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GP out-of-hours reforms linked to more emergency admissions for children

Government reforms of GP working practices in 2004 were associated with a rise in potentially avoidable for children.

The reforms altered GP contractual hours, allowing GPs to opt out of providing care out of surgery hours. A financially incentivised scheme aimed at improving quality of care provided mainly to adults was also introduced, which possibly detracted focused care from children.

A study published in Annals of Family Medicine, funded by the National Institute for Health Research, found that the GP contract was associated with an eight per cent increase in short stay admissions for potentially avoidable .

Researchers from London studied trends in 7.8 million unplanned admissions from 2000 to 2012. Over half were short stay admissions for potentially avoidable infectious and chronic conditions.

The number of children who were admitted to hospital with chronic conditions such as asthma and diabetes increased by 8,500 a year immediately after the policy changes. The reforms were not associated with an increase in admissions for potentially avoidable infectious diseases, which were increasing long before the incentive schemes.

Dr Sonia Saxena, a practising GP and lead author of the study from the School of Public Health at , said: “Chronic conditions in children require good quality management in primary care and are sensitive to changes in GP working patterns. Avoidable admissions can be detrimental to the child, inconvenient to their families and expensive for the NHS.

“GPs have worked hard to achieve significant health gains in adults as a result of these policies. Now we have clear evidence that the unintended consequences have been that children whose care was not prioritised have had to turn to the emergency services, which in many cases results in poorer health outcomes in children and waste in the health system.”

Emergency admissions have been rising for more than a decade. The rise is driven by short stay admissions, those of less than two days, which are potentially preventable with good care in the community.

Access to GP appointments has been a heated topic in the general election. Labour guaranteed an appointment within 48 hours, while the Conservatives promised access to appointments from 8am to 8pm, seven days a week. A recent British Medical Journal article by Imperial researchers concluded that both parties’ pledges would be challenging to achieve.

RCGP response to Imperial College study into unplanned hospital admissions for children

Professor Maureen Baker, Chair of the Royal College of GPs, said: “This research is largely based on ungrounded assumptions – there is no evidence to suggest a causal link between out of hours GP access and either increased emergency attendances or short-stay admissions for children.

“Any increase is most likely due to some hospital doctors taking a more cautious approach to admitting children for overnight observation, a response to pressure to meet the A&E four-hour target, and a lack of ability to discharge patients back into the community.

“The health of our child and young patients is a priority for GPs. A quarter of our patients are under 19 years old, so it is crucial that they have access to high quality services in the community whenever they need them.

“It is a myth that GPs do not work outside of normal working hours – and in an emergency, patients will always have access to a family doctor. Furthermore, our own research has found that 59% of out of hours services are either led or run by GPs with the remainder also staffed largely by GPs, despite the contract in 2004 giving them the option to opt-out.

“What is clear is that, according to the latest GP Patient Survey, 45% of people do not know how to access GP services out of hours. More needs to be done to raise awareness of these, so that patients know where to turn when they – or their children – fall ill in the evenings or at weekends.

“GPs and their teams already manage 90% of all NHS patient contacts for just 8.3% of the overall budget. We also have a severe shortage of GPs across the country and any increase in the provision of out of hours GP services would simply reduce the number of GPs available during normal working hours.

“We need to stop looking back to a contract that is more than a decade old to explain problems in the health service now. Instead, we need our new government to urgently implement measures to deliver thousands more family doctors, so that we can provide the care that our patients – young and old – need and deserve, out of hospital, whenever they need it.

“We are calling for 8,000 more GPs in England and for general practice to receive 11% of the overall NHS budget over the course of the next parliament.”

Source

E. Cecil et al. ‘Impact of UK primary care policy reforms on short stay unplanned hospital admissions for children with primary care sensitive conditions: interrupted time series analysis.’ Ann Fam Med 2015;13:214-220. doi: 10.1370/afm.1786.

Imperial College London and Royal College of General Practitioners