End “perverse” payment system that penalises emergency departments, says collegeBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4875 (Published 29 July 2014) Cite this as: BMJ 2014;349:g4875
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The College of Emergency Medicine makes two particular claims in their campaign to change the A&E tariff: one that demand and casmix are inexorably increasing; two that hospitals have to "subsidise" A&E using surpluses from other activities.
There are good reasons to challenge both claims. Both have been repeated many times and appear to be driven by anecdote based on expert opinion. Both can be challenged using data.
The first claim that demand and casemix are rising is often repeated. But the recent analysis of A&E HES (the comprehensive, patient level but pseudonymised data collected for English A&E department) by QualityWatch and the Nuffield Trust casts doubt on much of the anecdotal evidence. (the report, perhaps the first to do serious analysis on the most comprehensive datasource, is available here: http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/140724_... ).
Here are three conclusions from that analysis:
"Despite large increases in the number of people using A&E services overall, attendances at major A&E units (where waits are a significant issue) have only increased in line with what would be expected from population growth..."
"Although A&E departments see more older people than they did previously, this factor appears to only account for around 11 per cent of the observed decline in performance against the four-hour target. "
"We did not find evidence that cases being seen in A&E were becoming more complex."
So, apparently, the actual data doesn't support the idea that A&Es are being overwhelmed by demand.
The second claim that A&Es have to be subsidised from other services is undermined by the fact that the majority of trusts don't understand their costs well enough fro that claim to be credible. A recently published audit by Capita's CHKS team analysed the reliability of Hospitals' reference cost returns. The report is available here: https://www.gov.uk/government/publications/payment-by-results-costing-in...
This key conclusion from the summary is worth reading alongside any claim that hospitals have to subsidise one service from the surpluses from another:
"Just one-in-ten NHS acute trusts (12 per cent) have good quality costing information across all services..."
"34 per cent of the trusts audited had a reference costs submission that was materially incorrect; and
50 per cent of trusts had poor costing in one or more of the three areas. "
This doesn't suggest that trusts' anecdotal judgement about the costs of A&E and other departments are based on actual data.
Far too much debate and far too many policy decisions in the NHS are based on anecdote not data even when good data is available. We will not improve the NHS or invest in those services which deserve more if that is how we conduct the argument.
Competing interests: No competing interests