Best Practice Tariff Queries

This means there is an enhanced tariff payable to Trusts in England that deliver care considered to be best practice to their patients requiring emergency general abdominal surgery. If care does not meet those standards, Trusts will be paid at a lower rate. The specific aim of the EL BPT 2023-2025 is to improve the proportion of patients who receive both a formal mortality risk assessment before surgery AND input by peri-operative teams experienced in the management of frail older patients.

The BPT metrics are set by NHS England, and are not chosen by NELA. Many processes are important in optimising care for patients, but early recognition that a patient is at increased risk of complications postoperatively is essential if the required standards of clinical care are to be met. Improving care for older and frail patients remains one of the worst performing metrics within NELA, but is of significant clinical importance. The NELA Year 8 report, which included data from 1 Dec 2020 until 30 Nov 2021, shows that less than a third of elderly and/or frail patients benefitted from elderly care input postoperatively. The same report showed an association between elderly care input and a halving of mortality risk. Improving elderly care resources requires a financial investment in many hospitals - and the decision was made by NHS England to reward those Trusts that prioritise this area.

The previous metrics of ensuring direct consultant-delivered anaesthetic and surgical care for high-risk patients in theatre as well as critical care admission are still considered best practice, but BPT will now focus on:
• Risk assessment - proportion of patients who receive a documented assessment of risk as part of the decision to operate. Target: 85% of all NELA patients
• Peri-operative team input - proportion of patients aged 80 or over, or 65 or older and frail (CFS≥5), who receive input by peri-operative teams experienced in the management of older patients. Target: 40% in 2023-24, increasing over time.

Yes. If either metric falls below the target (85% and 40% of eligible patients respectively) the BPT will not be payable.

Guidance published in 2021 is available from the Centre for Perioperative Care (CPOC), which notes that "all hospitals should have a perioperative frailty team with expertise in Comprehensive Geriatric Assessment and optimisation, providing care throughout the pathway (for frail and elderly patients)". The perioperative frailty team should be multidisciplinary and have expertise in comprehensive geriatric assessment and optimisation methodology to deliver:
• preoperative assessment and optimisation of frailty, cognitive disorders and multimorbidity
• prognostication and shared decision making
• assessment and management of postoperative medical complications, hospital acquired deconditioning, postoperative cognitive disorders
• rehabilitation, goal setting and discharge planning with onward referral to community services
• treatment escalation and advance care planning
• effective communication with patients and carers throughout the perioperative pathway
• streamlined care working with other disciplines and specialities

NHS England have indicated that a patient will have received appropriate input if they have been seen in the post-operative period by a geriatrician-led service, or by a perioperative medicine-led team with established referral pathways to geriatrics. The BPT will not have been met if patients have only had an intensivist or anaesthetic review whilst on critical care, PACU or as part of an outreach service.

Trusts need to have agreed multidisciplinary pathways of care in place, agreed by key stakeholders within the Trust who are involved in delivering care, including emergency departments, elderly care, anaesthesia, critical care and surgery. As a minimum these pathways should cover a diagnostic pathway as well as a laparotomy pathway once a decision to operate has been made.

NELA provides reports at hospital level covering a number of process measures. However, BPT is assessed at Trust level, and this might be important if your Trust has more than one hospital performing emergency abdominal surgery. NELA will produce Trust level reports specifically around BPT performance.

BPT compliance will be assessed directly through data submitted to NELA. However payment will be based on HRG codes that represent common (but not all) emergency laparotomy operations, regardless of whether or not these are entered into the NELA registry, and regardless of the patient's age or frailty profile. Hence the BPT is paid for all patients with those HRG codes, not just those that are aged 80 or over, or 65 or older and frail. Commissioners are likely to consider whether overall NELA case ascertainment rates are high enough before approving BPT payments.

The BPT will be payable quarterly. Cases need to be entered and locked in the NELA database within 60 days of surgery in order to appear in the BPT report. It is not possible to retrospectively add patients to a previous quarter in order to receive the BPT for that previous quarter.

Your medical director, leadership and finance teams and NELA clinical leads in surgery, medicine and anaesthesia will want to know about this BPT, as it may alter income for the Trust. They may wish to make enhancements to clinical services to facilitate enhanced income. It is important to note that the tariff for those Trusts that do not meet the BPT criteria will be lower: Trusts may need to include any potential shortfall in their business planning.

Given the financial benefit that arises from the BPT, we would expect Trusts to support those involved in co-ordinating NELA data entry within hospitals, including job planned time for clinical leads, audit facilitators and clinical coding teams.

Your Trust could target BPT metrics to bring extra income into the Trust helping to fund the Trust's quality improvement/service improvement aspirations.

The difference varies according to HRG code as shown in the table below. The average difference is about £900, so a Trust undertaking 100 HRG-code eligible procedures per year might see a potential income difference of £90,000. These HRG codes can be passed to your own coding departments who will be able to model the financial implications for your own Trust.

The BPT is intended to support improved services for emergency laparotomy patients. Some Trusts have indicated they will use the enhanced tariff to support increased elderly care capacity, or improved access to perioperative medical input for frail and elderly patients.

This is a decision for commissioners to make, as they will need to decide whether case ascertainment is sufficient to represent Trust activity.

Additional information about the BPT and payment tariffs can be found at:

NHS England guidance on all current BPTs:

HRG coding and financial detail: