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GPs go forth

Emergency admissions continue to rise

Preventable emergency admissions have risen by 40% in a decade despite extra resources being ploughed into programmes aimed at preventing such admissions, new figures have shown.

A study of 140 million emergency admissions at NHS hospitals between 2001 and 2011, published in the BMJ, concluded that more radical approaches will be needed to tackle avoidable emergency admissions, a measure that will form a quarter of CCGs’ quality premium payments.

Researchers from the Nuffield Trust found that the number of unplanned admissions for clinical conditions that could have been reduced by timely and effective primary care increased by 40% between 2001 and 201. They rose from 701,995 to 982, 482 - an increase of 280,487 admissions per year.

Most of the increase in admissions was for acute conditions such as urinary tract infections, gastroenteritis and for vaccine-preventable conditions such as pneumonia. Increases were seen across most age groups, and even after taking into ageingdemographics, admissions still rose by 21% over a decade.

Some decreases were seen in avoidable admissions for conditions such as perforated and bleeding ulcers, pelvic inflammatory disease and ischaemic heart disease, but the scale of the reductions was much lower than the increases seen for other conditions, according to the study.

The reductions seen in admissions for cardiovascular disease could be due to changes in health-related behaviours such as reduced smoking and availability of effective preventive treatments such as statins, the researchers said. Likewise the reductions seen in avoidable admissions for ulcer complications might be linked to increased use of antibiotics and PPIs, they suggest.

But the overall increase in avoidable emergency admissions could be attributable to health service system changes, the study said. .

‘It may be that admission decisions are in part influenced by the perceived lack of alternatives to inpatient care,’ they authors added.

However, the study provided only weak evidence to link increases in avoidable admissions with policies such as the introduction of the four-hour A&E target and changes to the GP out-of-hours contract.

The study authors said it was notable that unplanned admissions increased despite funding incentives in primary care aimed at preventing hospital admissions and major changes to OOH care.

‘Increases in rates of emergency admissions suggest that efforts to improve the preventive management of certain clinical conditions have failed to reduce the demand for emergency care. Tackling the demand for hospital care needs more radical approaches than those adopted hitherto if reductions in emergency admission rates for ambulatory care sensitive conditions overall are to be seen as a positive outcome of for NHS,’ they report said.

Dr Andrew Mimnagh, a Liverpool GP and chairman of the Sefton LMC, said that the findings raised more doubt about the decision of the NHS Commissioning Board to link 25% of quality premium payments for CCGs to reducing avoidable emergency admissions.

He said the target had been set despite there being no evidence to suggest it was achievable.

‘Our own review of emergency admissions as part of the QoF suggested that the majority arose from the out of hours and other periods. One of the only areas where there is room for clinical improvement would be in better co-ordination of OOH and general practice care. Obviously there is then the difficult question of would you look at the resources to genuinely extend the comparable levels of standards across a large area of the day? I suspect the government hasn’t got the funding to do that,’ he said.

‘The evidence would suggest extending the quality of provision and staffing. We already work effectively from 8am till 8pm, five days a week, and the system would appear to really need 6pm-midnight cover and that means workforce expansion and a very major structural change.

‘So is it workable? Yes. Do the CCGs have the levers to do it? No. Is there political will to really tackle the issue? Not with the budget there currently is.

“’ou need to be looking much broader than a CCG remit. You need a whole NHS remit. We’ve had a wealth of resources poured into the NHS creating novel ideas over the last decade. They would have been a lot better just reinforcing and increasing the current models rather than having so many novel models of care.’

Readers' comments (5)

  • I assume the data comes from diagnositc coding and not case by case....its very easy to make assumptions about such admissions. However when the individual case with multiple comorbidities are taken into account in an aging population the picture becomes much more blurred. I always question who is deciding an admission is inappropirate and on what criteria. Its not as if we all want to admit people unnecessarily to hospital.

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  • Jmd

    as Dr Bennett I assume the coding is where teh data comes from. I am sure there are compounding factors in the coding sysyetm. However, i assume the comparison is made like for like data available. Thus coding may be irrelavant.
    Issues leading to increase acute admissions I think are:
    1. defensive medicine/litigation
    2. patient and family pressures
    3. poor social input
    4. poor community or hospital at home facilities.
    5, aging population- living in isolation.
    6. ooh-- as the drs have no knowledge of the patient and hnece back to my point 1.
    There is no one reason for this increase. The Goverment needs to look at these issues. Howver, they have washed theirs hands and passed the batton to GPs via OCCG. So teh GPs are between the rockand teh hard.

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  • As Ks Pandher says, there is a huge number of factors that come into play when a person is admitted as an emergency - yet we set targets based on simplistic notions of 'inappropriate' admissions. We rarely acknowledge the complexity of human behaviour (staff and patients), social factors, disease factors and service factors and how these interact with the complex systems that are NHS health services. If we were to get a better understanding of how these whole systems work, we would be able to create a more efficient NHS; as it is we tinker with tiny parts of the whole system, without any consideration of the effect on the whole. If we changed from focussing on numbers and targets (which are far to simple a way of looking at something as complex as health care) to focussing on understanding our current systems, we would be a lot further forward in having an efficient national health care system.

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  • This is a brilliant effort to bring together such a large data involving huge number of thing is clear that the emergency admissions across the country are on the increase and there should be drastic measures and changes to counteract this increase. We cannot hide that fact that the population is ageing and complications are rising so is the expectations of the people for better care.
    But this information was based on coding from hospital which is very tricky it is extremely difficult to rely on the accuracy of coding.
    Admission with UTI may have increased but UTI may not be only one reason for admission. What about the other coexisting conditions and social problems with those patients?
    Regarding vaccine preventable pneumonia it is difficult to prevent pneumonia just with vaccination as Pathogens are usually variable.
    Gastroenteritis - if a patient is significantly dehydrated what would be the best treatment for the patients? Keep him in the community and wait for complications to develop or refer him to hospital for better care and close monitoring?
    We probably will need to do much more work on :
    Working together and supporting GP and social service to enhance their ability rather than coming up with different projects and plans that probably will be ineffective.
    Improve effective communication among the primary, intermediate, social care and secondary care providers.
    Faster outpatient appointments so early intervention
    Stronger community service that forms a strong bridge between the GP and the secondary care.

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  • If these admissions are actually so inappropriate then why do the hospital doctors admit them and generally keep them for several days or more?

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