BMA rejects proposal that GPs should pay cost of patients’ unnecessary visits to emergency departments

BMJ 2008; 336 doi: (Published 24 April 2008) Cite this as: BMJ 2008;336:910
  1. Lynn Eaton
  1. 1London

    GPs’ leaders have criticised the suggestion that primary care trusts should be able to recoup from general practices the costs of any unnecessary visits made by their patients to emergency departments or walk-in clinics.

    The proposals, apparently passed to the government for consideration in the review being carried out by the health minister Ara Darzi, suggest that charges are imposed if a patient uses emergency services because they cannot see their own doctor in normal surgery hours.

    Laurence Buckman, chairman of the BMA’s General Practitioners Committee, said that the proposal, from the NHS Confederation and NHS Employers, could mean that many general practices would lose all their funds. Those in areas where there was a culture of patients tending to go to emergency departments would be the hardest hit, he said.

    “These tend to be in the more deprived areas,” Dr Buckman told the BMJ, suggesting that doctors whose patients tend to use emergency departments inappropriately might be forced to ask them to move elsewhere “or the practice would go bankrupt.”

    “The whole point of the new contract,” he said, “was to stop [the removal of patients] happening.”

    The proposals were reported exclusively in the Health Service Journal (17 April 2008, p 4; However, neither the Department of Health nor the NHS Confederation would comment other than to confirm that the department had commissioned NHS Employers and the NHS Confederation to undertake a piece of work to look into the matter of a tariff for walk-in centres, minor injuries units, and temporary residents.

    “This report has now been received and the Department of Health will consider its findings,” said a spokesperson for the deparment.

    NHS Employers reiterated this statement, adding that because the report was now with the Department of Health “we aren’t in a position to discuss the content of this review.”

    According to the report in the Health Service Journal, the threat to fine GPs is intended as another lever to encourage GPs to extend their opening hours, making surgeries more easily accessible than at present. As much as £940m (€1200m; $1900m) could be at stake, according to the journal, because this is the amount of money spent on visits to emergency departments or walk-in clinics that do not lead to admission.

    The average cost of a visit to a walk in centre is £44 and to an emergency department it is £66, according to the journal.

    If a general practice received £70 for a patient a year from the government but was charged £59 if the patient attended an emergency department, the practice would no longer be financially viable, said Dr Buckman.

    But NHS Employers have argued that it doesn’t make sense for primary care trusts to fund care for patients through their GP only to have to pay a second time if that patient unnecessarily visits an emergency department or walk-in centre when they could have received the same treatment from their GP.

    Although a similar cross costing arrangement is in place in New Zealand, according to Chris Ham, professor of health policy at Birmingham University, the funding model for GP services there differs from that in the United Kingdom.

    “That is very important,” he told the BMJ. “New Zealand GPs get paid by the number of patient consultations as well as through a government capitation funding.”

    For a similar scheme to work in the UK, he said, GPs would have to have some kind of payment for each consultation so that if the patient used an alternative provider the funding would go there instead.

    But he thought the government might well consider this as another way to pressure GPs into longer opening hours: “If you want to drive increased accessibility you can put more money in—which they already have done—or you can say that some of the money should be taken away.”

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