Our hospitals have long been bursting at the seams with ambulances stacking up, patients stuck on trolleys and many accident and emergency departments struggling to cope with demand.
This winter the government proudly announced £400 million pounds is being spent to head off a crisis in A&E.
However, Channel 4 Dispatches – airing Monday at 8pm – can exclusively reveal that government penalties also mean that more than a billion pounds has been withheld from English NHS hospital budgets since 2010.
· More than a third of a billion pounds (£390,477,765) has been withheld from English hospital budgets under a policy that penalises hospitals if a person is readmitted within 30 days for something considered avoidable – even if it’s not the hospital’s fault
· Hospital Trusts told us that £710,743,553 has been witheld from their budgets as a result of the Marginal Emergency Tariff between 2010 and 2013
· Over seven million pounds (£7,182,210) worth of penalties has been withheld relating to Ambulance Clinical Handover Times and Trolley Fines since it was introduced in April 2013
The investigation also found that ten NHS hospitals in England had more than 22 million pounds each withheld since 2010 because of the Marginal Emergency Tariff and readmissions. Three of these hospitals had more than 25 million pounds withheld (please see Notes to Editor for full breakdown).
Background To Targets And Penalties
Demand on A & E Departments and emergency admissions to hospital have risen over the last decade. The Labour government decided that they could help solve the problem by giving hospitals targets. But David Cameron reckoned these were making matters worse and said he would scrap them.
Speaking on 4th January 2010 he said: “ We’ll say to doctors and nurses, ‘those national top-down targets you hate because they distort clinical priorities, they are gone’.”
Despite the PM’s promise, his government has kept some targets, and even added new ones, with extra financial penalties for NHS hospitals in England.
While the money from these financial penalties stays in the NHS, it’s no longer up to the hospital how to spend it.
Penalties For Readmitted Emergency Patients
The current government’s first NHS reform was a new penalty that applies to readmitted emergency patients.
The government was concerned that too many patients were ending up back on the wards, soon after being discharged.
If some patients come back for more treatment within 30 days, which could have been avoided the hospital may not get a single penny for looking after them.
Using the Freedom of Information Act, Channel 4 Dispatches obtained readmission data on 143 out of 156 Acute Hospital Trusts in England.
The figures reveal that more than a third of a billion pounds (£390,477,765) has been withheld from English hospital budgets under this readmissions policy since 2011.
The government decided the withheld money must be reinvested in community care services to stop patients coming back into hospital.
However, a third of hospital trusts say that they didn’t know what the previous two year’s money had been spent on.
Newly formed local clinical commissioning groups, known as CCGs, spend this NHS cash, and many of them say this investment in schemes to cut readmissions is now happening.
The government is currently looking at urgent and emergency care funding. The surgeon who’s leading that review admits he doesn’t know how or where all the witheld money has been been spent.
Professor Keith Willett, NHS England’s national clinical director for acute care says:
“That money’s remained in the healthcare health care system. It hasn’t disappeared…. prior to NHS England taking over that responsibility I agree, we don’t have that exact clarity.”
“It came in with the right intention but I don’t think anybody can track that money through to say exactly how it was spent….But it had the effect that was wanted. We’ve seen the reduction in the growth in the number of people coming to hospital and patients are getting a different type of care and that’s the important thing.”
The Impact Of The Marginal Emergency Tariff
A&Es have become much busier over the last ten years – perhaps due to the population becoming bigger, older or frustrated by changes to GPs out of hours.
The last Labour Government introduced a radical reform in an attempt to reduce the number of patients being admitted to English hospitals. It’s called the Marginal Tariff.
They decided that for every patient that trusts admit beyond the figure in 2008, the hospital would only be paid 30% of the cost of looking after that patient.
The 70% withheld from the hospital stays in the NHS with the people who decide where to spend it locally, the commissioners. Since last April, that’s the CCGs.
Many CCGs told Channel 4 Dispatches that they are now investing some of the cash in services to help stop people turning up at A&E – exactly what the government expects them to do.
But 60 Hospital Trusts told us that they don’t know where the money withheld in the first three years of the policy was spent.
Around England, many hospitals face a substantial shortfall. We got Marginal Emergency Tariff figures, from 139 Trusts, out of the 156 we asked.
Altogether 710 million pounds has not been paid to them in the last three financial years. Together with readmitted patient penalties that’s some hole in hospital budgets.
NHS England insists the policy is about improving care and has helped to slow the rate of growth in patient admissions. But the man leading their review into urgent and emergency care admits for the first time that it might now be time for a rethink.
Professor Keith Willett says: “Well, I don’t think anything is set in stone…We want to see the care commissioned in a way that actually gives exactly what we want for the patient, so the patients can be treated properly, they can be treated as near to their home as possible, they can be returned to home as quickly as possible. So one of the things we are looking at is the whole commissioning and payment structure that sits around emergency care – so maybe it will go…. I don’t think it’s sophisticated enough and I don’t think it reflects the patients care and the journey that they need. So I expect it to change.”
Penalties Relating To Ambulance Clinical Handover Times And Trolley Fines
Last year, another new target came in designed to get patients off ambulance trolleys and into hospitals quickly, freeing up the paramedics to answer other calls.
Since last April, if that process takes longer than 30 minutes, the hospital should be fined £200. If it take longer than an hour, that rises to a thousand pounds.
Half the trusts in our survey have been given some extra time to get this working before the penalties come in.
Patrick Crowley, Chief Executive, York Teaching Hospital NHS Foundation, says:
“If the hospital is full and you can’t pass people through A&E you’re financially punished for not being able to turn around the ambulances in time”.
“It feels unfair in any way that you look at it and it certainly makes managing our hospital in terms of the resources we have for the demands that are placed on it more difficult than perhaps it needs to be.”
The government says the ambulance handover target has been a success with delays down by a third.
Fines for A&E waiting times
Doctors are supposed to treat, admit, or discharge 95% of emergency patients within 4 hours.
The policy was introduced by the Labour government a decade ago and they said it helped to cut waiting times dramatically. Back then, the target was higher – 98%. The current government relaxed it to 95%.
NHS England say financial penalties or incentives encourage hospitals and those who look after patients in the community to work together more closely.
Professor Keith Willett says:
“We use penalties where we must protect safety and patient experience. And that’s the right thing. It makes people sit up and notice. Like the four hour wait A&E target. It made everybody in the hospital, right through management right through wards, have a focus on A&E. And that’s a really important thing to do, that was the priority at the time.
We will have different priorities going forward. And it’s about having the right commissioning and funding system. As of April last year NHS England, the Clinical Commissioning Groups put clinicians in the driving seat, those are exactly the people you want now in the health care system going forward.”
Response From The Department of Health
The Department of Health say that, whilst the majority of patients continue to get excellent care in A&E, their review into the future of accident and emergency funding will address some of these concerns:
They say that since 2010, one million more people are visiting A&E and the NHS needs to change to cope with an aging population. This is why they were reviewing how the NHS should respond to demands for emergency services
“In the longer term we are bringing back the link between GPs and elderly patients and investing £3.8 billion in joining up health and social care.”
A&E’s Missing Millions – Channel 4 Dispatches, Monday 17 February at 8pm.