Every winter, the demand for local A&E services rises, reflecting a range of underlying epidemiological factors as well as choices that we make in order to access healthcare. The press has widely reported the recent crisis in our A&E services, fixing on the statistic that 1 in 20 patients (or more) who need to be admitted to hospital via A&E have to wait more than 4 hours. This has been attributed to a variety of special reasons, for example the long, cold recent winter weather, an ageing population, staffing problems in some departments, and the introduction of new protocols as part of the new 111 out-of-hours care number. Most experts agree that there is no single reason for the current crisis. Most experts also agree that demand for A&E attendance (and the subsequent demand for hospital admission, from the minority of patients who need to be kept in hospital), is generally very predictable, year to year, month to month, day to day, even on an hourly basis in each hospital. The sustained delays experienced in many hospitals throughout the Easter period (and even now in the early summer), are hard to justify and may benefit from a different (in this case a market) perspective.
The NHS is absolutely committed to address the problems of unreasonably long waiting times, however its thinking is limited to the notion of a centrally planned and managed service. The NHS focuses upon the underlying epidemiological factors and ‘system management’ as opposed to the choices we make as individuals about our own healthcare. Whilst it publicly acknowledges the importance of choice to patients in their care, the NHS behaves as a central planning authority as if it can control demand by optimising supply. For example it regards it as a ‘mistake’ that patients choose to attend A&E departments for minor conditions, when they ‘ought’ to visit their local GP. This rather misses the point that for many people it is easier to attend an A&E department than to try to get to see a GP or nurse practitioner at their local surgery.
In a market system, customers respond to prices, which reflect producer costs as well as our willingness to buy. In the NHS, the price to customers (patients) is free at the point of delivery and we pay for producer costs (NHS) through taxes. However access to healthcare in the UK, even for ‘urgent’ conditions, still involves at least some element of choice, most of the time and patients still incur ‘costs’ even when choosing to access a ‘free’ service. Similarly, the NHS still struggles with the idea of seeking customer feedback. As a heavily professionalised service it behaves as if it already provides ‘best care’ (despite the evidence from numerous published audits that point to wide variability of outcomes for patients across England). Results from the recently introduced Friends & Family test, for instance show response rates in A&E services at less than 10% in many hospitals, as if feedback is something extra rather than an essential requirement for an organisation to learn and improve.
The remainder of this article suggests how market principles could serve to promote the policy aim of ensuring fast and easy access to healthcare 24/7, when people most need it. The basic idea is to incentivise patients to make the ‘right’ choices that mean they get to access healthcare more easily, when they need it. By aligning incentives with ‘the system’, we should all find it easier to get better healthcare. Of course, at a time when we experience a personal health crisis, choice is the last thing on our mind; it is a comfort to know that after dialling 999 we are, once the ambulance arrives, less than 20 minutes away from arriving at an A&E department. However, it is a common misconception, for example, that most people who attend an A&E require an ambulance or even require to be admitted to hospital afterwards; whilst the statistics vary from place to place, most people who attend a hospital A&E department make a choice to do so and arrive ‘under their own steam’ and typically 80% or more of attenders return home soon afterwards.
For markets to operate effectively and to result in an efficient use of resources customers require good information about services in order to make effective choices, for example benefits, outcomes, whatever pertains as ‘quality’ and about prices (i.e. costs of obtaining the services). In the NHS the price to access urgent care services is nil, although there may be differential costs such as the time it takes to get to and wait for a service. So, would-be attenders for non-emergency ‘urgent’ care may make a decision on whether to attend their local GP, go to the nearest A&E department or some other solution based on perceived quality, outcome and waiting time.
However there is very little information available on which to make this decision as the NHS monopoly brands all care as equally good (even though, when audited there are significant differences between hospitals and even differences in outcomes on when you are treated). And published waiting time information is usually weeks or months out of date. So we could say that:
(1) Patients are currently making rational decisions on ‘where to go’, when choice exists;
(2) In a market where prices are set to zero, decisions may be based on perceived quality and waiting times;
(3) In the absence of accurate and up-to-date quality and waiting time information , it is inevitable that patients make sub-optimal choices (viewed retrospectively); and
(4) The system would achieve better resource usage if it provided better information to the public on waiting times, outcomes and perceptions of experience in using different forms of urgent care facility.
For example, the Independent newspaper recently reported (13 June) that a Manchester hospital is to become the first in the country to publish performance ratings for all its consultants, allowing patients to rate their doctor and make choices about who provides their care. And if real-time waiting time information at different NHS facilities was available through the internet (as it is for train times), some patients might choose to take their health problem to an NHS facility with a shorter waiting time, or choose an ‘off peak’ time to access healthcare.
A&E is only one part of the whole urgent care system. A range of healthcare options exist outside hospital, in primary care (through your GP, or other practitioners or retail outlets) which, if they were available 24/7/365 would mean that fewer people would choose to attend A&E. Critically, GP surgeries are not available 24/7 or for most of the weekend. GPs organise ‘out of hour’ services in a range of ways but often not consistently to meet patient expectations of genuine 24/7/365 coverage. If it was easier to see your GP, when you wanted to, fewer people may choose to attend (and clog up) A&E.
So why not incentivise GPs to provide better (i.e. more customer orientated) primary care services? GPs offer a growing range of services in larger practices, but most require queuing in a busy waiting room with lots of other ill people. Why not offer a ‘fast-pass’ ticket, that you pay for in advance to make a scheduled, booked, routine appointment with the GP of your choice. The NHS has lots of other examples of co-payment, for example for prescriptions, or if you need contact lenses or a dental appointment. Fast-pass GP sessions could pay for themselves; for people not willing to pay there would be fewer people waiting in line for unscheduled appointment slots, shortening their waiting time. Payment wouldn’t necessarily ensure faster treatment (your GP of choice might not be available), but it would give patients a choice to reduce their waiting time, and by making a visit to the GP an easier and better experience reduce demand on the rest of the healthcare system.
Clinical Commissioning Groups
A further innovation would be to extend the role of Clinical Commissioning Groups such that individual Practices are held financially accountable for the care of their patients. Putting GPs in charge of the NHS commissioning system is the fundamental reform of the recent NHS Act.
However it only puts GPs in charge of commissioning through budgets that are rigidly segregated from the Practice’s own budgets and contracts. So (currently) there is no alignment between CCGs’ commissioning performance and the remuneration of GPs that make decisions on individual patients. This has been fiercely resisted for two reasons. Firstly, GPs were concerned that linking their pay to commissioning performance would result in some GPs losing out financially (which from a market perspective one could argue is a necessary feature of an incentive based approach and ultimately a good thing). Secondly, there were public concerns that GPs might place their own financial interests ahead of the interests of patients (who might then lose confidence in the Practice and potentially the entire managed healthcare system), so a governance concern. One could argue that if patients lost confidence in a particular GP or Practice they should be free to move their registration to a Practice in which they did have confidence; with GPs paid mostly on the basis of registered patient numbers, this would counter-balance the apparent conflict of interest by rewarding Practices that did behave with integrity.
So if Practices, through CCGs were held financially accountable for the whole system, this would incentivise Practices to look for the best value care and would radicalise the current QIPP (quality, innovation, productivity and performance) initiatives offering financial gain to practices. Best clinical practice is to keep patients out of hospital wherever clinically possible (which is usually both the cheapest and the safest option for patients). At the moment, despite a plethora of system-led QIPP initiatives, these have clearly not delivered the levels of ‘demand management’ required in a centrally planned system to achieve short waiting times and to keep people out of hospital and away from A&E departments.
So far I have scarcely mentioned hospitals! Once the patients arrive at A&E, the hospital has to assess, diagnose, treat and eventually discharge the patient. For the uninitiated, it is important to recognise that the ‘A&E problem’ goes well beyond the A&E department and is often caused by a problem of not being able to find a bed for a patient who needs to be admitted. This might be because of problems elsewhere in the health system (for example, delays in discharging patients home or elsewhere, resulting in ‘blocked beds’). How can we better incentivise this process? Firstly, in the same way that CCGs could become regarded as the ‘system managers’ of healthcare (and hold budgets that reward best practice commissioning, keeping patients away from hospital unnecessarily), hospitals could hold the budget for managing patients that present at their front door. For example, in some places where primary care is poor, a hospital may decide to commission its own GP-managed Urgent Care Centre on-site and redirect non-emergency patients to this service. There are already examples of this in London and elsewhere. Or it could hold a budget for social care, paying the Local Authority (or private care home providers) for ‘step down’ care enabling patients to move out of (expensive) hospital beds into a more appropriate (and less expensive) facility, i.e. helping to unblock the A&E pathway.
The weekend lottery
The press has recently headlined research that clearly shows that patients who have surgery later in the week and at weekends have poorer outcomes. This has been known for a long time within the NHS and despite the evidence that people get ill throughout the week, the NHS is still largely managed on the basis of a 5-day working week with out-of-hours arrangements for people who inconveniently fall ill in the evenings and weekends. So, quite recently, some hospitals are considering the implications of organising themselves on a 24/7/365 basis to address public concerns about the weekend health lottery.
Incentivising senior clinicians (and the rest of the workforce) to work weekends will be expensive but all the evidence suggests that early intervention by senior clinicians in a patient’s care episode results in better outcomes and faster discharge home (alleviating pressure on beds and A&E waiting times). Whether politicians can feel confident about progressing the agenda is another matter as this is likely to create a further major push towards having fewer, larger A&E hospitals (to make best use of the extra people required to sustain a 24/7/365 system). So far, whilst the evidence clearly points to better results for patients and fewer lives lost from this approach, the unpalatable downside (to the public, media and politicians) would be the loss of some local and smaller A&E services that may become clinically unviable.
Kyn Aizlewood is a specialist in healthcare programmes and business cases. After working in the private sector for eight years he re-joined the NHS and now works at the NHS Trust Development Authority, based in central London. The ideas expressed in this blog article are entirely his own and do not represent those of the TDA.