Refusing to Play, Refusing to Pay

A little while ago I read this article about a number of NHS trusts refusing to sign this years NHS budget, which in its current form has imposed a further series of ‘efficiency savings’ (dressed-up budget cuts) to the tune of £1.7 billion. This cut is achieved by reducing ‘tariff payments’ – the system upon which hospitals are paid to treat patients. The reduction in tariff payments would represent the fifth consecutive year of this reduction and would require trusts to effectively reduce their budget by 3.8% this year alone. This year, it has become too much for the system to bear.

The tariff system is an imperfect one, but one that has worked reasonably well for some time. It is a complex series of algorithms which calculate a cost per case: this is calculated based on a patient’s presenting complaint, other medical problems, which investigations/interventions were performed and how long they were in hospital. It invariably underpays for some cases (thorcacoabdominal aneurysm repair, for example, is dramatically under-costed by the tariff system) but other cases over-pay and, overall, a balance is maintained. Reducing the tariff payments directly reduces hospital income, and the government is taking the money ‘saved’ by cutting front-line hospital services and reinvesting it in other NHS areas (thereby sticking to one of their election pledges not to cut the overall NHS budget). Money has been redirected to things like the Cancer Drugs Fund and the Better Care Fund (I have issues with both of the above, but that is for another time).

It’s not altogether surprising that cutting front-line budgets is not sustainable, particularly in a world where:

  • More and more people are accessing healthcare.
  • More of these people are accessing healthcare via A&E, which is paid tuppence to do so.*
  • People are living longer with more complex conditions.
  • New (and expensive!) drugs and therapies to treat the above are constantly being invented.
  • The government instigate a top-down reorganisation of the NHS (which, incidentally, they pledged not to do at the last election) costing over 1.5 billion pounds.
As such it is not surprising that at some point, when asked to sign a document stating that they will provide a high, safe standard of care on budget x (where budget x is not enough to provide that standard of care), NHS trusts will refuse to sign. That is sensible and right, because even with the current cuts there is associated morbidity. That is not okay, and making it worse is beyond not okay. It’s a travesty.

Now, I’ve heard a couple of people say that trusts refusing to sign the new budget is a political move to discredit the current government just before the elections. I disagree – this is a patient safety issue. That it has political ramifications is notable but ultimately, this is not a politically motivated action. Instead, this is what happens if, after 5 years of cuts, your A&E attendances are still rising by 279,375 compared to the same quarter a year earlier. This is what happens if care services (part of local government budgets and therefore directly cut by the government) are slashed. This is what happens if you take all the slack out of a system that needs to be able to cope with surges in demand, and then there is a surge in demand.

Yes it is unfortunate for you politically, Cameron D et al, that the crunch has come in the months before your general election, but this is a direct result of your policies. You’ve cut and trimmed and streamlined funds, you’ve savaged and squandered the goodwill of NHS staff, and you’ve crippled the social care budget by cutting the income of the councils that pay for it. You’ve gotten away with it for four-and-a-half years, but the last few months have seen the tiniest of surges. Maybe it was the inefficacy of the ‘flu vaccine this year; maybe it was that extra few percent of A&E attendances; maybe it was Jeremy Hunt being unable to wait to take his children to their GP and bringing them to the Emergency Department instead, but it doesn’t really matter, now. You can’t cut front-line services and expect nothing unpleasant to result. People have been treated in tents and had their operations cancelled and their waiting times extended because of your cuts. You should hardly act surprised when the NHS stands up and refuses to sign off on more of the same.

david cameron signature

*A&E gets paid only a small portion of the tariff paid for an actual hospital admission, to try to motivate hospitals to avoid A&E admissions. Unfortunately, hospitals have no control over A&E admissions. For example – if someone comes in to AMU (an inpatient ward) and has a blood test, an ECG, a chest x-ray and is then discharged home same-day the hospital gets the full tariff, which could run to over a thousand pounds depending on the complexity of the patient. If  the exact same complex patient comes in to A&E and has identical things done, and is sent home, the most that an A&E department can be paid is £237. Thats what they get if the patient was admitted and resuscitated, intubated, ventilated, then had a CT scan, MRI scan and review by every specialty in the hospital.

A couple of references
http://www.nhsconfed.org/resources/key-statistics-on-the-nhs
https://secure.collemergencymed.ac.uk/…/Casemix%20…/

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