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The bouncing patient effect

The law of unintended consequences dictates that any given action has effects that are both unpredictable and unspecific.

The law of unintended consequences dictates that any given action has effects that are both unpredictable and unspecific.



It is a rule that fits health policy particularly well – and the unforeseen consequences usually turn out to be nasty surprises.

When ministers push and pull at the levers of power, it is rare that they chance upon a way of cutting costs or easing health inequalities. Even policies that are successful in their aims often seem to have a habit of somehow, somewhere else in the system, making things worse.

So when we learn that GP outpatient referrals and emergency readmissions have both jumped, it is natural to look for the culprit among recent policy initiatives.

In a giant, vastly complex system like the NHS, a standout trend like a 16% rise in GP referrals, or a 12% jump in readmissions, does not just happen.

Something is driving it. But precisely because the health service is so complicated, it is often difficult to work out what the drivers are.

Hospital tricks

GPs have suggested a number of potential theories for the leap in referrals. One of the most convincing is that it is a product of the hugely influential 18-week referral-to-treatment target, which has had all sorts of consequences, only some of them intended.

Pulse this week reveals a few of the tricks that hospitals are using to clear their decks for new patients and optimise their chances of meeting the target.

They are treating increasing numbers of patients as day cases while cutting down on follow-up appointments, leaving general practice to pick up the pieces. It's hardly surprising, then, that GPs have had to send a substantial proportion of those patients straight back to hospital.

But bouncing patients out of hospital and back in again is hardly the most efficient use of resources and there is evidence it may be having an unintended – and deeply ironic – consequence all of its own.

The number of patients waiting over eight weeks for an outpatient admission, although down 29% in the past year, leaped by an astonishing 42% between July and August this year.

In the desperate rush to meet one waiting time target, trusts are apparently so overloading themselves with referrals that they are busting another. It could almost be funny, if it wasn't so damaging to GPs and their patients.

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