No good evidence yet that this trend is inappropriate

The National Association of Health Authorities and Trusts reports that providers of secondary care are under pressure from ever rising numbers of acute medical admissions, which were up between 7% and 13% from average rates during 1993–4.1 This is not a recent concern: the Audit Commission, extrapolating from routinely collected hospital data, predicted a doubling of acute admissions to Birmingham hospitals between 1987 and 1996.2

The National Association of Health Authorities and Trusts suggests that the probable causes of the increase include more detected illness, raised expectations of general practitioners (especially fundholders), premature discharge, and worries over litigation. Others point accusingly to variations in general practitioners' referral rates; Acheson was irritated in 1985 that “a phenomenon so gross can continue to defy analysis.”3 Fundholders are accused of protecting budgets, although they generally do not have to pay for emergency care.

Unfortunately, evidence to illuminate this issue is scarce. Although a substantial body of research exists on total referrals to hospital, remarkably few data exist …