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At the heart of general practice since 1960

When making cuts makes no sense

Reading stories about how managers and politicians think we can save money in the NHS is good for a laugh.

Your recent story on hospital admissions is a case in point ('GPs told to cut hospital use by 15% in one year', www.pulsetoday.co.uk/news). There is a desire to save money. It is postulated that we could:

1. reduce admissions

2. reduce length of stay

3. reduce attendances at A&E.

Think of a ward of x beds with y staff needed to safely cover the beds available. The major cost lines for this ward are the same, regardless of how fully occupied the beds are, since it is necessary to fully and safely staff the ward, keep it warm and lit and so on.

If fewer beds are occupied, the cost per bed therefore increases, since the same cost is divided by fewer beds.

So if we reduce admissions, then to maintain efficiency, we increase occupancy by increasing length of stay. On the other hand, if we reduce length of stay, we increase the rate of throughput (discharges, and, oh, admissions).

Has anyone yet noticed the tautological nature of the argument here?

So targets 1 and 2 are mutually exclusive – unless one shuts the unit altogether.

Now for item 3, reduce A&E attendances. Again, we need a basic service, with a basic cost. Increment per patient on top of basic cost is relatively minute. But if the unit can happily see 2,000 patients, the cost per patient is x/2,000. If we reduce attendances at A&E, say to 1,000, then you can see the cost per patient is doubled. On top of this, patients needing to be seen go elsewhere in the NHS, adding extra costs there, so the actual cost more than doubles by reducing attendances. Plus staff become deskilled through lack of experience.

Oh dear, another failure.

From Dr David Church, Machynlleth, Powys

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