Is the emergency (999) service being misused? retrospective analysis

Introduction

The number of emergency admissions to hospitals in the United Kingdom has increased for reasons that are not fully understood. The increase can be traced back to the early 1980s and is not simply the result of organisational changes in the NHS.1 The ageing population is not the principal factor as demographic changes between 1981 and 1994 account for only 5.6% of the total increase in emergency admissions, and the increase has occurred in all age groups. More important is the increase in the proportion of patients admitted several times over a five year period: this number rose by 92% between 1981–5 and 1990-4.1

Other causes cited for the increase in emergency admissions include higher patient expectations and a rise in referrals from general practitioners.2 Both general practitioners and hospital doctors have become increasingly fearful about litigation.1 The falling death rate among patients admitted as emergencies indicates that patients are being admitted with less serious problems than before,3 and most researchers are agreed that the increase is too steep to be explained by a worsening of the health of the population.1

In the United Kingdom the number of emergency (999) calls to the ambulance service has increased. In the area served by the Westcountry Ambulance Service the number of such calls increased by 28%, from 74 141 in 1993–4 to 94 730 in 1996-7. Many 999 calls to the ambulance service have been claimed to be inappropriate.4 We determined whether the recent rise in 999 calls represented an increase in inappropriate calls.

Subjects, methods, and results

This accident and emergency department is the only such department serving a mixed urban and rural population of 410 000. Details of all new patients brought by ambulance to the department from 1993 to 1996 were taken from the department's database. Severity of illness or injury was assessed using the outcome measures of admission, follow up, and discharge, which have been previously validated.5 Patients who dialled 999 but were not transported to hospital were excluded as were patients whose admission had been arranged by their general practitioner.

The 1 shows patient numbers and outcomes. Total outcomes were slightly less than 100% (97.82%) because of information that had been insufficiently coded. The average annual increase in patients attending the accident and emergency department on the basis of a 999 call was 8.9%, which relates closely to an 8.6% increase in the numbers admitted. The difference in the percentage of patients admitted is greatest in the years 1995 and 1996 but comparison of the proportions admitted is not statistically significant (P=0.171). There had therefore been no significant change in the proportion of people attending the accident and emergency department on the basis of a 999 call in the past four years.

Comment

The annual increase in emergency admissions is a cause for concern for both healthcare workers and purchasers. To date, none of the reasons postulated for this increase can explain the size of the rise. As the increase in numbers is far in excess of rises in bed capacity there is a commensurate increase in pressures on elective activity.

If the rise in 999 calls indicated an increase in the number of inappropriate calls the percentage of patients admitted based on those calls would fall. The numbers of patients admitted to accident and emergency departments have, however, risen in parallel with those admitted on the basis of a 999 call.