It's not as if we are not trying to reduce our need for emergency care. The past decade has seen a host of initiatives, innovations, policies and practices that should be helping to avoid the sort of health crises that lead to an emergency admission to hospital.
But have these worked? A recently published paper by the Nuffield Trust used a standard measure of health service performance to see what changes had occurred over the past decade.
The analysis looked at emergency hospital admissions for conditions where good quality preventive care might have been able to avoid the need for admission. These conditions are known as ‘ambulatory care sensitive’ (ACS) and the list includes familiar chronic conditions such as diabetes as well as acute health problems.
Though some level of emergency admissions is inevitable, the theory is that the better health systems minimise the rate of admission for these problems. This approach to monitoring preventive care has been around for some time and has been widely used around the world to look at how health systems perform.
Indicators based on these can be found in the latest Department of Health outcome frameworks and in the more recent NHS Commissioning Board guidance on the use of quality premiums for clinical commissioning groups (CCGs) intended "to reward clinical commissioning groups for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing inequality."
Our analysis looked at changes in the levels of these admissions over a period of ten years for all of England, using data on approximately 46 million admissions.
The results showed that firstly, there was no evidence that health care policy over the past ten years had led to overall reductions in emergency admission for these conditions. Between April 2001 and March 2011 the number of admissions for ACS conditions increased by 40 per cent – in line with the general rise in emergency admissions.
However, within this big picture there was some good news for some conditions where it is possible to see reduction in admission rates.
In most cases the conditions with falling rates are ones for which there appears to be documented progress in improving the populations’ health status and/or treatment options – for example, heart disease, peptic ulcer etc.
This good news is tempered by changes in other groups where admission rates have increased – and on a much greater scale.
Some of the biggest increases are in conditions such as urinary tract infections or pneumonia – relatively non-specific diagnoses amongst older people. These are areas where we suspect the underlying population need has stayed the same, but the ways that we deal with the problems have changed – something that is manifest in the use of emergency admissions.
As in other cases the demand for care is not the technology of treatments or underlying need, but the way the health systems operates.
For those clinical commissioning groups striving to get their quality premium, our study contains some clear pointers about which groups of patients they will need to target. We also know that there are differences around the country in the way these indicators behave – for example, some ACS measures are strongly linked to deprivation.
For us, this national overview is only the start of the story in understanding variations around the country and the underlying reasons. We are planning further work to explore what this tells us about changes in quality of care in the years of financial hardship we see ahead.
This blog was also published on GPonline.com