Of course the smart move would be to combine PBR with targets. Currently the
targets are too "black and white": there's no reward for getting 97.9%, and
this can demoralise and act as a disincentive, in the worst cases with some
hospitals abandoning emergency care in order to balance their budget.
Meanwhile the hospital that achieves 98.1% gets all the glory, and the gold
star. Yet there is probably precious little to separate these hospitals in
real terms of standards of care.
You see the current rigid target makes no allowance for the inherent
variability of our demands. Yes, we can predict diurnal variation up to a
point, but no amount of weather forecasting, population profiling or
soothsaying can predict the subtle superimposed variations that can turn an
average day into "hell on earth". And you can't staff your
department/hospital for the peaks; it's just not practicable. [What
surprises me is the relative stability of it all. Why, when serving a
population of 400,000, are my daily attendance figures always between 200
and 250, give or take a few? It would only take a subtle alteration in that
huge population to produce 500 or even 1000 attendances. Of course, it could
just reflect that most attendances are for medical illness, and the
prevalence of medical illness is fairly static. No doubt a statistician on
the list will inform me...]
If you look at privately run healthcare systems in other countries, they
often remark at how we - in Britain - have to "push" patients through the
system, i.e. there is inherent "inertia" and "resistance" at all levels,
whether it's getting that CT done, or getting that bed on time. PBR might
represent an opportunity to change all that to a "pull through" system. If
CT got paid for their emergency CTs, and if wards/directorates got paid for
taking patients - on time - then you might just have a system that actually
improves health care - or at least the process of delivery of health care;
other quality measures are much too subtle to capture, I suspect.
Such a system wouldn't lead to perverse incentives either. For example, if
radiography get paid for the emergency scan then only they should benefit
from that scan so there would be no incentive to book extra tests just for
the hell of it, to convert a low-cost case into a high-cost case as has been
suggested. And our targets could then be graduated. So, for example, those
units that achieve only 97% or 96% would simply suffer a larger financial
penalty, or receive less "reward", than those who achieve 98% or 99%. So it
would be in management's interest to at least "work towards" the target, yet
it wouldn't be a disaster to get 97.9%. Emergency services would still be
"protected" to some extent, because of the financial incentives in achieving
the "graduated" targets.
Wonderful if they could get it to work, but I'm concerned that we don't yet
have the IT infrastructure in many hospitals, so there would inevitably be a
huge amount of bureaucracy involved that might well offset any advantage.
Still, it could be the way to go long term. No doubt there are a few DoH
"spies" lurking on the list who have thought of all this before!
Just reading the Budget responses and looking at the NHS job cuts across the
country, it's sad that it now looks as if New Labour are abandoning the NHS.
It's simplistic to say that they underestimated the cost of this settlement
or that development. I blame the targets. Having an exceptionally stringent
and rigid target made "good copy" in its day, but it's now come back to
haunt them. If New Labour had settled for a more sensible target, or some
form of graduated target, then at least there wouldn't be so many units in
dire financial circumstances at this time.
Adrian Fogarty
Royal Free Hospital
London
----- Original Message -----
From: "Rowley Cottingham" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, March 22, 2006 10:14 AM
Subject: Re: Corrected tariff for the 2006/07 Payment by Results
> Maybe it has moved, but I find it here:
>
> http://www.ic.nhs.uk/casemix/downloads/sub8/AEDefinitionsManual.pdf/file
>
> I see the blame is placed firmly at a Dr Marrow's door!
>
> /Rowley./
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