This article examines what has been happening over the last five years with emergency admissions to acute hospitals - probably the biggest driver of all healthcare spend.

They create one of the biggest headaches for acute providers. How do you organise services to deal efficiently with the variable demand alongside the various targets for accident and emergency and admission times and manage within the bed stock?

The first graph shows that the number of emergency admissions had been steadily rising until 2006-07 but then flattened off last year. Whether this will still be true at the end of this year remains to be seen.

This may be a result of a new pathway trend to get patients seen by consultants sooner after their admission. These days it is rare for patients to be clerked in by a junior doctor only to wait to the next day to be seen by a consultant. The first graph also shows how the number of patients being discharged on the same day as admission has been rising.

The second graph looks at the method of admission and shows that while more patients are being admitted via A&E, there has been a steady decline in the numbers sent in by their GP (the average reduction is 2.5 per cent a year). As previously highlighted in this column, some of the early A&E rise may have been fuelled by the four-hour treatment target but this is not the only reason. The decline might be due to GPs becoming more selective in who they refer as payment by results has come in, but might also be due to patients finding access to GPs more difficult.

Same-day discharges

The third graph shows a steady rise in the number of patients being discharged on the same day as admission. For admissions through A&E, the number discharged on the same day has risen from 16 per cent in 2003-04 to 26 per cent in 2007-08. Meanwhile, the number of GP-referred admissions that were discharged on the same day rose from 22 to 29 per cent over the same period. (It is perhaps not surprising that the A&E proportion is lower as it will include the most acutely ill patients.)

The fact that this increase affects GP-referred admissions just as much as it does admissions through A&E shows it is not just an effect of the four-hour target but a real provider service change.

Also, with virtually three out of every 10 patients referred by a GP for an emergency admission being seen, diagnosed and discharged on the same day by the hospital, the calls for a system of "urgent" care are strongly supported by this analysis.

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