Published: 20/01/2005, Volume II5, No. 5939 Page 17
Only those who have never managed or worked in hospitals could seriously suggest that acute trusts might deliberately instruct clinicians to admit patients inappropriately for financial gain (news, pages 5-6, 6 January).
It is an absurd innuendo that shows a complete misunderstanding of how nurses and doctors carry out their duties.
As healthcare professionals - with our own code of conduct - we would not contemplate such an unethical proposal. Indeed the clinicians and on-call hospital managers who spend many frantic hours trying to find beds point out that too many admissions compromise the quality of care we are able to offer our patients.
The rising trend in emergency admissions started at least five years ago, way before payment by results was a twinkle in ministers' eyes.
Resources are being stretched to the limit to meet the A&E 98 per cent four-hour waiting-time target.
In this respect, hospitals really do not need any more work. Indeed, some of the failure to reach the 98 per cent target across the NHS by last month's deadline has a lot to do with a lack of beds as the early results from Birmingham and the Black Country (and, no doubt, the rest of the NHS) illustrate.
The majority of patients selfpresent to A&E or ring 999 without contacting either their GP or out-ofhours service. The patient, by exercising choice to present to the A&E department, circumvents the GP service, resulting in a higher level of admissions from A&E. This is because self-referring patients are rarely known to A&E clinicians and tend to bring little useful information with them.
Understandably, A&E staff will therefore tend to err on the side of caution when considering admission. Patients are also increasingly presenting earlier and medical advances mean they can be treated more quickly.
In most acute trusts, the A&E target is not an incentive to admit. If careful clinical governance deliberations conclude it is appropriate for a patient to wait in A&E past four hours, that is what will happen.
We see much merit in Noel Plumridge's assertion (Opinion, page 19, 2 December 2004) that patient choice is starting to impact on A&E because of low waiting times and a guaranteed same-day service.
The real issue for commissioners and hospitals alike is whether to provide alternative models for a relatively small minority of A&E patients who could be treated in the community while simultaneously funding a system that has to meet care needs on a daily and immediate basis. Foundation status plus payment by results could offer some exciting possibilities.
Spurious assertions In times of financial difficulty, it is all too easy for different parts of the NHS to blame someone. However, spurious assertions of blame rarely offer a solution or deal with an underlying root cause.
Commissioners are starting to realise they are responsible for demand management and the payment by results tariff will focus attention on an issue that hospitals have largely been left to cope with for too long.
Many of us have been arguing for some time that the tariff is too crude for emergency admissions. However, some tension does need to exist between those who commission services and manage demand and those who provide care and meet need.
In the light of this, I wholeheartedly approve of the government's decision to think more carefully about the widespread introduction of payment by results for A&E (news, page 5, 13 January).
In Birmingham, the picture on A&E demand is far more complicated than ill-informed commentators believe. A primary care trust-led multi-disciplinary team studied the medical records and case notes of admissions made to our medical assessment unit. This suggested the vast majority of admissions were appropriate, speedy and had well-supported discharge arrangements.
It is worth noting that 63 per cent of patients stayed less than 24 hours while only 18 per cent stayed longer than two days. This should be a cause for celebration, not an opportunity for berating hard-pressed and dedicated clinicians who work in a pressurised hospital environment.
Thanks to the 98 per cent target, acute trusts have improved access, care processes and the health status of patients.
Our study found that 63 per cent of patients either self-presented or came via a 999 ambulance. Of these, 47 per cent had respiratory or chest pain, 14 per cent acute gastrointestinal conditions and 9 per cent stroke and other neurological conditions, with a further 7.5 per cent being admitted because of self-harm.
The multi-disciplinary team concluded that only 16 per cent of admissions could have possibly been avoided had better community facilities existed. However, we do not know at what cost and quality the admissions might have been avoided, and this is the issue that frustrates commissioners and hospitals alike.
The recent King's Fund report suggests it is too early to claim that any one alternative emergency care model is superior to others (news, page 16, 2 December 2004).
We do know however that, thanks to our much improved clinical 'pull' system within University Hospital Birmingham foundation trust - which employs an assessment unit to direct patients appropriately - patients suffering acute coronary syndrome or chest pain have been much better cared for within the hospital for a minimum period of time. This is both cost and quality-effective.
Mark Britnell is chief executive of University Hospital Birmingham foundation trust.
HSJ conference HSJ is holding a conference on payment by results on 2 February. The keynote speaker is Chris Watson, head of the Department of Health's payment by results team.
www. hsj-paymentbyresults. co. uk
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