Should GPs be fined for rises in avoidable emergency admissions to hospital? No
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1391 (Published 05 March 2013) Cite this as: BMJ 2013;346:f1391
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This article is good to read and is well written. Shedding the global view on this contentious problem in an unbiased manner.
I do agree that we need to have open honest discussions with all the stakeholders involved in dealing with increased footfall in emergency department. If regular reviews and planning (admission avoidance team meetings) has not helped to achieve the intended objective of reducing the A&E attendances, we need to change our tactics.
I think it is naïve to suggest that we need to penalize GPs over avoidable A&E attendances. It may be avoidable to ones viewpoint but may not be from others. A good open discussion among all the involved parties (hospital team, GPs, PCTs / CCG, patient representatives, OOH providers, NHS 111 and other community health care providers) is required to know why a patient decides to visit A&E over seeing his GP during weekday (surgery opening hours). If the review feels that some of the admissions / visits could have been avoided by the primary care teams than before thinking about penalizing, we would be talking about if there is need for extra help required to the teams involved, including extra-training.
We have to realize that patient’s expectations have been increased over the past decade. The amount of work up required for dealing with a patient for a condition has increased a lot (paperworks, guidelines, increased tests, follow ups, extra). I don’t know how much of the heightened patient expectation is due to government minsters making various promises to the electorate without increasing proportionate funding in the health sector. In the last few years, overall funding in the primary care has only decreased. GPs are facing real pressure dealing with contract changes, QOF changes, CQC, revalidation, commissioning work etc. I genuinely feel that too much is expected from GPs to deliver. Work satisfaction among GP colleagues is on a downward trend. Last year there were 9000 clinicians emigrated to other countries (US/ Canada/ Australia), effectively (after taking out the number of doctors joined UK).
We do need to have an open discussion and come up with positive solution keeping patient in mind.
Competing interests: No competing interests
I am inclined to agree with the author. Financial incentives or fines will bring disrepute to the patient-doctor relationship.This is against the primary domains of good medical practice. The main influential factor affecting emergency admissions is the provision of out of hours practice. Longer opening hours is probably one of the solutions.
A significant proportion of direct admissions would avoid going to A&E units if high quality out of hours care is available. It should be local,easily accessible and staffed by a team of experienced GPs. This service can also operate geographically next to the Emergency departments. These solutions are simple and be effective in bringing down the 29% of the potentially avoidable admissions.
Competing interests: No competing interests
Re: Should GPs be fined for rises in avoidable emergency admissions to hospital? No
Dear Sirs,
Having read the debate on this subject, we would like to comment on the authors statements: ‘Clinicians have a responsibility to improve care no matter where a patient is on a pathway’ and ‘The GP is only one player in a multiplicity of factors that influence emergency admissions’. In our opinion there is an opportunity to bridge a gap between primary and secondary care in the delivery of the emergency services.
Firstly, we propose a closer clinical cooperation between primary and secondary care, with GPs’ actively involved in regular session work, perhaps within surgical or medical assessment units. Liaison between acute care nursing staff and their community colleagues would help to ensure prompt implementation of patient discharge plans. This type of practice already exists, with hospital Consultants providing elective outreach clinics in primary care and similarly, GPs’ providing practitioner roles in secondary care.
Secondly, the development of frequent specialist secondary care clinics that are focussed on preventing the common medical causes of readmission, such as with Heart Failure clinics (1), can be implemented so as to give ready and rapid access to patients recently discharged. Continuing care of the acute episode can therefore be part completed in the community. The idea of moving care ‘closer to home’ could thus be translated into everyday clinical practice.
Lastly, the experience of primary care in dealing with a range of medical emergencies and improved discharge arrangements in secondary care, would have benefits in not only reducing avoidable emergency admissions, but also reducing length of stay (LOS). Data from Veterans Hospitals in the United States (2) have shown no relationship between a reduced LOS and hospital readmission rates for medical patients, highlighting that clinical safety could still be assured despite less actual in-patient time.
Yours Sincerely
Karol Rogawski, Consultant Urological Surgeon
Calderdale & Huddersfield NHS Foundation Trust
Richard Khafagy, Consultant Urological Surgeon
York Hospitals NHS Foundation Trust
References
1.Thomas R, Huntley A, Mann M, Huws D, Paranjothy S, Elwyn G, Purdy S.
Heart. 2013 Feb;99(4):233-9.
Specialist clinics for reducing emergency admissions in patients with heart failure: a systematic review and meta-analysis of randomised controlled trials.
2. Kaboli PJ, Go JT, Hockenberry J, Glasgow JM, Johnson SR, Rosenthal GE, Jones MP, Vaughan-Sarrazin M.
Ann Intern Med. 2012 Dec 18;157(12):837-45. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals.
Competing interests: No competing interests