Reducing emergency admissions: are we on the right track?

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.

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.

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

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.