“HRG drift” and payment by resultsBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7491.563 (Published 10 March 2005) Cite this as: BMJ 2005;330:563
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Rogers et al report that the ten first-wave foundation trusts showed a greater increase (24.2%) in short-stay (0-1 day) hospital admissions via A&E than a comparator group of non-foundation trusts (16.2%) and all non-foundation trusts (16.8%) during April-September 2004 compared with April-September 2003.1 Their aim was to examine whether payment by results was leading to increased admissions in foundation trusts for non-clinical reasons. Recent articles in the HSJ and Public Finance have also commented on the increase in hospital admissions via A&E departments since 2003/04.2-3
The Healthcare Commission undertook a similar analysis as part of its review of foundation trusts.4 We identified an alternative comparator group - trusts with similar volumes of A&E admissions and of similar type (ie teaching, non-teaching) in the same Strategic Health Authority (Rogers et al used volume of activity). We also examined admissions in relation to A&E attendances.
Our results are broadly similar to Rogers et al for foundation trusts, but not for other trust categories (Table 1). It was not possible to identify the reasons for the discrepancies, although one possibility is that Rogers et al used Nation Wide Clearing Service data whereas we used Hospital Episode Statistics.
Our analysis showed that foundation trusts had a higher proportionate increase in short-stay admissions via A&E between April-September 2003 and April-September 2004 than other trusts. However:
1. There were marked differences in the percent changes in admissions between individual trusts within each of the categories, hence average values may not be a reliable marker.
2. Compared with previous years, short-stay and all admissions via A&E increased sharply from 2003/04 in all trust categories. The patterns vary depending on the choice of comparators, which is discretionary.
3. In 2003/04 and 2004/05, short-stay admissions via A&E increased more sharply than A&E attendances in all trust categories, leading to increased proportions admitted. Increased proportions were not apparent for 1+ day admissions. Foundation trusts overall showed minor differences from other trust categories in the proportions admitted, irrespective of length of stay. There were marked variations in these proportions within each trust category.
The Healthcare Commission’s analysis shows that admissions via A&E increased in all trust categories (foundation and non-foundation alike), and that foundation trusts were not consistently divergent from other trusts in terms of the proportion of A&E attendances resulting in admission. It is unlikely that increased admissions in foundation trusts were related to payment by results, as admission rates for these trusts were rising before they achieved foundation status and before the introduction of payment by results. It is possible that the four-hour A&E target (introduced in 2003/04) may have contributed to the general increase in short-stay emergency admissions via A&E departments in 2003/04 and 2004/05.
Dr Veena S Raleigh, University of Surrey Jeremy Cooper Ian Horrigan Janet Ratigan
Informatics, Healthcare Commission
30 June 2005
1. Rogers R, Williams S, Jarman B, Aylin P. HRG drift and payment by results. BMJ 2005;330:563: http://bmj.bmjjournals.com/cgi/content/full/330/7491/563/DC1)
2. Harding L. DoH under pressure to tackle perverse finance incentives. Health Services Journal, January 6 2005.
3. Slipman S. A fundamental lack of trust. Public Finance January 2005: http://www.cipfa.org.uk/publicfinance/features_details.cfm?News_id=22543
4. Healthcare Commission Foundation Trust Review (2005)
Competing interests: Methods and Research, Informatics, Healthcare Commission
Competing interests: No competing interests