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A faulty production line

Many emergency admissions are avoidable, Government watchdog finds

Many emergency admissions are avoidable and many patients stay in hospital beds longer than necessary, a major review by the Government auditors has revealed.

A review by the National Audit Office found that there has been a 124% increase in short-term emergency admissions in the past 15 years, which is now costing the NHS £12.5bn a year.

It recommended that NHS England and the DH must address staffing issues and should examine what the barriers are to seven-day working in emergency departments.

The report found a number of reasons for the increase in admissions, with the four hour waiting target, which compels hospitals to see 95% of patients attending A&E within four hours, ‘one of the main reasons’.

The auditors said the target had improved waiting times, but had led to people being needlessly admitted into hospital, with a quarter of people attending A&E being admitted between 3 hours 50 minutes and 4 hours of arriving.

Other factors for the increased admissions included: a lack of effective alternatives to admissions, an increase in elective procedures as day cases, which means complications were dealt with as an emergency admission; an increase in the frail elderly population; increasing pressure on A&E departments in general; and a change to ‘payment by results, which ‘may have given hospitals a financial incentive to admit more patients’.

It is also found that GP referrals to A&E had reduced by 34% since 1997/98, but found there was still variation in GP referral rates.

The NAO concluded: ‘Many admissions are avoidable and many patients stay in hospital longer than is necessary. This places additional financial pressure on the NHS as the costs of hospitalisation are high. Improving the flow of patients will be critical to the NHS’s ability to cope with future winter pressures on urgent and emergency care services.’

The report recommended that NHS England and the DH must address staffing shortages. It said: ‘The Department, NHS England, Health Education England and NHS trusts need to develop both short- and long-term strategies to address staffing shortages in A&E departments. In the short term, this may involve changing the mix of staff in A&E, for example greater use of geriatricians. In the longer term, the Department needs to consider how more doctors can be encouraged to work in A&E departments.’

It also found that the current consultant contract remained a barrier for reducing emergency admissions.

It said: ‘The Department and NHS England should examine what the barriers are to seven-day working in hospitals and take action to remove these barriers. For example, the Department should review the consultants’ contract, which gives consultants the right to refuse to work outside 7am to 7pm Monday to Friday.’

Dr Angelo Fernandes, the RCGP spokesperson on emergency care, said: ‘There is an acute shortage of emergency medicine consultants now, but there’s just as much of an acute shortage of emergency medicine trainees. So there aren’t people coming into that profession, and we can’t fill the places that we’ve got.’

Speaking to the report’s recommendation to renegotiate consultants’ out of hours contract, Dr Fernandez added: ‘When you talk about out of hours in all these different documents, they’re not talking about GP out of hours; they’re talking about out of hours in hospitals. There’s enough evidence to suggest that the [current] out of hours in hospitals results in worse outcomes for patients.’

‘The case for change in hospitals has been long made, in terms of seven day working. The question is, how do you do it within the staffing you’ve got, and the resourcing you’ve got?’

Professor Keith Willett, director for acute episodes of care for NHS England, said: ‘We are an ageing population and the majority of those requiring emergency admission are our elders and those who are frail; very often they have increased care needs as much as a medical need.’

‘As the report recommends, we must collectively take substantial steps to ensure patients receive the best possible care preferably out of hospital but also when necessary in hospital. To achieve that it is clear the way we provide health and social care must change so our hospitals, GP and community services have the space to do that.’

Readers' comments (8)

  • Well spoken Dr Fernandez. The problems have been caused and exacerbated by Hunt and his cronies as well as managers at the DoH. What do they do? Make the problem worse and then blame the doctors.

    Tick the box and send them to any country that would take them.

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  • Can I recommend this to splashed liberally over every broadsheet for the next 3 months - GP ADMISSIONS TO A>E REDUCTION 34% since 1997

    Mr Hunt's lambasting of the 2004 contract as a reason for more admissions/attendances makes no appearance here

    That fallacy has become gospel truth in the population due to media manipulation


    some revenge needs to be served cold loud and proud

    where are our GP political Leaders? WHY HAVE THEY NOT SEIZED THIS?

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  • So the DOH is preoccupied about the shortage of A+E staff .

    What does it think will happen if it precipitates a shortage of GPs ? Admissions will rocket. The NHS will collapse. The DOH better start rolling back some of its' pronouncements and start showing it values General Practice. Many of us are hanging on, hoping there will be a sign from the DOH that our practices have a future and more resources will be found for us. We will not hang on forever. Once we go, primary care will go into a death spiral .

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  • News that there are too many emergency hospital admissions in England highlights the urgent need for better management of care for patients with long-term conditions.

    By offering the right care, in the right setting and through improved self-management supported by teams of primary, acute and community health care professionals working together, hospital admissions – both planned, and unplanned - can be averted.

    The real issue at the core of the problems the NHS is facing is the need for an integrated care system, where the key components of patient-centric services are joined together with health coaching providing a human mechanism to sit at the centre and evaluate all available, linked data, and identify areas where technology can help reduce costs, improve care pathways and get care delivered to patients in the home. This is a far more sustainable way of delivering care and critically supports patients before their condition exacerbates and they become an emergency admission.

    This type of integrated care system furthermore provides the facility for a supported discharge, when hospital attendance is unavoidable. Focusing on the holistic needs of the individual patient ensures that services are in place to prevent readmissions from occurring. All of this can be achieved by Health Coaching models focused around the holistic needs of the patient, not just specific disease care, and is already proving to have deliverable results.

    Leicester City CCG has successfully averted a total of 134 hospital admissions since December 2012 through a scheme combining telehealth with a health coaching programme for support of COPD patients and has benefited from a saving well in excess of £500,000 to date.

    Wendy Lawrence, CEO, Totally Health

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  • Well when I were a lad we saw 70k+ one consultant a staff grade and six sho's and that went on until the mid 90's in many places oh for the old days

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  • Oh dear, oh dear, Jeremy. It was always going to catch up with you and your mates in government.
    Not having a true understanding of the health service and how it has got to where it is-and worse not caring.
    Having an agenda to get their votes and not improve their care.
    34% decrease in GP referral past 15 years- try to old chestnut that patients now self refer because they cannot get a GP appt but remember the GP dose not admit -it is the hospital staff so there would not be a decrease in total admissions.
    Fewer attendences to A+E depts over past 10 years- falsely hiddden by secondary care now counting attendences differently.
    5% increase in A+E consultants annually over same time.
    But the reason needed is that the cases are more complex now !!!
    Who the hell do you think has been managing these poor frail individuals in the community to allow them to become so complex before going to hospital -usually as a last resort or as result of a crisis whic for your information can occur for many reasons other than illness.
    Your response is to blame the hard working GPs and community staff. =9% total budget- all to win votes.
    Think it is about time you move, although and one else is likley to be equally uninformed .OR- try something radical like look at hospitals, work with both primary + secondary care- listen to those experts who are at the coal face and make a difference. !!
    ps - really loved presentation of results of the GPs extended opening -8am -8pm 7 days a week to the public. Especially now that we all know the pilot has not started !!

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  • Anon 9 33
    The recent study which clearly showed telemedicine did nothing to prevent COPD admissions must be a little hard to take !!!

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  • I thought A&E stood fro 'accident and emergency, so if a patient has an emergency, A&E is where they are supposed to go!

    I regard myself as a vulnerable person with multiple health needs, I consider myself to be 'old' and in need of a lot of support from my GP.
    With all my ongoing problems, I have never needed to see my GP on during an evening or weekend.

    I have used A&E many times but have always been admitted for a problem that my GP could not have managed, he would have had no choice but to call an ambulance.

    The mention of encouraging doctors in elderly care, surely all doctors should be trained to deal with all ages to ensure they have a wide range of skills? What is the point in having a geriatrician in A&E when the patients is a child? Lets have doctors that care fro the human body regardless of age!

    Lets have joined up working, having been admitted for a cardiac problem and having a chest problem too, my cardiac issues were dealt have to be discharged and come back to have the chest problem seen to, why couldn't I have seen somebody whilst I was under one roof, rather than be given pain killers?

    Hospitals only deal with bits of the body, if I broke my leg and attended hospital, then had a cardiac arrest, would they allow me to die whilst the applied a plaster cast!

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