As I wandered through the forests of Sibelius' Finland, I marveled at how well the different plants co-exist in an integrated fashion.
Why can't our NHS be integrated like this forest? With berries and mushroom growing in abundance! Looks like our A & E departments will be the first of the Hospital Services to be culled.
Decisions being made on the ground, however, suggest that the policy is being pushed ahead without public debate. In July on the reconfiguration of hospitals in the capital. Eight of
A and E units were to close. In their place ‘minor injury’ and ‘urgent care’
units would be opened, but located ‘away from hospitals to prevent people
entering A and E unnecessarily’. Some of the eight targeted A and E
departments have already been closed or are scheduled to close, and Lewisham’s
would have been until Mr Hunt’s decision to close it was ruled unlawful. So it
seems fair to suppose that concentrating A and E and maternity services – and
the necessary depth of other supporting services – in a few very large hospitals,
and in effect closing many of the rest, is one half of the model that NHS
England are pursuing. London
What happens when there is a major E. Coli disaster. Who is going to pay for all the dialysis?
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
: 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. England
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 PCTs 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
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 case‐mix of emergency departments is being restricted, and this diminishes our specialty.
Traditionally, emergency departments in the
have received an undifferentiated case‐mix, 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. UK
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 , doctors are paid a salary. Johns Hopkins Hospital
: 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."
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 or
Oxford, when it is not Oldham or that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me. Oxford
…….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.
The Cockroach Catcher: NHS: Circle to Serco