Should GPs be fined for rises in avoidable emergency admissions to hospital? Yes
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1389 (Published 05 March 2013) Cite this as: BMJ 2013;346:f1389
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Presently I am able to tick the 'no competing interests' box with this Rapid Response.
But this will be impossible if this draconian proposal to fine me if any more my patients become 'avoidable emergency admissions to hospital' ! As Nagpaul makes clear, to implement such a proposal will be questionably ethical and subject to legal challenge. Actually, despite the dramatic headline, at no point does McShane actually favour FINING the GP. Instead he suggests that 'Financial incentives will help bring about the changes required to reverse this trend'. Yet engaging with even that sort of encouragement could land me up before the GMC for 'accepting inducements' that might be seen to deny my acting in my patient's best interest. This might explain McShane's recourse to emollient management-speak - "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"
Add to that the rather obvious fact that the inexorable rise in admissions is multifactorial. Since I became a GP I have never actually admitted any patient to hospital. Instead, whenever I thought a patient would be better off in hopital, I have negotiated with the patient, the family, the carer, and then the SHO guarding the drawbridge, or the bed-manager at the moat, or simply called an ambulance to deposit the patient at A&E. There they join the many other patients who took themselves direct to A&E with or without Ambulance transport, and without any leave from me.
If admitting these patient is avoidable, then why do my hospital colleagues not send the patient home forthwith ? Because even with their scanners and troponins they too have fears, concerns, doubts, limited options, and prefer to err on the side of caution, perhaps ? My hospital colleagues can be reassured that they are not alone, and that most hospitals in the country are doing likewise. And they will be monitored.
After the Francis report let us hope that admitting patients for appropriate indications, will improve their care. If it does not - then it is certainly not the GP's fault.
Competing interests: No competing interests
It is worrying in the wake of the Francis report to see another managerial response to a complex issue narrowly focusing on punitive, target-orientated measures to achieve what - as Dr Nagpaul succinctly evidences - are complex behaviour outcomes.
Dr McShane quotes the few of Francis's comments referencing GPs duties of care over monitoring, but fails to acknowledge the bulk and central focus of the report which repeatedly cites the harms to patients which arose from managerial over-attention to numerical and cost-based behaviours.
Linking GP remuneration to reductions in A+E attendance appears to be another one of these managerial initiatives which has little to justify it, while arousing significant cause for concern.
As a conscientious GP in a large inner-city Practice which spends many hours collectively auditing its A+E admissions about six times per year, I can say with confidence that we have found very few cases which were indeed avoidable.
That up to 30% of A+E admissions are avoidable is questionable. It needs further evidence, studied prospectively, in real time from the ground.
To apply a similar managerial construct to emergency surgical admissions, should we introduce penalties for surgeons whose patients admitted as emergencies do not then require surgery?
Personally, I think this would be a dangerous way to proceed. Good, safe Medicine needs to accommodate doubt and to budget for it.
Competing interests: No competing interests
When the author says "As a clinician working in commissioning" I think he means ex-clinician as I believe he has bee a manager for many years, as evidenced by the language used:
eg "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."
Perhaps it's NOT so easy to spot the patients who don't need to be admitted. Hospital doctors, with access to tests, in EDs and MAUs still seem to admit them - if they don't need admitting, then why are they not sent home at that point?
Erring on the side of caution has always been sensible in the practice of medicine. With the current levels of expectations and litigation, it is now mandatory.
Competing interests: No competing interests
Re: Should GPs be fined for rises in avoidable emergency admissions to hospital? Yes
I read with interest the arguments for and against fining GPs for rises in "avoidable emergency admissions to hospital". Penalising GPs implies fault or failure to act appropriately, whereas they are not in control of many, if not most, emergency admissions.
McShane reports a specialist who comments "I don't know if my patients will be safe or get the care they need delivered" - a sad reflection on communication between secondary and primary care, and perhaps indicating a need for more consultant-GP meetings, as well as clear instructions for ongoing care in discharge or out-patient letters.
McShane was "taken aback" by a practice that had audited their emergency admissions a year previously - but how often is such an audit useful? I would suggest once a year is ample, given the fluctuating nature of the problems presented that require emergency admission - something out of the GP's control.
Nagpaul comments that "Nor is there any conclusive evidence that the tools currently used by GPs and commissioners ... are effective in reducing emergency admissions.". Isn't this the wrong approach? The only way to look at the whole picture is for the DGH to audit their emergency admissions, separating these into patient initiated (including "999s"), out of hours and GP emergency admissions. These could then be reviewed to see which were avoidable. This infomation could be fed back to GP practices, giving their own figures and perhaps comparative figures for other practices. It may well be useful also to feedback information on a practice's emergency admissions for which a GP was not responsible, noting factors that might reduce these.
Analysis of the emergency admissions may also highlight deficiencies in other services in the community, which may be improved.
In summary, the lack of improvement may be partly due to not asking the right questions and looking at the wrong data. Only with the correct information and improved communication can we hope to learn how to reduce emergency admissions.
As a retired GP, I feel sorry for current GPs who already have to tick so many boxes to maintain their income and satisfy the Government, often with dubious benefit to patients. Fining them for something else that is mostly beyond their control seems inappropriate.
Competing interests: No competing interests