Incentives for GPs to cut emergency admissions could lead to “target culture,” warns GP leader

BMJ 2013; 346 doi: (Published 15 January 2013) Cite this as: BMJ 2013;346:f312
  1. Gareth Iacobucci
  1. 1BMJ

A plan to tie a proportion of the funding for clinical commissioning groups (CCGs) to reductions in “avoidable” admissions to hospital of patients with long term conditions risks distorting priorities and creating a new “target culture,” a senior doctors’ leader has warned.

A quarter of the new “quality premium” incentive payment paid to new commissioning organisations in England from 2014-15 would depend on their achieving a reduction or no change in emergency admissions for specific conditions between 2013-14 and 2014-15, says draft guidance from the NHS Commissioning Board.1

The money allocated to the premium, proposed as part of the UK government’s changes to healthcare,2 will be determined after parliament sets regulations in the next few months. It will be paid on top of each commissioning group’s main financial allocation for 2014-15 and the running costs allowance of £25 (€30; $40) per head of population.

But the BMA’s lead GP negotiator on commissioning, Chaand Nagpaul, warned that the move could “distort priorities” for commissioning groups and place undue pressure on GPs, who are already paid incentives through the Quality and Outcomes Framework for helping to prevent emergency admissions.

To achieve full payment of the emergency admissions incentive, commissioning groups would have to ensure no increases in numbers of unplanned hospitalisations of adults with “chronic ambulatory care sensitive conditions,” such as congestive heart failure, angina, and hypertension, and of children with asthma, diabetes, or epilepsy. They must also prevent increases in emergency admissions of adults with acute conditions that should not normally require admission and of children with lower respiratory tract infections.

A further 12.5% of the premium would depend on commissioners reducing potential years of life lost from “amenable mortality”; another 12.5% is attached to preventing healthcare associated infections; and a further 12.5% would depend on the “friends and family test” being introduced to measure patients’ experience of NHS services.

The remaining 37.5% would be split equally between three locally agreed measures, to be agreed with the NHS Commissioning Board after consideration by patients and local health and wellbeing boards.

Nagpaul warned that the premium could create a “target culture” as commissioning groups sought to avoid financial penalties.

He said, “It may distort priorities. We think there is a risk of a target culture where CCGs are chasing achieving the targets in order to reclaim this money.”

Nagpaul added that the onus being placed on commissioning groups and GPs to tackle admissions to hospital ignored the roles of other parts of the system.

“There will be pressure on general practices to contribute. But many of these admissions are outside the control of GPs: they relate to broader factors, such as increased morbidity in the population and increased life expectancy. Some relate to provider performance, some relate to social care—and therefore it’s inappropriate for CCGs to be fully held responsible.”

Research published earlier this month in BMJ Open concluded that previous efforts to improve the preventive management of certain clinical conditions had failed to reduce the demand for emergency care and said that the challenge of bringing admissions under control “should not be underestimated.”3

John Appleby, chief economist at the healthcare think tank the King’s Fund, said that it would be “difficult” for CCGs to bring emergency admissions under control.

“I’m sure they have a role to play, but they are not the only ones. It’s the whole pattern of urgent care in an area,” he said.

Appleby said that the NHS Commissioning Board faced a difficult balancing act in setting incentives that would have a meaningful effect without causing adverse consequences.

“One of the things you can tell from studies of this sort of performance related pay is that the actual pay bit has to be quite big. It is a very tricky thing. The bigger it gets, the more controversial it becomes. If you focus on some things you may forget about other stuff.”

A spokeswoman for the NHS Commissioning Board said, “It has been recognised in healthcare systems around the world for some time that real quality improvement can be achieved with the careful and considerate use of financial incentives.

“The quality premium indicators are designed to focus on outcomes spanning the five domains of the NHS Outcomes Framework and to leave flexibility for CCGs to determine how best to improve these outcomes.”


Cite this as: BMJ 2013;346:f312