The Study Day was held on the 10th of December 2009 at University Hospital of South Manchester and proved to be a useful opportunity to share ideas and aspirations concerning improvements in the current data collection software as well as some of the reports being sent back to burn services.  It also proved a useful discussion group for design features going into the next version of the database software. Participants had an opportunity to consider these before the meeting and to discussed them in some detail.

There was broad agreement and consensus that the planned way forward made sense for both the burn services and for the aims and intended uses of the burn database information.  Valuable additions and design features were offered and accepted with an indication that areas of further work when necessary, particularly in relation to the recording of surgical activity and aspects of physical therapy outcome measurement.

Other areas covered included the design of the recently reconfigured error and validation report (report E) with an acceptance that the new version of the software should make this report redundant as real-time validation and error checking is to be written into the software. The innovation of updating menu lists automatically from the central server was accepted as a major improvement and a way of keeping the database design contemporary and clinically valid.

A recently produced report was introduced, which is renewed each month and is an indication of the volume of data being transferred by each burn service into the database server. It was emphasised that this is now available to any registered user of the database and gives an indication of the volume of successfully uploaded data.  The database currently contains approxiamately 66,000 records.

Throughout the discussions it was accepted that one of the major drivers for the database design has been the wish to incorporate patient level costing methodology. This will undoubtedly increase the volume of data collection but in doing so make the record a more clinically relevant indication of the care provided.

It was discussed and appreciated that acceptance of the database as a commissioning tool will be a complex matter and based on successful negotiations with a number of groups, including the NHS Payment by Results team and the data team at the NHS Information Centre.

Additionally agreement needs to be reached with Specialised Commissioning Groups (SCG) within the NHS who need to accept the information from iBID as valid commissioning currency. This as pect will be discussed at the next national group meeting in Feb 2010 and subsequently at the SCGs Directors meetings.

Burn service attendees were reminded that all of the reports produced about their services remain available using the service specific username and password  previously circulated to clinical leads and available from burn network managers.  If any member of staff requiring access to these reports is unable to access them, then contact their network manager for the necessary access rights.

A presentation on the Patient Level Costing (PLC) pilot results from The Manchester Burn Service was well received at the European Burns Association (EBA) meeting in Lusanne in early September 2009. The paper received and outstanding abstract award and will be published in a supplement of the BURNS journal [Cost of Burn Care in the British Isles & Service Remuneration Options. Rob Duncan and Ken Dunn]. The intention has been to model the consequences of adopting PLC as the commissioning and remuneration methodology for burns care under the Payment by Results (PbR) development within the NHS. The results from the pilot are being used to guide the design of the next version of the iBID software, due for release in early 2010.

Abstract: Cost of burn care in the British Isles and service remuneration options.
Rationale:  Escalating  healthcare  costs  is  a  global  problem  &  threatens  the  UK National Health Service’s guiding principle of “free at the point of delivery”. New management styles & encouragement of inter-service competition have been introduced to gain efficiency savings. A new remuneration system numbers amongst the changes, whereby fixed tariffs are assigned to set diagnostic groups. This is a direct threat to burns services, who are served poorly by this style of remuneration, owing to the heterogeneity, complexity & high cost of burn injuries. A 1% TBSA burn has vastly different cost implications depending on site & a plethora of other factors. We advocate development of a “Patient Level Costing” system, whereby multiple patient factors inform care requirements/remuneration. A fundamental first step is to develop an understanding of the true cost of UK burn care, which for historical reasons is poorly understood.

Methods: Detailed interrogation has been conducted of the cost of burn care within our University Hospital. Costs were determined through amalgamation of two fundamental methodologies (1) Top-Down costing (from detailed budgetary analysis) & (2) Bottom-Up costing (detailed itemised costing of staff, equipment, drugs, consumables & maintenance). Avoiding duplication, these costs were then merged. All costs have been categorised & traced to specific care areas, using various apportionment tools. The resultant costs were then applied to detailed national burn injury data to estimate total UK burn care costs.

Results: An occupied burns intensive care bed day costs £2634 (even just keeping it unoccupied—but available for use, costs £2398). High dependency beds cost £1548
per day and standard ward beds £772, whilst burns theatre costs £993 per hour. Current UK burn care provision (by dedicated burns and plastic surgery services only) is estimated at £140 million.

Conclusion: We hope application of this new system of Patient Level Costing to British burn care will avoid the threatened viability of burns services imposed by changes in service remuneration, although it will inevitably be an iterative process. A fuller understanding of the true cost of healthcare, facilitates service development & planning, at both local & national levels.             doi:10.1016/j.burns.2009.06.039

The next version of the iBID software was considered in a meeting in Birmingham in early June with representatives from clinical teams, service commissioners and IT designers. The intention is to build on the experience from using the current version and the points made in the Study Days to build a system with greater data entry support. In addition greater flexibility is needed to reflect out-patient workload and greater detail concerning cost driving activities such as critical care and operative activity. This may lead to the database being used as the prime commissioning tool for burn care that fall within the specialised services definition agreement (see the general download section). The hope is to have the next version available for testing in early 2010.