By Alisdair Stirling
Smaller GP practices offering better continuity of care, and access to patients' preferred GP, have lower rates of emergency hospital admissions, a new study suggests.
The results, published in the Emergency Medical Journal, have important implications for both commissioners and practices trying to acheive the new productivity indicators in QOF and show that a shorter distance from hospital, smaller list size and certain patient characteristics are associated with higher admission rates.
There was no link with performance in the clinical or organizational domains of the QOF, but as the proportion of patients able to consult a particular GP increased, emergency admission rates declined.
For a 5% increase in patient reports of being able to consult a particular doctor there was a corresponding 3.5% decrease in admissions in 2006/7, the NHS-funded study showed.
The research suggests GP practices will struggle to make an impact on hospital admission rates, as required by the new quality and productivity QOF indicators, as many of the factors identified that directly influence admissions were outside of GP's control, including practice demographics - such as such as higher proportion of elderly, white ethnicity, female gender or increasing deprivation - and distance from the nearest hospital.
Researchers analysed hospital admission data for patients at 145 practices in two east midlands PCTs for 2006/7 and 2007/8, and analysed practice characteristics such as size, distance from hospital, QOF performance data, patient reports of access to their practices were analysed in relation to admission data.
Lead author Dr John Bankart, research fellow in medical statistics the department of health sciences at the University of Leicester concluded: 'The rate of emergency admissions to hospital is associated not only with patient age, ethnicity, deprivation, distance of the practice from hospital and practice list size, but also with patient reports of being able to consult a particular GP. Better access is associated with fewer admissions.'
'This finding is important because small changes in admission rates have substantial economic consequences, and it points to potential interventions to reduce emergency admission rates.'
Dr Michael Dixon, chair of the NHS Alliance and a GP in Cullompton, Devon said the findings chimed with previous work he had done on the doctor-patient relationship.
'Continuity has quite an important economic impact on use of secondary care services. I think this new finding is self-evidently true. If you've got a GP you know and trust, you'll tell them all your problems and you're more likely to get them sorted out.'
'The danger in practices where patients don't have a named GP is that you can get collusion of anonymity – where no-one knows the patient and they end up wandering off to casualty to get themselves treated there.'
But Dr Agnelo Fernandes, the RCGP's urgent care lead and a GP in Croydon, London, said practices with a higher proportion of elderly patients might struggle to achieve big reductions in emergency admissions.
But he added: 'The question as far as QOF is concerned is can practices do anything about it and the answer is yes they can. The new QOF indicators are about a reduction in rate not absolute numbers. You can't expect practices with high rates to halve them but they can still reduce through long-term condition management and early intervention.'
Practice deprivation score 1.6%
Distance from hospital (miles) -1%
Size of practices -0.001%
% of patients aged >65 3.0%
% patients white ethnicity 0.3%
% of patients male -2.0%
% able to see a specific GP -0.5%
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