HSJ EXCLUSIVE Acute trusts' 'perverse double incentive' could trigger meltdown: pages 5-6

Published: 06/01/2005, Volume II5, No. 5937 Page 5

Accident and emergency departments have been admitting record numbers of patients to hospital as trusts scramble to meet the increasing demands of the A&E four-hour target, HSJ research reveals.

The research also suggests that the trend of admitting patients at risk of breaching the four-hour target could trigger significant financial problems across the NHS from April, when the payment by results system currently being pioneered by foundation trusts is rolled out more widely.

A&E admissions have been rising steeply in the run-up to the final national deadline to deal with 98 per cent of all patients within four hours by the end of 2004.

Official figures show that 11 per cent more patients - 135,735 - were admitted to hospital beds via major A&E departments in the first six months of financial year 2004-05 compared to the previous year.

Under the current payment by results tariff, most patients admitted via A&E whose stay lasts less than 48 hours automatically trigger a£1,200 invoice to be paid by primary care trusts, even if the patient is discharged in less than 12 hours. This price has been cut in half for next year, but is still far in excess of the£200 charged for an outpatient appointment, for example.

Now there is concern that the combination of the payment by results tariff and the A&E target have created a 'double perverse incentive' for acute trusts to admit patients via A&E for non-clinical reasons.

The research into 14 of the 16 first and second-wave foundation trusts with available data, carried out for HSJ by NA Wilson Associates, shows that five foundation trusts had seen an increase in admissions far above the national average - although increases in A&E attendances were slight.

Bradford Teaching Hospitals foundation trust topped the survey, with a 21 per cent increase in admissions, compared with no increase in attendances.

Researchers estimate this increase has amounted to an extra£4.3m bill for commissioners, based on the 2003-04 tariff.

HSJ understands that the PCTs contested this bill, and that this was one of the fundamental issues that led to the current crisis at the flagship foundation trust, where over half of the admissions via A&E were reportedly under 12-hour length of stay.

Bradford now faces an end-of-year projected deficit of£11.3m.

The research found that University Hospital Birmingham foundation trust and Derby Hospitals foundation trust both admitted 18 per cent more patients via A&E, compared to just 4 and 3 per cent increases in attendances respectively, while Stockport foundation trust admitted 17 per cent more A&E attenders despite recording a 1 per cent drop in numbers attending.

Sixteen per cent more A&E patients were admitted at Cambridge University Hospital foundation trust, which recorded a 9 per cent increase in attendances.

Researchers said these jumps in admissions could have cost commissioners up to£3.5-4.5m extra compared to the previous financial year, based on the 200304 national tariff price for shortstay admissions.