shows the evolution of the PbR system up to 2019/20.

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