Should GPs be fined for rises in avoidable emergency admissions to hospital? NoBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1391 (Published 05 March 2013) Cite this as: BMJ 2013;346:f1391
Reducing avoidable emergency admissions is undoubtedly a desirable and worthy aim, not least because it will benefit patients. Additionally, emergency admissions are a considerable drain on NHS resources, representing about 65% of hospital bed days in England, at a cost of £11bn (€13bn; $17bn).1 The health data company Dr Foster estimated that 29% of these admissions are potentially avoidable and amenable to interventions in the community.2 Emergency admissions also have an adverse effect on provision of other hospital services—for example, by causing cancellation of elective operations at short notice—and Dr Foster says that overoccupancy of hospital beds is at “breaking point,” risking patient safety.2
Annual emergency hospital admissions have increased by 37% over the past 10 years.3 The NHS is required to save £20bn by 2015, and avoiding emergency admissions is a key policy to deliver this. Currently, commissioners use local referral incentive schemes to encourage general practitioners to reduce their emergency admissions. Furthermore, the recently announced quality premium4 will reward clinical commissioning groups if they are able to reduce or prevent an increase in emergency admissions within a fiscal year. Given the financially challenged budgets of commissioning groups, and reductions in GPs’ incomes, failing to hit such targets will in effect be a financial penalty.
Unfortunately, there is scant evidence, if any, that such financial levers will have any real effect on emergency admission rates. We know that financial incentives paid to GPs as part of practice based commissioning during 2005-11 were unable to stem the rise in emergency admission rates. Nor is there any conclusive evidence that the tools currently used by GPs and commissioners, such as risk stratification and case management, are effective in reducing emergency admissions.5
Solutions go beyond general practice
The fundamental flaw in linking financial payments to GPs to emergency hospital admissions is that the GP is only one player in a multiplicity of factors that influence such admissions. It is therefore inappropriate for GPs themselves to be held responsible for emergency admission rates. Evidence has shown that increasing age, social deprivation, morbidity, area of residence, self management, provision of community and social care services, hospital supply, and internal hospital organisation and admission policies will all influence emergency admissions.6
Furthermore, the 2004 GP contract transferred the responsibility for out of hours care to primary care trusts, and therefore hospital admissions during the out of hours period (70% of weekly hours) fall outside the control of general practices. Additionally, numerous other primary care access points, from telephone advice via NHS Direct, to other unscheduled care settings such as walk-in centres and new 111 urgent care services will also refer patients directly to hospitals, bypassing GPs. Similarly, GPs have no control of direct patient admissions from emergencies such as road traffic incidents. And some increases in admission rates could reflect national policies—for example, efforts by emergency departments to avoid breaches of the target of a four hour maximum wait may have increased short term hospital admissions.5
Another problem is that the relatively small number of patients in general practice lists could result in variations in admission rates by chance or volatility in the external environment (for example, infection outbreaks). Providing financial rewards or penalties to GPs as a result of erroneous interpretation of admission rates will unfairly discriminate against patients.
The division of GPs and hospital specialists into commissioners and providers, with payment of an activity tariff to hospitals, provides no incentive to hospitals to reduce emergency admissions, nor to collaborate with GPs. This creates the perverse effect of supplier induced demand.5
Making payments to GPs to reduce emergency admissions may also cause patients to mistrust the motives of GPs in managing their care, and risks breaching General Medical Council principles of good medical practice by adding a perverse financial incentive not to refer patients to hospital. Overzealous attempts to reduce hospital admissions could have unintended consequences. For instance, two recently published high quality randomised controlled trials of interventions designed to keep people out of hospital showed increased deaths among the intervention groups.7 8 Nor can we assume that avoiding admission is always cost effective, since the expense of keeping patients in the community may not necessarily reflect a cost saving.
The logical way forward should be a whole system approach, bringing together all stakeholders so that all influences on hospital admissions are aligned. There is evidence that hospital admissions can be reduced by integration between health and social care, as well as between primary and secondary care, and by improved internal hospital organisation of admission units staffed by more senior doctors.6 9 10 We need to jettison the current unhelpful competitive purchaser-provider spit between primary and secondary care and replace the tariff system of payment by results with a system of collaboration and shared financial ownership with goals aligned across primary, secondary, and social care. Wider determinants that influence hospital admissions must be addressed.6 9
Proposals to financially reward or penalise GPs as either providers or commissioners in their own right on the basis of emergency admission rates is likely to squander precious public resources on unproved ideology at a time of harsh fiscal austerity. It also carries the possibility of counterproductive effects and potential to do harm through unintended consequences.
Cite this as: BMJ 2013;346:f1391
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I am a negotiator for the BMA General Practitioners Committee with lead roles in commissioning and IT and a member of BMA Council.
Read the opposing side in the debate by Martin McShane, doi:10.1136/bmj.f1389.
Provenance and peer review: Commissioned; not externally peer reviewed.