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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.’