Published: 10/01/2001, Volume 112, No. 5787 Page 17
The winter pressures that cripple the NHS are entirely predictable and could be minimised if the right groups were targeted, says the King's Fund.
Paul Stephenson reports Winter pressures are the stuff of which ministers' nightmares are made: cold weather and flu epidemics combining to overwhelm hospitals and unleash a tidal wave of bad publicity. The remedy, of course, is more beds and more money. We all know that, do not we?
The reality is somewhat different, according to a study which shows that the timing of a large rise in emergency admissions over the winter months is entirely predictable. The study says the rise is only related to specific respiratory conditions, and is therefore, in theory, preventable.
The King's Fund report, Managing the Pressure: emergency hospital admissions in London, 1997-2001, shows there is no significant seasonal variation in emergency admissions other than for respiratory diseases. Most cases that result in long hospital stays are among older people, most of whom have chronic illness, so it is this group that needs to be targeted.
The report is a robust attempt to bust the myth of the winter crisis.
And it appears to be the first time the case against winter pressures has been so clearly put.
The study found that emergency admissions for respiratory diseases tended to peak in early January. Though the report examines admissions in London, a comparison with wider data shows the situation across the whole of England to be the same.
The report questions why it should be that the peaks in emergencies occur at almost identical times, and says it is unlikely that any virus would strike at the same time every year, or that cold weather would occur in this way.
It suggests the peaks are 'likely to be related less to the prevalence of illness, including influenza, or the weather, but more with the existence of bank holidays at that time of year, and related factors such as access to ambulatory NHS care and social support' during this period.
It says community support, in the form of primary care and social services, may be less available then, particularly for older patients. It adds that relatives of older people may also refer them to accident and emergency departments at the end of the holiday.
The most important diseases involved in the emergency admissions are pneumonia, chronic obstructive airways disease and other upper and lower respiratory infections. In terms of an age profile, the highest number of respiratory emergency admissions was in the under-fives.
However, their average stay was low, at not more than two or three days, whereas 75 per cent of respiratory emergency bed days were taken up by patients aged 60 or over.
The report says older patients with chronic respiratory disease are identifiable in advance of winter, particularly by primary care staff. It therefore calls for proactive management, including not only flu vaccination but also weekly (and possibly daily, in the case of the most vulnerable) visits during the critical few weeks in December and January.
It says this must be a key role for primary care, with support from acute hospitals, social services, community health services and possibly NHS Direct.
Though the report only looked at London, it clearly has important implications for the whole NHS. The authors recommend ensuring good access to primary care, community health services, NHS Direct and social services during the winter bank holidays.
King's Fund chief executive Rabbi Julia Neuberger says that people had previously thought there was a wide range of factors involved in winter pressures, but in fact the causes are quite specific.
'I think one of the things that is clear is that it is the chronic respiratory illnesses themselves [that cause the rise in admissions].
People who are at high risk of being admitted to hospital in cold weather can quite easily be identified by health professionals.'
In terms of what is needed, she says, 'it is monitoring, flu vaccination, plus quite a lot of the social services.'She says monitoring on a daily basis would be the exception, but 'there are groups of vulnerable people who end up in hospital pretty regularly'.
London regional office has already discussed acting on the recommendations of the report, which it found surprising in terms of showing just how predictable the patterns are.There are already a couple of pilot schemes in the capital working to identify vulnerable older people who can then be visited on a regular, possibly daily, basis.
Regional assistant director for corporate performance Chris Garrett says: 'I think it was a surprise that it is only a very small range of conditions that have this extreme variability.The other thing we would be wanting to stress is the predictability of emergency admissions. One of our emphases for next year will be better planning, because the numbers of emergency admissions are predictable.'
In terms of extra demands on primary care, Ms Garrett says: 'I do not know that it is more work; it is about doing things differently.'
She suggests that by arranging to see vulnerable patients regularly, hospital admissions could be avoided, which would cut out subsequent follow-up visits.
If the King's Fund is right, ministers might just sleep more easily next winter. l Managing the Pressure: emergency hospital admissions in London, 1997-2001 .Michael Damiani and Jennifer Dixon. King's Fund, 0207307 2591.£5.99.