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Stop playing games with the NHS

The Department of Health, under both the current and previous government, has had an Orwellian tendency to dream up names for its policies that bear little relation to their true purpose.

The Department of Health, under both the current and previous government, has had an Orwellian tendency to dream up names for its policies that bear little relation to their true purpose.

The planned quality premium, for instance, will tie GP pay primarily not to quality but to budgetary control – and is hardly much of a premium, given it is to be funded from the existing primary care budget.

Then there's QIPP, which again adopts the ‘quality' tag, throws in innovation and prevention, and leaves only the word ‘productivity' to hint at its main purpose of again driving down costs.

But of all the dodgy names for dodgy policies, none is as much of a misnomer as ‘payment by results' – the system for determining how much money PCTs, and now CCGs, should pay to hospitals.

Payment by results does not, in fact, pay hospitals by results at all, but by the volume of activity they generate. Attaching cash to each episode of care was supposed to make hospitals compete for the right to treat patients – but instead it has driven them into battle with primary care, and seen them suck activity into the costly acute sector.

Payment by results would be a failed policy even if every claim hospitals put in was justified, given it has worked directly against the Government's planned shift of care into the community.

But on top of that, there is now increasing evidence the policy has spawned a cottage industry in gaming of admission codes, to artificially boost hospital payments. The Audit Commission last month warned ‘inconsistent treatment descriptions' were ‘skewing management decisions and wasting NHS funding'.

It didn't spell out exactly how those inconsistencies were arising, but this week we reveal a group of GPs in Bristol has done just that, with a detailed dossier of dubious hospital claims.

It doesn't make pretty reading – with one patient admitted every day for three months, as part of a systematic classification of outpatient appointments as full admissions.

For GP commissioners, alleged gaming by hospital trusts is a huge issue.

It allows hospital managers to claim thousands of pounds of extra payment per patient, and threatens to leave multimillion-pound black holes in CCG budgets.

And under the quality premium, it will soon be GP practices that ultimately pay the price for those missing millions, because part of their payment is set to be tied to the ability of CCGs to stay within their commissioning budgets.

The Audit Commission released guidance clarifying the codes it said were being misused, and differentiating between day cases, outpatient attendances and full-on admissions.

It's essential the Government polices hospitals against that guidance, and stamps down hard on the kind of practices exposed
in Bristol should they be found to be in breach. But this is a problem that goes beyond a few ambiguous codes and the odd over-enthusiastic accountant. Successive governments have sought to turn the NHS from a collaborative public service into a competitive market.

When human beings are asked to compete, they bend or break the rules. It's in the nature of games.

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