A recent study has just fallen into my lap (under the Chatham House rule). It is the initial findings of a casenotes review of over 100 short-stay (zero- and one-day) emergency admissions at an English acute hospital.

For me the most interesting highlights of these short-stay admissions were:

• Only 33% were appropriate (and only 22% of those from A&E) under the AEP
• For 80%, the grade of doctor making the decision to admit was “unclear” or “not documented”
• 50% of admissions from A&E were in the last half-hour before the 4 hour target was reached

Given that short-stay emergency admissions are common and rising, this presents a huge opportunity to GP Commissioners. In the short term the combination of unclear records, inappropriate admissions, and the absence of previous GP involvement in the patient all point to opportunities to challenge the hospital’s claims for payment. In the longer term, it presents opportunities for GP triaging of A&E attenders, and the establishment of primary and community alternative pathways.

Isn’t that a bit rough on the hospital? Not really. Not just because the inappropriate admissions are, well, inappropriate. But also because there may be darker things going on underneath these headline figures.

The fact that half of admissions from A&E are made in a scramble, just before the 4 hour target is breached, ties in with national figures and offers a clue about why so many admissions are inappropriate. According to the Information Centre:

Of those patients discharged [from A&E] within the final 10 minutes of the 4 hour wait target, the highest proportion (64.7 per cent) were recorded as ‘Admitted / became a lodged patient’.

So late admissions and inappropriate admissions are linked together. Which raises an intriguing question: is the lack of documentation about the admitting doctor also part of the picture? With only minutes to go before the target is breached, perhaps doctors are in such a rush to admit that the notes are left unclear? Or worse, are some patients being admitted “administratively”, by a non-doctor, just to achieve the target (as is sometimes alleged by NHS staff on comment boards, e.g. here, here, and here)?

The problem at the moment is that hospitals are heavily incentivised to behave like this. Such compromise corrodes the soul. If GP Commissioners challenged payments on inappropriate admissions, so that they became a cost to the hospital instead a benefit, then the world could start to turn the right way up again.