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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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The latest blog by Rick Stern ‘If only …’ explores the idea of avoidable appointments, what practices have gained from the audit, and what might be possible with further investment in general practice.  It is available here and will also be published in Health Care Leader.

If only …

Just over two years ago we were finalising a report for NHS England looking at workload pressure in general practice called ‘Making Time in General Practice’. I remember a tense discussion about how to present the headline issues from the report.  A senior figure in NHS England wanted to say that ‘more than a quarter of all GP appointments are avoidable’.  While this was one way of looking at our work, we wanted to emphasise that appointments were potentially avoidable, only if other services were put in place first.  If only there is investment in other members of the practice team, in improving communication with hospital services, new resources for social prescribing. If only.

We did moderate the message.  We also were supported to develop the key tool at the heart of this debate – an audit of potentially avoidable appointments – and 270 practice reports later, we have now been asked by NHS England to develop a simple to use, automated, free to use audit tool, for all practices across England.

To get this right, we have been surveying practices who have used the audit so far.  Amongst a lot of positive feedback was a concern from one GP that he was unclear whether the audit was intended as a way of measuring what GPs can avoid doing now, or what might be possible with further investment.  This gets to the heart of what ‘avoidable’ might mean.  Avoidable is a subjective term. Each clinician will have a different perspective on their own role, what others can do, the importance of continuity for different groups, what patients can do for themselves, and what other organisations could pick up for the practice. 

The key here, is to get people to talk. By talking it through together, the practice team can collectively develop a better understanding what has to be done by the GP, or what could be picked up by a nurse, the practice pharmacist or GP associate.  Or even what might be directed to others outside the practice.

We are actively encouraging practices to complete the audit based on how general practice could be –– not just how it is now.  So, if you had more colleagues in the team, a different skill mix, better links with local pharmacies, better information sharing with local hospitals – what could be done by others?

We also found out that more than half the practices that got back to us had made immediate changes after looking at the results of the audit.  Practices were improving signposting to get patients to the right person in the team, offering more telephone appointments, using care navigators, advanced nurse practitioners and clinical pharmacists more, or making arrangements with the local pharmacy to deal with minor ailments. 

This is impressive.  But what might this look like if the investment from the GP Forward View, when it finally finds its way to general practices, was spent on the things that really matter to practices?  Some STP areas have already been looking at the results of the audit in this way.  Not just as a way of individual practices focussing on redistributing their over-stretched resources now, but whole health communities investing in general practice as a sustainable way of building the NHS for the future.  Now that would really be something.

If you want to know more about how to use this free audit tool, either for your practice, a group of practices, or across your CCG or STP, go to www.primarycarefoundation.co.uk or email Rick Stern at This email address is being protected from spambots. You need JavaScript enabled to view it.  


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At the end of March 2016 NHS England issued a patient safety alert on ‘Risk of death from failure to prioritise home visits in general practice’. The alert tells of a practice which while having a system to mange visits did not have a system for prioritising potentially urgent calls requiring an early response and rapid clinical intervention. The GP made other visits and did not have time to see this patient until the evening but before the GP arrived the patient had collapsed and had to be taken to hospital by ambulance and subsequently died.

Cases like this are unusual but on looking back at the National Reporting and Learning System, NHS England found another 11 incidents resulting in death or severe harm over the last two years. There may, of course, be others that were not spotted and reported.

This is an issue that the Primary Care Foundation specifically picked up in our 2009 report for the Department of Health, sent to all practices, on ‘Urgent Care in General Practice’. We developed a system and process to help practices become better organised to respond to all requests for care - not only urgent requests.

We have now worked with over 1,500 practices across the UK looking broadly at access and giving information to practices to help them identify how to improve. Often we find that the issue is that patients are coming back more frequently than would be expected and the question becomes how to address this.

But we also look specifically at how requests can be assessed and if necessary spoken to by a clinician within a reasonably short period of time - thereby avoiding the practices running the same risk identified in the patient safety notice.

So what practical steps can you take, particularly when most practices are feeling under increasing pressure to manage a rising workload? Practices have come up with a range of different solutions but they tend to combine a better system for spotting urgent cases with a reduction in the overall workload. So scanning all home visit requests – or finding a way that suits you of rapidly calling people back – can both identify that up to half of the home visit requests don’t really need a visit at all and can be managed in other ways while also spotting the very few that need a really rapid response.

Many practices use the duty doctor to screen home visit requests and make sure that they also have capacity to carry out the visit, while other practices build in a gap in the morning (so perhaps a couple of 10-minute appointment slots) to allow a GP to review requests that have come in and to carry out any telephone assessment of other cases too. Smaller practices find this works for them, but that visiting the patient is harder. But there are a number of examples of single-handed practices working together to set up a home visiting scheme with a GP able to cover a number of practices (see the case study in our report from Halton & St Helens).

If you need more help with managing home visits or for more information about the help we can provide with improving access do feel free to get in touch with me on This email address is being protected from spambots. You need JavaScript enabled to view it.

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I want to share a few thoughts as I hand over the baton to a new generation of leaders in NHS Alliance and return back to the Primary Care Foundation. The best example of offering advice to a new generation is the one and only no.1 hit with a clear and unambiguous public health message – Baz Luhrmann’s 1999 ‘Sunscreen Song’ – which highlights that the only advice he can offer, which is genuinely based on evidence is ‘use sunscreen’.

For my part, I would like to take a fresh look at how we make decisions in the NHS and the importance of something economists and psychologists refer to as action bias. Put simply, action bias is the idea that when faced with difficult situations we tend to get the feeling that we need to take some action regardless of whether this is a good idea or not. It follows that we would make better decisions if we had an awareness of the unconscious psychological processes that drives our decision making at times of stress.

I recently noticed a link to a great 7-minute video that focusses on what happens in a goalkeeper’s head when they try to save a penalty. Now this is all pretty close to home for me – as some of you may know my son started a career as a professional goalkeeper and has since managed to turn his passion for football into a career as a goalkeeper coach.

As my son always tells me, goalkeepers love penalties. They can’t lose. The striker is expected to score but if he saves a penalty he is a hero. Interestingly, when he was still playing in goal he took this a stage further and decided that he should do everything he could to distract the striker as he prepared to take the penalty. He would walk out of the goal and move the ball, argue with the referee and tell the striker where he was about to hit the ball. It was a nice theory, but it was at best unproven – the only certain thing was that he got booked a lot and created a name for himself with referees.

So what did the video have to say? Academics, with nothing better to do, spent a lot of time reviewing thousands of penalties and they found out something very interesting. They discovered that goalkeepers would save more penalties if they did nothing, or just stood still.  But, this isn’t what goalkeepers are trained to do and a heroic, if pointless gesture, feels much more satisfying than remaining rooted to the spot. This is where action bias comes in, we feel better doing something and there is plenty of evidence that doing less has better outcomes in other fields too. Traders on the floor of the stock market are primed to do things and make rapid decisions, but the research shows that those who trade less are actually more successful.

In healthcare, there are many examples of action bias. GPs opt to prescribe antibiotics even when they know it will have no impact and contributes to broader harm. And, politicians and policy makers exhort general practices to offer more appointments, doing more and working harder, when we know there is greater patient satisfaction in practices who offer fewer appointment slots. Or put another way, general practices that struggle most are those that respond to the increasing pressure they are under by doing more – offering more appointments rather than standing still for a bit and thinking.

So, I offer three reflections to the new leadership team.

First, the answers to problems are often counter intuitive. So, put simply, doing something – anything – especially when you have no evidence that it is the right thing to do, may not be smart. You may just be digging a deeper hole.

Second, productivity is not just about doing more – headline figures for productivity invariably rise at a time of austerity or financial crisis – but being genuinely productive, so improving how effective we are rather than just being more efficient, takes careful thought and reflection.

And finally, I would encourage everyone to spend more time following up random links and videos as they may just trigger a new way of looking at the same intractable problems. If we are serious about transforming general practice and primary care, rather than just doing more of the same, we need to give people the ‘headspace’ to come up with creative solutions.

Rick Stern

Outgoing Chief Executive, NHS Alliance

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It has been an extraordinary privilege to lead NHS Alliance alongside Michael Dixon. I had no plans to become a Chief Executive again but Michael is a difficult man to say no to, and the opportunity to work alongside him and the extended family of the NHS Alliance was impossible to resist. So as we hand over to aq new leadership team, I would like to offer a few quick reflections on how far we have come over the last 4 years. I came in at a difficult point when the Alliance was facing an uncertain future. So what did we do?

First, we successfully shifted the focus from clinical commissioning to primary care provision. The NHS Alliance has always enjoyed taking the moral high ground – and giving away our core membership to help create NHS Clinical Commissioners was the right thing to do but raised serious questions about the purpose and future of NHS Alliance. It was increasingly clear to us that how providers work together - including how general practice works at scale and works with the rest of the wider community - would be central to our future mission.

Second, to support this we needed to overhaul the way we worked. Today is a key milestone in this journey, but NHS alliance has already become increasingly virtual, without an office base. We also took steps to reduce our costs, establishing new partnerships and build on our strengths – bringing together leaders across primary care who are passionate about using their experience and expertise to make a difference, connecting what happens on the front line with policy making in Whitehall.

Third, we needed to be clear about who we were and what we believed in. We have published two major statements of our values and aspirations - our Manifesto for Primary Care 'Breaking Boundaries' and towards the end of last year, just before the FYFV, our own 'Think Big, Act Now: Creating Communities of Care.' and we continue to produce ground breaking work, including ‘Pharmacists & General Practice’ that has shaped the rapid growth of practice pharmacists, our work on tackling the current recruitment crisis by creating a new role for practice pharmacists, working with Pharmacy Voice on ‘We are Primary Care’, bridging the gap between health and housing including ‘Housing: Just what the doctor ordered’ and most recently our work 'Making Time in General Practice' leveraging significant changes from the secretary of State.

Finally, we have built and developed a new team to lead NHS Alliance, bringing together a new generation of leaders for primary care. We have welcomed not just bright new stars from general practice but leaders from across the breath of primary care and the wider community; from housing, fire and rescue, community development and the police. And today is the culmination of this process, making way for a new leadership team. T

his is also an opportunity to remind ourselves of what is so special about NHS Alliance. In the end, it is always the people, the connections and the relationships. We manage to achieve a lot together and I have no doubt that the future will be every bit as impressive in the hands of the new leadership team. Personally, I am looking forward to shifting back to being part of the team, as before, rather than leading it as we continue to make the case for health and well being across our communities.

Rick Stern

10th December 2015

Outgoing Chief Executive, NHS Alliance

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Andrew Anderson and Martin Roland have recently reported that experienced GPs can reduce the number of referrals from NHS 111 (Potential for advice from doctors to reduce the number of patients referred to emergency departments by NHS 111 call handlers: observational study - http://bmjopen.bmj.com/content/5/11/e009444.abstract).

It is no surprise that GPs can, when re-triaging patients after an NHS Pathways assessment by non-clinicians, arrive at very different dispositions.  The typical proportion of ‘Contact GP’ dispositions that an out of hours organisation using GPs to carefully assess each call can convert to ‘telephone advice’ is over 50% for example.

 But what is a surprise is the bullishness of the reports about the article in suggesting that there is a significant cost saving for commissioners.  For example Pulse reporting on the paper said that there could be a cost saving for commissioners of £11,112 if GPs were employed in the call centres, comparing savings made for A&E with GP salary costs”. 

The saving of £11,112 comes from subtracting the cost of the GPs providing the triage (£41,416) from the saving in A&E attendance (£52,528).  But Pulse has ignored the cost of the outcomes for those patients that are referred elsewhere than A&E (this is perhaps understandable as the original paper fails to mention them either).  There are increases in referral to other services such as Minor Injury Units (using the same set of reference costs at £49/case, this is £3742) and to the OOH service for face to face consultations (at a conservative £34 per case this is £20026, but it is probably rather higher) not to mention an unknown number of cases completed over the phone but advised to contact another service or their own GP next day.  However, even ignoring the latter, once these figures are added in there is no saving – the overall cost did not fall by 15%, rather it rose by at least 17%.

Of course, this is not the full story.  A reduction in cost is far from the only thing that we are interested in and we may be happy to pay more to reduce the pressure on A&E and to improve the patient experience.  And we don’t know other things too such as how many patients follow the advice that they were given (which the authors rightly point out would be useful to know as part of a full cost assessment) or how many of those referred to the MIU or OOH service were subsequently referred on to hospital.

And it may be that there is potential to reduce costs using GP assessment as described.  This was a small scale trial, had it been carried out at scale the cost per case might have been lower.  We have recently completed a model for NHS England, commissioners and providers that looks at the cost of integrated urgent care, focused particularly on NHS 111 and OOH services.  Using a figure of £15 or as an indicative cost per case for phone assessment by GPs the cost for the 1474 cases would have been low enough that a modest saving might possibly have been made.

The concluding sentence in the paper says that there is a need “for further research to establish the cost-effectiveness of different approaches to triaging telephone requests for care”.  I agree with this. 

But the approach adopted and described in the paper is far from the only one. 

Proponents of NHS Pathways would point to the importance of training call-handlers in probing when asking questions – rightly they would say that many existing 111 services have much to do in training call-handlers about how to do this - and that this would make a big difference in referrals to A&E and the Ambulance Service

There are also opportunities to increase the proportion of clinicians directly supporting call-handlers whilst they are taking the call.  Not all 111 services do this – and they certainly don’t have the number of ‘floor walkers’ to be able to give timely support to the majority of cases whenever the call-handler approaches an A&E or Ambulance disposition.  To avoid delay to the despatch of an ambulance this would seem to be the right point to intervene in the process at least for Ambulance dispositions (and the cost of these dispositions is much more expensive than those to A&E) so it would seem sensible to look at the benefits of this approach.

The new commissioning standards allow commissioners and providers these sorts of freedoms (provided proper risk assessment, management and audit is included as part of the change).  What is required as people experiment with different ways of working is a careful review of the impact looking at ALL of the costs and ensuring that this is reported widely so that others can learn.


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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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b2ap3_thumbnail_Rick.jpg  b2ap3_thumbnail_David.jpgSummary

This week saw the publication of a paper in the Lancet ‘Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial)’ by Professor John Campbell and colleagues.  We welcome this first multi-site trial across nearly 21,ooo patient consultations in 42 practices comparing the effectiveness of telephone triage by GPs or nurses in general practice with usual care for patients seeking same-day consultations in primary care.  To be clear, this research looks at telephone triage – returning all calls and then deciding how to deal with them – not more focused use of telephone consultations, where patients who want to consult with a doctor or nurse over the phone can take up this option as an alternative to a face to face appointment.

The headlines (Phone consultations 'do not cut GP surgery pressures', BBC, 4th August 2014) suggested that telephone triage needs to be treated with caution rather than heralded as a one-stop solution for transforming access in general practice.  GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days, and nurse triage with a 48% increase, compared with usual care. The report concludes that while “Telephone triage might be useful in aiding the delivery of primary care” … “The whole-system implications should be assessed when introduction of such a system is considered”.

The Primary care Foundation has been working with practices on access and urgent care for over five years since our report to the Department of Health ‘Access and Urgent care in General Practice’ in 2009.  We developed a web based tool, that takes a look at one week in the life of a practice, and makes comparisons with other practices and potential suggestions for making life easier in the practice and improving patient care. We have now worked with over 30 CCGs and PCTs and supported over 1,200 practices, so we thought it might be helpful to reflect on our experience. Below is a summary of some of the key factors we have found that practices tend to find useful when responding to demand an activity.

Reflections on improving access in general practice

Money is important, but it doesn’t explain everything

There is a great deal written about increasing demand and lack of resources and both of these are relevant across many parts of primary care.  However the resourcing is an issue that has a longer-term cycle and resolution and is beyond the short-term direct control of the practice team.  We may have seen some evidence of higher demand in areas of high disease prevalence possibly linked to deprivation, the age of the patient population, language or ethnicity.  In most places we see a spread of practices - some managing well with less activity and some struggling with higher than expected consultation rates.  We frequently see practices with matched resources and populations in the same street or health centre with very different activity profiles.  One practice has high activity (and perceived high demand) while the other has a lower than expected rate of activity.  When we cross reference the patient satisfaction we frequently find that the practice with the lower activity has higher levels of patient satisfaction.

The single most important factor remains good continuity of care 

So what is driving the difference?  In a word, continuity.  Many people, especially elderly people with more complex conditions, want an appointment with their ‘own’ doctor or nurse within the next 5 working days.  The perception that everyone wants a same day urgent appointment is often driven by what is available – increasingly, the choice in too many practices is an ‘urgent’ appointment today, or nothing for at least a week.

So the practice that can routinely offer an appointment or a call with the patients doctor of choice within the 5 working days tend to have lower activity levels as they don’t have patients making repeat contacts to try and get their own clinician.

It’s the system, not the patients

Access is of course in the first instance via a phone call to the practice.  The most common reasons for poor phone access are the way reception staff are organised or a lack of phone lines.  Patients are often seen as the problem – calling too often for unnecessary appointments and then failing to show up – whereas, in reality, the system set up by the practice is often the main source of the problem.  As pressure builds, practices try and set up more barriers to protect limited appointments – appointments available when the surgery opens, appointments ‘embargoed’ until later in the day, patients told to call back later – all of which drives us into more desperate behavior to get limited appointment slots.  So in an attempt to manage the pressure for appointments, the system becomes increasingly complex and patients become experts at ‘gaming’ the system that has been put in place to make life easier.  Practices which have a system generating high demand inevitably have higher phone volumes and often fare less well on phone access.  On rare occasions we do find lack of resources an issue but, in our experience, this tends to be an exception.

Phone or face to face?

We are great supporters of telephone consultations as an effective route of access to the practice.  Its time effective for both the patient and doctor and also expands the options for patients to choose what type of access would suit them.  Again continuity is a key factor so the patient must be able to get their own clinician.  The important factor is choice - the more routes in to get an appointment, the more choice patients have and the more likely they are to choose the most effective route for themselves and the practice.  The trick the practice has to pull off is to ensure each route of access has adequate capacity for the demand and delivers true choice.

Restricting patients to one form of access, such as exclusively through same day appointments, telephone triage, or through a duty doctor clinic, tends to lead to a bottleneck as different people will seek different solutions.  Young men, mothers with young children, working adults, people whose first language in not English, and the frail elderly will want to access care in different ways.  So multiple routes, including face to face care and telephone consultations, as well as booking appointments on line and increasingly email advice, will all have a part to play.  The more as patients we understand there is a choice, the less pressure there tends to be first thing in the morning. So, a simple question early on in the phone call to book an appointment “would you like to see the doctor or nurse face to face, or would you like them to call you back?” could go a long way to help.

A 'silver bullet'?

We don’t have a model or template that solves all the problems but a set of analytical tools that helps the practice make choices and review how they do things while benchmarking their activity locally.  There is no ‘silver bullet’ or one system that will work well in every practice.  No matter how the practice uses its resources putting access to the clinician of choice at the center of their design will deliver benefits.

If you want to find out more about how we can work with your practice or CCG, please contact us at This email address is being protected from spambots. You need JavaScript enabled to view it. or call Rick Stern on 07709 746771 or David Carson on 07703 025775.

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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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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'.


 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%.



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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These blogs are about the NHS - but also about numbers.  I hope that they raise some interesting points that come from the data.  Sometimes I suggest that the data doesn’t look right - but maybe it is.  Please tell me when I have got it wrong (as we all do, however carefully we look at it) or when I have got hold of the wrong end of the stick.  And especially tell me if you can see a rationale or logic for the picture that I describe that I have missed.


Thanks for your help - it is by challenging and correcting the data, the analysis and conclusions that progress is made!


For those that are interested most of the data comes from nationally reported data sets available to all - and most of the time the analysis has been done in Tableau.  Because it takes so long for data to be published, some of the analysis is of old data.  Please, if there are examples where there are better or alternative sources of data let me know about these too.


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About Us

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.