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Are emergency admissions rising as fast as people say?

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Reputable reports assembled by the great and good are frequently citing the dramatic increase in emergency admissions.  Recently the evidence assembled for the Bruce Keogh review into Urgent and Emergency Care said that "Emergency admissions to hospital in England are also increasing, with a rise of 40 per cent between 2003/04 and 2010/11". They supported this by referring to the excellent analysis by Ian Blunt, Martin Bardsley and Jennifer DIxon ('Trends in emergency admissions in England 2004-2009; is greater efficiency breeding inefficiency" from the Nuffield Trust). 

But they have got it wrong. Actually the report says in the first bullet point on the first page, under the heading 'Key Points' that:

"The number of emergency admissions in England rose by 11.8 per cent over the five-year period 2004/05 to 2008/09 – a total of approximately 1.35 million extra admissions."

What they seem to be referring to is the rise in emergency admissions through A&E, and they produce the graph shown below which, as you can see, is clearly labelled and defined as 'admissions through A&E'.

b2ap3_thumbnail_Trends-in-admissions-fig-3.JPG

 So what is really going on?  I have carried out a simple analysis of the reported data for all England. The graph (below )shows that emergency admissions are increasing, but at a more modest rate than is often claimed with the rise being less than 13% comparing the year to January 2013 with the financial year 2007/8, with the rise in emergency admissions through A&E of nearly 50% being offset by a reduction in non-A&E emergency admissions of approaching 30%.


b2ap3_thumbnail_Change-in-emergency-admissions-since-2007-8_20131104-165656_1.png

 

To provide the numbers;  In 2007/8 there were 4,753,318 emergency admissions, 2,546,425 through A&E and 2,206,893 not through A&E.  In the 12 months to Jan 2013 there were 5,357,115 emergency admissions, 3,781,495 through A&E but only 1,575,620 not through A&E

Another way of looking at this is to say that compared with 2007/8 (when the number of admissions through A&E were 2,546,425 out of a total of attendances of 4,753,318) the switch of patients (631,273 of them) from alternative routes for admission to going through A&E (if that is what we assume is happening) will have accounted on its own for a growth of 24.8% in emergency admissions through A&E and 13.2% in attendances at A&E.

As always in this blog, I am keen to start a discussion.  Do you agree with the picture above?  What am I missing?  What other similar analysis have you seen of this issue?

So what might be going on?  And here I stress that the remainder of this posting is speculation or hypothesis. 

The first thing is to dismiss the suggestion made to me that primary and community care is performing so well and their intensive focus on reducing emergency admissions is meaning that they are referring many fewer patients to hospital for admission - and that the reduction in non-A&E emergency admissions is because of that.  Some of my best friends are GPs and I know that they and their colleagues do a great job.  I wish it were possible, but I cannot believe that any practice could have managed to reduce emergency admissions of their patients by more than 25% (and if they did I would wonder what they had been doing wrong in the past).  I certainly think it is beyond belief that all practices and community services in England could have improved in less than four years to this extent.

So what else?  Could it be that this is a symptom of the increasing occupancy of hospitals across the country (a result as much of the difficulty in getting people out of hospital as the increase in numbers coming in) and that the shortage of beds is making all sorts of admission more difficult - in fact so difficult that the hard-pressed GP or other health professional has, in too many cases, no alternative but to call an ambulance or send the patient directly to A&E?  A&E is, after all, one of the few parts of the hospital that cannot close its doors to patients (labour wards for obstetrics and gynaecology is another example, but here demand for services is not mainly shaped by the way the NHS works but by other factors with a nine month lead-time).  Perhaps you have other possible rationales - it would be good to hear them….

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After a background in manufacturing organisations including roles as operational manager, accountant and general manager, Henry has spent some 20 years as a consultant to organisations in both the private and public sector. Much of this work has involved the specification and commissioning of a range of public sector services from benefits, through support services including (for the NAO) a review of the way in which IT services were outsourced by the Inland Revenue to primary and secondary healthcare services. He has advised the Care Quality Commission and the Healthcare Commission not just on their investigations into specific cases (such as the investigation into Take Care Now) but also in their wider evaluations of value for money (such as the report 'Not just a matter of time' into GP out of hours services). A particular interest is in making sure that the data collected through systems is useable and used to support improvement of the service. Work within the acute healthcare sector has involved him in A&E, Urgent Care services of all types, Diagnostics and Pathology, IT systems , Imaging, Medical assessment as well as in Health Insurance. In Primary Care, Henry has worked with many Out of Hours providers, particularly in benchmarking their performance and looked at the operation of numerous general practices, Walk in Centres and Minor Injury Units. He has also worked with Practice Based Commissioning groups looking to specify services, groups of GPs forming provider service organisations and in looking at mutual and social enterprise models of provider.

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Guest Monday, 23 April 2018

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The Primary Care Foundation was established to support the development of best practice in primary and urgent care.  The three Directors bring different skills and perspectives to understanding primary and urgent health care - for more details click below:

David Carson

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Henry Clay

 

 

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