Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: A controlled interrupted time series analysis.

Publisher: Public Library of Science Country of Publication: United States NLM ID: 101231360 Publication Model: eCollection Cited Medium: Internet ISSN: 1549-1676 (Electronic) Linking ISSN: 15491277 NLM ISO Abbreviation: PLoS Med Subsets: MEDLINE

Original Publication: San Francisco, CA : Public Library of Science, [2004]-

Health Care Reform/*trends ; Health Planning/*trends ; Hospitalization/*trends ; Interrupted Time Series Analysis/*trends ; Medicine/*trends ; State Medicine/*trends; Adolescent ; Adult ; Aged ; Aged, 80 and over ; Child ; Child, Preschool ; England/epidemiology ; Female ; Health Care Reform/methods ; Health Planning/methods ; Humans ; Infant ; Infant, Newborn ; Interrupted Time Series Analysis/methods ; Male ; Medicine/methods ; Middle Aged ; United Kingdom/epidemiology ; Young Adult

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.

Comment in: PLoS Med. 2017 Nov 14;14(11):e1002426. doi: 10.1371/journal.pmed.1002426. (PMID: 29135985)
Comment in: BMJ. 2017 Nov 14;359:j5253. doi: 10.1136/bmj.j5253. (PMID: 29138184)
Erratum in: PLoS Med. 2018 Feb 26;15(2):e1002527. doi: 10.1371/journal.pmed.1002527. (PMID: 29481566)

Soc Sci Med. 1996 Jul;43(2):173-86. (PMID: 8844922)
BMJ. 2013 Jul 10;347:f4351. (PMID: 23842464)
BMJ. 2014 Jul 17;349:g4644. (PMID: 25034351)
Int J Epidemiol. 2017 Feb 1;46(1):348-355. (PMID: 27283160)
BMJ. 1996 Jun 1;312(7043):1399-401. (PMID: 8646099)
BMJ. 2015 Nov 17;351:h6148. (PMID: 26578085)
Soc Sci Med. 1994 Mar;38(5):733-48. (PMID: 8171352)
J Health Econ. 2006 May;25(3):449-78. (PMID: 16188338)
Br Med Bull. 2011;97:7-15. (PMID: 21257619)
J R Soc Med. 2014 Oct;107(10):387-92. (PMID: 25271273)
Scand J Prim Health Care. 2001 Dec;19(4):223-6. (PMID: 11822644)
BMJ. 2012 Feb 16;344:e980. (PMID: 22344307)
BMJ. 1993 Feb 13;306(6875):433-7. (PMID: 8461728)
BMJ. 1994 Sep 17;309(6956):705-10. (PMID: 7950524)
Prev Chronic Dis. 2016 Jun 23;13:E82. (PMID: 27337559)
Soc Sci Med. 1991;32(10):1111-9. (PMID: 2068594)
Br J Gen Pract. 2006 Nov;56(532):876-82. (PMID: 17132356)
BMJ. 1999 Jul 10;319(7202):98-103. (PMID: 10398636)

MR/L011891/1 United Kingdom MRC_ Medical Research Council; P30 DK092924 United States DK NIDDK NIH HHS

Date Created: 20171115 Date Completed: 20171204 Latest Revision: 20240604

20240604

PMC5685471

10.1371/journal.pmed.1002427

29135978