Primary Care Foundation Blog

These blogs allow us to write about things that matter to us. They tend to be about general practice, primary care, urgent care and the wider NHS. They are also about numbers or data – so things that have caught our attention or just don’t look right. It would be great to hear your ideas too – feel free to comment or contact us by email or social media.

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Posted by on in Primary Care Foundation Blog

 

The BMA have made mistakes in their press release today.  We have all done this, but it is unfortunate if it undermines the case.  There is a real debate to be had about NHS 111 - but the claim that 'the number of calls referred through to GP services had gone up by 186% and to A&E by 192%' is not right.  Actually the growth figures are 39% and 43% respectively*.

 But even this does not present a realistic figure.  There are two things that they are ignoring.  First that the roll-out of NHS 111 was phased over a period so that the population covered has grown.  If we compare the figures per 1000 population we find that the growth is something near to 30%.  Second fewer of the out of hours services were fronted by NHS 111 in October 2013 than by October 2014 - and since the volume of out of hours calls is large, this makes quite a difference.  To make a proper comparison they should be looking at those areas where the volume of calls has not been increased by changes to the operational model of the urgent care system like this.

 There is another over-simplistic comparison when they say 'In its final full year of operation in 2011/12, NHS Direct received 4.4 million calls from patients. November 2014 figures show that NHS 111 has received and responded to over 12.4 million calls in the calendar year– an increase of around 250 per cent in comparison to the previous 0845 number'.  This ignores completely that in 2011/12 the out of hour services would have been receiving something over 7 Million calls a year.  Add this to the 4.4 Million for NHS Direct and you are approaching the 12.4 Million that they quote for NHS 111 - and bear in mind that at least one of the aims of NHS 111 was to offer an alternative to patients that might otherwise have used 999 so we might expect some growth.

 And finally they have compared the figure from our benchmark of out of hours services for 'advice' which includes advice to go to A&E, call the ambulance and more with NHS 111 self-care advice - another misleading comparison.

 I hold no candle for NHS 111.  We should be having a debate about it.  We should be discussing the high levels of referral to A&E and ambulance services compared with the previous model; we should be looking at the occasional long delays in transfer to out of hours services; the proportion of NHS 111 priorities that are escalated or downgraded; we should be looking at the differences between dispositions between one provider and another and we should be looking at alternative models and ways of working that will help to alleviate the pressure on the urgent care system. 

If the BMA can act as a catalyst for informed discussion that leads to these issues being addressed then their careless error will be forgotten.

 

 *It looks as though the BMA compared figures for the total from the initial pilots to October 2013 with the total, again from the initial pilots, to October 2014.  They have since provided a correction, but have chosen to compare the Nov 2012-Oct 2013 with Nov2013-Oct 2014.  Since most NHS 111 sites did not become active till part way through the first period there is no real comparability.

 

 

 

 

 

 

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Posted by on in Primary Care Foundation Blog

I have sympathy for anyone interviewed on television - I bet I would get it wrong!

But Keith Willett's claim needs correcting. He says: “We know that 15% of people that tried last year to get a GP appointment were unable to achieve one in the time they wanted and half of these turned up at an Urgent Care Centre or A&E”

 A quick sense check reveals this can't be right:
• There are about 300 Million GP consultations a year, roughly 5.5 times a year that we go to our GP
• 15% of 300 Million is 45 Million
• Half of that figure is 22.5 Million
• This is larger than the total number of attendances at A&E, MIU, WIC and UCCs in England which is reported to be 21.7 Million

I feel sure that he was referring to the GP Patient Survey results. If he had said: “The GP patient survey showed that 15% of people that tried last year to get a GP appointment were not able to get one or were offered an inconvenient one and 10% of these said that they turned up at an Urgent Care Centre or A&E” he would have been pretty much spot on.

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Posted by on in Primary Care Foundation Blog

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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The Primary Care Foundation supports the development of best practice in primary and urgent care. We apply our work shaping national policy to support local change. We use information to create understanding, driving improvements in care, reducing unnecessary variation across organisations and between clinicians and developing practical tools for front-line staff in general practice and urgent care.