Right on cue, both the benefits of treating more people in the community - and the costs of continuing present levels of hospital care - are set out in stark detail in our news pages today. It is just two weeks since the government signalled in its latest health white paper a switch from hospital to primary care. The 5% earmarked over 10 years may not sound much but it will coincide with a much tighter squeeze on hospital spending and amount by the end of the decade to some £2.5bn a year. The benefits of doing so - not just in costs but in the quality of life for patients - are indisputable.
This was not a new initiative. For the past three years health managers have been pressing ministers to switch their focus from the one million patients on elective care waiting lists - 70% of whom are treated within three months - and concentrate on the 15 million with long-term medical conditions who account for 50% of GP consultations and 75% of the use of hospital beds. Large though this demand already is, a new report estimates the hospital bill for managing these conditions could rise by 40% in the next 20 years. That is the bad news. Remember, the first of the 17 million baby boomers - born in the first two decades after the second world war - reach the age of 60 this year. The good news is the report's calculations of the savings from the large numbers currently being treated in hospital who could, with better preventive work in the community, need never have gone to hospital.
Drawn up by statisticians at the Health Department and the Dr Foster private data firm, the report estimates that more than a million emergency admissions a year to hospital are accounted for by people being repeatedly admitted. It suggests that with the right primary care they could have been better managed outside hospital. It identified 440,000 patients who had at least three emergency admissions in a year. Almost half of these so-called "frequent flyers" were over 65 and more than half were suffering from at least one of 19 chronic conditions. Many had multiple conditions. The most common problems were heart disease (angina and heart failure) and respiratory illness (asthma and chronic obstructive pulmonary disease). The repeated admissions cost the NHS £2.3bn.
The biggest demand for emergency hospital admissions comes, hardly surprisingly, from poor and undoctored areas - another shortfall the white paper promised to address. The variation is large, with a primary care trust in one of Birmingham's poorest areas having 10 times as many referrals as more affluent districts. Ministers have already set a target for reducing emergency bed days by a modest 5% by 2008. So what should happen now?
Progress is needed across a number of fronts. First is to ensure undoctored areas do get more GPs. This is a report on too frequent hospital attenders; but there is another equally important group, the not frequent enough attenders because they cannot get to a GP. It is important too not to blame the frequent attenders. Many will be frail and elderly, with multiple conditions. With earlier support they may have been able to look after themselves, as the burgeoning expert patient programmes are demonstrating. In these schemes, patients learn self-management techniques including handling pain relief and feelings of frustration or depression, and communicating more effectively with health professionals. Then there is the need to expand community matrons. In Cornwall, where there is a county-wide team of 30, emergency admissions were cut by 50%, saving £1m in hospital costs. The department is planning to have 3,000 community matrons by 2007. And some emergencies, as ambulance services are demonstrating, can be met by paramedics going to the home rather than taking the patient to the hospital. There is no shortage of schemes. What is needed now is sustained medical and ministerial commitment.
