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Emergency admissions to hospital: managing the demand

Many emergency admissions to hospital are avoidable and many patients stay in hospital longer than is necessary, according to a report today by the National Audit Office. Improving the flow of patients through the system will be critical to the NHS’s ability to cope with future winter pressures on urgent and emergency care services.

Today’s report points out that, at a time when NHS budgets are under significant pressure, the number of emergency admissions to hospitals is continuing to rise, albeit at a slower rate than in the past. More patients attending major A&E departments are now being admitted to hospital. In 2012-13, over a quarter of all patients attending major A&E departments were admitted, up from 19 per cent in 2003-04. The rise in emergency admissions is dominated by patients who stay less than two days (short-stay) in hospital.

The main factors behind the increase in emergency admissions include the slowness with which the NHS has developed effective alternatives to admission to hospital. The introduction by the Department of Health of the four-hour waiting standard for A&E departments has reduced a hospital’s ability to keep a patient in A&E for monitoring and observation. An increasingly elderly frail population are more likely to present at A&E and then be more likely to be admitted to hospital. Changing medical practices and models of care – such as the increasing admission of patients in A&E to assessment centres – are also factors.

All organizations in the health and social care sector have a role to play in managing emergency admissions: by reducing avoidable emergency admissions, effectively managing those patients who are admitted and ensuring they stay no longer than is necessary.  However, there are large variations in performance at every stage of the patients’ journey through the health system, suggesting scope for improved outcomes.

There are many local initiatives to prevent avoidable emergency admissions but limited evidence on what works. The management of those who are admitted has become more efficient with reduced waiting times and length of stay and improved outcomes. However, increasing bed occupancy is limiting the capacity of some hospitals to cope in winter and delayed discharges are placing more pressure on bed availability. A lack of alignment between hospitals and community and local services in the hours they are open compromises efforts to avoid out-of- hours hospital admissions and prolongs the length of stay of inpatients.

Among the NAO’s recommendations are the need for both short-and long-term strategies to address staffing shortages in A&E. The Department and NHS England should also address barriers to seven-day working in hospitals, such as the consultants’ contract, which gives consultants the right to refuse to work outside 7am to 7pm, Monday to Friday.

“Many emergency admissions to hospital are avoidable and many patients stay in hospital longer than is necessary. This places additional financial pressure on the NHS as the costs of hospitalization are high. Growth in emergency admissions is a sign that the rest of the health system may not be working properly. Making sure patients are treated in the most appropriate setting and in a timely manner is essential to taking the pressure off emergency hospital admissions.”

Amyas Morse, head of the National Audit Office

Notes for Editors

Key facts

Emergency admissions to hospital in 2012-13

Cost of NHS emergency admissions in 2012-13

Increase in emergency admissions, over the last 15 years

124 per cent
Increase in  short (less than two days) hospital stays as a result of an emergency admission over the last 15 years

26 per cent
Of  patients attending a  major accident and emergency (A&E) department were then admitted to hospital in 2012-13

24 per cent
Of patients were admitted from an A&E department between 3 hours and 50 minutes and 4 hours of arriving in 2012-13

0.83 million
Cute bed days were lost due to delayed discharges in 2012-13

50 per cent
Of emergency medicine training posts were unfilled in 2011 and 2012

1.    Press notices and reports are available from the date of publication on the NAO website, which is at Hard copies can be obtained from The Stationery Office on 0845 702 3474.

2.    The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Amyas Morse, is an Officer of the House of Commons and leads the NAO, which employs some 860 staff. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund have used their resources efficiently, effectively, and with economy. Our studies evaluate the value for money of public spending, nationally and locally. Our recommendations and reports on good practice help government improve public services, and our work led to audited savings of almost £1.2 billion in 2012.

PN: 60/13