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 to reverse this trend.

Narrow thinking

As a clinician working in commissioning I have been struck by how “siloed” professional and organisational thinking can be. Emergency admissions account for a relatively small proportion of overall activity in specialist care, yet a large proportion of cost. If you look across the health and care system most activity occurs outside hospital but most of the cost is consumed by hospital services.1

For a long time there has been the mantra of “moving care closer to home,” yet, except in a few isolated instances, this has not happened. Talking to a specialist recently, I asked why. His response was that there is no consistency outside hospital. “I don’t know if my patients will be safe or get the care they need delivered,” he told me. I was also taken aback by the response a practice gave me recently when I asked when it last looked at its emergency admissions. The staff proudly told me that they had done an audit—a year previously.

Many emergency admissions are the result of exacerbations of long term conditions, failure of coordinated care, and, increasingly, frail elderly people with comorbidities needing proactive care from primary, community, and social care.1 2 How many practices systematically analyse the root causes of emergency admissions?

Opportunity for change

The advent of clinical commissioning groups and health and wellbeing boards presents an opportunity to tackle the complex issues relevant to emergency admissions. The recent analysis of trends in emergency admissions by Bardsley and colleagues tells us one thing—we need to ask more and better questions and work collectively across the continuum of health and social care, if we are to move care closer to home and reverse the trend in acute admissions.3

Clinical commissioning groups will be commissioning the community and mental health care that can support that move, as well as the acute services, which are under pressure. To avert emergency admissions to hospital they will need to work in partnership with social care and some of the wider services that frail elderly people and their carers are so dependent on. The construct of health and wellbeing boards provides an opportunity to foster and forge a coherent and consistent common purpose across primary care. The responsibility of commissioning groups and the NHS Commissioning Board to improve the quality of primary care creates a new dynamic in the system which, if approached in the right way, can build on the potential of general practice to support collaborative coordinated care and reduce emergency admissions, especially if aligned with commissioning in the rest of the health system.

Success will require a range of enablers, levers, and incentives to help leaders to change attitudes, behaviours, and ways of working right across the system. The fact that colleagues say that most emergency admissions are out of hours or self referrals, as if that absolves them from any responsibility, is worrying. Clinicians have a responsibility to improve care no matter where a patient is on a pathway. There is no better way of articulating the role of primary care than to quote from the Francis report: “It will be important for the future that all GPs undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services . . . A GP’s duty does not end on referral to hospital but is a continuing relationship. They will need to take this continuing partnership with their patients seriously if they are to be successful commissioners of services. They should exploit to the full this new role in ensuring their patients get safe and effective care.”4

No part of the system is an island. In my experience, through better use of data, planning, service redesign, contracting, and monitoring performance—that is, good commissioning—it will be possible to improve quality while managing costs. The quality premium is one instrument in the toolbox to support new thinking and ways of tackling deep rooted problems. To consider the premium in isolation, or to label it as a fine, perpetuates a fragmented view of a complex adaptive system in which clinicians have now got a real opportunity to lead change and improve outcomes for patients.


Cite this as: BMJ 2013;346:f1389


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare that I work for the NHS Commissioning Board and one of my key objectives is supporting clinical commissioning groups to reduce emergency admissions.

  • Read the opposing side in the debate by Chaand Nagpaul, doi:10.1136/bmj.f1391.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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