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A&E visits are beyond GPs’ control

You can see the Government’s logic as it settled on 31 new QOF points for ‘reducing avoidable visits to accident and emergency departments’.

For those working on its QIPP efficiency programme, there are three great obsessions – driving down prescribing costs, preventing referrals to hospital and avoiding use of A&E. Presumably Department of Health officials glanced down at their clipboards, ticked the first two off, and murmured into the minister’s ear that it was now time for GPs to be held accountable for the third.

Unfortunately, however, not every cost to the health service is within the gift of GPs to control. GPs write prescriptions, they refer patients to hospital, but they are not generally holding their patients’ hands when they turn up at A&E.

Indeed, those patients who are using A&E most frequently are often precisely those who are not visiting their GP practice. GPs find it hard enough to change the behaviour of patients who they see week in, week out, without also being expected to do so for those they barely see at all.

Of course, to an extent the Government has acknowledged this in the design of its new QOF points. They pay not for a numerical cut in A&E attendance, but for reviewing a practice’s access arrangements, coming up with a plan for how they could be changed to relieve pressure on A&E, and submitting it all to the PCT.

Dr Richard Vautrey, deputy chair of the GPC, admits the key point of the indicators is simply to get GPs thinking about the potential link between the access they offer to patients, and their patients’ A&E use.

GPs may very well give it some thought, and conclude there isn’t much of a link at all. Certainly, the evidence suggests the factors predicting most strongly whether a practice’s patients will be high users of A&E are patient demographics and its proximity to a hospital.
Perhaps a few GPs practices will be tempted to up sticks and move, but beyond that there will be relatively little they can do to reduce the A&E attendance of their patients.
Dramatically improved urgent care at a practice might have some impact, but just how are GPs supposed to achieve that with fewer, rather than more, resources?

Dr Gavin Jamie, a GP in Swindon who runs the QOF Database website, calculates the implementation part of the new A&E indicators will fund just one extra GP or nurse consultation per week. That is some way short of an access revolution.

A Pulse survey sent out last week in the wake of the new contract found GPs are overwhelmingly opposed to the new A&E indicators. If this was an exercise designed to engage the profession in thinking about system-wide changes to access, it has not had an auspicious start.

GPs, of course, are perfectly willing to think hard about their place within the wider health system.

But they are much less happy to engage in meaningless box-ticking exercises targeted at problems largely beyond their control.