The proportion of patients attending accident and emergency departments who are not sick enough to require an admission varies widely across England, unpublished data seen exclusively by HSJ reveals.
Nationally, 20 per cent of patients attending A&Es during normal GP opening hours require an admission. But at some primary care trusts the average is as low as 6 per cent, suggesting significant numbers of patients are visiting A&Es in place of GP surgeries - even when practices should be open.
80% - Patients attending A&Es in-hours not needing an admission
The data from the NHS Information Centre links A&E attendances and admissions to each GP practice in the country. Crucially, it also distinguishes between patients who attended A&E during normal GP practice opening hours and those who attended “out of hours” between 6.30pm and 8am.
When aggregated at a PCT level the data reports that Bournemouth and Poole Teaching PCT had an in-hours admission rate of just 6 per cent and Gloucestershire had one of just 12 per cent.
At the other end of the spectrum, Mid Essex and Sefton PCTs had the highest rate of in-hours admissions at 35 per cent and 34 per cent respectively.
PCT Network director David Stout said: “This is patient choice in effect, and at the moment there is no consequence for GP practices in terms of hard responsibility for the cost of A&E attendances,” he said.
The data is labelled “experimental” and is incomplete in places, but was collated by the Information Centre at HSJ’s request to explore PCT concerns that patients were opting to use A&Es where their GP services were inaccessible.
NHS Alliance chief executive Mike Sobanja said: “At its simplest these figures may show that patients are ringing up for an urgent appointment and cannot get one, and so go to A&E.”
Concern about the inappropriate use of hospital A&E departments comes as the new government considers changes to the four-hour waiting target, which has been viewed as one driver of the recent increase in A&E attendances. But Mr Sobanja warned that any moves to make the four-hour wait a “standard” rather than a target must not harm patient experience.
“We want people who need to be seen quickly, being seen quickly, and if that means some people are seen quickly who don’t need to be seen as quickly, then so be it,” he said.
When compared with the results from the 2007-08 GP patient access survey, the data suggests a modest link at the GP practice level between potentially inappropriate A&E attendances and GP surgery access.
The top 10 per cent of practices in terms of patient satisfaction with securing appointments within 48 hours had the highest proportion of in-hour A&E attendees requiring an admission, at 20.9 per cent. That was 8 per cent higher than the lowest 10 per cent of performers in the satisfaction survey, which had an admission rate of 19.3.
Individual GP practices and PCTs contacted by the HSJ cited a number of reasons for their low rate of in-hour A&E admissions. Luton PCT chair Gurch Randhawa said he was not surprised his PCT’s figures for 2007-08 recorded an admission rate of just 7.2 per cent.
“We were under-doctored historically and there was tremendous variety in quality. These were issues in Luton and over the last three years we have had to sort that out.” He said the PCT had made improvements since the data was collected.
Nigel Cowley, GP partner at the Denmark Road Medical Centre, Bournemouth, whose patients had an in-hour admission rate of just 4.4 per cent, said: “One would expect people with minor ailments to attend A&E if they couldn’t get into surgery.” He could not verify the figures but said their low rate of admissions could be explained by “fractures, where people attend A&E but aren’t admitted, drink-related injuries or trauma incidents during the day”.
A spokeswoman for NHS Gloucestershire said their figures could have been affected by the flooding in 2007, which rendered some GP surgeries inaccessible. A spokeswoman for Bournemouth and Poole PCT said the data did not reflect more recent improvements made to primary care access in the area.
2007-08 in accident and emergency
- Total number of A&E attendances resulting in admission: 2.2 million
- Percentage of in-hour attendances resulting in admission: 20 per cent
- Percentage of out-of-hour attendances resulting in admission: 23 per cent
- Average cost of an A&E attendance without admission: £90
- Total cost of in-hour attendances without an admission: £354m
- Saving to NHS if all practices reduced in-hour attendances not requiring admission to national average of 80 per cent: £11.2m
(Source: NHS Information Centre experimental statistics 2007-08 for 6,293 practices. Small practices and incomplete entries deleted)