Part one of this series discusses how the more widely recognised factors, such as an ageing population, re-admissions and increasing expectations of medicine, only contribute to a baseline increase in emergency admissions. Seasonal variation is discussed in the context of the predictability, or otherwise of emergency admissions, in response to changes in the weather and the wider environment. However, these are unable to explain the observed cyclical events occurring in medicine every 4-6 years, and even longer cycles in surgical and trauma admissions. These cycles are discussed in part two, while part three investigates the implications on bed planning. The current methods for estimating the size of hospitals and bed pools within hospitals are shown to be inappropriate to the real needs of emergency care.

Over the years 2002–2003 and again in 2007–2008 there were up to 31 100 and 23 100 excess deaths respectively across the entire UK. These excess deaths have been linked to the spread of a presumed infectious agent. Analysis of death within 90 days of admission to hospital during 2008/09 reveals that the majority of the excess deaths were associated with just 460 diagnoses (out of 1,380 potential diagnoses associated with deaths within 90 days of admission). Of these 460 diagnoses the main causes for excess deaths (number of excess deaths in brackets) were lower respiratory tract diseases and infections (3,020), symptoms and unknown causes of morbidity (2940), cancers (750), injury and poisoning (340), diabetes (290), perinatal and congenital conditions (200), mental health (170), other infectious diseases (140). Approximately 70% of patients died in hospital. This pattern of diagnoses is consistent with increased hospital admission following recurring events which appear to be outbreaks of a previously uncharacterised infectious immune impairment, hence, an increase in diagnoses related to inflammation or infection including poor outcomes after trauma or anaesthesia.

Over the past few decades GP referrals have been increasing much faster than implied by demographic change, i.e. the ageing population. Up to the present this has been assumed to be a problem with the GP referral process which should be remedied by US style scrutiny of GP referrals and GP training. While some of this is warranted the mechanism for growth appears to be localised, unexpected and unexplained, leading to a permanent increase of around 15% within a one to two month period. This growth moves across the UK in a manner reminiscent of the infectious spread of a persistent agent which exhibits moderately slow transmission. The relative inability of existing demand management schemes to halt this spread suggest that a genuine infectious agent is involved.

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