An emergency admission is any instance in which a patient is admitted to hospital either immediately or with very little notice. In the past 15 years emergency admissions across the UK have risen by 47% and currently cost the NHS £12.5 billion. This is a figure that is likely to grow with increasing demand. 71% of all admissions in the UK are currently a result of A&E departments, with almost all of the increase in emergency admissions entering through A&E. This pathway is now seen as the default route for emergency healthcare. Other forms of referral to emergency admissions can be from the minor injuries clinics, walk-in centres, GPs and speciality A&E departments (National Audit Office, 2013). With such a range of healthcare services in place, all working towards the same goal of health improvement, it is essential that all care systems work together in order to develop higher levels of efficiency.
It is important to note that although the national rise in emergency admissions may be somewhat explained by demographic change, the organisation and financing of the emergency care system contributes to the increased pressures felt by all players involved in the emergency admissions pathway. Blockages within the flow of patients put great pressure on a hospital’s ability and flexibility to cope. As a result of strained quality of care, mortality rates can rise. Effective patient flow through the NHS system is therefore critical to the quality of care that each individual patient receives.
The NHS’ concerns for avoiding unnecessary emergency hospital admissions and effective management of those who are admitted is currently a major healthcare topic. Working towards resolving these issues will not only reduce the substantial cost of emergency hospital admissions on the NHS, but will also help to reduce the pressure and disruption on both healthcare services and individuals.
What do we know?
What factors have contributed to the rise in emergency admissions?
- An increase in the proportion of older adults within the population
- An increase in the number of people living with long-term conditions and severe exacerbations of these conditions
- An increase in short stay admissions
- An increase in emergency re-admissions
Currently across the UK 51% of A&E cases are brought to hospital via ambulance. The history of the ambulance service influences patients to feel a sense of trust towards the service to get them treatment quickly and efficiently. This, therefore, coincides with the ever-growing emergency admission rates in A&E as even for minor illnesses the ambulance service does not actively use alternative urgent care services; hence overcrowding in emergency departments. With NHS England (2013) stating that ¼ of all ambulance admissions could have been treated elsewhere, it is clear that by modifying the ambulance service, overcrowding in A&E could be reduced.
This relates to the issue of alternative urgent care services, which, if utilised appropriately by those who need them, could have a great impact on the level of emergency admissions in A&E. Although alternative services are often not considered by the public, there are a number of facilities in place to handle less severe injuries. Whether or not these are successful is, however, a different matter. They include:
- Telephone services, such as NHS111, which provide a diagnosis of symptoms without physically seeing the patient. Although this could greatly reduce unnecessary visits to A&E and resources, it is difficult for medical professionals to accurately recognise the degree of urgency without a physical examination. The lack of medical clinicians working in this service influences the lack of trust that patients feel towards it.
- Care plans for patients with long term conditions to self manage their symptoms. This requires a necessary level of confidence from the individual on their ability to care for themselves, as well as the correct amount of support from healthcare services.
- Out of hour GP services in order to make an alternative to A&E available 24 hours a day, 7 days a week.
- Minor injuries units (MIU). The benefits of using these in treating minor injuries as an alternative to A&E units is often unknown to patients and they are not utilised to their full potential.
It is not just the original admittance of patients that causes overcrowding within urgent healthcare services, but also the untimely and inappropriate discharge of treated patients. A correct discharge plan and high quality aftercare are vital in preventing patients from being re-admitted soon after their first admittance, thus reducing the number of bed days used unnecessarily. The number of acute bed days lost across the UK when patients are delayed in hospital, even though they are fit to be discharged, stood at 766,000 in 2012. This increased by 67,000 in 2012-13, a rise of 9% on the previous year (National Audit Office, 2013).
Facts, figures and trends
This data was collected from the Focus on Accident and Emergency report (2013) and presents data from 2012/13.
- 22 million patients were admitted to A&E.
- The rate of people attending Minor Injury Units has risen at a rate that is 11 times the rate of population increase between 2004/5 and 2012/13.
- At least half of every 1000 people who are admitted to Major A&E Units were below 2 or above 83.
- On average, 13 out of every 20 patients had referred themselves to A&E. 1 out of every 20 was referred to A&E by a GP.
- Following emergency admission, 20.8% of people were admitted to hospital, 39% were discharged with no follow up and 20% were followed up by a GP.
- Rate of readmission within a week remained consistent at between 7% and 8% since 2011.
- Emergency admissions represent 65% of hospital bed days; disrupting inpatient waiting lists (The King’s Fund, 2010) (see also delayed transfers of care).
- In Berkshire alone, on a single day, 106 admissions are emergency admissions and 208 patients visit A&E (Royal Berkshire NHS, 2013).
- Data from the Secondary Uses Services provided by the Central Southern Commissioning Support Unit shows that In 2011/12 there were 6,306 per 100,000 non-elective emergency admissions by Bracknell Forest residents. In 2012/13 this figure reached 6,829 per 100,000. This shows an increase of 8.28% between 2011/12 and 2012/13.
- With an increase of 8.28% in Bracknell Forest, out of all 6 unitary authorities (Bracknell Forest, Windsor and Maidenhead, Reading, Newbury, Slough, West Berkshire and Wokingham), Bracknell Forest had the 2nd largest increase between the two years (after Windsor and Maidenhead with an increase of 11%).
- 8.9% of the emergency admissions in the Bracknell and Ascot CCG area were for chronic conditions. All of the patients included in this data had chronic conditions that could have been treated via community care (see also cardiovascular disease and long term conditions in children).
- The mean length of stay for patients admitted to hospital in 2011/12 in the Bracknell and Ascot CCG area was 5.2 days.
- The NHS introduced the 4 hour A&E standard. It stated that 98% of patients must be seen, treated and admitted/discharged in less than 4 hours. This was relaxed to 95% in 2010. Berkshire East PCT (Heatherwood and Wexham Park) failed in meeting its target of 95% of patients waiting 4 hours or less in A&E in Q3 and Q4 2012/13 (figure 1).
Figure 1. percentage of patients who spent 4 hours or less in A&E in Berkshire East 2012/13
Source: Bracknell and Ascot CCG, 2013
Emergency admissions has been included in the Bracknell Forest main priorities for the reason that admissions remain consistently high, with the local authority having the second highest rate of emergency admissions out of the 6 unitary authorities between 2011/12 and 2012/13. Currently a number of actions are being taken in order to decrease this rate:
- The opening of the Bracknell Forest Urgent Care Clinic in April 2014 offering assessment and treatment to patients who are in need of non-emergency urgent care (see ‘national and local strategies’ below).
- The development of the Better Care Fund. This aims to integrate care teams across the whole healthcare system in order to improve and ease a patient’s treatment pathway, from admission to complete recovery.
- The promotion of self care through increased awareness of conditions, confidence in managing health issues and solid support from healthcare professionals.
- A focus on falls prevention through the expansion of falls services, the improvement in falls risk assessment and the improvement in data. For more information about emergency admissions for falls please visit the falls and mobility section and the JSNA summary.
What are the inequalities?
The following factors correlate with the inequalities seen in emergency admission rates:
- Social deprivation- Practices serving the most deprived populations have emergency admission rates that are between 60 and 90% higher than those serving the least deprived populations.
- Morbidity- Those with higher morbidity levels in a population have higher emergency admission rates. As do those populations with higher levels of chronic illness (Majeed et al, 2000, cited by Purdy 2010)
- Area of Residence- those living in urban areas have higher emergency admission rates. Is this, however, a result of inaccessibility to A&E in rural areas or better management in urban areas? Similarly, those who live closer to A&E, regardless of other risk factors, have higher emergency admission rates.
- Age- babies or elderly patients have the highest risk of emergency admissions, with those aged 5-14 year old having the lowest risk.
National and local strategies (current best practices)
In June 2013 the Berkshire West Federation Urgent Care Programme Board published an A&E Recovery & Improvement Plan in order to aid the NHS’ objective of dramatically reducing emergency admission rates. This plan includes strategies that aim to reduce ambulance admission rates via alternative care and GP advice, educating the public on unnecessary admission rates, controlling the flow of patients through Wexham Park A&E and ensuring that discharging of patients is efficient and well planned in order to prevent re-admission.
The Government Response to the House of Commons Health Select Committee Report responds to the issues highlighted by the Health Select Committee, explores these issues and provides evidence of current and developing strategies that they believe will improve the emergency care system.
Everyone Counts: Planning for Patients 2013/14 presents the incentives that are being used between April 2013 and 2014 to improve NHS services for patients. The review outlines the issues within the current NHS system and presents developed principles for future delivery of urgent and emergency care.
The NHS 111 scheme has been recently launched as an alternative emergency pathway for patients to use (previously NHS Direct). Run by trained health professionals, it allows for patients to be directed to the correct local health service for their symptoms. It is available 24 hours a day and is aimed at those experiencing an emergency (but not life-threatening) situation.
The NHS has suggested ’12 system design objectives’. These are potential outcomes, which should be delivered by any future urgent and emergency care system. They are not yet agreed solutions but have been developed in order to explain what future emergency care systems might look like. The 12 objectives include:
1. Make it simpler for me or my family/carer to access and navigate urgent and emergency care services and advice.
2. Increase my or my family/carer’s awareness of early detection and options for self-care and support me to manage my acute or long term physical or mental condition.
3. Increase my or my family/carer’s awareness of and publicise the benefits of ‘phone before you go’.
4. If my need is urgent, provide me with guaranteed same day access to a primary care team that is integrated with my GP practice and my hospital specialist team.
5. Improve my care, experience and outcome by ensuring early senior clinical input in the urgent and emergency care pathway.
6. Wherever appropriate, manage me where I present (including at home and over the telephone).
7. If it’s not appropriate to manage me where I present (including at home and over the telephone), take or direct me to a place of definitive treatment within a safe amount of time; ensure I have rapid access to a highly specialist centre if needed.
8. Ensure all urgent and emergency care facilities are capable of transferring me urgently and that the mode of transport is capable, appropriate and authorised.
9. Information, critical for my care, is available to all those treating me.
10. Where I need wider support for my mental, physical and social needs ensure it is available.
11. Each of my clinical experiences should be part of programme to develop and train the clinical staff and ensure their competence and the future quality of the service are constantly developed.
12. The quality of my care should be measured in a way that reflects the urgency and complexity of my illness.
The Bracknell Urgent Care Clinic is due to open in April 2014 in the Royal Berkshire Bracknell Healthspace, Brants Bridge. It will be replacing the MIU at Heatherwood Hospital, which is soon due to close. The clinic will be open 8am-8pm, 7 days a week, 365 days a year and plans to offer treatment to anyone who is in need of urgent care that is not life threatening. It will also be open to people who are unable to get an immediate appointment with their GP. Not only will the facility contain X-rays, blood tests and ultrasound tests on site, but it will also offer a children’s clinic each evening in order to meet the needs of young families. An inbuilt patient education centre will also inform people of what forms of healthcare they need to use and when depending on their symptoms.
Recommendations for consideration by other key organisations
- The issue of fragmented patient flow through the emergency care system could be addressed by ensuring that all services and commissioners collaborate effectively. Poor relationships are likely to result in reduced performance and increased difficulty in care for the patient.
- It is recommended that rapid access to a senior opinion should become the norm. Many hospitals are now developing Acute Medical Unit (AMU) consultant job roles; specialists in assessment and early treatment; networkers across the hospital to conduct patients to the right speciality; and a source of advice to community based clinicians to prevent admission. This would be beneficial in all areas of emergency care, whether it is face to face treatment or via NHS 111.
- It would be beneficial to increase the availability of same day appointments at general practices and provide increased out of hours appointments.
- Walk in centres and minor injury centres could work with the ambulance service to promote the centre as an alternative when appropriate.
- There would be great value in implementing See and Treat for patients. A senior clinician diagnoses those with minor injuries soon after they arrive at A&E and treats them there and then in order to reduce discharge time and control overcrowding.
- High re-admission rates could be addressed by not only controlling admissions but providing further successful management in effective discharge plans and community aftercare. This would enable patients to recover appropriately and in the most effective setting and reduce the number of unnecessary bed days.
- Self care is becoming a key objective in reducing emergency care admissions. Further promotion of self care for long term conditions, as well as preventative measures for long term conditions to begin with (e.g. stop smoking services, falls prevention etc) is recommended.
- It is recommended that the 12 system design objectives are used as guidelines when working towards the improvement of emergency admission rates.