8.1 Introduction

The provision of emergency acute care is one of the most challenging tasks of a modern health care system. Emergency admission to hospital is unplanned, immediate and may require the temporary re-deployment of resources which will affect other services. Also, the costs associated with emergency admissions are higher than those for planned admissions of people with broadly similar health needs (Department of Health, 2004).

The government has introduced a number of service and policy initiatives relating to emergency care. NHS Direct provides advice by telephone to callers with specific health concerns and seeks to direct them to appropriate services (Department of Health, 2003). Accident and Emergency departments also have targets to admit, treat or discharge within 4 hours of arrival (Health Care Commission, 2005). Out-of-hours primary care services are also changing, with general practices now able to opt out of providing them (Statutory Instrument 291, 2004). All of these may impact upon emergency admission in ways which remain unclear until sufficient research has been carried out. Also the underlying epidemiology of the population may change over time, leading to changing patterns of health need.

The purpose of this chapter is to provide some summary statistics about how people in the West Midlands are provided with emergency in-patient services.

Table 8.1 shows that there were over 440,000 emergency admissions in the Region in financial year 2003/2004. Demand for emergency admission has increased in recent years and the rate of this increase appears to be growing (figure 8.1 and table 8.1). Overall the percentage rises appear modest but in absolute terms almost 20,000 extra admissions were needed in 2003-2004 than in the previous year. Clearly this will have implications for the providers involved and the purchasers paying for this care.

We can also see from table 8.1 that the rate of this increase is geographically variable. We need to take into account the underlying demographics of the populations in these localities. As has been reported previously in Key Health Data, there is considerable variation in the age structure of populations across the Region (University of Birmingham, 2001).

When we look at the age-sex standardised rate of admissions per 100,000 residents, we see that a number of populations with high percentage increases in admissions, appear to have a stable rate over the years in question (figures 8.3-8.6). We also see that, PCTs which have a more deprived population, have higher rates. There is also an urban / rural split with urban populations having higher rates than their rural counterparts.

These data raise the question of whether the increased use of emergency admission is due to an increase in the incidence of serious illness and injury. A case mix coding frame was devised to separate out admissions of people with less intensive health needs so that this component of overall activity could be examined in isolation. This coding frame flagged short admissions (less than 48 hours) where no surgical (including invasive diagnostic) procedures were carried out and where the patient was discharged alive after just one episode* of care. Also, admissions were limited by diagnosis; only admissions where the primary diagnosis was either signs and symptoms with no subsequent disease, minor illnesses or superficial injuries were included. The increases in these less intensive admissions were considered separately (figure 8.2 and table 8.2). This showed that the numbers of these admissions had grown much more than for emergencies as a whole. Of the 19,883 extra admissions which occurred in 2003-4 compared to the previous year, 6,497 (33%) were in this less intensive category. This proportion was highly variable. In some PCTs most of the total rise occurred in admissions of this type. The age sex standardised admission rates for these admissions are shown in figures 8.7 – 8.10.

This analysis does not suggest that these admissions are inappropriate. Many presentations of signs and symptoms can only be appropriately investigated in an acute hospital setting. However the reasons why these presentations are increasing are likely to be complex and will require further investigation to understand fully.

	Figure 08.01 Total Emergency Admissions of Residents of West Midlands Government Office Region, Financial Years 2000/2001 - 2003/2004.
	Figure 08.02 Total Less Intensive Emergency Admissions of Residents of West Midlands Government Office Region Financial Years 2000/2001 ? 2003/2004.
	Table 08.01 Emergency Admissions by PCT Resident Population In the West Midlands Financial Years 2000/2001 - 2003/2004.
	Table 08.02 Less Intensive Emergency Admissions by PCT Resident Population In the West Midlands Financial Years 2000/2001 - 2003/2004.
	Figure 08.03 Emergency Admissions by PCT Resident Population In the West Midlands, Directly Age / Sex Standardised Rate per 100,000, Financial Years 2000/2001.
	Figure 08.04 Emergency Admissions by PCT Resident Population In the West Midlands, Directly Age / Sex Standardised Rate per 100,000, Financial Years 2001/2002.
	Figure 08.05 Emergency Admissions by PCT Resident Population In the West Midlands, Directly Age / Sex Standardised Rate per 100,000, Financial Years 2002-/2003.
	Figure 08.06 Emergency Admissions by PCT Resident Population In the West Midlands, Directly Age / Sex Standardised Rate per 100,000, Financial Years 2003/2004.
	Figure 08.07 Less Intensive Emergency Admissions by PCT Resident Population in the West Midlands, Directly Age/Sex Standardised Rate per 100,000, Financial Years 2000/2001.
	Figure 08.08 Less Intensive Emergency Admissions by PCT Resident Population In the West Midlands, Directly Age / Sex Standardised Rate per 100,000, Financial Years 2001/2002.
	Figure 08.09 Less Intensive Emergency Admissions by PCT Resident Population In the West Midlands, Directly Age / Sex Standardised Rate per 100,000, Financial Years 2002/2003.
	Figure 08.10 Less Intensive Emergency Admissions by PCT Resident Population in the West Midlands, Directly Age/Sex Standardised Rate per 100,000, Financial Years 2003/2004.

References

Department of Health, Reference Costs 2004, 2004, Department of Health, London

Department of Health, Developing NHS Direct. A strategy Document for the Next Three Years, 2003, Department of Health, London.

Healthcare Commission 2005, Performance Indicators for the Performance Ratings 2004/2005, 2005, The Healthcare Commission, London.

Statutory Instrument 291, The National Health Service (General Medical Services Contracts) Regulations 2004: Sch.3, HMSO, London

University of Birmingham, Key Health Data 2001, 2001:p6

Notes to data

Admissions data were obtained from Hospital Episode Statistics from the West Midlands Public Health Observatory Safe Haven.

Admission rate denominators were PCT resident populations projected from the 2001 census, obtained from the Office of National Statistics. They were age sex standardised to European standard populations.

* An 'episode' is an NHS term which describes a period of time during an admission spent under the care of one consultant. Hospital stays with more than one episode indicate that a transfer has been made between specialities. Typically 90% of all emergency admissions will only consist of one episode.