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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.