Emergency Admissions to hospital - Public Accounts Committee Contents

1  Oversight and responsibility for urgent and emergency care

1. On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and NHS England about emergency admissions to hospitals in England.[1] The number of emergency admissions continues to rise at a time when NHS budgets are under significant pressure. Between 2000-01 and 2011-12 the rate of increase has been much higher in England than in Wales, Scotland and Northern Ireland. In 2012-13, there were 5.3 million emergency admissions in England, an increase of 47% over the last 15 years. These admissions accounted for around 67% of hospital bed days in England, and cost approximately £12.5 billion.[2]

2. Patients may be admitted to hospital as an emergency through various routes, including from: major A&E departments; single specialty A&E departments, minor injuries units or walk-in centres; referrals by GPs or other health professionals; and referrals following outpatient appointments. In 2012-13, 71% of emergency admissions came via major A&E departments and almost all of the increase in emergency admissions has come through these.[3]

3. The services which make up the urgent and emergency care system are delivered through a wide range of local bodies and organisations.[4] When the health system is working effectively, only those with a genuine urgent need to be treated in a hospital should be admitted for emergency care. For everybody else, there should be appropriate services based in primary care or out in the community that help to keep people well, or treat them away from hospital if they do become ill.[5] All parts of the health system— including ambulance services, A&E services, other departments within hospitals, primary and community health services, and social care services— have a role to play in managing emergency admissions by preventing patients from being admitted to hospital when they do not need to be, making sure those who are admitted stay no longer than is necessary, and ensuring that they are treated in the most appropriate setting.[6]

4. When health and social services are not working effectively the pressure is usually felt by A&E departments having to deal with more patients.[7] Approximately one-fifth of emergency admissions to hospital are avoidable, and many patients stay in hospital longer than is necessary.[8] Poor quality access to primary care can lead to more people attending A&E rather than going to their GP surgery.[9] Shortcomings in social care, primary care and community care can also put pressure on A&E services by delaying the discharging of patients which places more pressure on bed availability.[10] The fragmented delivery of urgent and emergency care services can result in duplication of activities, such as the condition of patients being assessed twice.[11]

5. It is crucial to have clear accountabilities in a devolved delivery chain like the NHS. The Department told us that it retains overall responsibility for the urgent and emergency care system in England, but it discharges its duties through a large number of arms-length bodies.[12] For example, NHS trusts are accountable to the Trust Development Authority; NHS foundation trusts are accountable to Monitor; and both are accountable to the Department. NHS England is accountable for the commissioning and performance of the NHS, including holding clinical commissioning groups to account for the commissioning of local services.[13] Foundation trusts are also individually accountable directly to Parliament. However, the Department and NHS England could not clearly explain to us who is accountable for ensuring A&E services are delivered efficiently and how particular failings in local services would be effectively challenged and addressed.[14] In particular, the Department struggled to convincingly set out for us which body a citizen should complain to about a failing local urgent and emergency care service, and what would be done about that complaint.[15]

6. The Department said that urgent care working groups had been established to bring together the statutory bodies (clinical commissioning groups, NHS England and local authorities) responsible for the delivery of health and social care services with local care providers to create more accessible and integrated local urgent and emergency care systems. However, while the Department asserted that these groups exert significant influence, it accepted that they had no powers to deliver services and instead operated as a network that relied on the good will of all those parties involved.[16]

7. The Department told us that a tripartite group, accountable to the Department and comprising NHS England, Monitor and the Trust Development Authority, would oversee the urgent care working groups. However, neither the Department nor NHS England could clearly explain under what circumstances the tripartite group would step in and who will drive change when local urgent and emergency care systems were not working effectively together.[17]

8. The main financial incentives to reduce emergency admissions sit with hospitals, despite all parts of the health and social care system having a role to play. Currently, local clinical commissioning groups pay hospitals a tariff for each patient that they treat. Since 2010-11, commissioners have set limits on the level of emergency activity that they will pay hospitals at full tariff, based on the number of emergency admissions at each hospital in 2008-09. When emergency admissions exceed this level the commissioners only pay the hospital 30% of the tariff.[18] NHS England told us that the savings made from the remaining 70% of the tariff were supposed to be reinvested in out-of-hospital care to reduce admissions, but until recently commissioners were often spending the savings on other aspects of care. This equated to removing about £250 million a year out of the acute care system. Since 2011-12, commissioners have also not paid hospitals a tariff for patients who are readmitted to hospital within 30 days of being discharged.[19]

9. Since 2011-12 there has been some attempt to expand the range of incentives, when the new GP contract started to include payments for GPs to review and reduce local emergency admissions levels. From 2013-14 NHS England introduced a 'quality premium' for clinical commissioning groups to reduce avoidable emergency admissions. However, there are still no financial incentives for community and social care services to reduce emergency admissions.[20]

10. A new 'year of care' funding model is being piloted in eight areas that aims to promote the integration of services for patients with long-term conditions by providing funding per head of population for the totality of their care, both in and out of hospital. NHS England intends that this will encourage hospitals to take a holistic approach to caring for such patients, and it plans to roll-out this funding model in 2015-16.[21]

  1. In addition, starting from April 2015, the £3.8 billion Better Care Fund aims to ensure better integration between health and social care, particularly in out-of-hospital care. Local health and wellbeing boards will be responsible for allocating this fund.[22] The fund will comprise £1 billion that the NHS already transfers to local government, £800 million from the Department, and £2 billion that will need to come from additional NHS savings, mainly in the acute care sector.[23] NHS England told us that this will be a massive challenge, as these savings are on top of the 4% efficiency savings that the NHS already needs to make in 2015-16.[24]

1   C&AG's Report, Emergency admissions to hospital: managing the demand, HC 739 Session 2013-14, 31 October 2013 Back

2 2   C&AG's Report, paragraphs 1, 1.9 Back

3   C&AG's Report, paragraph 1.11 Back

4   Q93 Back

5   C&AG's Report, paragraph 1.3 Back

6   Qq27, 72; C&AG's Report, paragraphs 2 & 3 Back

7   C&AG's Report, paragraphs 1.3 & 1.4 Back

8   Qq 36, 47; C&AG's Report, paragraphs 11, 22 Back

9   Qq71-72, 75-76; C&AG's Report, paragraph 2.12 Back

10   Q27; C&AG's Report, paragraph 15 Back

11   Qq42, 45, 102-103, 113 Back

12   Qq1-3, 12 Back

13   Qq2-3, 8, 44, 48, 52 Back

14   Qq9-13 Back

15   Qq6-8 Back

16   Qq42-43, 45-47, 52; C&AG's Report, paragraph 3.6 Back

17   Qq42-48, 52 Back

18   C&AG's Report, paragraph 2.23 Back

19   Qq152-153; C&AG's Report, paragraph 2.24 Back

20   C&AG's Report, paragraphs 3.8, 3.9 Back

21   Qq155-157 Back

22   Qq63-65 Back

23   Qq125-134 Back

24   Q134-137 Back

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Prepared 4 March 2014