Is hospital the right place?

Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth

Background

The English NHS faces financial pressures that may render the growth rates of elective admissions seen between 2001/2 and 2011/12 unsustainable. A better understanding of admissions growth, and the influence of policy, are needed to minimise the impact on health gain for patients.

Objectives

This project had several objectives: (1) to better understand the determinants of elective activity and policy to moderate growth at minimum health loss for patients; (2) to build a rich data set integrating health, practice and local area data to study general practitioner (GP) referrals and resulting admissions; (3) to predict patients whose treatment is unlikely to be cost-effective using patient-reported outcomes and to examine variation in provider performance; and (4) to study how policies that aim to reduce elective admissions may change demand for emergency care. The main drivers of elective admissions growth have increased either supply of or demand for care, and could include, for example, technical innovations or increased awareness of treatment benefits. Of the factors studied, neither system reform nor population ageing appears to be a key driver. The introduction of the prospective payment tariff ‘Payment by Results’ appears to have led to primary care trusts (PCTs) having increasingly similar lengths of stay. In deprived areas, increasing GP supply appears to moderate elective admissions. Reducing the incidence of single-handed practices tends to reduce referrals and admissions. Policies to reduce referrals are likely to reduce admissions but treatments may be particularly reduced in the lowest referring practices, in which resulting health loss may be greatest. In this model, per full-time equivalent, female and highly experienced GPs identify more patients admitted by specialists.

Results

It appears from our studies that some patient characteristics are associated with not achieving sufficient patient gain to warrant cost-effective treatment. The introduction of independent sector treatment centres is estimated to have caused an increase in emergency activity rates at local PCTs. The explanations offered for increasing elective admissions indicate that they are manageable by health policy.

Conclusions

Further work is required to understand some of the results identified, such as whether or not high-volume Clinical Commissioning Groups are fulfilling unmet need; why some practices refer at low rates relative to admissions; why the period effect, which results from factors that equally affect all in the study at a point in time, dominates in the age–period–cohort analysis; and exactly how the emergency and elective sections of hospital treatment interact. This project relies on the analysis of secondary data. This type of research does not easily facilitate the important input of clinical experts or service users. It would be beneficial if other methods, including surveys and consultation with key stakeholders, could be incorporated into future research now that we have uncovered important questions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Fighting fires?--emergency hospital admission and the concept of prevention

Although the UK's health and social care system has always been geared towards dealing with crises, evidence suggests that this is becoming increasingly the case. Changes in health care and the prioritisation of scarce resources have resulted in a situation where those with low level needs are often left unsupported until they experience a major life crisis. To rectify this situation, the government has introduced a range of policies designed to emphasise the need for preventive work. Against this background, this paper focuses on the issue of emergency hospital admissions, critiquing the research methodologies that have been used to investigate the scope for preventive work in this area. Despite the use of more sophisticated and objective research tools, there is a need to develop new ways of researching emergency admissions which build on the strengths of existing approaches while at the same time incorporating more of a user perspective.

Appropriateness versus efficiency: the economics of utilisation review

The aim of routine utilisation review is to identify patients who are inappropriately placed in an acute unit and who could be alternatively treated in a lower technology facility. Utilisation review was designed as a means of cost control in the USA. but problems with rising emergency admissions and consequent acute bed shortages in the UK have led to a substantial and growing interest in the concept of appropriateness and in the development of utilisation review instruments. Appropriate care is not necessarily the same as efficient care, however, and inappropriate care could potentially be more cost-effective than the alternative. This will depend on, first, whether the design of utilisation review instruments is such that they will encourage efficiency, and second. whether efficiency objectives would be met by the application of utilisation review in the context of the UK health care system. The first issue is discussed in relation to the effectiveness of alternative forms of care. The second is discussed in relation to the potential for reductions in cost, the issue of institutional resistance in the UK, and the validity of utilisation review instruments. The paper concludes that the potential impact of utilisation review on technical efficiency in the UK is ambiguous and questions its purpose in the National Health Service.