Emergency Hospital Admissions…..does the admission route matter ?

Guest blog by Dr Iseult Roche

A&E direct hospital admissions have increased since 2002 and new research (published in the Journal of the Royal Society of Medicine) also shows emergency admissions via GP’s  have fallen in the same period of 2002-11. However, why this increase has happened is “unclear”.

This possibly gives another potential reason why there is an increased burden on A&E departments; not only from an increased number of admissions, but also in the type of work staff and departments are expected to carry out and manage. A&E departments are supposed to deal with acute presentations only, but this is far from the case.

The research author, Thomas Cowling writes “A&E staff now have increased responsibility as gatekeepers for inpatient care and as care coordinators, which is not reflected in how A&E departments’ activity is measured or reimbursed.”

This is certainly true and places  A&E departments at risk in varying ways – from targets and finances, to staffing levels and duties, and most importantly optimum patient care.

Mr Cowling noted: “New models of urgent care services that employ GPs in or alongside A&E departments as gatekeepers to specialist urgent care ought to be evaluated before they are scaled up to avoid further ad hoc developments. This also applies to the current government’s pilot scheme of extended opening hours in general practice.”

Although the number of direct Speciality Admissions via GP referral had fallen during that time, it would be incorrect to consider one as being entirely responsible for the other.

There are many hypothetical reasons for these patterns and Doctors have suggested these:
– Firstly, during this time frame the total overall number of Emergency admissions have increased.
– Secondly, the general population are more health aware and self-refer if they have acute worries.
– Thirdly,  urgent tests cannot be obtained as speedily via a GP compared to A&E ; even basic blood tests take time and for some direct speciality referrals, such results are necessary (or at least useful) for a speedy and successful acceptance. In some cases GP’s may send a patient to A&E with a letter, rather than spend a lengthy period of time in discussion with a busy on-call registrar.

Other reasons suggested have included the advice given by 111 service (or its’ predecessor),  the negative attitude portrayed of GP’s in the media – so patients believe they will not get an urgent appointment and go to A&E rather than consult their GP – and also Speciality accepting protocols which may require admission via A&E rather than directly to the admitting team on-call.

For patients in care or nursing homes, there is a burden of responsibility placed on the staff and they may well resort all too quickly to sending patients to A&E rather than wait for a GP call-out (even if a GP consultation would be sufficient).

The potential reasons for the correlation are legion, but certainly it would be incorrect if the results were to be taken at a simplistic or face value.

Also, in reality, if a patient is acutely unwell and is actually admitted via A&E rather than GP, surely how they were admitted is less important, when compared to the fact they actually did need admitting. Although there are many patients who may present to A&E unnecessarily and a GP appointment would have prevented this (however that is a slightly different matter).

GP’s do an incredibly demanding job, balancing holistic long-term care with acute needs. Moral seems to be at a low point among GP’s and trainees. This is a time for health workers to stick together for the benefit of all, especially our patients.

Certainly the results pose questions about the current strategy in place to reduce pressure on Emergency departments and hospitals generally.