1.Nearly one and a half million emergency admissions could be avoided with better preventive care outside hospitals. In 2016–17 there were 5.8 million emergency admissions to hospitals in England. Some 24% of the emergency admissions were avoidable if people had more effective community health care and case management to prevent them getting so unwell that they needed emergency hospital care. The proportion of avoidable admissions has been rising faster than the overall rate of emergency admissions since 2013–14. However, the NHS had not made the necessary investment to fund this kind of preventative work and the need to make short term savings means local areas have been overlooking investment in preventative services. Social services also help prevent people needing an emergency admission, and we find the combination of rising demand for social services and limited local authority finances particularly worrying.
Recommendation: NHS England should identify gaps in capacity in primary and community health care and set out how it intends to fill those gaps. It should also consider the impact of pressures on social care provision on emergency admissions and use this understanding to inform discussions with the Ministry of Housing, Communities and Local Government and HM Treasury about the Green Paper on future funding of social care.
2.Rising bed occupancy rates further jeopardise hospitals’ ability to cope with emergency admissions. The average number of available hospital beds at any one time dropped by nearly 6% from 2010–11 to 2016–17. The use of hospital beds is also intensifying and hit a seasonal peak of 91.4% in the first three months of 2017 and NHS Improvement told us that hospitals are running at too high an occupancy rate. Most worryingly, in January, because of seasonal pressures caused by rising emergency admissions, the NHS postponed or cancelled numerous planned operations and as a result there were some 23,000 fewer operations in January 2018 than in January the previous year. While NHS England recognises that no-one wants to postpone planned operations, the Department considers that the NHS’s approach to dealing with pressures last winter was more strategic and gave greater certainty to patients, including cancelling operations in advance rather than on the day. However, this gives little comfort to patients whose operations were cancelled and we remain concerned that cancelled operations are a sign of failure in how the system is operating.
Recommendation: NHS England’s and NHS Improvement’s regional teams should assess the capacity that hospitals need in terms of beds, staff and funding to deal with emergency admissions throughout the year. We have previously highlighted the need for Trusts to have greater certainty earlier in the year of additional funding to cope with winter pressures.
3.NHS England has not systematically engaged with the voluntary sector to understand fully the importance of its support in reducing emergency admissions. The voluntary sector can play an important role in supporting health and social care teams to look after people in the community. Yet NHS England has not always actively involved the sector in efforts to reduce emergency admissions. We heard some evidence from our NHS witnesses of how the voluntary sector gets involved, such as with the ambulance services, but only piecemeal examples. It is disappointing that there is no central understanding of the work of the voluntary sector in helping to reduce emergency admissions or how reliant Trusts may be on voluntary sector support, both paid and unpaid.
Recommendation: The Department should encourage better sharing of best practice on how the voluntary sector supports health and social care efforts to reduce emergency admissions and understand the reliance the system has on the sector. It should report back to the Committee on this.
4.Without a better understanding of what works best to reduce emergency admissions, NHS England cannot prioritise resources effectively. NHS England is trying to reduce emergency admissions with various interventions in several different programmes, including the urgent and emergency care programme, new care models and the Better Care Fund. However, neither NHS England nor NHS Improvement know what is most effective at reducing emergency admissions. We recognise there is some good practice but it is still too piecemeal and varies regionally. Factors such as deprivation and demographics can affect levels of emergency admissions substantially in different areas. But, even after adjusting to take account of such factors, in 2016–17 the number of emergency admissions across England still varied between 73 and 155 admissions per 1,000 people. There is clearly significant local divergence of what is and what is not working in reducing emergency admissions. When challenged on the lack of evidence on the impact of particular interventions, NHS England does not seem to understand which particular interventions are working or why. This lack of understanding hampers improvement and prevents the cash-strapped NHS from targeting taxpayers’ money on the things that work best.
Recommendation: NHS England and NHS Improvement should set out their plans for how and by when they will determine which interventions are most effective at reducing emergency admissions and how they will use any findings to ensure a more targeted use of resources and funding.
5.Poor data on daycase emergency care and readmissions stops NHS England knowing if its efforts to reduce emergency admissions are helping or potentially harming patients. In most cases, it is better for people, particularly older people, if they do not have to stay in hospital overnight. NHS England is trying to provide more emergency care without an overnight stay, which it calls daycase or ambulatory emergency care, which is both more appropriate for some patients and also frees up beds. Certainly a large proportion of the growth (79%) in emergency admissions was caused by people who did not stay overnight. However, hospitals record this kind of emergency care inconsistently; some record these patients as admissions and some record them as outpatients. The inconsistent recording prevents NHS England knowing to what extent patients are being spared an unnecessary overnight stay in hospitals, and may also allow hospitals to game admissions to receive higher payments. There are similar problems with the data on readmissions, which NHS England has not been recording. One study suggests that in the last five years there has been a 22.8% increase in people being readmitted back to hospital. Readmission rates are not necessarily a worrying sign; they can reflect improving clinical practice and show the success of the NHS in helping people recover from illness or injury. But a readmission can also be the result of previous poor clinical judgement. However, a lack of data prevents NHS England knowing how many people are readmitted back into hospital in an emergency. Without good data, NHS England cannot assess if readmission rates are at harmful levels.
Recommendation: NHS England and NHS Improvement should improve data they collect and that hospitals record so that by the end of 2018 care can be tracked and publicly reported, together with a clear statement of what is a harmful level of readmissions for people’s care.
Published: 8 June 2018