Understanding trends in emergency care

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Admitting a patient to hospital as an emergency case is costly and often avoidable, yet the number of emergency admissions to hospital has been rising for some time.  Using Hospital Episode Statistics, this project examines the possible reasons for the rise over a five year period from April 2004 to March 2009. The findings from this project were published in July 2010 in the report: Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency?, by Ian Blunt, Martin Bardsley and Jennifer Dixon. 

Findings

The analysis presented in the report shows that the number of emergency admissions across England has risen by approximately 11.8 per cent over the last five years – or by around 1.35 million extra admissions.  This rise accelerated in particular between 2003/04 and 2005/06.

Over the same five year period the number of short-stay admissions (patients admitted for one day or less) increased by a similar number.  The rise in emergency admissions is occurring in patients across all age groups, and across a range of diagnoses.  The short length of stay of the extra cases suggests that less severe cases are being admitted, implying that the threshold for emergency hospital admission has lowered in the last five years. Lower mortality in admitted patients also suggests the same. Selected central policy initiatives and targets do not seem, in of themselves, to have had an obvious effect in accelerating the rate of emergency admissions in England. However, for some individual trusts an association with the A&E target is apparent.

Within England there is significant variation between NHS Trusts – in some, emergency admissions have declined by up to a third while in others they have almost doubled between 2004/5 and 2008/9.  There is also significant variation between PCTs.

The report concludes that the rise in short stay emergency admissions has, in part, been caused by a lowering of the clinical threshold for emergency admissions.  Advances in medical care and management have reduced the length of time patients stay in hospital, which in turn has freed up more available beds and allowed doctors to admit more patients (possibly for reasons such as clinical decisions becoming more conservative or lack of faith in primary care services to monitor patients).

Recommendations

The analysis calls on policy-makers to scrutinise and reform the system of reimbursing providers for care (potentially by the use of capitation payments), craft incentives which encourage providers to keep people well so that admission is avoided, and understand more fully the contribution of inadequate out-of-hospital care to the rise in admissions. 

Local clinicians and managers are called on to review how decisions to admit patients to hospital are made, ensure that shorter stays for admitted patients are translated into reducing the number of hospital beds rather than further lowering the threshold for hospital admission, develop higher quality out-of-hospital care and work with patients to identify how they could be better supported to reduce the risk of ill health and admission.

An expert seminar on the patterns of increasing activity and demand for urgent care was held on 8 June 2010. Follow the links below to download the presentations from this event and to access other resources from the 'Understanding trends in emergency care' project:

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Seminar presentations