Background

The 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 findings

We 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.

Conclusions

Our 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.

中文翻译：

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2012 年《健康和社会保健法》与英格兰专家就诊和住院之间的关联：受控中断时间序列分析

背景

英格兰 2012 年的《健康与社会保健法案》（HSCA）促成了英国国民医疗服务体系（NHS）历史上最大的医疗保健改革。它将 670 亿英镑的 NHS 二级保健预算控制权交给了全科医生 (GP) 领导的临床委托小组 (CCG)。预期的结果是，患者护理将从昂贵的医院和专家机构转向更便宜的基于社区的模式。然而，几乎没有证据表明这种方法的有效性。在这项研究中，我们旨在评估 NHS 改革与住院和门诊专家访问之间的关联。

方法和发现

我们进行了受控中断时间序列分析，以检查实施 HSCA 之前和之后的门诊专家就诊率和住院率。我们使用了 2007 年至 2015 年间英格兰所有 NHS 门诊专科就诊和住院患者的国家常规医院管理数据（医院事件统计）（平均每年新增 2680 万次门诊就诊和 1490 万次住院患者）。作为对照系列，我们使用了苏格兰住院人数的等效数据。主要结果是：总住院次数、选择性住院次数和急诊住院次数，以及总次数和全科医生转诊的专家访问次数。两国在基线时的所有结果都有稳定的趋势。在英格兰，政策实施后，有 1.1% (95% CI 0.7%–1.5%; p< 0.001）每季度总就诊次数增加，GP 转诊专家就诊次数增加 1.6%（95% CI 1.2%–2.0%；p < 0.001），相当于每季度 12.7%（647,000 人次超过预期的 5,105,000 人次）和到 2015 年底，每季度的访问量分别增加 19.1%（507,000 次，超过预期的 2,658,000 次）。在苏格兰，专家访问没有变化。两个国家的住院趋势均未发生变化：总住院、择期和急诊住院的斜率变化分别为 -0.2%（95% CI -0.6%–0.2%；p = 0.257）、-0.2%（95% CI -0.6 %–0.1%；p = 0.235）和 0.0%（95% CI -0.5%–0.4%；p= 0.866) 在英格兰每季度。由于政策实施期间发生的其他事件，我们无法排除混淆。然而，我们通过包括相关的控制系列来限制这种混淆的可能性，其中没有看到任何变化。

结论

我们的研究结果表明，将医疗预算控制权交给 GP 主导的 CCG 与总体住院人数的减少无关，而与专科医生就诊的增加有关。