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Flagship scheme puts GP hospital admission targets in doubt

By Lilian Anekwe

Exclusive: The feasibility of tough Government targets for GPs to keep patients out of hospital by revamping management of long-term conditions has been called into question by a flagship pilot scheme finding no reduction in admissions.

Primary care researchers found a £1 million COPD project – including a new intermediate care service and round-the-clock telephone support – failed to achieve its intended reductions in hospital admissions or to improve prescribing.

Researchers said the findings ‘raise questions' about the Department of Health's QIPP efficiency drive, which requires GPs to use ‘a new model of care' to cut unscheduled admissions for long-terms condition by 20% and length of stay by 25% by 2013.

GPs will also be expected to help reduce the number of A&E attendances by 10%, to contribute towards the £20 billion efficiency savings target ministers have set the NHS.

The COPD scheme, run in two PCTs – NHS Southwark and NHS Lambeth - in conjunction with two London hospital trusts, compared hospital admissions and prescribing rates with those in two neighbouring PCTs with no scheme.

The scheme was designed to reduce admissions and achieve financial savings by using an enhanced hospital-based admission-response service, enhanced integrated pulmonary rehabilitation, a new intermediate care service, a 24/7 telephone support for advanced disease and a new electronic COPD clinical record.

The study contrasts with findings from an integrated COPD service in Salford, which did appear to reduce unscheduled hospital admissions and lengths of stay.

Researchers from King's College London examined data from 6,068 COPD patients in 98 GP practices between February 2008 and February 2010. Some 82% were seen by the admission response service, 15% by pulmonary rehabilitation and 18% by the intermediate care service. Mean admission rates did not change substantially from 1,100 a year.

The research, presented at a regional meeting of the Society for Academic Primary Care earlier this month, concluded: ‘No differences were seen between admission and prescribing rates in the intervention population. The potential for admission reduction among the most severe COPD patients may be limited.'

Study leader Dr Patrick White, a senior lecturer in general practice and primary care and a GP in Lambeth, said the findings ‘raise questions' about the DH's controversial QIPP targets.

‘I'm very enthusiastic about improving care for COPD, but there has to be a question raised about what the Government is doing and how effective it is. It's much more difficult to reduce admissions in the general population than we thought up to now.'

He added that it might simply be too difficult for GPs to prevent emergency admissions among many COPD patients, as severe episodes could only be managed in hospital.

Professor Martin Roland, professor of health services research at the University of Cambridge, said: ‘A wide range of things have been tried to improve coordination. Generally these show it's possible to improve care, but they often don't save money. There certainly doesn't seem to be any quick fix to save costs by reducing emergency hospital admissions.'

But Sir John Oldham, QIPP lead at the Department of Health, defended DH policy. He told Pulse: ‘This study examines a hospital-based system, whereas the approach we advocate is rooted in the community - a sociomedical model of care, not just biomedical.

‘The most frequent unscheduled admissions are people with multiple conditions, not just one. It is therefore unsurprising that focusing just on COPD has not impacted very greatly. The cause for their admission could be something else.

‘There is much other work which shows that a community-based, integrated care approach to reducing COPD admissions works.'

Dr Sam Everington, a GP in east London and the DH's integrated care clinical lead for Tower Hamlets, cautioned that the researchers had not monitored important aspects of care, such as patient satisfaction and improved quality of life.

An NHS London spokesperson said: ‘We will look with interest at the study to see how NHS care could work better for patients.'

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