The number one issue facing the NHS in England is reversing the ‘unsustainable’ rise in emergency hospital admissions, the think tank Nuffield Trust has warned.
Its study reveals there has been an almost 12% rise in admissions over the last five years. The comprehensive analysis reveals the number of emergency admissions in England rose by 11.8% between 2004/05 to 2008/09 - resulting in around 1.35 million extra admissions. It is estimated that treating these extra patients in emergency hospital care is costing the NHS an additional £330 million per year.
The research used Hospital Episode Statistics to examine monthly emergency admissions over the five-year period. All hospitals in England have been covered, although some admissions (such as in mental health, those for which no diagnosis was recorded, or those occurring in merged NHS trusts) were excluded as appropriate to each analysis. Emergency admission is defined as any spell with admission methods via A&E, GP, bed bureau, consultant OP clinic or NHS Direct.
The report reveals that emergency admissions now make up 35% of all hospital admissions in England - at a cost of around £11billion to the annual NHS budget.
The report found significant variation between NHS hospital trusts. In some emergency admissions reduced by up to a third over the five years, while in others they almost doubled.
A key finding from the Nuffield Trust analysis is that the rise in emergency admissions has been linked with a dramatic increase in the number of short-stay admissions - those patients that are admitted as an emergency for one day or less. In England in 2008/09, 592,724 more patients were admitted for one day or less compared to 2004/05 - a marked jump, with zero and one day admissions accounting for 49% of all emergency admissions in 2008/09 compared to 42% in 2004/05. Some hospital trusts have seen a much larger increase in short-stay admissions than others.
The report concludes that this has, in part, been caused by a lowering of the clinical threshold for emergency admissions. Advances in medical care and management have reduced the length of time patients stay in hospital, which in turn has freed up more available beds and allowed doctors to admit more patients. To break out of this cycle in future will mean creating better out-of hospital care and preventive care to reduce the risk to patients of admission and enable expensive hospital beds to be closed, the report warns.
Other possible reasons for the rise, include the impact of targets, the ageing population, and variations across different hospitals:
• Ageing population: the report found that people aged over 85 were nearly 10 times more likely to have an emergency admission than someone in their 20s, 30s or 40s. But despite this, only 40%, at most, of the extra admissions can be explained by the growing ageing population.
• Growing ill-health: the rise is not down to any one particular type of illness and levels of self-reported ill health do not appear to be rising. The report notes that the growth in admissions is mostly due to new single cases rather than individuals being admitted more often each year.
• Geographical variations: within England there is significant variation between NHS hospital trusts. In some, emergency admissions declined by up to a third, while in others they almost doubled. There is also significant variation between primary care trusts. Although admission rates are known to be higher in more deprived areas, there is no clear link between deprivation and the rise in emergency admissions.
• Central policy initiatives: such as the A&E four-hour maximum waiting time target, the introduction of payment by results and more autonomous NHS foundation trusts, have had little overall impact on rising emergency admissions. However, for some individual NHS trusts an association with the A&E target is apparent.
Commenting on the report, Nuffield Trust director Dr Jennifer Dixon said: “Reversing this unsustainable rise in emergency admissions must be the number one priority for the NHS in England - any reform to the health service that does not tackle this will fail. Our hospitals are over-heating and are on an unsustainable path in which they are treating patients at great cost to the NHS and to patients themselves. This cost could be avoided by preventing ill health through better care by GPs, community care services or social care, and better co-ordination of care between doctors in hospital and general practice.
“Avoidable emergency admissions will continue to rise unless care is more integrated and hospitals and beds are closed. Otherwise the risk is that the NHS becomes unaffordable.”
Read the full report.
Tags: Admissions
One of the potential causes not mentioned is the change in emergency primary care provision. Patients are now seen, especially out of hours, by a GP that has never seen or met them before. They often dont appear to know of their background and thus the default position is to refer them into hospital.
Given the ease at which these referrals are now accepted by secondary care often in the form of a form filling nurse it is no wonder that the numbers admitted and then quickly discharged is rising.
The best way to reduce his rise would be to insist that GPs look after their own patients out of hours and that they have to discuss and then is appropriate refer the patient to a senior hospital doctor.