Reducing emergency admissions Contents

1Management of emergency admissions

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department for Health and Social Care (the Department), NHS England and NHS Improvement.1

2.The Department sets NHS England’s mandate for arranging the provision of health services, which includes a measurable reduction in emergency admissions rates by 2020. While NHS England has no specific target for reducing emergency admissions, the Department has an internal ambition to reduce the growth in emergency admissions to 1.5% in 2017–18.2

3.Between 2013–14 and 2016–17, emergency admissions increased by 9.3% and in 2016–17 there were 5.8 million people admitted to hospital as an emergency.3 Around 1.4 million (24%) of these were people who had health conditions that with better preventive care out of hospital should not have become so unwell that they needed to be admitted to hospital.4 The cost of emergency admissions rose by 2.2% from 2013–14 to 2015–16, from £13.4 billion to £13.7 billion, compared to an increase of 7% in the number of emergency admissions over that time.5

Avoidable admissions

4.There has been a steady increase in emergency admissions that could have been avoided if people had received better community health care and case management. These types of admissions increased by 14% from 2013–14 to 2016–17, compared to a 9.3% increase for all types of emergency admissions. Avoidable admissions made up nearly a quarter of all emergency admissions in 2016–17.6

5.NHS England stressed to us that many of these admissions were not avoidable by the time the person got to hospital. The failure occurred much earlier when the NHS had been unable to give the care the person needed and alternative types of treatment, investigation and care were not available.7 NHS England and the Department told us that they would prefer to manage emergency admissions not at the hospital door, but earlier: in the community, in GP practices, in social care services and with the help of the voluntary sector.8

6.Clearly, there are gaps in the provision of these alternative forms of care. Earlier this year the National Audit Office reported that sustainability and transformation partnerships were overlooking investment in these types of preventative services in order to make savings in the short term.9 Research also showed shortfalls in investment in ‘intermediate care’. This type of care consists of health, community and social care services outside hospitals that help bring about faster recovery from illness and maximise independent living, particularly for elderly people.10

7.Despite the importance of community health care, at the time of our evidence session there was not a clearly defined plan for how the £10 billion of annual spend on community care could be better used to manage current and future demand. NHS England’s proposals for programmes to focus on community care had stalled.11 NHS England was aware that the ever-increasing gap between the need for social care and the availability of social care would put extra pressure on hospitals. Despite this, NHS England had not estimated of the impact of social care spending on the NHS.12 The Department and NHS England both acknowledged the financial pressures on social care. The Chief Executive of NHS England commented that “I think everybody agrees … that there needs to be a sustainable solution for health and social care funding and that is growing increasingly urgent.”13

Bed occupancy

8.The average number of available general and acute beds in hospitals fell by 6,268 (5.8%) from 2010–11 to 2016–17. The intensity of the use of those beds, shown by bed occupancy rates, has increased and hit a seasonal peak of 91.4% in the first three months of 2017. NHS Improvement acknowledged that they were seeing percentage bed occupancy percentage rates in the mid-90s, which is a level that leads to elective work being cancelled or postponed.14 This problem tends to come to a head for the NHS in winter, and the Department added that in the winter just prior to this session, the NHS faced additional challenges caused by the particularly cold weather and levels of flu.15 NHS England told us that as a result of cancelling operations in response to winter pressures, there were some 23,000 fewer operations in January 2018 than in January the previous year although it did not quantify the number of cancelled or postponed operations.16

9.NHS England acknowledged that no-one—the patient, the surgeon, the hospital board, the chief executive—wants to postpone or displace elective operations but that the emergency patient will take precedent.17 The Department considered that there was a more strategic approach to postponing operations this winter, rather than individual trusts postponing as winter progressed. It told us that this strategic approach gave greater certainty to patients and enabled trusts to redeploy staff to deal with emergencies.18 NHS Improvement acknowledged that it would need to do more work than in the past to look at the capacity of each hospital and that it hoped to reduce bed occupancy significantly from levels currently seen.19

Engagement with the voluntary sector

10.The voluntary sector could be a powerful force in helping to keep people out of hospital, particularly to support health and social care teams looking after people in their homes and communities. Volunteers could help ease pressures on busy health and social care professionals. We challenged NHS England on the apparent lack of emphasis on engaging the voluntary sector in reducing emergency admissions. NHS England told us that the Department had supported the voluntary sector over several years, particularly as part of the “discharge to assess model” in making sure that people who go back into the community have support. It also told us that, when an ambulance is called to attend an elderly patient who lives alone or in warden-controlled accommodation, paramedics can contact the “single point of access”, who can mobilise the voluntary sector rapidly to come and be with the patient when the patient does not need conveying to hospital. NHS England also said that, in several parts of the country, voluntary sector groups could make referrals into the “single point of access”.20

11.However, there remains plenty of scope for the Department and NHS England to engage with the voluntary sector much more systematically and consistently on this issue, over and above what it is doing with the ambulance services. There seems to be no national ambition to engage with the voluntary sector proactively and to best effect at the local level. NHS England gave us a commitment to look far more proactively at the role the voluntary sector can play. It also commented that some, albeit a modest amount, of last winter’s money had gone to support the Red Cross with its hospital discharge and support scheme, and mentioned that the Greater Manchester area had entered into a memorandum of understanding and partnership agreement with nearly 15,000 voluntary organisations.21

1 Report by the Comptroller and Auditor General, Reducing emergency admissions, Session 2017–2019, HC 833, 2 March 2018

2 C&AG’s Report, para 3

3 C&AG’s Report, para 6

4 Q 12; C&AG’s Report, para 6

5 C&AG’s Report, para 10

6 Q 12; C&AG’s Report, para 6

7 Q 12

8 Q 83

9 C&AG’s Report, Sustainability and transformation in the NHS, Session 2017–19, HC 719, January 2018

11 C&AG’s Report, para 3.9

12 C&AG’s Report, para 2.14

13 Qq 79–81

14 Q 27; C&AG’s Report, para 3.2

15 Q 30

16 Q 24

17 Qq 27–28

18 Qq 30–32

19 Qq 27–28

20 Qq 69–70

21 Q 71

Published: 8 June 2018