Media Briefings

SURGES IN EMERGENCY ADMISSIONS REDUCE QUALITY OF CARE FOR NHS PATIENTS

  • Published Date: March 2016

Unexpected emergency admissions lead to reductions in the quality of care provided by NHS hospitals – and this is felt primarily by emergency patients and not elective patients. NHS reforms introduced in 2006 have exacerbated the priority given to elective care. These are the findings of research by Thomas Hoe, to be presented at the Royal Economic Society's annual conference in Brighton in March 2016.

Accident and emergency wards have to deal with sudden and urgent admissions on a regular basis. When a hospital’s limits are stretched, it may have to cancel planned surgeries and discharge patients early: these people are then worse off and more likely to need care again within 30 days. Reforms in 2006 meant that hospitals were charged for any patients who were readmitted as emergencies within this time.

The study finds that this reform, along with another that let patients choose where to be cared for, encouraged hospitals to pay more attention to elective patients than before so as to avoid penalties and encourage them to come back. But this has meant that emergency patients receive worse care as there is less incentive to focus on them.

The author suggests addressing the adverse side effect of the 2006 reforms by introducing more direct monitoring of the quality of care for emergency patients; revising the methodology for imposing readmission penalties; and relaxing the waiting time targets for elective care to give hospitals more flexibility to manage patient flow.

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Hospitals in England are increasingly under pressure from emergency admissions. This poses a number of challenges, not least because these admissions are highly volatile and often involve the most urgent cases.

This research shows that unexpected emergency admissions lead to reductions in the quality of care provided by hospitals – and that this is felt primarily by emergency patients and not elective patients. Reforms introduced in 2006 exacerbated the priority given to elective care.

The research, conducted by Thomas Hoe of University College London and presented at the 2016 Annual Conference of the Royal Economic Society, is based on data for overnight patients in trauma and orthopaedic departments at NHS hospitals in England between 2006 and 2010. The main findings of the research are that:

• Unexpected emergency admissions lead to the cancellation of elective surgery and to earlier discharge of patients. The patients who are discharged are more likely to be readmitted during the following 30 days, suggesting that health outcomes are also adversely affected.

• The adverse effects on length of stay and readmission are found only for emergency patients and not for elective patients, suggesting that hospitals prioritise elective care.

• For a 70-bed department, an increase of five unexpected emergency admissions (one standard deviation) is estimated to, on average across the period studied, lead to a 3.4% decrease in the length of stay and a 0.2 percentage point increase in readmissions of emergency patients. These effects compare with an average hospital stay of nine days and a readmission rate of 7% for emergency patients.

The priority given to elective care is partly explained by two reforms introduced in 2006. These were the NHS Choices reform, which granted elective patients a choice over where to receive care, and the Payment by Results reform, which introduced financial penalties if discharged patients were subsequently readmitted as an emergency within 30 days.

The former created a financial incentive to maintain the quality of care provided to elective patients because any deterioration might discourage patients from using that hospital in future.

The latter policy did not explicitly distinguish between penalties for readmission of elective and emergency patients but, as later policy changes made clear, the penalties were likely to have been more punitive for elective patients because it is easier to establish liability on behalf of the hospital in these cases.

The analysis shows that:

• Readmissions for both elective and emergency patients followed a similar trend up to 2006. But after 2006 the trends clearly diverge: readmissions for emergency patients increase while those for elective patients decrease.

• This evidence suggests that the reforms created an incentive for hospitals to substitute care from emergency to elective patients.

This adverse side effect of the 2006 reforms could be addressed by:

• Introducing more direct monitoring of the quality of care for emergency patients.

• Revising the methodology for imposing readmission penalties.

• Relaxing the waiting time targets for elective care to give hospitals more flexibility to manage patient flow, though the benefit of this option would need to be weighed against any potential deterioration in the quality of care for elective patients.

The 2006 reforms have previously been shown to improve the survival chances of heart attack patients (Cooper et al 2011; Gaynor et al 2013). Further research is therefore needed to establish how the equity losses identified in this new research compare with the gains previously estimated.

ENDS

Thomas P. Hoe
University College London
thomas.hoe.12@ucl.ac.uk