A & E

The Ambulance service is being paid bonuses for not taking patients to hospital in a bid to help the NHS hit targets. NHS managers have agreed to pay £38 for every casualty that ambulance staff "keep out of A&E departments after a 999 call has been made. The tactic is part of an attempt to manage increasing demand for emergency care amid failings in the GP out-of-hours system. Staff at Britain's largest ambulance service have been encouraged to maximise the organisation's income, by securing payments for diverting patients to telephone helplines.

The bonuses are among dozens of schemes being tried out by ambulance trusts across the country as they attempt to improve their emergency response times and help A&E departments meet controversial targets to treat all patients within four hours of arrival. Another plan uncovered would see thousands of 999 calls currently classed as urgent downgraded so that callers receive telephone advice instead of an ambulance response. The changes were due to be introduced across the country, but the Government committee governing ambulances has delayed its decision amid safety concerns.

An investigation was launched at the ambulance trust piloting the scheme following the death of a man whose case was referred for telephone advice when an ambulance should have been immediately dispatched. Dozens of Primary Care Trusts in London are now paying the capital's ambulance service a £38 bonus for each patient crews do not send to hospital. While the maximum amount of money the ambulance service can make from the scheme is "capped," board papers suggest increasing the number of patients diverted from hospital by 20% a year "in order to reach the maximum level of funding available".

In the current financial year, London Ambulance Service has made £850,000 through the scheme. Earlier this month, ambulance services in Berkshire, Buckinghamshire, Hampshire and Oxfordshire abandoned plans to reward crews with shopping vouchers if they sent patients to a GP, instead of taking them to hospital. South Central Ambulance Service had offered paramedics raffle tickets to win £200 of store coupons if they used the GP referral scheme, but dropped the plans following fury from crews.

Jonathan Fox, from the Association of Professional Ambulance Personnel said the use of financial inducements for individuals or organisations was too dangerous. The paramedic said, "Trusts simply shouldn't put finances ahead of the clinical need of the patient; it is too risky and puts too much pressure on staff. Time and time again we come across incidents where red flags that a patient's situation is life-threatening are missed. Not every patient sent to hospital needs to be there, but paramedics need to take decisions based on what is best for the person they are treating, not the finances of their trust."

London introduced the bonus payments ahead of a pilot scheme to downgrade more than a dozen categories of calls currently classed as urgent and requiring a "blue light ambulance". Since October, calls, including those involving stab victims and people suffering breathing difficulties, have been downgraded by London Ambulance Service. More than a dozen types of medical crisis currently designated as urgent, and requiring a blue light ambulance within 19 minutes are instead either passed to telephone advisers or phoned back within 15 minutes of dialling 999.

A report by the ambulance trust on the pilot scheme, which was written last July says, "Inevitably utilising telephone triage and advice rather than the dispatch of an ambulance may involve an increased risk". The paper concludes that the level of danger is acceptable, but says the scheme should be supported by a "communication strategy" to make staff and public aware of the new response to emergency calls, and "remove the potential for disappointment". The ambulance trust refused to disclose details of the 13 categories downgraded. (Source: Daily Telegraph, Mar/10)

Hospital A&E departments are turning away patients who might die, because they are too expensive to treat. It means ambulances carrying critically ill patients from 999 calls must travel further, because crews know the nearest hospital trust will not take them. With the average A&E admission costing £86, hospitals do not want to bear the £300 cost of those with life-threatening conditions. Health Department figures show the number of casualty units taking the most dangerously ill has fallen by 25% since Labour came to power.

Emergency units are given a set sum by the Government, no matter how many patients they treat, and routinely go over budget. But as the NHS ran up debts of more than £1billion, savings had to be made. A Health Department spokes man said, "Life-threatening emergencies often require a wide range of specialist services. It can be appropriate to concentrate major services on one site, rather than having multiple sites." Other figures show the number of hospital beds is also down. In 2003 there were 399 per 100,000 people. That fell to 376 in 2006. (Source: Sunday People, Jun/07)

The quality of care given by Derby's accident and emergency services has been ranked as the second worst in the region. The findings were revealed in a report by the Healthcare Commission, which assessed 170 of the country's 202 A&E departments, including Derbyshire Royal Infirmary and Derbyshire Children's Hospital's emergency department. The health watchdog checked hospitals on the length of time taken to give pain relief to children and patients with broken hips, as well as when tests on patients with paracetamol overdoses were given.

The findings, which are based on figures between 2003 and 2005, also looked at the waiting times and the cleanliness at each hospital. In Derby, 38% of children who were in moderate to severe pain were given pain relief within an hour of arriving at A&E, the second-worst performance of seven hospitals in the Trent region. Chesterfield and North Derbyshire Royal Hospital came top with 96%. Just over a third of A&E patients with broken hips were given pain relief within an hour, again placing the DRI second from bottom of the seven hospitals.

Around 10% of patients were found to have spent four hours or more in A&E between April and June 2004 but the department, which sees 80,000 patients a year, came top for cleanliness, scoring 100%. Kay Fawcett, the Derby Hospital NHS Foundation Trust's director of nursing, said that the results were "very disappointing" and that improvements had included introducing a new treatment guide for A&E nursing staff, allowing nurses to give patients painkillers which doctors then confirmed. Also, children are now being given painkillers as nasal drops to prevent them failing to say how much pain they are in to avoid injections. (Source: Derby Evening Telegraph)