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Risk-profiling DES could increase emergency admissions, says QOF architect

One of the leading architects of QOF has cast further doubt on the effectiveness of the risk-profiling DES, claiming it may actually increase emergency admissions and will not result in a reduction of related costs.

Professor Martin Roland, chair in health services research at the University of Cambridge, became the latest high profile voice to question the Government’s attempts to reduce hospital admissions through GPs identifying patients deemed to be at risk, following criticism from GP leaders.

He said that while it may improve care for the elderly population, there is no evidence it will cut emergency admissions in practice.

In an interview with Pulse, Professor Roland said: ‘The reality of this is that this doesn’t seem to have worked in practice and there have been a number of valuations that seem to suggest not only that intensive case management of people might not reduce admissions but the most recent evaluation suggested that admissions might actually increase from the additional attention that intensive case management will bring. So there is not much evidence at the moment that risk-profiling reduces emergency admissions.’

This was because of what economists call ‘supply-induced demand’, Professor Roland added.

‘So you put in additional services and go and give older people more attention, they find more things wrong with them and they find things that those people could benefit from if they were in hospital, and you find more care being given,’ he said. ‘So you could quite easily imagine a situation where an old person has a chest infection, wasn’t really managing, was seen by a community matron on Friday, who really felt they needed to be in hospital. Had that community matron not visited, the old person would have muddled along, managed over the weekend and maybe not been admitted.’

‘It is very easy to see how there are situations where putting in extra resources could actually have the reverse effect to that which was originally intended. And the answer is, with these processes of identifying people at risk and then intervening with some sort of intensive management, you could see that there could be a balance and either outcome could result. I think it may provide better care for older people but I think that that is much more likely than reducing costs.’

Click here to listen to the Big Interview with Professor Martin Roland

The warning comes as the GPC has published survival guides for GPs to the new DESs on the BMA website, including how to do the actual case management.

The GPC also warned that the risk-profiling DES specifically is heavily reliant on input from CCGs, which will manage the DES locally for NHS England including in its design, monitoring and reporting GP performance.

Commenting on the warnings, deputy GPC chair Dr Richard Vautrey said: ‘As with similar initiatives in the past, there is little evidence yet that such schemes really do reduce the need for hospital admissions. They can be valuable in addressing unmet need, and many patients appreciate the extra visits or attention, but that does not necessarily lead to reducing the ultimate need for hospital care at some point in the future as people get older and their illnesses progress.’

Professor Roland, who is also a GP in Cambridge, was formerly the director of the National Primary Care Research and Development Centre. He was one of the main advisers to the Department of Health in the design of the QOF in 2004.

Readers' comments (9)

  • This is so patently obvious to any practising GP that it hardly bears repeating. Until there is good evidence that this risk profiling actually has the desired outcomes it should stay firmly in the realms of research. It beggars belief that such far-reaching policies are implemented on the basis of no evidence whatsoever.

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  • I think you meant 'supply induced demand' not 'supply and use demand'.

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  • As GP`s we should all be more aware of events in patients who are "profiled" into "high risk" hence more likely to intervene which may prevent admissions but may cause more admissions as the breathlessness ( 59% co existing dysfunctional breathing) in a COPD may lead to a routine home visit request by patient but now the Matron may call in middle of surgery asking for advice and one may have to make a call on whether one needs to leave patients waiting and do home visit or call 999. I suspect many will advise 999 as default and hence increase admissions.

    Time will tell. As with 111 this may paradoxically worsen the pressure on hospitals and increase admissions.

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  • I have a patient who I regularly see. It's someone who is likely to be profiled as high risk.

    She often complains of dyspnoea and her sats are around 91% and always looks the wrong shade of white. She's seen every consultant imaginable and really there is no treatment to improve her symptom. If I go and see her, I would reassure, give appropriate Tx and review again. If someone else goes, she ends up in hospital for a day or two (hence known to many consultants). "risk Profiling" would make others more likely to admit her I would imagine....

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  • Perhaps Roland may care to review the usefulness of QOF as a whole?

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  • Interestingly GPs ring, through our Community Service, to arrange admission in Acute someone with a chest infection. We then offer our service in the community and in many of these instances this is accepted and the admission is avoided. Had this Community service not intervened the GPs would have admitted a patient unnecessarily

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  • 'I have a patient who I regularly see. It's someone who is likely to be profiled as high risk.

    She often complains of dyspnoea and her sats are around 91% and always looks the wrong shade of white. She's seen every consultant imaginable and really there is no treatment to improve her symptom. If I go and see her, I would reassure, give appropriate Tx and review again. If someone else goes, she ends up in hospital for a day or two (hence known to many consultants). "risk Profiling" would make others more likely to admit her I would imagine....'

    I would suggest that is due to innapropriate use of risk profiling (ie building a whole intermediate service staffed by community nurses around the high risk patients).
    The appropriate use of risk profiling is to have a management plan for that patient that states the normal sats of 91%, resp rate of 20 and degree of anxiety, with your name on as the regular clinician etc. This gives any visiting clinician more clinical information to make better decisions. GPs are good at managing risk in our complex patients but for good reasons we aren't at our patients side 24 hours a day. It is predictable that this patient will become acutely ill several times a year - better information sharing and planning might help with decision making in the community.
    Having said that I completely agree re the original article and risk of supply induced demand. Again that's why in our own practice we advocate a GP surgery based approach to these patients rather than a large external time consuming MDT approach.

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  • All comments above have provided good argument as to why risk profiling may increase admissions. Dare I bring Telehealth into the equation? at least if the patient is being monitored remotely there are some baseline observations which may indicate the patient is heading for period of exacerbation. This accompanied by a good management/treatment plan and active management may just help to avoid unnecessary admissions

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  • 'Dare I bring Telehealth into the equation? '
    Please don't!

    Telehealth as hoped for by the big suppliers is marketed as improving self management but is actually to opposite - 'do your readings every day and the doctor will tell you when you are unwell'.

    Using information about our at risk patients is important. Risk profiling doesn't give you the answer but it asks the question. As scientists we should be interested in all the detail about our patients, and risk profiling helps highlight one aspect of their health. As GPs we are good at managing this in conjunction with the wealth of bio/psych/social information we have about our patients in primary care.

    Telehealth however, as currently pushed, is an expensive outdated tool that goes against the aspirations for self management and wellbeing for those with complex health problems.

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