Inappropriate A&E use could mean fines for family doctors

They would represent the first time the government has threatened to take money away from GPs to incentivise them to change.

The move follows concern that poor access to GP services has driven patients to attend A&E, walk-in centres and minor injury units. As GPs are paid according to the number of patients on their list, rather than those they see, primary care trusts are concerned that they pay for some treatments twice.

As much as£940m could be at stake - this is the annual cost to the NHS of the 14 million visits to A&E, walk-in centres and minor injury units that do not result in a patient being admitted to hospital.

PCT Network director David Stout told HSJ: “We have a system where we pay GPs through the [per head] global sum [formula] for a range of general practice services and then we have alternative services on top of them, such as walk-in centres. Arguably that duplicates what general practice is already being paid for, so we end up paying for it twice.”

The DH has asked the NHS Confederation and NHS Employers to look into a tariff for walk-in centres, minor injury units and temporary residents.

NHS Employers core negotiator Philip Grant said the report was now with the DH and that it fulfilled a pledge in the 2006 white paper to review the funding arrangements for walk-in centres.

HSJ understands that the tariff could form the basis for a set of “cross charges”, which could be billed to GP practices when their patients received basic primary care services elsewhere.

Birmingham University professor of health policy and management Chris Ham told HSJ the principle was already used in New Zealand, where it was credited with improving access to primary care. “It encourages GPs to open for longer because they know that if they close down at 4pm and patients go somewhere else for their treatment, they will lose money,” he said.

If implemented in the UK, the DH would need to develop a tariff for treatments accepted as being part of a GP’s basic service.

DH figures show that in 2006-07 there were 3.7 million patient visits to walk-in centres and minor injury units which did not result in admission. Of those visits, 1.7 million did not result in any treatment, yet still cost£58m. Data on A&E visits for quarter three of 2007-08 indicates that 78 per cent of patients at major A&E departments are not admitted.

NHS Alliance chair Michael Dixon said the proposals formed an extension of the principle behind practice-based commissioning, where practices are incentivised to give cost-efficient care. But the incentive would be more direct as it would come out of GPs’ pockets, not commissioning budgets, he added.

British Medical Association GPs committee chairman Laurence Buckman said the notion was good in theory but could not work in practice. “It wouldn’t be an incentive, it would be a punishment and work as a disincentive for people to work in areas with high A&E use,” he said.

Cost to the NHS of patient visits to non-GP services

Attendances without admission at NHS A&E, walk-in centres and minor injury units

Sources: DH reference costs 2006-07; DH quarterly monitoring A&E dataset (Feb 2008).

*A&E figures estimates, based on type 1 A&E dept non-admission rate of 78 per cent, Q3 2007-08

For more analysis, see this week’s leader