HES data are available from 1989-90 onwards. Changes to the figures over time need to be interpreted in the context of improvements in data quality and coverage (particularly in earlier years), improvements in coverage of independent sector activity (particularly from 2006-07) and changes in NHS practice.
Payment by Results (PbR) is a system whereby hospitals are paid for the number of patient treatments, known as activity, they perform and the complexity of these treatments. It was introduced in a phased way from 2003-04 onwards. In order to get paid correctly, hospitals need to record the activity they perform and the clinical codes that outline the patients’ conditions and treatment.
The introduction of Payment by Results (PbR), increased private sector involvement in the delivery of secondary care and brought about some changes in clinical practice (including some procedures occurring as outpatient appointments instead of hospital admissions). It is likely that these changes will have affected trends.
This has provided a major financial incentive for hospitals to ensure all of the activity they perform and the clinical coding is fully recorded. This improved recording of information captured by HES could be one of the factors leading to the reported activity increases.
In order to manage patients’ waiting times there has been the need for additional elective operations to be performed as well as a requirement for more capacity in NHS funded care to perform this activity. In the middle of the last decade, additional capacity was brought in from the private sector via treatment centres, with the NHS funding some patients to be treated there for routine operations.
Improvements in technology and the need to increase efficiency to allow more patients to be treated have led to a reduction in the length of time patients need to stay in hospital for certain planned operations. In particular, many of those operations that would have involved an overnight stay at the start of the period are now routinely performed as day cases. In addition, many operations where a patient would have been admitted to hospital at the start of the period are now routinely performed in outpatients. This has led to increases in day case rates and outpatient attendances over the period.
The recent period has also seen a rise in the number of emergency admissions. One factor contributing to this is likely to be the increased demand on health services from an ageing population. Alongside this there has been the introduction of observation or medical assessment units at many hospitals to which patients arriving in A&E departments are admitted, often for around a day, to enable observation and tests to be performed on them.
Care should be taken when interpreting these changes, as improvements in coverage in HES will contribute alongside growth from increased activity.