David Oliver: Reducing acute admissions—a timely reality check

In March NHS England published Next Steps on the NHS Five Year Forward View, a mid-term report and road map to 2020 of the plan by its chief executive, Simon Stevens, to sustain the NHS in the face of unprecedented crises in funding, demand, and workforce.1

Reducing urgent care activity and hospital beds have been key themes of England’s 44 sustainability and transformation plans (STPs). These are key vehicles for delivering the strategy Stevens set out in the NHS Five Year Forward View. They’ll now be called not plans but “partnerships.”

I welcome Next Steps’ long overdue realism and tempered expectations. It acknowledges inevitable trade-offs between priorities, such as urgent care, cancer care, and elective surgery.

A crucial graph is in the section on integrating care locally.1 This compares data from the 12 months to December 2016 with the 12 months to December 2015 in new models of care vanguards.2 The growth rate of acute admissions per head was only 1.1% in primary and acute care system vanguards, 1.9% in multispecialty community providers, and 3.2% in the rest of England—a lower growth of emergency admissions, not any kind of absolute reduction.

Sadly, many initial STPs make promises wildly at odds with these modest gains. They promise anything from 9% to 30% fewer admissions by 2020 and reductions in acute hospital beds as high as 21%.34 To be fair, Stevens set out a “patient care test” in response, saying we shouldn’t allow further acute bed closures without alternative community capacity to ensure care wasn’t compromised.5

This is just as well, since nobody—neither the STPs’ authors, nor the management consultants hired to tell them this nonsense, nor decision makers in NHS England or NHS Improvement pushing them from the centre—can believe that this is deliverable. The promises are based on how much money must be saved, not on any realistic prospect of delivery.

Promises are based on how much money must be saved, not on any realistic prospect of delivery

Meta-analyses have shown no credible evidence that admissions can be prevented on this scale.6 Recent history has shown annual increases in urgent activity throughout England even as bed numbers fell. Even modest plans to reduce admissions by 3% as conditions for the Better Care Fund failed to deliver.

Even if admission rates can be reduced, little good evidence shows that shifting care closer to home saves money, according to rigorous analyses by the Nuffield Trust.78

If we want to deliver more joined up, preventive care to help patients stay out of hospital or leave sooner, let’s do it. But let’s stop promising undeliverable and non-evidence based reductions in acute hospital admissions.

It’s a shame that Next Steps aims for a return to 95% by 2018 for emergency departments’ four hour target. Another reality check may be needed soon.