Just 10 per cent of primary care trusts have successfully reduced emergency admissions to their local acute trusts.

Only 15 PCTs cut emergency admissions between 2007-08 and 2008-09, according to analysis of hospital episode statistics data by independent health intelligence provider CHKS, shared exclusively with HSJ.

The NHS will go bankrupt, even without the [wider] financial problem, if it’s not taken seriously

The rest of PCTs recorded an average increase in emergency admissions of 5 per cent.

The analysis has prompted warnings that an increase in admissions at this rate is financially unsustainable for the health service as a whole.

It is made worse by the fact that CHKS also found that elective admission rates rose by an average of around 6 per cent during the same period. Just nine PCTs reduced their rate.

CHKS head of market intelligence Paul Robinson said: “The continuing rise in emergencies - especially as the winter peak figures are not yet in - shows little evidence of change to me and reinforces my concern that the growth is unsustainable financially.

“The NHS will go bankrupt, even without the [wider] financial problem, if it’s not taken seriously.”

Mr Robinson says preliminary data for this year suggests another overall rise in emergency admissions of 5-5.5 per cent and a rise in electives of 3-4 per cent.

This is despite coding changes and drives to meet waiting time targets explaining some of the 2007-08 to 2008-09 elective increases.

He suggested that now most acute trusts were meeting the 18 week waiting target there should be a “flattening off” of elective admissions - though this trend was yet to fully materialise.

Demand management was the “obvious issue” in controlling admissions, he added.

In a bid to control demand management, the NHS operating framework for 2010 says any emergency activity above 2008-09 activity levels will only be paid for at a rate of 30 per cent of the relevant tariff.

But PCT Network director David Stout, who agreed “we can’t continue to see that level of increase”, said the change to the tariff was unlikely to eradicate rising emergency admissions.

“It will have an effect but will not be the answer, ” he said.

PCTs were likely to reduce elective admissions once they had got rid of any backlog in meeting the 18 weeks target, he said, but overall he said they would need to take out capacity to reduce admissions.

“It doesn’t mean demand management schemes haven’t worked. If you leave capacity available it will fill.”

NHS Confederation policy director Nigel Edwards said the trend of increasing emergency admissions was down to a “complex dynamic in supply and demand factors”.

He highlighted increased caution among GPs, especially when it came to residential home patients, as one factor likely to have driven up referrals. The growth in long term conditions was another.

But he said: “The reasons are not fully understood. It is unlikely we can design a national solution.”

Responsibility for demand management should not rest solely with PCTs, as trusts made the final decision to accept referrals and patients were increasingly having the power to refer themselves. “The idea that PCTs [as only part of the system] can solve the problem is extraordinary,” he said.

Mr Robinson said PCTs should learn from examples of best practice.

He noted NHS Kingston’s use of a GP at the front of accident and emergency, and NHS Cornwall and Isles of Scilly’s focus on community services for patients with long term conditions (see box).

NHS Sefton also appeared to have significantly cut its emergency admissions. But a temporary spike in emergency admissions in 2006-07 is likely to have skewed the next year’s rate.

Latest board reports from November show the PCT is experiencing “overperformance” in secondary care, which is threatening its ability to break even in April.

NHS Sefton chief executive Leigh Griffin told HSJ: “We have got a challenging year ahead which requires robust action.”

NHS Mid Essex had the largest increase - 27.3 per cent - in emergency admissions, while Coventry Teaching PCT had the largest increase in electives, at 34.7 per cent. Both PCTs recorded large increases for both forms of admission but said coding changes affected their figures.

Coventry Teaching PCT director of planning and performance Alison Walshe said the rise in emergency admissions was largely the result of a service redesign to hit the four hour A&E target, while the apparent rise in electives was down to “outpatient plus” procedures being reclassified as day cases.

NHS Mid Essex director of commissioning and redesign Sallie Mills Lewis said a change in how treatments were recorded mainly accounted for its increase.

NHS Brighton and Hove said it undertook an in-depth analysis of its increase in emergency admissions in 2008-09.

Deputy chief executive Amanda Fadero said: “The number of emergency admissions has plateaued since the introduction of a number of initiatives, including an urgent care centre and the provision of additional community beds.”

NHS Milton Keynes deputy director of contracts Claire Weston said its elective increase showed better access to services.

She said: “It should also be remembered Milton Keynes has a very fast growing population.”

Isle of Wight PCT associate director for elective and surgical services Liz Warner told HSJ the reclassification of endoscopy from outpatients to day cases was a major factor in its apparent rise in electives, combined with a significant increase in the number of people with age-related macular degeneration being treated in ophthalmology.

Success stories

NHS Cornwall and Isles of Scilly Director of service improvement and professional practice Carol Williams said the PCT had introduced a range of initiatives targeted at long term conditions, focusing particularly on self care. These include case management of “frequent flyers” by community matrons and exercise programmes for patients with chronic obstructive pulmonary disease.

As a result the PCT saved £1.7m in 2008-09 by reducing emergency admissions in 15 conditions - the majority for heart failure, hypertension and COPD.

The PCT won the 2007 HSJ Award for chronic disease management.

NHS Kingston has introduced a “GP in A&E” model to assess patients for suitability for admission to hospital or diversion to other services.

Director of performance Penny Taylor said: “We’ve commissioned a GP service within the A&E department of Kingston Hospital which runs from 10am to 10pm and sees an average of 30 people per week who would ordinarily end up as emergency admissions.

“We are also working with our primary care partners and community based services to care for patients with long term conditions in their own home to prevent them from needing an admission to A&E.”

Change by PCT

Emergency admissions

Top 10

  • Sefton-12.7%
  • Greenwich Teaching-11.3%
  • Kingston-5.5%
  • Knowsley-5.5%
  • Liverpool-5.3%
  • Cornwall and Isles Of Scilly-3.5%
  • Hammersmith and Fulham-3.4%
  • Salford Teaching-2.0%
  • Walsall Teaching-1.9%
  • North Lincolnshire-1.2%

Bottom 10

  • Calderdale-10.0%
  • Croydon-10.1%
  • Coventry Teaching-10.7%
  • Bradford and Airedale Teaching-11.0%
  • Brighton and Hove City Teaching-11.2%
  • East and North Hertfordshire-11.7%
  • Ealing-12.0%
  • Barnet-12.7%
  • Derby City-23.5%
  • Mid Essex-27.3%

Elective admissions

Top 10

  • Tower Hamlets-4.9%
  • Cornwall and Isles Of Scilly-4.3%
  • Wandsworth-4.1%
  • South East Essex-4.0%
  • North Lincolnshire-3.8%
  • City and Hackney Teaching-0.7%
  • Sutton and Merton-0.6%
  • Kingston-0.6%
  • Peterborough-0.1%
  • Bath and North East Somerset-0.2%

Bottom 10

  • Tameside and Glossop-15.2%
  • East and North Hertfordshire-15.4%
  • Central and Eastern Cheshire - 15.5%
  • Buckinghamshire-15.6%
  • Mid Essex-17.0%
  • Wolverhampton City-22.0%
  • Isle of Wight Healthcare - 23.6%
  • Swindon-24.5%
  • Milton Keynes-32.2%
  • Coventry Teaching-34.7%

PCT responses at a glance

Mid Essex

Director of commissioning and redesign Sallie Mills Lewis said the increase in emergency and elective admissions was down to a change in recording practice.

“Mid Essex Hospital Services Trust has a short stay emergency admissions unit, which was not recorded prior to the end of 2007-08. Activities that go through this unit account for more than 25 per cent of emergency activity.

“The story is similar for the increase in elective admissions. Chemotherapy users as well as short stay ward attendees had begun to be recorded as elective admissions just at the end of the year 2007-08.”

Derby City

A spokesman said: “Our figures, taken from the Department of Health weekly sitrep reports for emergency admissions show a similar trend but to a much lesser degree.

“We have a collaborative plan with our local health community which is focused on ensuring we are delivering the best quality and most appropriate pathways for our patients.

“We are also currently piloting innovative models including patient navigation across a range of services, signposting patients to the most appropriate place to meet their needs, and intermediate care modelling, both of which have seen benefits already in changing demand patterns.”


Director of commissioning and performance Joanne Murfitt said: “We are well aware of the increase in short stay emergency admissions. Many of these are for patients with a stay of less than 24 hours.

“We have taken a number of steps to provide alternatives to hospital admission; for example, we have commissioned acute admission avoidance beds in our local community hospital.

“We have also worked with Ealing Hospital to commission an acute medical unit with direct GP referral and have re-commissioned how urgent mental health support is provided into the hospital.”

East and North Hertfordshire

NHS Hertfordshire director of system management Beverley Flowers said: “There were a number of complex reasons for the increase in elective and emergency admissions in East and North Hertfordshire during 2007-2008 and 2008-2009.

“One contributing factor was the change in coding and this affected PCTs in different ways. An example of the changes that impacted on us was the coding of non-consultant activity. There was also a significant backlog of elective admissions at the time that needed to be dealt with, in order to achieve the 18 week target.”

Brighton and Hove City Teaching

Deputy chief executive Amanda Fadero said: “The PCT undertook in-depth analysis of the increase in emergency admissions in 2008-09, both from a data and patient pathway perspective. Both internal and external audits demonstrated that usage was appropriate and in line with comparator areas.

“The number of emergency admissions has plateaued since the introduction of a number of initiatives, including an urgent care centre and the provision of additional community beds. The PCT continues to work with colleagues across the local health economy, including the acute trust, in order to ensure that services are used appropriately.”

Bradford and Airedale Teaching

Head of acute care development Mike Edmondson said: “The increase in emergency admissions relates specifically to patients being admitted to Bradford Teaching Hospitals Foundation Trust rather than the whole district covered by NHS Bradford and Airedale.

“A number of health economy-wide initiatives are currently under way or planned for the near future to counteract this increase. We have commissioned a utilisation management study focusing on emergency admissions at both acute trusts.”


Director of strategic commissioning Jessica Brittin said: “Whilst there was an increase in admissions in Croydon during this period, there was also an increase across London in the same period.

“NHS Croydon is working to minimise emergency admissions by focusing on better management of chronic long term conditions and encouraging better use of primary care services, such as GPs, pharmacies and walk-in centres.”

Milton Keynes

Deputy director of contracts Claire Weston said: “While NHS Milton Keynes would like to see people cared for outside hospital, we are also keen to improve appropriate access to hospital services for all Milton Keynes residents.

“These figures demonstrate better access and supports the achievement of the 18 week pathway for most specialties. It should also be remembered that Milton Keynes has a very fast growing population.”

“Additionally, some services have become available in Milton Keynes that previously were only available elsewhere - for example, angiography is now available in Milton Keynes, for which patients used to have to travel to Oxford.”

Wolverhampton City

Director of commissioning Harry Ward said: “We do not recognise the figure given by CHKS of a 22 per cent increase in elective admissions between 2007-08 and 2008-09.

“Our own data and data from Dr Foster show a 7.1 per cent increase in elective admissions between 2007-08 and 2008-09. The rise was due to increased activity around achieving the mandatory 18 week target.”


A spokeswoman said: “We don’t recognise these figures and can’t comment on them as we have been unable to ascertain how they were derived and which providers they relate to.

“We are already working with GPs and acute care colleagues to reduce outpatient and emergency demand so that the system breaks even this year and remains sustainable.”

Central and Eastern Cheshire

Associate director of practice based commissioning Jerry Hawker said: “Our analysis shows there was a 13.3 per cent increase in elective activity between 2007-08 and 2008-09. This increase was predominately associated in an agreed change in coding with East Cheshire Trust.

“The increase in day case activity reflects an agreed coding change from 2006-07 activity which was coded as outpatient procedures. This was a fully planned change, contractually agreed between the PCT and East Cheshire Trust and had no financial implications.”

Tameside and Glossop

A spokesman said: “NHS Tameside and Glossop saw a rise in elective activity in 2008-09 primarily due to the need to meet 18 week targets.

“We have, however seen a reduction so far in 2009-10 in GP referrals to all our NHS acute providers of about 4 per cent compared to the same time period last year and as we progress with practice based commissioning we expect to see this trend continue into next year.”

Coventry Teaching

Director of planning and performance Alison Walshe said: “Emergency admissions had been reducing from 2005-06 to 2007-08. The increase in admissions in 2008-09 was largely a result of the redesign of emergency care pathways to achieve the A&E target.

“Apparent significant ‘growth’ in elective inpatients is particularly a result of a technical coding issue in 2008-09 whereby a number of outpatient plus procedures were reclassified as day cases due to national payment by results guidance.”


Assistant director of finance and performance Haydn Jones said: “The data that CHKS are looking at on HES is all the activity that our providers have submitted that relates to Swindon. However, not all of these services are chargeable to NHS Swindon.

“There is a noticeable increase in the activity from 2007-08 to 2008-09 as more of our providers started submitting data into the Secondary Uses Service which then feeds into HES. We were clear with our providers through our contracts what activity was chargeable and what activity was not chargeable.”

This is PCTs’ admission of failure – but everyone shares the blame