Intended for healthcare professionals

Head To Head

Should GPs be fined for rises in avoidable emergency admissions to hospital? Yes

BMJ 2013; 346 doi: (Published 05 March 2013) Cite this as: BMJ 2013;346:f1389
  1. Martin McShane, director for domain 2
  1. 1National Commissioning Board, Leeds LS2 7UE, UK
  1. martin.mcshane{at}

Commissioning organisations in England face losing a quarter of the “quality premium” if they do not keep down their emergency admissions for specific conditions. Martin McShane supports the plan, but Chaand Nagpaul (doi:10.1136/bmj.f1391) worries about possible unintended consequences

Major changes have occurred in healthcare over the past 30 years. I remember, as a house officer, having to admit patients for several days just to start them on a new drug—the angiotensin converting enzyme inhibitor captopril. As a surgeon I became adept at performing vagotomy and pyloroplasty for duodenal ulcer and recently winced when a colleague pointed out that, in effect, we used to perform surgery for an infectious condition. While a general practitioner, I witnessed the closure of long stay geriatric wards and the proliferation of large residential and nursing home facilities for which GPs were expected to provide medical care, looking after frail elderly patients with complex comorbidities. We have seen startling decreases in mortality and morbidity in cardiovascular disease and improvements in cancer treatments and survival. Despite this we have also seen an inexorable rise in emergency admissions. Financial incentives will help bring about the changes required …

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