A&E attendances and emergency admissions have shot up in recent years - but only in England. Alison Moore asks why the record is so inconsistent across the UK

Differences between health services in the four countries of the UK have become more striking over the past 10 years. But while some of the more obvious variations in structures and delivery are widely known, there are hidden factors that may tell us about how policy translates into practice - and the unexpected side-effects of well-intentioned policies.

HSJ has been given exclusive access to data assembled by health information firm CHKS, comparing the health services of England, Scotland, Northern Ireland and Wales.

The findings, gathered from routinely collected data, show accident and emergency attendances have risen rapidly in England in recent years. This rise has not been mirrored in Scotland, Northern Ireland or Wales. Emergency admissions have also increased substantially in England.

So what is behind these rises - and why are they different in different parts of the UK?

CHKS head of market intelligence Paul Robinson suggests that part of the answer may lie in the introduction of four-hour targets for A&E waits. England’s figures for both attendances and admissions rocketed from the year to March 2004 onwards.

While 260 people per 1,000 attended A&E in the year to March 2004, by March 2006 this had leapt to 352. Emergency admissions rose from 83 per 1,000 in the year to March 2004 to 94 per 1,000 two years later; those admissions originating in A&E rose from 49 to 58 per 1,000 over the same period.

The target to deal with 98 per cent of A&E attendees inside four hours was introduced in November 2004 and trusts had done much to reduce waits beforehand. “The English emergency admissions started going up when the four-hour target came in. It is an unexpected consequence of policy,” says Mr Robinson.

Wales - which historically has a high level of A&E attendances and emergency admissions - also has a four-hour target, but this is less stringent than in England and some trusts have had problems meeting it. The principality’s rise in emergency admissions emerged later and has not been as sharp as in England. Neither Northern Ireland nor Scotland have such targets and their numbers have shown a slow rise, although Northern Ireland does have higher rates overall of A&E attendances. It is easy to see how a four-hour target would affect emergency admissions. If patients need to be treated and discharged or admitted within four hours, there will be some who need to be admitted simply to give clinicians more time to make assessments and diagnoses.

Access to help

Has the four-hour limit also changed patient behaviour? The wide publicity over the target may mean that patients in England turn to A&E because they know they will be seen within that time, whatever the nature of their condition.

Accident and emergency consultant and council member of the College of Emergency Medicine Martin Shalley says: “I’m sure a lot of people realise that things are now much better and they will get seen more quickly. I think that has an impact on the way in which people think.”

But he also highlights some of the difficulties patients face in accessing other forms of help, such as in getting a GP appointment quickly.

NHS Confederation policy director Nigel Edwards agrees public perception is important. “If you feel you need treatment now, you can’t get to see your GP, you know you will be treated in accident and emergency within four hours and you are not bothered about continuity of care, then accident and emergency looks like a rational choice,” he says. “People make decisions based on what they perceive as the best route through the system rather than what we see as the right way.”

The figures for A&E attendances also include minor injury units and English walk-in centres established since 2003. This may be distorting the picture. Walk-in centres will be treating some patients for primary care problems which are not urgent and could have been treated by their GP.

Mr Robinson points to a growth in the proportion of patients with a zero length of stay: these now account for around 25 per cent of emergency admissions in both England and Wales. This may indicate that patients are being admitted for tests or observation, assessed by a senior doctor and then discharged on the same day. Many hospitals have also changed the way they admit patients, through the increased use of medical admissions units where patients can be seen quickly by a senior doctor. This fast discharge may be an indicator of more efficient care: patients are assessed early rather than being admitted by a junior doctor and occupying a bed for a couple of days waiting for the consultant’s round before being discharged.

However there has also been a rise in patients readmitted after an emergency attendance (from 11.5 per cent in 2003 to 13.3 per cent in 2007 in England). There are some interesting blips in the figures: you are more likely to be readmitted if your first admission was on a weekend - possibly because you are more likely to see a junior doctor then, suggests Mr Robinson.

But the rise in rates may be a sign of pressure in the system. Northern Ireland is not experiencing the same rise: its readmission rate has actually dropped. “It looks as if NI has something quite positive going on,” says Mr Robinson.

There may also be other factors affecting A&E attendance. Changes to GPs’ contracts and out of hours primary care services may have led more people to turn to it, for example. But these changes have affected doctors across all four countries so might be expected to have similar effects across the board.

“As far as I can see, there is no direct impact of the GP contract,” says Dr Robinson.

But there are differences in the way people in the four countries can access urgent (as opposed to emergency) care. In Scotland all calls go through NHS 24, the NHS Direct equivalent that provides a single point of contact.

In England, there may be more confusion with what feels like overlapping layers of care. Faced with the choice of a minor injuries unit, a GP out-of-hours service, NHS Direct (which many doctors claim refers people to A&E in large numbers) and out-of-hours dental services, those confused over how to access care may opt for accident and emergency.

NHS Alliance spokesman David Jenner points out that England is the only country to have the payment by results tariff system, which gives acute trusts a big incentive to count patients correctly and bill primary care trusts for their treatment. “If you pay people at a piecemeal rate, then they get better at recording activity,” he says.

Unpalatable truth

The Department of Health says it is unaware of any national evidence to suggest a single cause for the rise in accident and emergency attendances in England. “It seems likely that better reporting, as a result of the focus on the accident and emergency standard, along with inclusion of attendances to walk-in centres [in the statistics] from 2003, may well have contributed to these rising attendances. In more recent years, the rate of growth in attendances has been falling,” a spokesman suggests.

Mr Robinson agrees: the rise started to flatten out in 2006-07 but anecdotally accident and emergency departments in urban centres are again seeing a significant increase.

Mr Shalley says his department at Birmingham Heartlands Hospital has seen a 10 per cent rise this year - a trend mirrored in many other urban departments, including some in Scotland and Wales. This is putting enormous pressure on units, he says, as recruiting extra middle-grade doctors is difficult. He believes rising patient expectations are behind part of the increase and will be extremely hard to change.

“It will require a huge amount of public education, and I can’t see any change happening within the next five years. And I can’t see polyclinics altering it at all,” he says.

But there may be an unpalatable truth lurking in the background. However laudable it is to increase the number and accessibility of routes into unscheduled care, the end result may be that the public just uses more of it rather than switching to the most appropriate route.

King’s Fund fellow Tony Harrison suggests there is evidence that increasing access merely leads to more demand. “Good access promotes demand and bad access deters it,” he says. “There is demand elasticity throughout the NHS.”

Nigel Edwards describes this as supply-induced demand, adding that it puts policy makers in a cleft stick: make services more accessible and convenient for people, as the government wants, and you may in fact increase the number of people you are seeing overall rather than diverting demand from other services. PCTs wondering whether to put money into additional routes into healthcare will be given pause for thought.

Long term conditions - long term problems

Wales tops the list for emergency admissions to hospital caused by long term conditions per head of population; in some cases admissions are more than twice the rate in the three other countries.

In part, this is explained by a higher rate of people with chronic conditions in the principality; in 2001 23 per cent of people reported limiting long term conditions, compared with 18 per cent in England and 20 per cent in Scotland and Northern Ireland. Other likely causes are an ageing population, social deprivation and the legacy of an industrial past.

This strains Welsh health services. Its admission rates for asthma in 2007, for example, although lower than in previous years, were 0.88 per 1,000 population compared with England’s 0.39 and Scotland’s 0.25. A strategy in January admitted the position was unsustainable and there was an “over-reliance on traditional and often inappropriate models of care”.

The highest rates of emergency admissions tended to be in the old industrial heartland of the South Wales valleys. But across Wales two thirds of over 65s have at least one chronic condition.

Not all of this is increased prevalence - some of it may be due to patient pathways. The CHKS data shows emergency admissions for bleeding in early pregnancy are much higher in Wales than elsewhere, for example, which may indicate more willingness to admit rather than more cases. Also the country struggles to stem the tide of chronic conditions. Admissions for asthma and congestive cardiac failure have dipped, but others like lower respiratory tract infections have not. Those due to community-acquired pneumonia have risen sharply.

Wales dropped charges for prescriptions in April 2007. One reason was to ensure that those with chronic conditions could get appropriate medication. It is probably too early to see much effect from this policy but there were dips in 2006-07 in emergency admission rates for several of these conditions. Wales is also adopting a new approach to care with community based teams and greater integration with social services.

Elaine Tanner, Welsh heart health co-ordinator for the British Heart Foundation and Welsh Long-term Conditions Alliance spokesperson, says more needs to be done on educating patients to manage their conditions, but she points out the link between deprivation and having a chronic condition as significant.

Many patient groups argue that more could be done to reduce emergency admissions across the UK. Asthma UK says written care plans can cut admissions, yet adoption has been slow and a target of all English patients having one by 2010 is likely to be missed. The charity’s assistant director of policy and public affairs Mikis Euripides says Northern Ireland’s positive steps include incentives for GPs to provide management plans and regular reviews. This may have aided the fall in asthma-related admissions.

See also Divide and rule: time for the UK to debate its four health systems and Huge contrasts found between UK nations

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