Payment by results (PBR) and patient choice are examples of system reform that are having profound effects on the way healthcare is being organised in England.

Many primary care and acute hospital trusts are experiencing severe financial pressures at a time when they are expected to balance their books and compete with independent treatment centres and other trusts for elective waiting list work.

There are increasing anxieties that some existing hospital services, if not whole hospitals, will close as a consequence of the financial pressures. Foundation Hospital status which is increasingly being sought by acute trusts does not appear to necessarily protect hospitals from these pressures.

The preliminary results from the BGS England 2005 survey, which will be reported in the next newsletter, suggest that medical care of the elderly departments are already feeling these pressures, particularly in relation to the provision of rehabilitation services.

The payment by results policy is gradually being implemented, initially for elective procedures, but it will soon apply to emergency admissions, initially just in the foundation trusts but the policy will later roll out to all trusts, especially if or rather when they are all foundation trusts. The single national tariff for each procedure or medical condition will force trusts to review the costs of providing services and inevitably, they will review whether to continue to provide loss making services. The higher tariffs however, for patients with significant co-morbidity has led to new interest in accurate coding and discharge information amongst clinicians and hospital managers.

Trusts with high overhead costs will inevitably be challenged by payment by results as the tariff is the same for all trusts. The policy would more appropriately be called payment by activity, as outcome is not directly linked into the payment systems at the outset though perhaps high quality services will be rewarded by the reform.

Traditionally a large number of hospital beds have been used to provide care of older people but they have often been poorly staffed and / or occupied by patients (or customers!) whose discharge has been delayed. The reimbursement policy has, however, probably reduced the overall number of delays but many of these rehabilitation beds have now been closed as trusts seek to save money.

Another national policy aim is to stem the tide of emergency medical admissions at a time when there is reduced out of hours GP cover and increased numbers of A&E attendees. Developing alternatives to hospital admission should involve joint working between local primary and secondary care clinicians. The roll out of payment by results and practice based commissioning may produce a massive incentive for primary care to deal with more patients in the community. There is a fear that older people could be denied access to services in some areas.

Geriatricians traditionally have used policy initiatives to help develop their services. There are potential opportunities that might accompany payment by results. If the tariffs are set fairly and elderly care is dealt with as a discrete financial entity (or cost centre in a trust) then the chronic problem of fighting for resources might become easier as the cost of providing care and the income generated becomes explicit.

GP fund holding led to competition between providers. There are already signs that payment by results and the challenges of the 2009 working time directive are forcing adjacent hospital trusts to develop partnership working between themselves and the primary care trusts to ensure that the services provided for the local populations are cost effective and quality assured.

The challenge for geriatricians in 2006 is to use payment by results as an opportunity to develop better services for older people. There is initially a need to ensure that where rehabilitation beds are being or have been closed, that effective alternatives are established that can deliver patient centred care in the right environment, with the best possible patient outcomes in a system that integrates primary and secondary care to other services.

James Barrett
Chair : BGS England Council