Penalties for trusts doing too many emergency admissions, introduced in April, do not appear to have brought the numbers down.

Analysis of board papers by HSJ, supported by data from CHKS, shows emergency admissions were still continuing to increase in April and May, and are up by an average of 8.5 per cent from 2008.

Is anyone surprised by this? No. But given the apparent inevitability of this outcome - the tariff cap was always a long shot - what should happen now?

There is no question that avoidable emergency admissions need to come down. If they continue at this rate, the cap will mean acute trusts are paid £500m less per year than they would get at full tariff price.

But while acute trusts, supposedly blinded by the pound signs in their eyes, have in the past been accused of “sucking in” patients, the introduction of the cap - and its failure to make a difference - suggests the problem goes well beyond hospital doors.

Relaxing the four hour accident and emergency target could reduce the number of people admitted as emergencies as an alternative to breaching the target - but won’t solve the problem overall.

In any case, the abolition of targets could have multiple effects - the removal of the 48 hour GP access target may well lead to busier A&E departments.

Uncertainty is unhelpful. There are already anecdotal reports that GPs, knowing their hour cometh, are shrugging off primary care trusts’ attempts to make them a part of the drive to rein in emergency admissions.

The government needs to make clear the transitional arrangements for PCTs and clarify its position on vertical integration, which is the likeliest route to addressing cost shunting or responsibility shirking between primary and secondary care.

It’s the cooperation or competition debate writ large - if we’re to have both we need to know how.

Clarity is the key to tackling excess admissions