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GPs ‘lack levers’ to influence A&E attendance

Controversial new QOF indicators aimed at cutting A&E attendance will fail because improving access to GP services has no impact on patients using emergency services, researchers suggest.

Research by a team from Imperial College London, published in the British Journal of General Practice, concludes longer surgery opening hours, telephone access and other attempts to improve access to GPs are a ‘blunt instrument' when it came to influencing patients' A&E usage.

Under the new 2012/13 GMS contract, announced last month, new QOF indicators will see GPs for the first time incentivised to cut A&E visits.

Practices have to undertake a review of their patients' A&E attendances by next August. The review should include ‘consideration of whether access to clinicians in the practice is appropriate'.

But analysis of population data, hospital episode statistics and access data from 71 GP practices in NHS Brent in northwest London showed the strongest influence on avoidable A&E attendance was deprivation in the practice area.

The study found every unit increase in a practice's index of multiple deprivation prompted an increase of 6.13 per 1,000 patients per year in A&E attendances - accounting for 47.9% of the variance. Of the other indicators considered, only standardized mortality ratio, incapacity benefits and lone-parent households also demonstrated a link.

Lead researcher Dr Matthew Harris, academic clinical lecturer in public health at Imperial College, said: ‘We didn't find any of the access indicators had any association with variation in A&E use.'

‘QOF indicators may be useful for GPs in terms of going through the process of reviewing attendances but I'm not sure they will bring about much in the way of change on this evidence.'

‘The levers to bring about changes are not always in GPs' hands.'

GPC negotiator Dr Chaand Nagpaul claimed the new QOF indicators were ‘in no way' based on a causal link between GP access and A&E attendance.

He said: ‘The indicator is more about getting GPs to think about and analyse their commissioning needs,' he said.

‘GP access may be one of the factors they can look at to see if a patient attended A&E because of a system in the practice, but deprivation, proximity of the surgery to A&E and the impact of NHS Direct and other triage services will come into it as well.'

But Dr Krishna Chaturvedi, a GP in Southend on Sea, Essex said: ‘I totally agree that lots of patients shouldn't be going to A&E, but I don't like QOF indicators being attached to it. GPs don't have any control over it.'

Brit J General Prac 2011; 61: e787-e793


The new QOF indicators

QP12: practice to meet internally to review A&E visits by 31 July 2012 – review to include ‘consideration of whether access to clinicians in the practice is appropriate' – 7 points

QP13: external peer review with other practices to compare A&E attendances data and agree improvement plan by 30 September 2012 – review to include ‘proposals for improvement to access arrangements in the practice' – 9 points

QP14: practice to implement improvement plan and report on action taken by 31 March 2013 – 15 points