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

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f312 (Published 15 January 2013) Cite this as: BMJ 2013;346:f312

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

The target driven culture at the NHS Commissioning Board (CB) and elsewhere at the Department of Health (DH) is disturbing evidence of an inability to lead by example and to be led by the evidence.

There are several issues with such targets.

Firstly, they present an unspoken opinion that having given GP's the responsibility for the NHS budget the CB 'knows' that they are incapable of making sound decisions based on local priorities therefore will give them the benefit of a higher wisdom by imposing targets with attached rewards for performance.

Secondly, such targets are not evidence-based in that an extensive series of articles has demonstrated that the volatility associated with admissions and costs (1-25) is far higher than the DH or CB will acknowledge. By implication it is not statistically possible to demonstrate that ‘good’ performance in a single year is due to a specific set of actions or merely arose through chance, i.e. both statistical randomness and additional volatility due to the role of the external environment (including localised infectious outbreaks).

Thirdly, additional studies have demonstrated that medical admissions, in particular, follow long-term cycles which are at present poorly understood (7-12, 26-41). While these cycles appear to affect some diagnoses more than others there is never the less the implication within this particular target that ‘preventable’ admissions are insensitive to the external environment.

Hence, it is highly likely that particular CCG’s will be rewarded and others thereby penalised due to the outworking of both statistical and environmental volatility – over which they have no control. This is yet another post code lottery.

Far better for the reward money to be used to seed fund relevant schemes which will become self-rewarding in their own right. No one will deny that targets do work, in that organisations are forced to focus on achieving the target, but usually for the wrong reasons and at the expense of often more important areas of priority. GP leaders are right to oppose such mindless and scientifically erroneous targets.

References

1. Jones R (2004) Financial risk in healthcare provision and contracts. Proceedings of the 2004 Crystal Ball User Conference, June 16-18th, 2004, Denver, Colarado, USA. http://www.hcaf.biz/Financial%20Risk/CBUC_FR.pdf

2. Jones R (2008) Financial risk in practice based commissioning. British Journal of Healthcare Management 14(5): 199-204.

3. Jones R (2008) Financial risk in health purchasing Risk pools. British Journal of Healthcare Management 14(6): 240-245.

4. Jones R (2008) Financial risk at the PCT/PBC Interface. British Journal of Healthcare Management 14(7): 288-293.

5. Jones R (2009) The actuarial basis for financial risk in practice-based commissioning and implications to managing budgets. Primary Health Care Research & Development 10(3): 245-253.

6. Jones R (2010) What is the financial risk in GP Commissioning? British Journal of General Practice 60(578): 700-701.

7. Jones R (2010) Cyclic factors behind NHS deficits and surpluses. British Journal of Healthcare Management 16(1): 48-50.

8. Jones R (2010) Do NHS cost pressures follow long-term patterns? British Journal of Healthcare Management 16(4): 192-194.

9. Jones R (2010) Nature of health care costs and financial risk in commissioning. British Journal of Healthcare Management 16(9): 424-430.

10. Jones R (2010) Trends in programme budget expenditure. British Journal of Healthcare Management 16(11): 518-526.

11. Jones R (2011) Cycles in inpatient waiting time. British Journal of Healthcare Management 17(2): 80-81.

12. Jones R (2012) Time to re-evaluate financial risk in GP commissioning. British Journal of Healthcare Management 18(1): 39-48.

13. Jones R (2012) Why is the ‘real world’ financial risk in commissioning so high? British Journal of Healthcare Management 18(4): 216-217.

14. Jones R (2012) Volatile inpatient costs and implications to CCG financial stability. British Journal of Healthcare Management 18(5): 251-258.

15. Jones R (2012) Cancer care and volatility in commissioning. British Journal of Healthcare Management 18(6): 315-324.

16. Jones R (2012) Gender and financial risk in commissioning. British Journal of Healthcare Management 18(6): 336-337.

17. Jones R (2012) End of life care and volatility in costs. British Journal of Healthcare Management 18(7): 374-381.

18. Jones R (2012) Age and financial risk in healthcare costs. British Journal of Healthcare Management 18(7): 388-389.

19. Jones R (2012) High risk categories and risk pooling in healthcare costs. British Journal of Healthcare Management 18(8): 430-435.

20. Jones R (2012) Year-to-year volatility in medical admissions. British Journal of Healthcare Management 18(8): 448-449.

21. Jones R (2012) Risk in GP commissioning: the loss ratio. British Journal of Healthcare Management 18(11): 605-606.

22. Jones R (2012) Financial risk in GP commissioning: lessons from Medicare. British Journal of Healthcare Management 18(12): 656-657.

23. Jones R (2013) A fundamental flaw in person-based funding. British Journal of Healthcare Management 19(1): 32-38.

24. Jones R (2013) Population density and healthcare costs. British Journal of Healthcare Management 19(1): 44-45.

25. Jones R (2013) Financial risk and volatile elderly diagnoses. British Journal of Healthcare Management 19(2): in press.

26. Jones R (2009) Trends in emergency admissions. British Journal of Healthcare Management 15(4): 188-196.

27. Jones R (2009) Cycles in emergency admissions. British Journal of Healthcare Management 15(5): 239-246.

28. Jones R (2009) Emergency admissions and hospital beds. British Journal of Healthcare Management 15(6): 289-296.

29. Jones R (2009) Emergency admissions and financial risk. British Journal of Healthcare Management 15(7): 344-350.

30. Jones R (2010) Unexpected, periodic and permanent increase in medical inpatient care: man-made or new disease. Medical Hypotheses 74: 978-83.

31. Jones R (2010) Can time-related patterns in diagnosis for hospital admission help identify common root causes for disease expression. Medical Hypotheses 75: 148-154.

32. Jones R (2010) The case for recurring outbreaks of a new type of infectious disease across all parts of the United Kingdom. Medical Hypotheses 75(5): 452-457.

33. Jones R (2010) Emergency preparedness. British Journal of Healthcare Management 16 (2): 94-95.

34. Jones R (2010) Forecasting emergency department attendances. British Journal of Healthcare Management 16(10): 495-496.

35. Jones R (2010) Gender ratio and hospital admissions. British Journal of Healthcare Management 16(11): 541.

36. Jones R (2011) Cycles in gender-related costs for long-term conditions. British Journal of Healthcare Management 17(3): 124-125.

37. Jones R (2011) CMV and health care costs. British Journal of Healthcare Management 17(4): 168-169.

38. Jones R (2012) Gender ratio and cycles in population health costs. British Journal of Healthcare Management 18(3): 164-165.

39. Jones R (2012) Diagnoses, deaths and infectious outbreaks. British Journal of Healthcare Management 18(10): 539-548.

40. Jones R (2012) Excess deaths following a procedure in 2008. British Journal of Healthcare Management 18(10): 554-555.

41. Jones R (2013) Could cytomegalovirus be causing widespread outbreaks of chronic poor health. Hypotheses in Clinical Medicine, Chapter 4, Eds M. Shoja et al. New York: Nova Science Publishers Inc (in press)

Competing interests: The author provides consultancy to health care organisations.

18 January 2013
Rodney P Jones
Statistical Advisor
Healthcare Analysis & Forecasting
Camberley, Surrey