Why a better understanding of emergency admissions needs better data

Each local healthcare economy is trying to reduce its levels of emergency care activity. Fewer emergency hospital admissions, accident and emergency attendances and ambulance journeys create both a better experience of healthcare and – if the totals are reduced – a better financial position for a healthcare economy.

But this is a difficult task and previous attempts and investment have done little to reduce the total levels of activity per financial year. There is a need to create a better experience of healthcare. Is this possible with current approaches, where a “more of the same” ethos largely prevails?

Focusing on emergency hospital admissions and A&E attendances, new thinking from NHS Wakefield District shows that the trend to immediately look for tangibility and certainty in approaches to lower emergency activity is limiting our overall level of understanding in this area and our chances of success.

The growth in community based services has featured heavily in primary care trusts’ attempts to reduce emergency hospital admissions and A&E attendances.

The backdrop to the growth in community services pitted commissioning leads against one another. With the availability of new money, clinical areas with a high number of emergency admissions stood a greater chance of receiving new investment than those with a lower number. This was largely based on whether or not the cost of the emergency admissions per year could justify the cost of a particular service.

The perverse elements of this approach were largely ignored. For areas with a comparatively small number of emergency admissions, should commissioning leads have been hoping that more people would be admitted to “justify” the cost of a proposed service?

This also became the thought process behind the emphasis on frequent flyers – individuals who have experienced a number of repeat emergency hospital admissions and/or A&E attendances in a year – and the approaches to trying to predict who they will be.

The focus on particular clinical areas with a relatively high number of emergency hospital admissions and frequent flyers formed the definition of “tangibility”. The simple fact of knowing that in these cases there had been the prior use of emergency services justified the time and resources being spent on them. They became – and still are – accepted areas of “certainty”, where there is an expected return on investment.

A focus on these areas is insufficient. Total levels of emergency demand per year have not significantly reduced, nor are they likely to as a result of efforts in a small number of tangible areas of certainty.

Approaches to measuring the impact of services are still very bound up with a form of measurement that reflects the desire for a return on investment.

Historical measurement

The example in the table above shows a reduction in emergency hospital admissions for clinical area “x” of 20 (from 200 to 180) between years 2 and 3 (see figure 1, below). The applied measurement, ie measuring the success of the investment, in this case clinical area x, would consider this a good outcome. This will not have considered the fact that the overall number of paid admissions has increased by 30.

If this is taken into consideration it will be to make the point that without the reduction of 20 then the total number of paid admissions in year three would have been 1,020 rather than the actual 1,000. Unfortunately, though, this is not true. It is a product of the need for tangibility and certainty.

Historical measurement method

The fact that the total would not necessarily have been 1,020 is a difficult point to make. This is because it is the complete opposite of what our current method of measurement tells us. It is not widely recognised that emergency admissions activity is the result of ever-changing situations.

Looking back at a year’s activity and applying a reduction in admissions for “x” to the total demonstrates this. It assumes there are no other factors that would have influenced the total other than the reduction in admissions for “x”. The achievements for “x” do not lead to a reduction in the total, nor an actual (and tangible) financial saving. The total rose.

A different way

Emergency hospital admissions are the result of dynamic, ever-changing situations throughout a year.

There is a real lack of detail applied to emergency care demand to show this. The actual account is reduced to data counts by activity type, where even learning the number of individuals who were admitted can be difficult and erroneous. 

Yet when such detail is gathered it can prove illuminating. The table below highlights the difficulties with tangibility and certainty. It shows for the 2010-11 financial year the number of individuals from the registered population of NHS Wakefield District who experienced an A&E attendance, and the number who experienced an emergency admission.

A different type of measurement (2010-11)

*Activity from the NHS Wakefield District registered population

The figure for A&E attendances and that for emergency admissions represent over 70 per cent of the total level of each activity type for 2010-11. These figures outweigh the current service approaches to reduce these types of activity. They also mask the expected range of individual circumstances, decision making and behaviours within the size of such populations.

It is unlikely that these figures represent an anomaly. Other local healthcare economies will be in a similar situation and need to start actively measuring in the approach shown in the table on the right.

Discussions within health economies must start with this table and build on this information. Emergency care types, such as A&E attendances and emergency admissions, have to be viewed more as areas to directly consider in their own right, rather than as a “tag” to community care.

Explore the options

The first forward step is to begin exploring. There are two simple viewpoints possible. The first is the current position, the idea that certainty breeds certainty. The second is the advocated position, to start with the belief that things are uncertain, and that only by thinking in this way is there any chance of certainty.

The table shows the scale of the problem, however this approach is often ignored in favour of the needless measurement of anything and everything.

There is a need to understand much more about the relationship between the number of A&E attendances and emergency admissions, for example. There is also a need to focus attention towards entire populations, and not just on the current and particular subsets that have experienced previous levels of emergency demand. We have to acknowledge that we do not know more than a very small minority of the population who will experience either one or both of these types of demand.

It would be better to start with a belief, for example, that everyone within a particular registered population is at equal risk of at least one A&E attendance. This would lessen, if not remove, the current preoccupation of local healthcare economies with individual risk-scores to one that specifically looks at the type of care approaches that may work to reduce total activity levels.

Two particular examples would be to actively contact as much of a population as possible to simply ask if they are well, and to link this to a model such as the patient access approach, where the emphasis in general practices is no longer on bookable appointments but on telephone conversations between the patient and their clinician.

The former may be deemed to be ridiculous, but can any strength be gained from ignorance? There is a case to be made that it offers a caring approach and that it offers a scale of approach equivalent to that shown in the table.

Exploring different ideas will allow us to understand where we currently are, and where we need to be, to stand a chance of reducing the total levels of emergency care activity.