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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.’