Policy Analysis

Emergency admissions

July 2010 The Nuffield Trust has published a briefing: Trends in emergency admissions in England 2004–2009: is greater efficiency breeding inefficiency? Ian Blunt, Martin Bardsley and Jennifer Dixon. Thirty-five per cent of all admissions in the NHS in England are classified as emergency admissions, costing approximately £11 billion a year. This paper examines the 11.8% rise in emergency hospital admissions in England from 2004/05 to 2008/09 and tries to identify the possible explanations.

At most 40% of increase due to aging population
No one age group, type of illness the cause
Self-reported ill-health stable
Big increase in short-stay admissions and reduction in number of admissions that end in death - suggests lowering of threshold for acute admissions
Local but not national affects of A&E 4-hour target and PbR - trend started before these were in place
Proportion of A&E attendances rather than number of attendances is the big growth - grew by 14.3%
Significant variation between trusts - some declined by up to a third, others almost doubled
No clear link with deprivation

The Nuffield Trust argues that the most plausible supply-side factor is advances in medical care and management have reduced lengths of stay which has freed up more beds to allow more admissions. This cycle is reinforced by fragmented systems.

It argues that improving out of hospital care and reducing beds won't be enough to reverse the trend and recommends:

Reworking of financial incentives and who bears financial risk to avoidable admissions
Understand more about impact of inadequate out of hospital care and pilot ways of improving coordination
Incentivising keeping people well
Keep coding and definitions up-to-date with models of urgent care
Regulators should assess quality of care and consider using avoidable admissions as an indicator of inadequacy of coordination
Clinicians should review decision-making about admissions
Ensure shorter lengths of stay translate into fewer beds not lowered thresholds for admission
Develop higher quality out of hospital care with better coordination and communication
Identify patients at high risk of future admission using risk-stratification
Learn from those places where admissions have gone down.

July 2010 Two papers from the NHS Confederation by Nigel Edwards

The triumph of hope over experience: Lessons from the history of reorganisation

The writer argues for more analysis about what we can learn from previous experience “Although there is widespread acknowledgement of the problems of frequent reorganisation, there is still a tendency for it to be enthusiastically advocated as a solution – often with little reference to the problem it is trying to solve.” Evidence outside healthcare: no more than 25 to 30 per cent of mergers and acquisitions in the commercial sector succeed. Given the greater complexity and level of risk in the NHS, this success rate would be optimistic. While modest savings can be made over time, dysfunctional effects of reorganisation include a loss of focus on services, delays in service improvements and a difficulty in transferring good practice within the merged organisation. Frequent organisational change has often led to a loss of momentum, some significant risks of harm to staff and risks of creating cynicism, particularly among clinicians. He cites Stoke Mandeville and Maidstone hospitals as examples of serious quality and safety lapses, where the Healthcare Commission highlighted poor integration following large-scale mergers. There is good reason to suppose restructuring will have some adverse effects, may fail to deliver the promised benefits and may be carried out in haste or with insufficient thought, leading to further reorganizations later.   He notes that acute hospital trusts have been much more stable than other health bodies as they have experienced fewer changes; and that community organisations are at risk if there is not proper analysis done. There is a section on “An illusory search for the best fit” in terms of size of PCO and region.

Dealing with the downturn: using the evidence

No further clarity on whether it is £15 or £20 billion or something else, and over what time period, and whether this includes all the changes anticipated by Wanless. However, likely that up to half of the efficiency gain will need to be cash-releasing. Very little capital will be available. So what are the solutions?

He asks whether providing care closer to home reduces costs and offers a helpful analysis of how you remove cost from the system and why it’s so difficult (and therefore why hospital at home schemes may have similar quality but rarely reduce costs – important issues of large-enough scale and easier if overall expenditure is rising). He argues relocating services without redesigning them is unlikely to succeed, including necessary and significant redesign of professional roles.   He also asks about managing long-term conditions to reduce cost and highlights the problems that IMPRESS has highlighted of carving out single disease pathways given the challenges of people with comorbidities and, even in a younger population, single-disease pathways can actually increase overheads and costs. The most likely scope is earlier intervention, admission avoidance (see Nuffield paper above), reductions in length of stay and improved outcomes. There’s also a very helpful section on how reducing variation is tougher than sometimes assumed and very much in line with IMPRESS thinking: need to ensure cost comparisons include the same bundle of care (eg the rehabilitation phase); and that root cause is in the control of the NHS – eg not housing, poor social care etc and that the “right” level of referral is not assumed to be the lowest. That is, understand the context. There are examples of good effects of decision-support aids although not terribly relevant to non-surgical/intervention specialties.

Skillmix and substitution: there are some challenging points made: “the lower cost of nurses was often offset by lower productivity, higher recall rates and higher levels of tests and investigations." Larger teams in primary care tend to be the result of increased skill mix substitution, which brings advantages in terms of higher quality care and, if carefully designed, lower costs. Costs can rise, however, where the transaction and coordination costs of multi-disciplinary teams start to outweigh the benefits. In the acute sector, the research evidence suggests that diluting skill mix may have adverse effects on morbidity and mortality and that a higher ratio of qualified and skilled nursing staff is associated with reduced length of stay. There may also be benefits in reduced stress and burnout. He talks about skilling up not down. He also argues that clinicians should use improvement methodology to ensure the work they are doing adds value.   He also quotes the Ovreteit paper about improving quality does not necessarily reduce cost and then need to realign incentives. He then looks at organisational shapes and says there is significant scope to reduce demand through joint health and social care commissioning. With regard to community services, he refers to his other paper (see above) as well as Leutz’s five laws of integration relevant in avoiding some of the most significant hazards in integrating health and social care.
Leutz’s five laws of integration

• You can integrate all of the services for some of the people, some of the services for all of the people, but you can’t integrate all of the services for all of the people.
• Integration costs before it pays
• Your integration is my fragmentation.
• You can’t integrate a square peg and a round hole.
• The one who integrates calls the tune

Other tips for success: keep it simple, remove complexity from the system, involve clinicians and patients from the start, make use of the most expert opinion (supported with diagnostics) as early in the care process as possible, for example consider skilling up rather than down. use primary care as the platform for improving long term conditions care and managing demand, look at frailty as well as disease pathways.

King's Fund report on A high-performing NHS? A review of progress 1997-2010
The Labour government was elected in 1997 with a promise to ‘save the NHS’. So is the NHS in England a better health care system in 2010 than it was in 1997? This review examines the progress made by the NHS in the past 13 years.

NHS Confederation's policy analysis published pre-Election in March 2010: Rising to the challenge: health priorities for government and the NHS

King's Fund Publication – Our Future Health Secured – September 2007  The Kings Fund commissioned Sir Derek Wanless to undertake a retrospective review of NHS spending since he wrote his highly influential report for the Treasury Securing Our Future Health in 1992 (the terms "fully engaged scenario" come from this).  Full details of this may be downloaded from the King's Fund website