1. © Nuffield Trust July 2010 Trends in Emergency Admissions in England 2004-2009

2. Why emergency admissions? Emergency hospital admission is: Undesirable Expensive Recorded in routine data and Thought to be increasing in number © Nuffield Trust

3. Are emergency admissions rising? Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? Possible reasons Aging population Public expectations More treatable illness Defensive medicine Central targets/ Payment by Results Changes in other linked services Over reliance on A&E for urgent care Number of emergency admissions in England 1996-2009, with period investigated marked in red

4. Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency Is it just emergency admissions?

5. Our analysis The aims of the research were to: Unpick the rise in admissions Highlight characteristics of excess admissions Explore variation at hospital and area level This work used the Hospital Episodes Statistics (HES) dataset to examine monthly emergency admissions over a five year period from April 2004 to March 2009. © Nuffield Trust

6. Is the increase due to more readmissions?

7. Estimated cost of the rise in emergency admissions is equivalent to at least an additional £330 million in 2008/09 (compared to 2004/05 activity costed at 2008/09 payment levels). However, the actual value is likely to be higher due to inflation in the tariff over time and payment for non- tariff work. How does the rise consume resources?

8. Is the pattern of stay length changing? Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? Number of emergency admissions categorised by emergency bed days (EBDs) used in spell, excluding spells in mental health and undefined Healthcare Resource Groups (HRGs) 2001-2009

9. Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency Is the increase related to age?

10. Has the case mix of emergency admissions changed?

11. Emergency admissions that end in death, showing observed deaths, expected deaths (standardised for age, sex, and HRG at 2004/05 rates) and percentage of total emergency admissions Has the case fatality rate changed?

12. Is the rise linked to the A&E target in England? Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? Trade-off analysis between four-hour target breaches and short stay emergency admissions in England (all A&E types)

13. Is the rise linked to the A&E target in particular trusts? Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency Trade-off analysis between four-hour target breaches and short stay emergency admissions in another trust (all A&E types)

14. Do all PCTs show the same pattern? Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? (a)Age and sex standardised emergency admission ratio in 2004/05 (green, lowest, to red, highest) (b)Absolute increase by 2008/09 (blue, dark = highest, light = lowest)

15. The evidence in summary... Possible reasonComments Aging populationAccounts for some of the increase, but not all Public expectationsIncreased demand for health services More treatable illnessNo significant change in case mix, although vague symptoms increase disproportionately Defensive medicineThe increase is due to short stay admissions; but could be many other explanations for these... Central targets/Payment by Results No evidence of 4-hour target driving systematic increase, and slightly pre-dates PbR Change in other linked services Could regional variation in the increase be a symptom of this? Over reliance on A&E for urgent care A&E attendance is increasing, as are admissions through A&E

16. Efficiency breeds inefficiency paradox? Provider efficiencySystem inefficiency Better and more efficient care Reduction in length of stay More beds available Admission threshold reduced Lower acuity cases using costly inpatient care Less severe cases admitted

17. www.nuffieldtrust.org.uk Sign-up for our newsletter www.nuffieldtrust.org.uk/newsletter Follow us on Twitter (http://twitter.com/NuffieldTrust) July 2010 © Nuffield Trust