There are some things we can change, and some we can’t. According to the serenity prayer, the key is knowing the difference. With limited management and clinical capacity, this is crucial for CCGs and the NHS.
Unplanned care is one of the main challenges facing the NHS. Rising demand, admissions and a reducing social care budget create a perfect storm for hospitals and practices struggling to meet A&E targets, improve access and quality. It can be difficult to look up, to examine the system, when we are running on a treadmill that seems to relentlessly increase in pace.
Locally, we have commissioned an annual review of hospital admissions for each of the last 3 years, using a validated external tool. Over a defined period, how appropriate are admissions, what is the situation on the wards, where are the gaps in services outside hospital? Many areas do similar studies. The challenge for the new commissioning system will be to make a difference, but it will take a partnership approach, involving providers and social care.
What were the main findings? The majority of patients are admitted appropriately. 11% were thought to be medically inappropriate (17% in 2011). Approximately half of these inappropriate admissions were unavoidable because local services didn't exist that might have cared for them. Inappropriate admissions were not related to patient age.
42% of patients admitted had a mobility problem. 25% had cognitive problems. Respiratory illness was the most common cause of inappropriate admission.
67% of admissions were from A&E, 28% via GPs, consistent with previous years. GP admissions were more likely to be inappropriate (15%) compared to those from A&E (8%), where investigations were possible beforehand.
70% of patients who were in beds could have been discharged from acute beds earlier, with variation between wards and specialities. Increasing age was related to delayed discharge.
We are currently reviewing the results and discussing the findings with social care and healthcare providers. Discovering what we can change. There are clear messages already. When discussing increasing admissions and increased pressure within hospitals, we need to know our population, know our local services and look beyond the hospital walls.