Analysis

Emergency admissions – why targets to reduce them are not being met

Investment in social and intermediate care is essential to meet NHS England's goal of decreasing the number of emergency admissions by 2020, say health experts

Investment in social and intermediate care is essential to meet NHS England's goal of decreasing the number of emergency admissions by 2020, say health experts


Picture: iStock

The unrelenting focus on the four-hour emergency services waiting time targets can mask the fact that there are other important indicators of the health of the system.

While the numbers coming through the door of an emergency department (ED) matter, the patients that have most impact on the workload of staff are the emergency admissions.

As a result, the government set the health service a target of reducing them by 2020.

To help the NHS make progress towards this goal, the rise in emergency admissions should be limited to 1.5% for this year (2017-2018), down from 2.1% the year before, the government says.

But data published for 11 of the 12 months so far suggests that this interim target will be missed.

Sustainability challenges

5.8 million

emergency admissions in 2016-2017, in England

The National Audit Office (NAO) warns that the lack of progress poses a ‘serious challenge’ to the sustainability of the service and its finances.

What has gone wrong? A number of national programmes have been developed to try to stem the rise in admissions.

These include the Better Care Fund (BCF), a pooled pot of money shared between councils and the health service, NHS England’s urgent and emergency care programme and the new models of care being trialled under the Five-Year Forward View (see Box 1).

But the NAO says these are making limited progress.

Box 1. Three-pronged plan to cut admissions

Better Care Fund

Launched in April 2015, the government scheme encourages councils and the NHS to pool local budgets. The size of the pot has grown from £3.8 billion to £5.9 billion this year. One of the express aims is to fund social care packages that relieve the pressure on hospitals.

Urgent and emergency care programme

NHS England’s response to the struggles emergency departments (EDs) have experienced in recent years, the programme includes greater clinical involvement in the NHS 111 service, dedicated call lines for care homes, streaming away from ED, GP evening and weekend opening, and hospital staff providing assessments in the community.

New models of care

Developed as part of the Five-Year Forward View, the programme is seeing many areas piloting different ways of working, including super GP practices encompassing nurses, community services and hospital staff, and integrated systems involving primary, secondary and mental health providers.

 

Data on the BCF shows only 32% of local areas had met their targets to reduce emergency admissions, while NHS England was ‘unable’ to demonstrate that the interventions in place under its urgent and emergency care programme, which includes greater clinical input into NHS 111 and GP evening and weekend opening, had led to a slow down in admissions.

£13.7 billion

the cost of emergency admissions in 2015-2016

Some of the new models of care appear to have seen slower increases, the NAO says, although there was ‘considerable variability in performance’.

The watchdog also flagged up the differences in admission rates between areas. The NAO said even after controlling for demographics, deprivation and health needs, the number of admissions per 1,000 people ranged from 73 to 155.

'To be expected'

RCN Emergency Care Association chair Janet Youd says to some extent this lack of progress is to be expected.

‘It’s going to be hard to reduce emergency admissions. The patients who are being admitted are genuinely sick. We are doing all we can to turn them round quickly.

‘But what we need now is a massive investment, particularly in step-up and step-down services and social care.

‘That could make a difference to the numbers coming in and our ability to get them out of hospital. But even with that I would question whether it is realistic to expect the number of admissions to fall.’

The NAO agrees with her. It pointed to the need for investment in social care and intermediate care.

A recent audit of the latter found that, despite strong evidence of the effectiveness of the service, there had not been ‘any step-change’ in investment in recent years and because of higher costs the number of intermediate care beds had fallen by one quarter to 20.9 per 100,000 since 2015.

‘People – particularly older people – are not getting the support they need in the community, which leads to more emergency admissions and dangerous levels of bed occupancy when demand is high'

Donna Kinnair

RCN director of nursing policy and practice Donna Kinnair says this is part of a wider squeeze on community services that has been happening for years.

‘There has been a 15% drop in the number of full-time equivalent nurses working in community services in England between 2010 and 2017.

‘People – particularly older people – are not getting the support they need in the community, which leads to more emergency admissions and dangerous levels of bed occupancy when demand is high.

‘Keeping people out of hospital when they can be treated at home or in a walk-in centre should be a priority. Yet services are not up to the task.’

Saffron Cordery, deputy chief executive of NHS Providers, which represents trust chief executives, agrees. ‘NHS community services are central to the ambitions to improve preventive care and deliver more care closer to home,’ she says.

‘Although there is some excellent work, it’s clear that historically community services have not been given enough priority and have been underfunded. That must change.’

If it did, the impact could be profound, the NAO suggests. Overall approximately one quarter of emergency admissions are considered preventable.

But NHS England medical director for acute care Keith Willett has defended the record of the authorities.

He says that while reducing admissions remains a challenge, it could have been even worse if it wasn't for the programmes that have been introduced.

Professor Willett also points to the fact that in financial terms the cost of emergency admissions has been curbed.

2.1%

increase in emergency admissions between 2015-2016 and 2016-2017

Between 2013-2014 and 2015-2016 the financial burden of emergency admissions rose by more than 2% to £13.7 billion, compared to the 7% rise in numbers.

Same-day discharge

The increasing efficiency can be largely put down to the fact that growing numbers of patients do not stay overnight – one in three are now discharged on the same day.

Professor Willett says that is a sign that admissions are being managed ‘more efficiently’.

The NAO acknowledges that this could be the case, but there could be another explanation too.

It says there is some evidence that the number of readmissions is rising which can be an indicator that patients are being rushed out and not properly supported.

One thing is certain: there remains much work to be done on emergency admissions.

Case study – how one area has reduced emergency admissions

A new phone service has had a major impact on emergency admissions and emergency department (ED) attendances in Cambridge and Peterborough.

The First Response for Mental Health scheme sees those people who call NHS 111 choose a special new local option where they are put through to a dedicated team and pointed to the right place for treatment avoiding ED where appropriate.

To support the service, the area now has two sanctuaries with outreach facilities for rural areas which provide a safe space for people in crisis available all year round from 6pm to 1am.

An evaluation last year of 10,000 calls found 25% fewer people needed to go to an ED and 19% fewer needed to be admitted to hospital.

There was also a 16% reduction in the number of overdoses. It is estimated this could save the local healthcare system between £2.2 million and £4.7 million a year.

Cambridge and Peterborough mental health lead Emma Tiffin says: ‘Ensuring that people are accessing the right service at the right time is important to reducing costs, duplication and confusion.

‘Above all, it means that patients will have a better experience of care and better outcomes first time.’

 

Further information


Nick Evans is a freelance health writer

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