Editor’s blog Tuesday 8 June 2010: The joys of unintended consequences - Lansley's new fines for 30-day acute readmissions

I think I may just be able to see an unintended consequence or two in Health Secretary Andrew Lansley CBE MP's new policy announcement today of fines for hospitals whose patients are readmitted as an emergency within 30 days, announced in today's Guardian.

Let us assume that the fines will not be negligible sums. (Let us do so because if they are negligible, people will pay them, and the policy will be discredited and ignored very fast).

So - who is in hospital? Patients for elective surgery, it is true - increasingly, the penny has dropped about day cases, and rates are increasing, though less fast than probably is ideal. In general, this group is not massively problematic in emergency readmissions.

Pregnant mothers are in hospital.  In general, this group is not massively problematic in emergency readmissions either.

Who else? Ah yes, older people with multiple co-morbidities. Often frail, and unable to return home safely because of lack of community support and domestic adaptation.

It is totally unclear from the trail in the article whether the bulk of growth in 30-day readmission rates relates to the over-75s and to discharges from medical wards rather than surgical ones. I will bet you a pint that it does.

(We have also been under a regime of trying to deliver 'better care closer to home, have we not? Very few of us live in hospital, thank God.)

This being the case, Mr Lansley is asking hospitals to effectively insure commissioners against any possible cause of an emergency readmission within 30 days among a cohort of seriously ill, probably mulitply comorbid older people.

That is one hell of a risk to insure.

There is also in this a failure to understand that as healthcare and many other factors have enabled people to live longer, the duration of infirmity lengthens. Up to a point (where quality of life declines below what the individual finds acceptable), this is a good problem to face.

There is an excellent point to be made about the need for much better preparation of patients, families and homes to enable safe discharge from hospital. There is a gap in the system for the kind of 'step-down' community hospital service in many areas that would ensure hospitals are where you go when you are really, genuinely in need of ongoing medical care. Let's see if Mr Lansley makes it.

But here are the unintended consequences: either trusts who cannot afford the fines will discharge more slowly - possibly much more slowly - and bankrupt their commissioner, as well as shooting waiting times into outer space.

Or they will develop protocols that refuse to admit the highest-risk patients.

Update: The NHS Alliance (with whom I sometimes do paid work, COI fans) have recently put out a release highlighting one of the possible issues with acute discharges: the hardy NHS perennial of bad, late and incomplete-to-useless discharghe summaries.

How dispiriting that this remains such a big issue after all this time, five years after the Alliance first ran this survey.