Intended for healthcare professionals


Rising hospital admissions

BMJ 2010; 340 doi: (Published 02 February 2010) Cite this as: BMJ 2010;340:c636
  1. Stephen Gillam, general practitioner
  1. 1Institute of Public Health, Cambridge CB2 2SR
  1. sjg67{at}

    Can the tide be stemmed?

    Whoever wins the next election, years of famine are upon us. Budgetary belts are tightening in anticipation. All the more disquiet therefore attaches to a report from consultants Caspe Healthcare Knowledge Systems (CHKS; an independent provider of healthcare intelligence and quality improvement services) that, “threatens bankruptcy for the NHS.”1

    The growth in hospital admissions for elective and emergency care apparently rose by an average of 6% in England between 2007-8 and 2008-9.1 This compares with an average annual growth of 4.6% for the preceding three years, and it is mirrored by similar rises in Wales and Northern Ireland. Emergency admissions, which are inherently less susceptible to manipulation and therefore the main cause for concern, formed the bulk of these increases. Three simple questions present themselves. Firstly, are these hospital episode statistics reliable? Secondly, if so, what is driving these increases? Lastly, what can be done to reduce unnecessary use of hospital services? Unfortunately, the answers are not so straightforward.

    Hospital admission rates have long been of concern. Earlier supposed increases in emergency admissions were mainly attributable to internal transfers after admission.2 The figures have also been artificially boosted by coding differences and the conversion of patients who exceed the four hour emergency care waiting target into admissions, but this seems unlikely to explain these rises. Short stay admissions may account for much of the surge in emergency admissions.3

    To some extent the NHS is a victim of its own success. Increasing capacity and shortening waiting times have probably increased public expectations and lowered referral thresholds. Demographic change is tending to increase healthcare needs in older age groups. Political rhetoric that promises choice has encouraged the use of health services while simultaneously requiring frontline practitioners to contain exactly those expressed needs. Fragmented out of hours primary care was one predictable consequence of the contract for general practitioners introduced in 2004. Seasonal factors affect admission rates for respiratory and other conditions, but subtler influences may be contributing.

    A multitude of new access routes (from nurse led community based services to NHS Direct) have eroded the gate keeping function of general practitioners. The advent of the quality and outcomes framework is likely to have had paradoxical consequences. Improving the quality of chronic disease management should reduce hospital admissions, but the incentives to identify and treat earlier disease may counter this. The labour of once expert generalists is being divided among salaried doctors, specialist nurses, and others. What might be termed the “clinicisation” of general practice—polyclinics in process if not in structure—is compromising continuity of care and reducing access to just those practitioners who may be able to contain and manage comorbidities in the community.

    This year emergency admissions in excess of baseline 2008-9 values will attract only 30% of the relevant tariff, thereby reducing hospitals’ incomes. It remains to be seen how marginal tariffs will affect activity rates. So what else can be done to reduce demand for hospital admissions? The answers often involve general practitioners.4 If they can be persuaded to improve their management of “ambulatory care sensitive conditions”5 and reduce referrals (for example, for elective conditions by use of structured guidelines), admission rates may be reduced. Various reviews have examined the research in support of different approaches to demand management (box).6 Suffice to say, the evidence is limited.

    Approaches to reducing unplanned admissions with a limited evidence base

    • Education in self management

    • Managed care programmes

    • Integrated health care and social care

    • Coordinated discharge planning

    • Multidisciplinary case management

    • Specialist nurses

    • General practitioners in the accident and emergency department

    • Referral guidelines

    • Referral management centres

    • Telecare

    The CHKS analysis showed large variations between different primary care trusts. Fifteen saw cuts in their admissions for 2008-9, but little is known about why. Attempts by primary care trusts to drive down referral rates have involved the use of local enhanced services agreements that link payments to target reductions. It is hard to envisage an equitable system of referral quotas given the quality of most referrals data, which are not adjusted for age and sex differences between practice populations. Other widely used approaches are general practitioner services in the casualty department and local referral management centres.7 Disappointingly few evaluations of local policy initiatives are available to guide commissioners. Without a clearer understanding of causes and solutions, crude systemic responses may generate perverse consequences for patients, breaching the principle of treatment according to greatest need.

    Practice based commissioning affords potential levers to provide early intervention in the community, but savings in secondary care expenditure are seldom visible. Not surprisingly, enthusiasm for commissioning is limited. General practitioners are reluctant to accept liability for overspends for which they do not feel responsible. Conservative proposals to firm up budget holding at practice level are one favoured solution, but the effect of fund holding on referral rates was equivocal.8 More radical alignment of financial incentives would involve capitated budgets for all primary care and secondary care in a similar manner to integrated care organisations in the United States.9 This would help relocate many hospital based specialist services into the community.

    With the NHS facing a projected shortfall of £8.4bn (€9.7bn; $13.4bn) for 2010-1,1 politicians must be hoping for patient restraint in times of austerity; simply telling the public how much an inappropriate visit to the accident and emergency department costs would be a start. Tough measures may indeed be part of the solution; on the “burning platform,” the previously unthinkable (hospital closures) may become acceptable. In the meantime, prepare for longer waiting times.


    Cite this as: BMJ 2010;340:c636


    • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No Non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Commissioned; not externally peer reviewed.