Emergency hospital admissions are a huge concern and, worryingly, they are on the rise. They are one of the most costly elements of the UK health service, and often result in poor outcomes for the patients involved, with a chronic shortage of beds, exposure to infections, and delays in discharge from hospital adding to problems.
Thanks to advances in patient data collection and analytics we can predict which people are likely to be admitted in an emergency and try to help them avoid a crisis. Information such as age, diagnoses and past history of hospital visits can be used to calculate a person’s risk of an emergency admission up to one year ahead. More than 30 risk tools are available to primary care staff in the UK for identifying patients for preventative care. However, our new research adds to a growing evidence base that questions whether these tools actually help reduce emergency admissions.
Since 2013, the NHS has paid UK GP practices over half a billion pounds to tackle emergency admissions – mainly by identifying high risk patients and managing their care (known as case management). An estimated 95% of UK general practices have participated in such initiatives. But the introduction of GP-led case management was based on the presumption that it would benefit patients and reduce admissions, and not on evidence of its effectiveness.
For our recently published research, we used the introduction of an emergency admission risk tool in Wales to study what difference it made to patient care. The PRISM tool was developed for NHS Wales and rolled out across 32 general practices as part of a randomised trial. Its rollout overlapped with the introduction of payments to practices to support case management work. Surprisingly, we found that across the 230,000 people who were patients at these practices, emergency admissions and use of other services didn’t fall, they rose slightly – and there was little evidence of patients benefiting from the tool.
Through interviews, we found that GPs were willing to use PRISM, but were concerned over a lack of community services to support patients that had been identified. Typically they used the tool to deliver the contractual work on case management, but much of this work was staff meetings and paperwork rather than direct patient care. This feedback ties in with criticisms of the contractual work as bureaucratic, adding to the work of already stretched GPs. As workload has been cited as a major factor in reports that 82% of GPs expect to leave the profession or reduce hours within five years, any innovation which places new demands on the profession should be considered with care.
Although the largest study in this area to date, ours is not the only one to cast doubt on the value of GP-led case management for high-risk patients. An evaluation in Manchester had similar findings. It has been suggested that an emphasis on those with the highest risk scores is not appropriate, as there may be little which can be done to keep these people safe and well at home. Instead, there may be more potential for impact with those at lower risk. And, as leading health services professor Martin Roland said, when considering our research, perhaps the emphasis on reducing admissions and cost savings is wrong - it should be focused on improving care.
There is another message here too, about the challenges of ensuring that health policy is based on the best research evidence. While our study was taking place, NHS England brought in three years of annual payments for case management of those at risk of admission. Would they have committed these costs if our results were known in advance? Perhaps not. But the time it takes to design, gain funding, and then deliver robust research (seven years in the case of our study) is at odds with a desire to address immediate health challenges.
Emergency admissions remain an immediate challenge. In the last year alone they increased by 6.6%. The latest GP contract in England includes the use of similar data tools to identify and proactively manage people with frailty in primary care. Unfortunately, the approach again lacks the kind of robust evidence we need to determine if it is likely to be successful. We hope it is, but let’s not rely on hope alone, and instead continue to strive for research to inform evidence-based care.