Reducing emergency admissions: are we on the right track?
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6017 (Published 18 September 2012) Cite this as: BMJ 2012;345:e6017
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This article makes some very valid points about attempts to reduce hospital admissions which have focused on case management of high risk patients. However, the authors do not appear to come up with any practical solutions to a problem which will only worsen with our ageing population. Surely focusing on these patients is the only way we can make any impact on the problem in the immediate future. These are the patients we are striving hardest to keep out of hospital but who still require repeated admissions and longer stays in hospital.
In our practice we have focused on our high risk patients but have been led by our secondary care physician to develop a virtual ward approach. This allows us to have an integrated model to improve the management of our high risk patients in their own home even when a crisis develops.
With the input of our consultant physician and community nurses we have shown a significant reduction in our admission and readmission rates since setting up our virtual ward.
I accept we are a small practice and as such our small numbers make it difficult to be sure the reduced admission rates are a result of our interventions alone. However, I feel certain that closer working with our secondary care colleagues, with the shared aim of reducing unscheduled admissions of high risk patients, is currently the only practical solution to the problem of increasing hospital admission rates.
Competing interests: No competing interests
To reduce emergency admissions we need firstly to challenge the notion that a patient reaches a certain absolute threshold of illness that then requires admission. The reality is far more complex. Often I find myself phoning the hospital to discuss(some doctors may be more assertive than that)a possible admission because I seem to have run out of available options for furthering the management of an ill patient in an acceptable time. I may just need the diagnostic facilities eg a scan, x-ray or blood test, to be done in the next few hours and it is invariably hospital doctors that have that luxury. With diagnostic help I could probably often treat the patient at home. A hospital doctor, especially if relatively junior, needs the patient to be 'parked' in hospital bed, for this often what an admission amounts to, while diagnostic tests are arranged and results discussed. They then then feel they ought to treat the patient, who has become a passive recipient in a bed, in hospital and the patient can't go home until a 'discharge' is arranged and if the patient is elderly the ward staff worry that they won't be able to cope back at home. All very inefficient, and the elderly patient rapidly becomes even less able able to cope just by being in a bed for a day or two. Another 'threshold' factor is that doctors often feel that they must make a decision on diagnosis and management on just one consultation. A re-visit to review the clinical signs and symptoms a couple of hours later could prevent an 'admission' but the doctor may not think that is an option and doesn't want to make work for another doctor taking an out of hours shift for example. There is probably no incentive for the out of hours service to re-visit patients or even to get a second opinion from a more experienced GP. I conclusion there is lot that can be done by GPs to reduce emergency admissions but we will need to get away from the mind-set that there is an absolute admission threshold.
Competing interests: No competing interests
Roland and Abel's article is to do with risk reduction of emergency admissions.
A more productive approach would be to look at the narratives of the individual patient in relation to the run up to the admission. A careful history on the post take ward round can point out instances where that admission might have been avoided.
These seemingly preventable admissions are not infrequent and more should be done about them, for instance, data about them should be recorded and fed back to the GP concerned.
Unfortunately the NHS is becoming increasingly fragmented and the GPs are no longer able to be responsible for their patients in the way that they used to be.
If this responsibility for their patients could be restored to the GP, focusing on preventable admissions would make more sense than it would do at the moment.
Although a cliche, joined up handwriting is urgently required in the NHS
Competing interests: No competing interests
The analysis of the authors in the article “Reducing emergency admissions: are we on the right track” (BMJ 435 29 Sep 2012) is right on the mark.
Like their political forefathers who tried to link an improvement in the health of the nation - brought by ‘cradle to grave’ healthcare provided by a National Health Service - with an eventual reduction in healthcare costs, current politicians continue to feel that improving access and quality will help control the cost of healthcare.
Though I empathize with the naivety of their predecessors, current health planners should have learnt that the goals of improved quality and access, however laudable, only leads to greater demand for healthcare.
Even it wasn't for the greater health and care needs of an aging population, improved health awareness, varied and sophisticated diagnostic and therapeutic procedures, and better imaging and diagnostic investigations would inevitably lead to an up-spiraling of costs.
I am afraid, it will certainly take a much more informed debate on what in health and social care is the responsibility of society and what is down to the individual, before we have any hope of striking the right balance.
Competing interests: No competing interests
It was not clear to me what was meant by an emergency admission. I could see
1. The unexpected emergency unpredictable by current knowledge and practice e.g. RTA, perforated peptic ulcer, myocardial infarction, 1st episode schzophrenia
2. Unplanned and unanticipated but are patients whose illnesses are already known to community services
3. Planned but not individually anticipated such as a diabetic service expecting and providing for a certain number of emergency admissions a year but not knowing in advance which patient would be admitted
4. Planned admissions that become urgent
As the article explains it follows that a hospital accepting emergency admissions should be able to calculate its annual admission demand (to include an allowance for year on year increase).
If we do not wish to admit we must provide those services currently only provided by the hospital at the patient residence and that the posssibility of reducing emergency admissions is severely limited if this does not or cannot happen.
When current supply of emergency services is closely matched to average demand then queues will frequently and rapidly build up and can prove difficult to disperse. The mathematics of queuing theory that would illuminate such findings seems to absent from NHS theory and practice.
Risk averse primary care should not affect admissions as triage at A&E should only allow the admission of those actually needing that service.
Lastly even in such a sympathetic article phrases such as 'frequent fliers' should not be used. This is one of a number of stimatising terms current in medicine, and represent disgraceful medical prejudices particularly against the older patient.
Competing interests: No competing interests
I am not surprised at the findings of Martin Roland and Gary Abel suggesting that all previous interventions to reduce admissions often showed little effect. Our practice, which has 13,200 patients, has carried out three audits in the past year on 100 consecutive discharges from the local acute hospital (planned and emergency admissions). All three audits have shown that nearly 70% of patients had not been admitted by GPs. Sources of admission were:- from out of hours providers, from hospital outpatient clinics, from walk-in clinics, planned, A & E departments and unknown sources.
We have reviewed the data on all patients admitted by the partners in the practice and only 5% of the admissions could have been prevented. However, we have not been able to comment on the admissions from other sources as we are not privy to the presenting complaints to the hospital at the time of admission.
The gatekeepers to the hospital have now disappeared since the new GP contract and whatever efforts GPs make to reduce admissions they are not going to be productive as there is no control over the other stakeholders who refer patients to A & E or admit patients to hospital, and there are no governance arrangements to audit their work.
The solution is not going to be simple as we are never going to return to the old system where GPs were the gatekeepers for hospital admissions. Recent reports of a single GP providing out of hours care to between 300,000 and 500,000 patients will not help the situation as in the past GPs covered between 2,000 and 10,000 patients. They knew the patients and their medical histories and took calculated risks in managing patients in the community, followed them up by revisiting them or reviewing them in the surgery rather than admitting them to hospital.
Dr. I. A. Lone
GP Middlesbrough
Competing interests: No competing interests
Roland and Abel’s contribution to the literature is welcome. What a pity that Roland’s earlier published thoughts had not been constructed prior to the imposition of the Quality Improvement Programme Indicator 13 (QP13) forced onto us general practitioners as part of our “voluntary” activities to maintain practice income.
Three weeks ago in this rural area a doctor from each of nineteen constituent practices of the Clinical Commissioning Group (CCG) spent three hours discussing attendances of our patients at Accident and Emergency (A&E) departments and ways of reducing those attendances. The official chairing the meeting, “Programme Manager, Local Business Change” inviting every attender to read out details of the reactions of each practice to details of each practice’s patients attendances. We had been required to submit these thoughts by email by a deadline several months ago. That earlier task had been made more difficult by the CCG providing the details of the patients’ identities by NHS numbers only, apparently for reasons of security. The information was sent to all practices by NHS.net which is said to provide a secure environment in which to send such information. The absence of names of patients created a lot of work for practices to identify the patients to prepare a response to the CCG.
The reason, of course, for the one hundred per cent attendance of a representative, in some cases more than one from each practice, from each practice was to ensure payment under the quality and outcomes framework (QOF). The homework given to those attending was to return and discuss with members of their own practices ways of reducing attendances at A&E. Of course no clear consensus emerged from the meeting.
The implicit value of Roland and Abel’s paper on the more general matter of reducing hospital admissions is that CCGs may be wasting clinicans’ time and administrative monies merely to comply with yet another Department of Health target
Competing interests: General practitioner struggling with the concept that the Quality and Outcomes Framework (QOF)is a voluntary activity
Roland and Abel’s paper brings much-needed rigour to the whole discussion of emergency admissions, particularly in their call to reconsider potentially faulty assumptions. One confounding factor not discussed is the nonsensical way in which emergency admissions are funded. The Department of Health, in 2010, published a 68 page document curiously titled ‘A Simple Guide to Payment by Results.’ This paper reminds us that, from 2010-11 providers have been paid a marginal rate set at 30% for increases in emergency activity. This tariff is still in operation and means, in simple language, that for admissions above contract, providers will be paid just 30% of the usual rate. This is too rarely acknowledged by those who criticise acute Trusts when patients wait on trolleys or when ambulances queue to unload.
The last Government’s tortured logic was that the reduced tariff would deter acute Trusts from trying to increase admissions as a way of increasing their income. Even at that time it would have been difficult to find many acute Trusts that didn’t have more emergency work than they could handle; they also have little control over who arrives at the ‘front door.’ Since 2010 we have seen increasing admissions with decreasing numbers of available beds. The prevailing ‘wisdom’ is that work should transfer from hospital to community and that funds should move in parallel. What has happened instead is that the purchasers/commissioners have been able to get extra emergency admissions for much less money whilst the acute Trusts bear full costs for all the admissions and are punished for failing targets which prove impossible to meet as admissions increase beyond expectations.
This state of affairs hardly gives purchasers/commissioners much incentive to reduce emergency admissions, even if the reasons for doing could be validated. If, as Roland and Abel suggest, the usual reasons for manipulating admissions are unproven, the current system of payment is doubly damaging.
Competing interests: No competing interests
I think this is a well written article on a topical subject, especially in primary care, more so in the recent past.
I feel the approach which has been taken across the NHS in primary care to reduce emergency care is a somewhat naïve one. It’s quite obvious with the majority of the patients that they are not keen on getting admitted, given an option they would prefer to be managed in the community. With the current commission groups, unsurprisingly realising, the cost of emergency admissions are trying to highlight the issue among surgeries. In some regions there is name and shame of practices with high emergency admissions (I am not sure if there is carrot shown to some practices in some regions).
But the root cause has to be dealt if we want to see long lasting results of reduced emergency admissions. Services which are lacking in the community need to be looked at. There should be planned measures regarding how to put these services back into the community, which patients can then access when in need. Thus they can be dealt with in the community and don’t end up ringing 999 and getting admitted to hospital (unwillingly most of the time).
We get monthly PARR data for our practice patients; we have monthly MDTs (multidisciplinary meetings) to reduce emergency admissions. We do try to discuss how to rectify potential problems for patients to reduce future admissions. But there is a great shortage of various services in the community, which needs to be addressed to see real benefits.
Competing interests: No competing interests
Re: Reducing emergency admissions: are we on the right track?
This excellent and well balanced article and the responses which it has elicited provide an excellent overview of a problem which stretches back many years.
The section 'Thinking that we know what to do' presents the opportunity to consider where the cause of the problem may lie. Figure 1 of this article depicts a 10 year trend in emergency admissions between 2000/01 and 2010/11 where there are two step-like increases around 2002 and 2007.
Recent analysis has shown that these step-like events occurred across the whole of the UK (1-9) not just England, and can also be seen in Australia, Canada and USA (10-11) and also in Austria, Estonia and Switzerland (unpublished). They are confined to a cluster of medical conditions (5-7, 12) and are age and gender specific (7-12) and initiate profound shifts in costs (9,11,14,15). Even more telling is the curious observation that they are associated with a change in the incidence of particular cancers (16) and spread across the UK of increased GP referral to particular conditions (17,18) and a synchronous but temporary increase in deaths (19).
Is it possible that amidst the relentless barrage that the problem is to do with a lack of 'efficiency' (partly true) that we may have missed a far more fundamental cause?
References
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Competing interests: The author provides consultancy services to health care organisations.