Friday, March 28, 2014

A&E: Food Chain of FT Hospitals!


Looks like the plot is already there about our A&E which without doubt is still trusted by the average punter (aka patients) and business is booming that our SoS is forced to act. Ha, perhaps he is powerless.

A&E is the beginning of the Food Chain for FT Hospitals.


The launch of a new plan to address the crisis in accident and emergency (A&E) units was marred by leaked emails revealing panic among health officials about how much money could be made available to help struggling hospitals.


“Urgent care boards” are to be established across England with a remit to devise “local recovery and improvement plans” for each A&E department in their area, in response to growing concern about lengthening waiting times. However, internal NHS England messages suggest that the Health Secretary, Jeremy Hunt, had wanted to announce a £300m-£400m rescue fund to “solve” problems in A&E, but had to be dissuaded owing to confusion about finances. The plan announced today made no mention of a £400m pot, and tonight the Department of Health denied that the Health Secretary ever intended to announce such funding.

But the emails, sent on Wednesday and obtained by the Health Service Journal, reveal turmoil among NHS managers about the plan. One unnamed finance officer said he had struggled to dissuade Mr Hunt from using the figure. “The SoS [Secretary of State] would like to announce tomorrow that £300-400m is being invested to solve the A&E problem. We have spent most of the day trying to hold him off doing this,” the email read.

A second email from a national official said that from an analysis of financial plans by NHS England’s 27 area teams for the current financial year, “we can only see £70-80m …in plans”. Another email said: “We are struggling to bridge from the £300-400m to the £70-80m. We think this is due to a) baseline adjustments and b) local contract discussions.”




There is much “intertwining” in the natural world: can we learn from it?

©2010 Am Ang Zhang 

It must be hard to believe that with the number of highly paid management consultants working for the government that any apparent oversight is due to cock-up rather than conspiracy. Yet reading through the Select Committee reports one begins to wonder.

Could it be that for too long, accountants dominated the NHS reforms and somehow nobody took any notice of what the doctors are saying anymore?

On the other hand, could the need to pass health care provision to private providers before anybody could raise enough objections be the reason or was it simply a means to contain cost and let the patients blame their GPs?

A&E(ER to our US readers) is perhaps something accountants would like to get rid of. It is unpredictable, unruly (literally) and ungainly as there is a need for the specialist backups. In the era of PCTs and Hospital Trusts, serious battle is fought aro . The silly time limit set has caused more harm than the good it is suppose to achieve. That many major A & E departments are staffed by Trust staff and the new GP Commissioners will try their best to avoid paying for A & E attendance & any unplanned admission. 

All too messy.

Hospitals tried their best to make more money from A & E and admissions in order to survive. Where is the patient in this tug-of-war of primary care and Hospitals!

What happens when there is a major E. Coli disaster. Who is going to pay for all the dialysis?

There is no better illustration to the wasteful exercise then in all of this internal market and cross charging during recent years and one must be forgiven for concluding that the purpose was to allow private involvement in our National Health Service.

We must be forgiven for not believing that all these AQPs are not great philanthropists and are all there not for the profit but for the common good.


On last count: over 20 million patients would have attended A & E: A rise from 12 million around 10 years ago!

It is not difficult for anyone in the NHS to see how the internal market has continued to fragment and disintegrate our health service.


Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts)  for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.



Urgent Care Centres are one of the most contentious parts of the NHS reforms. Both the College and the King’s Fund  have consistently questioned the evidence base and the clinical and cost effectiveness for this major policy change. Surprisingly many of the NHS pathway groups still recommend such units. The public will be very confused by the desire of some Primary Care Trusts (PCTs) to re-name the ED as an “Urgent Care Centre” for ambulatory patients.

The perceived problem that CCGs are trying to solve
There is a perception that many patients attending the ED should be treated in primary care. The College’s view is that a relatively small number are clearly non-urgent primary care problems that should have been seen by their general practitioner. A larger group of patients with urgent problems could be seen by primary care if there was timely access to the patient’s GP or out-of-hours services - e.g. at weekends. The College believes that improving access to GPs is the best way of dealing with this issue. At most we think that 25% of ED patients might be treated by general practitioners in an ED setting. There is no evidence to support the contention that 50-60% of ED attendances can be treated in Urgent Care Centres.

The approach of setting up an Urgent Care Centre in front of every ED is an example of demand management. This has already been shown to be unsafe when tried in the USA.



Since April 2006, emergency departments have been paid according to the number and nature of the patients they treat. This seems perfectly reasonable, but many Primary Care Trusts are now paying more for their hospital emergency service than they used to, and as a result are looking at ways of “gate keeping”—that is, restricting the number of patients who enter emergency departments. This has lead to the concept of urgent care centres, where ambulant patients seeking emergency care are triaged by staff employed by the Primary Care Trust. Certain diagnostic groups are allowed through into the emergency departments, but many are seen by onsite general practitioners or nurse practitioners. In this way the PCTs can control expenditure, and many patients with minor trauma who would previously have been managed in emergency departments are no longer seen there. The result of this is that the casemix of emergency departments is being restricted, and this diminishes our specialty.

Loss of inpatient specialties
Traditionally, emergency departments in the UK have received an undifferentiated casemix, and have either provided definitive care or have referred on to hospital specialties. We may have wished to mimic the Australian model of emergency care, but the truth is that very few emergency departments in the UK have the staff or facilities to provide continuing inpatient care. Emergency medicine in the UK has therefore remained dependent on inpatient specialties to help it provide a comprehensive service.
Unfortunately, the government clearly intends that in future many hospitals will not have the full range of core specialties, and this will radically affect the sort of service their emergency departments can offer. In particular, many emergency departments will not be able to receive patients with major trauma or paediatric emergencies.




This is certainly not how Kaiser Permanente would run things: all integrated and no such thing as “cross charging”. In fact the doctors are not on a fee-for-service basis but like Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital, doctors are paid a salary.




Q143 Chair: No. I am sorry. My point is that if, as a commissioner, you have to have A&E and you have the power to defend whatever is required to deliver A&E, why do you need a power to designate?

Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. Designation is all about making sure that there is continuity of the provision of the service even if the provider themselves gets into difficulty where there is no alternative provider.

On the integrated care for A&E, yes, there are similarities. I think the     critical issue is where you draw the boundaries. If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.


Dr David Bennett is head of Monitor and is NOT a medical doctor.




"Whatever the benefits of the purchaser/provider split, it has led to an increase in transaction costs, notably management and administration costs. Research commissioned by the DH but not published by it estimated these to be as high as 14% of total NHS costs. We are dismayed that the Department has not provided us with clear and consistent data on transaction costs; the suspicion must remain that the DH does not want the full story to be revealed. We were appalled that four of the most senior civil servants in the Department of Health were unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing in PCTs and provider NHS trusts. We recommend that this deficiency be addressed immediately. The Department must agree definitions of staff, such as management and administrative overheads, and stick to them so that comparisons can be made over time."

                                                  House of Commons


See Prof Waxman in an earlier post

The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham orOxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.

…….Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.



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