Our plans focus on reducing inappropriate unplanned care demand in hospital settings by increasing primary care and community services access as well as better supporting high risk patients.
Commissioning unplanned care
During 2014/15, we have increased the use of ambulatory care across the county in both acute hospitals. We have also extended the high risk patient care planning process to more people across the county. The care plans are not just pieces of paper in Northumberland; each patient is discussed at weekly multi-disciplinary meetings in practices and the care packages are adapted, with the involvement of patients, as required. We have also reduced A&E attendances, created a community pathway for deep vein thrombosis diagnosis and implemented patient transport eligibility criteria in line with national guidance.
We have developed a paediatric model of care to be implemented when the new emergency care hospital opens in June 2015. This is a model that spans both acute trusts (Northumbria healthcare as the provider of a short stay paediatric assessment unit and Newcastle Hospitals as the provider of a full suite of paediatric outpatient and inpatient services, including specialised services commissioned by NHS England).
NHS England has recognised our excellent work in delivering system resilience by giving us ‘earned autonomy’. Nationally we have seen increased pressures in the system and this has been reflected locally. Our main acute provider has, however, maintained one of the best performance levels nationally. Early communication and warning signs have been managed through the strength of the Northumberland Urgent Care Operations Group. We have already held review meetings to learn lessons from this winter to ensure we are even better prepared for next year.
Our plans for 2015 include:
- Significantly extended primary care access across the county from 8am until 8pm and into weekends. This will use a variety of models including individual practices, groupings with neighbouring practices and working with other providers such as acute hospitals and community services
- Enhanced primary care access for vulnerable and complex patients designed to avoid admissions to hospital settings, focussing on care homes and keeping people well and independent at home. We will provide enhanced community based support, backed up by specialist provision
- Managing same day primary urgent care demand through new ways of working with community nursing services and releasing time to care for complex and vulnerable patients
- Combining the high risk patient pathway and end of life pathway, to enhance access for vulnerable and complex patients across primary, community, social and acute care. We will create a large scale vehicle for avoiding unnecessary admissions to hospital and including care planning for patients with long term conditions as well as the primary care developments above and offering medical support to community based professionals
- Enhancing delivery of services from all providers across 7 days per week, improving transition and increased planned care to reduce the demand and reactive service delivery
- Improving the ambulance response times for 8 minute calls, towards the north east target. With this, we will also focus on the 111 service and increasing its integration with emergency service responses
- Commissioning the Northumbria Specialist Emergency Care Hospital, and its associated pathways, including a new model for paediatric and maternity care. We are also focussing on the configuration of services that will remain on the base sites, following the opening of the new hospital – creating centres of excellence for planned care as well as retaining community based urgent care access across the county
Financial recovery in already achieved unplanned care
Northumberland has consistently experienced pressures in unplanned care. Benchmarking data has been used to both quantify and prioritise the unplanned care work over the last two years and into the future. For example, the CCG ‘Quality profile’ (see below) shows there is a higher use of A&E across all the patients cared for in Northumberland and there was a particularly high conversion rate of A&E patients being admitted into a hospital bed for a day case and released home without procedure (IP25). These were concentrated within the Northumbria Healthcare and in particular in Wansbeck General Hospital
CCG Quality Profile 2014/15
The relatively high volume of activity translates into high cost too. The November 2014 “commissioning for value pack” shows our spend on non-elective care is 35% higher than our 10 most similar CCGs.
The CCG recognised it’s historically high spend in unplanned care and developed a number of programmes at its inception, to reduce this spend. For example, in partnership with Northumbria Healthcare and Northumberland County Council, the CCG developed a high risk patient pathway initiative aimed at integrating health and social care across the county to provide a seamless service for frail and elderly patients which aimed to:
- Enable patient-centred joint working across the health and social care system for over 26,000 older people.
- Successfully involve patients, their families and key stakeholders in developing the pathway.
- Improve health and wellbeing through a consistent evidence-based approach across the health and social care system.
- Significantly reduce unnecessary admissions to hospital and residential care.
- Support more people with very complex needs to live at home for longer.
- Improve access to specialists.
In 2013/14 the CCG saw a significant reduction in urgent admissions to hospitals from the community and from care homes and found that the patient experience has improved significantly.
The CCG has experienced significant pressure in non-elective activity in 2014/15, due to a number of factors. For example, the national high risk patient care DES shifted practices’ focus from identifying and monitoring patients at high risk of an emergency admission to completing the necessary paperwork to meet the requirements of the DES. The CCG has also experienced significant pressures during the winter, along with the rest of the country, which has increased emergency admissions.
Activity remains lower than the trend line, as shown in the following two tables, and actions are agreed with partners including primary care to drive out further efficiencies in 2015/16.
Non Elective Admissions 2009-2014 (Activity) – showing a reduction in admissions since the CCG implemented its unplanned care work.
Table X – non elective admissions 2009 – 2014 (cost) – showing a reduction in cost of admissions since the CCG implemented its unplanned care work.
Financial recovery planned for 2015/16
We are working with our providers – secondary, community and primary care – to design and implement non elective pathways that are better value for money and cost effective for the CCG, whilst delivering quality outcomes. This includes refining the delivery of ambulatory care and preparing for the opening of the new emergency care hospital; whilst also managing same day primary urgent care demand through new ways of working with community nursing services and releasing time to care for complex and vulnerable patients.
The Better Care Fund programmes capture our plans to reduce unplanned care activity by £4m, through improved joint working between the health and care sector. We recognise that a large volume of unplanned care work is a result of patients being admitted to hospital, in the last days of their life – often from care home settings.
Of the 1603 Northumberland CCG patients who died in hospital, 548 (34.2%) were on either the high risk patient pathway or the end of life pathway. The following chart shows the emergency admission frequency in the last 100 days of life for patients who are on one or both of these pathways, including the admission in which they died, relating to the period November 2013 – October 2014. Compared to the all patient group, the emergency admission pattern has less of a peak towards 0 days and there is more hospital activity with the last 7 days. Patients spent on average 22.5 emergency days in hospital in the last 100 days and the length of stay ranged from 0 days to 82 days. The average number of admissions per patient was 1.75. The chart below shows the volume of activity being targeted.