Hospitals could be fined millions of pounds even if they reduce C difficile infection risk
24 November 2008
NHS Hospital Trusts that are successful in reducing Clostridium difficile risks in line with government targets still have a 50% chance of paying a financial penalty each year, and around a 95% chance of being fined at least once in the next three years, concludes a study on bmj.com.
Researchers from the Medical Research Council Clinical Trials and Biostatistics Units and the National Institute for Health Research say a recent initiative to encourage trusts to reduce C difficile infections have resulted in a ‘perverse situation’ where, in the worse case, Trusts can be heavily penalised if they go over the set target by just a single extra case and, in general, penalties will be very hard to avoid completely.
Penalties may involve millions of pounds, for example, a 2% fine of a large Trust with a revenue of £500 million would be £10 million.
The authors argue that the current system, introduced as part of the 2008–9 National Health Service contract for acute services, may be a disincentive to Trusts to perform well and encourage hospitals to automatically reserve funds to pay penalties, whether or not they achieve the target. This could divert resources from delivering vital services to patients.
The authors suggest that the problem with the current penalty system lies in the manner the targets and financial penalties are applied to Trusts.
Dr Sarah Walker explains: “The NHS contract does not distinguish between the underlying risk of each new patient getting C Difficile and the number of cases observed in a particular Trust. Though the intended aim should be to reduce the underlying risk by about 10% year on year, the targets focus on the number of cases. These are only an approximate measure of the underlying risk, particularly in smaller Trusts where the overall number of cases could be small. Even if this underlying risk is reduced by the right amount, for a relatively rare event like C difficile the play of chance means that the actual number of cases seen may be higher or lower than this.”
Professor David Spiegelhalter from the MRC Biostatistics Unit adds: “There is also the problem of the penalties being uneven. In the worse case scenario, a Trust with 199 cases of C difficile cases in the previous year and 199 cases in the actual year will escape penalty. However, if the Trust reaches 200 cases it is automatically fined 2% of its revenue. Thus a single case could cost a Trust millions of pounds. This means that realistically, Trusts will have to exceed the target risk reduction by 5–15% to avoid being fined.”
According to the authors, the efforts a Trust puts into reducing infection rates and improving C difficile control such as enhanced cleaning and hand-washing are not taken into account in this scheme.
Dr Walker suggests: “A fairer system, and one supported by the Healthcare Commission, would be to estimate a baseline number of cases for each Trust from several years’ data, calculate target risk reductions for the next three years, and then only penalise Trusts where there was strong statistical evidence that they have not met these targets.”
The authors conclude that while there is a strong case for incentives to reduce C difficile cases in NHS Trusts, the system to achieve this aim should be fairer and better designed so as not to penalise Trusts which are working hard to reduce infection rates and meet targets, but experience normal year-to-year variation in their number of cases.
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Ref: Walker et al. Analysis: Fairness of financial penalties to improve control of Clostridium difficile control, BMJ Online BMJ.2008; 337: a2097.
