NHS "Target" insanity

Targets intended to cut long waits in hospital Accident and Emergency [ER] units have cost the NHS in England 2 billion pounds over the past five years, an assessment of healthcare information has concluded.

The extra costs come from patients who are in danger of having to wait more than four hours in A&E – the target limit – and are admitted to hospital “just in case”. Many are later discharged the same day, suggesting they had no real need to be admitted, with today – Christmas Eve – having the highest proportion of patients sent out on the day of admission.

Primary care trusts have to pay as much as 1,000 pounds per admission, compared with about £100 for a patient treated in A&E. So the costs of admitting a patient – even for less than a day – are large. Data collected by the CHKS Group, an independent provider of healthcare information, suggest that over the past five years, about two million extra patients were admitted to hospital through A&E units in England. But in Scotland and Northern Ireland, which do not have the four-hour target, there has been no increase in admissions. In Wales, which implemented the target later, the rise was delayed, but began to appear in 2005.

Dr Paul Robinson, Head of Market Intelligence at CHKS, said: “There is no obvious clinical reason why growth in emergency admissions should differ between countries in the UK. However, the A&E target in England has clearly had an impact and potentially cost the taxpayer more than 2 billion. “It is only England that showed this increase, and it is difficult to see why other places did not, unless the A&E targets were the cause. “There are some other possible explanations, including changes to out-of-hours care, and NHS Direct. But a large proportion of the increase must be due to the target. It’s another example of how targets that are good in principle can have unexpected effects”.

The A&E target was introduced in the NHS Plan of 2000 and came fully into force in England at the end of 2004. It charges hospitals with ensuring that patients attending A&E departments should be admitted, transferred or discharged within four hours. A hospital is deemed to have met the target if 98 per cent of patients are dealt with within four hours. Studies have shown that the target causes a huge flurry of activity as the four-hour wait nears its end, with a substantial proportion of patients being dealt with in the last 20 minutes.

Between 2002 and 2006 emergency admissions to English hopsitals rose by 20 per cent, a total increase of 720,000 a year. Admissions through A&E accounted for 37 per cent of this increase. CHKS analysis of NHS data shows that more than a quarter of emergency admissions are discharged the same day. The majority of these are patients admitted through A&E. CHKS data shows that “same day” discharges after admission through A&E rose by 65 per cent between 2001 and 2005, when the target was being introduced in England.

Each week, Friday is the peak day for patients to be discharged on the same day they are admitted. But Christmas Eve is a Friday writ large. People prefer not to be admitted for Christmas and doctors prefer to keep them out of hospital, Dr Robinson said. But to discharge so many more on Christmas Eve – 8 to 10 per cent more than on an average day – implies a change in discharge criteria. One reason, he suggests, could be “poor medicine and rushing through the workload on the day” but there is no evidence for this in increased readmission rates. The numbers readmitted within 14 to 28 days are very similar to those discharged on any other day.

The increase in admission through A&E could have another explanation, apart from the four-hour target. To admit more patients is greatly in the financial interests of hospitals because under payment by results they get paid much more. Using the system in this way is called “gaming” within the NHS and is frowned upon. But trusts have been under such pressure to balance their books that some degree of gaming cannot be ruled out. Dr Robinson said: “There is the potential for that, but I wouldn’t see it as the main motivator.”

In a study published earlier this year by Cass Business School, City University, London, Les Mayhew and David Smith said that payment by results could have encouraged some trusts to “push patients through A&E even more quickly so benefiting from the higher inpatient tariff as compared to A&E tariffs. “The possibility of perverse incentives such as these was not the original aim behind the introduction of A&E targets, which were primarily a response to patients’ concerns, and may have encouraged the manipulation of data,” they said.

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