Costs and costing systems

Gillam makes the important point that fragmentation of primary care “is compromising continuity of care and reducing access to just those practitioners who may be able to manage comorbidities in the community.”1 This hypothesis calls for systematic prospective research.

The suggestion that integration may be a solution is unlikely to work. Talbot-Smith and colleagues showed that, in the US, the Kaiser highly integrated system was associated with much higher costs than in the NHS.2

The comment about the new costing system for emergency admissions to hospital needs discussion because it has profound ethical and clinical implications. Hospitals are about to be punished, in effect fined, for admitting as emergencies, people—many of whom are old with multiple illnesses—who need specialist care. Such frail and vulnerable patients will become financial burdens to hospitals and they will be unwelcome. Increasing pressures will probably be exerted on hospital doctors and general practitioners not to admit emergencies to hospital. Is this either wise or ethical?