UK: Like King Canute, Attempts To Stem The Tide Of Emergency Admissions Appear Increasingly Futile

Last Updated: 11 November 2013
Article by Karen Taylor

Most Read Contributor in UK, August 2017

A common marker of success for health systems is their ability to control rates of emergency admission.  Indeed, there are few health policy issues that have received greater attention than how best to meet the demands on hospital A&E departments and manage the associated unscheduled admissions to hospital.  Last week the National Audit Office added to the clamour of concerns about our emergency care services in a report identifying serious failings in the way emergency admissions are being managed.   It found that in 2012-13 there were 5.3 million emergency admissions to NHS hospitals in England (47 per cent overall increase since 1977-98); costing the NHS around £12.5 billion. Some 3.7 million of these were from A&E Departments (116 per cent increase), 0.7 million were from outpatients (17 per cent increase) and 0.8 million were from GP referrals (34 per cent decrease).  A tenth of these were readmissions which the hospital, in theory, doesn't get paid for. 

The NAO suggests that many emergency admissions are avoidable and that many patients are staying in hospital longer than clinically necessary. The report identifies large variations in performance at every stage of the patient pathway, suggesting scope for improved outcomes; and a need for short term interventions to manage winter pressures and longer term interventions to create a more accessible, integrated, urgent and emergency care system.  It concludes that until the systemic issues are addressed, value for money in managing emergency admissions will not be achieved.  So now we have the diagnosis and a suggested treatment regime, unfortunately, past experience suggests that it will be some time before we see any meaningful improvement. 

Most of the NAO recommendations that are within the gift of hospitals to address are already being implemented, albeit with varying degrees of success. For example many hospitals are in the process of introducing or indeed have implemented new staffing models for their A&E Departments. These include initial triage by senior clinicians, geriatrician of the day, new nurse practitioner roles, rotation of middle grade doctors into A&E, Elderly Care Assessment units etc.  Hospitals are also increasingly seeing the four hour emergency target as something that is owned and delivered by teams across the whole hospital, not just the A&E Department.  While these should have some impact, the waves of patients continue to flood into A&E.  More and more of these patients have increasing acuity, providing staff with little alternative other than to admit, thereby escalating the challenges still further. 

The NAO report rightly highlights the misalignment of incentives as a key issue and recommends that the Department, NHS England and Monitor should consider how best to align incentives across the health system to reduce emergency admissions.  It suggests that payment mechanisms should reflect the fact that different providers need to work together to manage the flow of patients through the system and make sure patients get the best treatment; and that all parts of the health system need to be encouraged to reduce emergency admissions.  Furthermore, that Monitor should assess whether emergency care services provided by hospitals are loss-making and ensure that remuneration for these services covers the costs of providing a safe and efficient service.

So very easy to say –but seemingly impossible to do - and unfortunately this is arguably the opposite of what is actually happening in practice.  Currently commissioners need only pay 30 per cent of the tariff for any emergency admission over 2008-09 levels but are supposed to spend the 70 per cent saving on preventing admission.  The policy is estimated to costs hospitals around £500m annually, with limited evidence that the proceeds are invested in preventing admissions.  This financial penalty, together with the prospect of commissioners not paying for re-admissions, threatens the financial viability and quality of care in hospitals.  Especially when the lack of  alternatives models of care that are trusted by patients means the hospital continues to be seen as the default position. 

Indeed, increasing numbers of people think "Hospital first" when seeking a diagnosis or treatment.  These include those of working age, who are unable to see a GP at a convenient time and for whom waiting up to four hours is a price they are more than willing to pay; and, of course, the growing numbers of frail elderly who are regularly sent to or abandoned at the emergency department by their carers and care homes and for whom there is little choice. For this group of patients with complex medical needs the hospital is not only the best option medically but also provides a much needed comfort blanket.

As always, all is not lost, hospitals' adoption of new ways of working are, in pockets, having some impressive results.  One example is the introduction of an acute physician within the medical triage unit, providing early senior decision making and introducing an ambulatory care area where patients on ambulatory pathways are treated in chairs, freeing up emergency medical beds for those patients that really need it. Another is to redesign the patient pathway for care of the elderly, providing a "frailty score" within a short time of arrival and those deemed to have complex frailty needs being treated by the acute care of the elderly team. Indeed some hospitals segregate their vulnerable and elderly patients from the main A&E population, much as they do with children, providing a less noisy and threatening environment in which to treat and, by reducing distress, hopefully discharge them. 

While the above approaches are the responsibility of the hospital to deliver, many hospitals frustrated at the inertia in primary and community care and the failure of commissioners to influence the provision of the much needed alternatives,  are adopting their own vertically integrated solutions. These include funding the installation of telehealth in care homes and extending the use of hospital at home and early supported discharge services.  Furthermore , a number of  hospitals, in the absence of capacity in the community, are opening up step down facilities staffed by their own staff which provide a dedicated ward with access to therapy and a focus on rehabilitation and reablement to help prepare people better and sooner for discharge.

Whether the above initiatives will be enough, only time will tell and with this winter threatening to be the biggest wave yet to break on the shores of our hospital A&E Departments there is a risk that they will be simply another drop in the ocean. 



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