Date Published: November 14, 2017
Publisher: Public Library of Science
Author(s): James A. Lopez Bernal, Christine Y. Lu, Antonio Gasparrini, Steven Cummins, J. Frank Wharham, Steven B. Soumerai, Aziz Sheikh
Abstract: BackgroundThe 2012 Health and Social Care Act (HSCA) in England led to among the largest healthcare reforms in the history of the National Health Service (NHS). It gave control of £67 billion of the NHS budget for secondary care to general practitioner (GP) led Clinical Commissioning Groups (CCGs). An expected outcome was that patient care would shift away from expensive hospital and specialist settings, towards less expensive community-based models. However, there is little evidence for the effectiveness of this approach. In this study, we aimed to assess the association between the NHS reforms and hospital admissions and outpatient specialist visits.Methods and findingsWe conducted a controlled interrupted time series analysis to examine rates of outpatient specialist visits and inpatient hospitalisations before and after the implementation of the HSCA. We used national routine hospital administrative data (Hospital Episode Statistics) on all NHS outpatient specialist visits and inpatient hospital admissions in England between 2007 and 2015 (with a mean of 26.8 million new outpatient visits and 14.9 million inpatient admissions per year). As a control series, we used equivalent data on hospital attendances in Scotland. Primary outcomes were: total, elective, and emergency hospitalisations, and total and GP-referred specialist visits. Both countries had stable trends in all outcomes at baseline. In England, after the policy, there was a 1.1% (95% CI 0.7%–1.5%; p < 0.001) increase in total specialist visits per quarter and a 1.6% increase in GP-referred specialist visits (95% CI 1.2%–2.0%; p < 0.001) per quarter, equivalent to 12.7% (647,000 over the 5,105,000 expected) and 19.1% (507,000 over the 2,658,000 expected) more visits per quarter by the end of 2015, respectively. In Scotland, there was no change in specialist visits. Neither country experienced a change in trends in hospitalisations: change in slope for total, elective, and emergency hospitalisations were −0.2% (95% CI −0.6%–0.2%; p = 0.257), −0.2% (95% CI −0.6%–0.1%; p = 0.235), and 0.0% (95% CI −0.5%–0.4%; p = 0.866) per quarter in England. We are unable to exclude confounding due to other events occurring around the time of the policy. However, we limited the likelihood of such confounding by including relevant control series, in which no changes were seen.ConclusionsOur findings suggest that giving control of healthcare budgets to GP-led CCGs was not associated with a reduction in overall hospitalisations and was associated with an increase in specialist visits.
Partial Text: The 2012 Health and Social Care Act (HSCA) in England has been described as “the biggest and most far reaching [reorganisation] in the history of the NHS” [1, 2]. The reforms centred around the introduction of general practitioner (GP) led Clinical Commissioning Groups (CCGs), which received about two-thirds of the National Health Service (NHS) budget (£66.8 billion in 2015–2016) to commission (plan and contract) secondary care, including hospital and specialist services . CCGs represent all GP practices in their local area, and the key difference from the previous commissioning structures was purported to be a major new role for GPs as key decision makers in the commissioning process [1, 3, 4].
To our knowledge, this is the first study of the potential impact on secondary care activity of a universal, national policy that gave control of an unprecedented two-thirds of the English NHS budget to GP-led CCGs. Contrary to the underlying hypothesis, we found no evidence of a reduction in hospitalisations or specialist visits in England following the HSCA. Moreover, we found evidence of an increase over and above the underlying trend in specialist visits in England, with no comparable increase in Scotland, where this policy did not occur. This increase was equivalent to approximately 3.7 million additional specialist visits since the policy was implemented (compared to those expected), of which the majority (approximately 2.9 million) were GP referred.