NHS readmission policy is sticking plaster on a bad system

The Health Secretary Andrew Lansley, announced yesterday that hospital trusts will not be paid for the second visit if they discharge a patient who returns within 30 days. This is to discourage trusts from discharging patients too early to try and save money.

Sticking Plaster

There are problems with this.

Firstly, there is a report from the Department of Health that says that there is no evidence that hospitals are discharging patients too soon in order to save money. From an article in the Guardian:

Only 25% of readmissions appeared to be for the same reason as the original admission and that proportion had not changed for some years. The problem of rising readmission rates appeared linked with an ageing population presenting ever-more complex problems. “It may be that for people who suffer from long-term conditions, a sequence of readmissions is sometimes preferable to a longer stay in hospital,” says the report.

So this policy seems to be coming from the assumption that trusts would discharge early to save money without solid evidence that this is indeed happening.

Secondly, what of the cases where a patient is discharged after treatment for one condition but is admitted for another within 30 days? There will have to be mechanisms in place to pick this apart and that cost would be borne by the trust.

Trust Is Earned

The third problem is that this assumption that trusts would game the systems comes from the fact that the system is set up as it is. Trusts get their funding on a ‘payment by results’ basis. This means they get a set amount of money for doing defined actions. In fact ‘payment by results’ makes it sounds quite virtuous, it should be called ‘payment by activity’. They get paid for doing things, not for providing the appropriate care.

Lansley is imagining how trusts could cheat a cheatble system with no evidence that they are doing so. This is not to say that the system should not be changed, but applying a sticking plaster to a wound that does not exist is definitely no way to treat a patient.

Change the System

The structure should be that demand is understood and funding provided to meet that demand. Budgets should be adjusted each year to adjust for changing demand and the services that the NHS is willing to provide. This demand and the services available will change as the population ages and technology develops. In parallel, the services need to be improved so that patients spend exactly the right amount of time in a hospital bed. Enough to receive treatment and recover or be monitored, but not too long so as to use up excess resources. The length of stay will continue to fall as more techniques like less invasive surgery is used more and perfected, but there is much to be done in how the system in hospitals, GPs and PCTs are run to streamline admission, treatment and discharge to optimise value and remove waste.

Patient Care Leads to Cost Savings

New medical techniques are difficult and costly to invent and perfect and improving the patient flow through the health system is much easier in comparison. In the short term improving patient flow can provide much bigger benefits to the patient and in addition massively reduce costs.

This is the change the new Health Secretary should focus on, rather than constantly patching up the NHS.



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