Interviewed on local radio last week, Keith McNeil, the chief executive of Addenbrookes hospital, Cambridge, confirmed that the trust was offering incentives to wards to discharge two patients a day by 10am. A ward managing two discharges a day for a week will get £1000, while perfect performance for a month will attract £5000, with the dubious additional bonus of having the chief executive spending a day on the ward doing whatever it wants him to. Wards are also being encouraged to compete for the awards.
Why would he want to incentivise people to get rid of two patients a morning? Let’s look at what’s really going on here. The background is that like all NHS trusts, Addenbrookes needs to be financially as well as clinically sound. Under a regime of payment by results it gets paid for what it does, so it needs to maximise throughput, keeping keeping patients in for as little time as possible consistent with their clinical needs. If patients ‘block’ beds by staying longer than necessary, often because they are thought to be too infirm to return safely to their own homes, then tightly scheduled elective surgery may have to be postponed, or admission of acute cases may be delayed for lack of beds.
So at first sight, getting people ‘to do their discharge planning pre-emptively, so that when patients are ready to go, they can be moved efficiently and quickly from those beds, so that other patients who need those beds can be moved into them’, sounds sensible.
But hang on: given that pressure to get patients out of the door is already heavy enough that no one can be unaware of it, what does McNeil want clinical staff to do differently? Of course, he says, ‘all of my clinical colleagues know that patient safety comes first’, so that no one will be put at danger. The whole point of incentives is to indicate management priorities: so the introduction of at least the shadow of a conflict of interests, at a time when the whole medical profession, and nursing in particular, are coming in for heavy chastisement for lack of care in the wake of Mid Staffs, seems questionable to say the the least.
One health commissioner is confident that confronted with incentives ‘most clinical staff’ will continue to do the right thing, but that there may be a temptation to hold back patients to the next morning who could have been discharged the evening before, or alternatively to discharge people before they have completed all the follow-ups, like seeing the occupational therapist, say, at the price of calling them back later. More insidiously, doing things in a hurry could cause corners to be cut, leading to subsequent readmissions. ‘The tendency is to make everything sharper and quicker,’ she says. ‘You can understand why he [McNeil] wants to keep things moving, but it doesn’t always add up, particularly for the frail and elderly.’ Getting it right first time, she says, may seem slower and more expensive in the short term, but in the longer run it is likely to be much more cost effective.
Andy Brogan, a consultant at Vanguard Consulting, currently engaged in some interesting work on demand in the NHS, notes that the contradictory play of incentives is ironically one powerful reason why the system is becoming so overloaded. There is an incentive for hospitals to get people in and then one to get them out again, and for various reasons (not least that getting them out depends on relationships with other agencies, each driven by its own incentives) they are better at the former than the latter. ‘The trouble is that incentives at the back end are a blunt instrument,’ says Brogan. ‘It’s like giving a brain surgeon a chain saw – you take out the tumour, but the danger is that the rest of the body goes with it too.’
More than that, one of the reasons that incentives are perceived to be necessary at the back end is the perverse incentives that drive admission at the front. Thus the effect of the four-hour wait limit in accident and emergency (A&E) is to increase the number of hospital admissions as patients approach the cut-off point, whether they need to be admitted or not: better to take them in, with all the bureaucratic expense involved, than risk breaching the target (for chief executives still a sacking offence). Brogan’s work at a sample of three hospitals shows that partly because of these extreme short-term pressures 50 per cent of admissions are short stay, in and out within two days. Some of these of course are perfectly legitimate medically, but many are repeat presenters who have pitched up at A&E as a last resort because they can't get their problems solved elsewhere.
It’s true that, as comments on a previous piece have pointed out, distinguishing between value demand (what that we want and are we are here to do) and failure demand (the result of not doing something or not doing it right the first time) is more difficult in health than in other settings. Nevertheless, there is more than an element of the absurd in ‘introducing incentives to get rid of people who shouldn’t be there in the first place,’ as Brogan puts it. The moral of the story: it’s not just in the private sector that incentives are dangerous. On the one hand they provide a conflicting de facto purpose to the original one, with potentially dangerous consequences (have we learned nothing from Mid Staffs?); on the other when applied to efficiency measures that are also detached from purpose, they inevitably make things worse, not better.