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Gold, incentives and meh

Surge in non-elective hospital activity hits CCG budgets          

CCGs are facing added financial pressures because of an unexpected rise in emergency admissions and a further rise in A&E attendances, a Pulse analysis of Hospital Episode Statistics data for England suggests.

The analysis, which compared the latest HES data with previous reports, reveals that between April and July this year A&E attendances increased by 5% and emergency admissions (including admissions via A&E) by 3.7% compared with the same period in the previous year.

This reversed the previous trend of decreasing emergency admissions. Between April and July 2010 and the same period in 2011, there was a slight fall in emergency admissions from 1,750,681 to 1,723,399. However, this increased to 1,786,341 between April and July this year.

A&E attendances continued their increase from 29.2m in April-July 2010 to 29.4m in April-July 2011 and 30.9m in April-July 2012.

The figures will come as a blow to the Department of Health, which in 2010 set GPs a target of cutting A&E attendances by 10% by the end of 2013, as well as a cut in unscheduled hospital admissions of 20%. At the time the DH’s clinical lead for quality and productivity, Sir John Oldham, warned there was ‘no plan B’.

Dr Michael Dixon, president of NHS Clinical Commissioners, said the figures were ‘disappointing’. He said CCGs `would be worried about financial pressures’ posed by emergency admissions, although they would not have to meet the full costs if these admissions rose beyond a certain point.

He said: `You can only keep people at home who would otherwise need referral if you have got good community resources. To date there are insufficient resources in the community, particularly if patients are frail and elderly or have complex conditions.’

He said there were places where unscheduled admissions were being avoided successfully but that support for patients ‘costs money, takes time and needs considerable will to set up’. Once it was set up, care could be `cheaper and better’, he said.

Dr Agnelo Fernandez, urgent and emergency care lead for the RCGP and joint chair of Croydon CCG, said emergency admissions were going up `everywhere’ and CCGs needed to explore the reasons behind the rise, although he cautioned that ‘GPs are not likely to be a factor in rising admissions’.

However, he added that primary care could have an influence on A&E attendances so the conversion rate of A&E attendances to admissions should be studied to identify `how much is patient factors and how much is the behavioural factors of clinicians’.

Dr Beth McCarron-Nash, a former GPC negotiator and a GP in St Columb Major in Cornwall, said the rise in emergency admissions should not be seen as a reflection on the new quality and productivity indicators introduced in the QOF.

‘It’s unfair to say the rise means the QP indicators have failed because we never thought that they would make a huge difference,’ she said. ‘The QP indicators were about looking hard at the data, understanding the patters and making a plan to try and make services better for patients. They weren’t about outcomes.’

A DH spokesperson said: `Eighty percent of in-patients are now in and out of hospital on the same day and the NHS is meeting the challenge of rising demand for services, but it is important that we remain focussed on delivering a good service for patients. Where clinically appropriate, it is better for patients to be treated or continue their treatment at home or in their community rather than in hospital.’

Readers' comments (10)

  • It will be upto GP's via CCG's to commision more community care if that is the answer. I suspect part of the answer is access to GP services. In my area there is a peak in A&E demand on a Thursday afternoon, which is 1/2 day closing for the practices.

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  • I think previous study has NOT concluded simply improving primary care access (i.e. more appointments) will not reduce AED attendance See:

    'Inappropriate' attendance at an accident and emergency department by adults registered in local general practices: how is it related to their use of primary care?
    Martin A, Martin C, Martin PB, Martin PA, Green G, Eldridge S.

    Of course the AED attendance will go up - waiting time is getting longer, secondary care services are cut and becoming incredibly beuraucratic, demand for appointment is increasing etc

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  • Not surprising. No amount of primary care access will stem this tide. A tide of high expectation from the user in a system which is bursting at the seam.The user of the service has no legal or financial consequence for inappropriate use. Most of what we see in daily practice are on the whole with self limiting minor illness or the worried well. You can not contain this. The worm is out of the bag, the rot set in with the new contract! Time to get the user of the service to take some responsibility.

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  • Looking at the data for emergency admissions (QP9) is interesting - and can produce surprises.
    One is the source of the admission: A&E, GP, Consultant via OP, bed bureau - I recognise all of these - but what is "Emergency other means"?
    Another is the high number of patients admitted for 0 days (including 2 infants with the diagnosis of "ankyloglossia" (tongue-tie - had to look that one up!)) where the reason for it being an *emergency* seemed a bit obscure.
    Then again, looking at discharges and matching with the data on time of arrival at A&E might be interesting: if a patient is admitted for under an hour and then discharged, was there any relationship (say 4 hours) to the time of arrival in A&E?
    I appreciate hospitals are in financial difficulties - and have a legal duty to be in financial balance - but the same applies to PCTs and CCGs.

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  • There is absolutely NO incentive for hospitals to turn away ANY patient that claims they need to be seen. The PCT/CCG has to pay the tariff even when a patient has blatantly lied about appointments at the GP surgery. We still operate an open surgery EVERY day Mon- Fri morning where you can sit and wait to be seen and people still pitch up at A& E claiming they 'had to wait 2 days for an appointment' when plainly they did not want to wait in surgery. If A&E were able (and willing) to check with GP surgeries they could halve some of their non-emergency attendances. Everyone is too scared that they will be sued to tell it like it is to people who abuse the system.

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  • 'Everyone is too scared that they will be sued to tell it like it is to people who abuse the system'
    I include myself in this category

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  • We're planning to put a 111 freephone in our A&E reception which we will encourage waiting patients to use when the wait is too long, so they can be 'advised' to go somewhere else if it's more appropriate.
    We also need to start identifying 'inappropriate ' attendances (by first agreeing a set of criteria) and feeding this back to the patients GPs. Maybe they'd then like to feed it back to 'their' patients!

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  • Not exactly a surprise - when GPs are seen as rationers rather than advocates of healthcare - patients will bypass them and go direct to people who are only too willing to provide the care. Utterly, utterly predictable!

    I wonder what the figures are for these 'emergency' attendance increases where GP commissioners have introduced rationing programmes - I'd wager they have higher increases than elsewhere?

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  • With companies like Harmoni running the out of hours service it is not difficult to see why patients turn up to A&E

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  • Maybe it has something to do with A&E constantly discharging patients with no social care package. Not referring them to Rapid Access Chest Pain Clinics along with all the other "GP to kindly arrange..." Things they know we have no easy acces to. That way the patients just keep ending up in A&E to the point they eventually need emergency admission. All whilst we are charged per attendance. The acute trusts are ensuring we cannot in any way meet the unplanned attendance targets whilst creating further work on over stretched GPs. It takes even more time to try to fight this!

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