A helping hand for the NHS

When commissioning adviser Jacqui Lyttle was asked to carry out an audit of patients in a district general hospital she found that over a quarter of them had no medical need to be there.

Many could have been treated in a community setting - a step-down environment or at home - and some had been unnecessarily admitted in the first place. The problem is that there was a lack of sufficient community-based services.
“I think what we identified was typical across the UK,” she suggests. “The problem is delayed disharge, which means that patients [who need to be treated in hospital] can’t be admitted because of bed pressures.”

Ms Lyttle, an independent consultant asked by Bupa to carry out the audit, says that the 336 patients the audit looked at (paediatrics and areas such as intensive care were excluded) over two weeks in May accounted for 590 unnecessary bed days.

‘We are spending too much at the crisis end. We don’t have a systematic approach to supporting people to self manage’

Two hundred and fifty seven of these could have been saved if services were available to support patients at home, and 230 more if they had access to a step-down service. Of the remaining days, 63 could have been saved if patients received IV antibiotics. In total, 87 patients would not have needed to be in hospital if the right service was available elsewhere.

The audit gives some indication of the scale of the problem for the NHS, but also the opportunities. Sir Stephen Bubb, chief executive of the Association of Chief Executives of Voluntary Organisations (ACEVO), sums it up: “Too many people receive care in acute settings when they could be cared for at home or in the community.”

If the acute sector is to cope with the predicted surge in emergency admissions this winter, having good alternatives will be vital. Research by the Nuffield Trust and Health Foundation has shown that preventable admissions have risen by 26 per cent in a decade - and halting this rise will be a priority for providers and commissioners.

While avoiding unnecessary admissions is important, the bigger savings are likely to be in discharging medically fit patients earlier. This will require good organisation within hospitals and also the right mix of services in the community to support early discharge.

NHS Confederation policy director Johnny Marshall says out of hospital care “is taking on a new significance as resources are stable, demand is growing and vulnerable older people are coming into A&E with more complex problems”.

‘We are spending too much at the crisis end of the spectrum. We don’t have a systematic approach to supporting people to self manage. We don’t have well-funded social care’

And Jeremy Taylor, chief executive of National Voices, says: “We are spending too much at the crisis end of the spectrum. We don’t have a systematic approach to supporting people to self manage. We don’t have well-funded social care. And we have GP services that are a cottage industry.”

At the Dudley Group of Hospitals the development of out of hospital services has been crucial in ensuring the trust is ready for the coming winter. This has included an out of hospital antibiotic service and a team delivering a virtual community ward.

Without these sorts of measures, chief executive Paula Clark says there could be “protracted trolley waits, ambulance turnaround and having to regularly cancel surgical patients. That would affect our 18-week target but it is also about the quality of patient care.”

But her trust is in an unusual position of running both acute and community services - others will need to work with other providers and commissioners to ensure those services are available.

Out of hospital care can be more cost effective than hospital care. Sir Stephen Bubb has warned that “a reactive approach to treatment is financially unsustainable”. But looking after people closer to home also has other advantages.
“Patients prefer to receive their care in a setting where they feel most comfortable, and for many this is the home environment,” says Tiffany Hall, managing director of Bupa Home Healthcare.

It can also propel them towards independence and mean they are less likely to be exposed to infections. So what could be a game changer this year? There is intense pressure on hospitals to prepare for and cope well with the inevitable increase in emergency admissions over the winter period and to maintain quality - which is infinitely harder if emergency departments are overflowing with patients who can’t move into beds.

The answer could be in a new approach to providing care – one that follows the particular needs of a patient rather than assuming that hospital is the best place for all patients.

“Commissioners need to look at who is out there as providers and put together a package of support from whoever has the talent,” says Mr Taylor. “But we still need a service which wraps around the individual’s needs.”

There is a key role for the NHS to play in providing these much-needed services. However, given the scale of the demand and existing pressures on the NHS, commissioners are turning to some independent organisations that can provide services such as IV antibiotics or an integrated approach encompassing care in a residential setting and care at home.

There are variations in the way that local areas are preparing for winter - some are better prepared than others, and the approach is far from systemic.

The challenge is not convincing people out of hospital care is necessary, but getting it to work within existing funding flows and overcoming artificial divides between health and care services.

A Mission to cut admissions

Since two thirds of emergency hospital admissions involve people with long term conditions, keeping this group as healthy as possible and helping them cope with any exacerbation of their illness is key to reducing the pressure on hospital A&E departments and beds.

In 2010 there were 15 million people in England with one or more long term conditions: that number is expected to grow to 18 million by 2025.

However, the number with three or more long term conditions is expected to grow from 1.9 million in 2008 to 2.9 million by 2018.

‘A patient with diabetes was admitted at the weekend and ended up staying nine days, at a cost of £5,000’

How can these people be kept as well as possible and preferably out of hospital? In the longer term, early intervention and health promotion could reduce the burden on ill health on both the individual and the healthcare system. Chief executive of the Association of Chief Executives of Voluntary Organisations Sir Stephen Bubb advocates addressing the underlying causes of poor health, and offering support to stay healthy.

In the shorter term, however, it is also important to think about practical ways health and social care services can adapt to avoid unnecessary admissions to hospital.

Many health economies are therefore looking at admission avoidance and supporting people at home or other appropriate care setting in the community.

NHS Confederation policy director Johnny Marshall says about 20 per cent of unplanned admissions to hospital should be treated in the community - although he adds that a short stay in hospital at the ‘right’ point in someone’s illness is preferable to an unplanned admission.

“The aim must be to try to manage their independence. It is important to facilitate that outcome rather than trying to stop people being admitted to hospital.”

Dr James Kingsland, president of the National Association of Primary Care, uses the example of a patient with diabetes who was admitted at the weekend and ended up staying in hospital for nine days, at a cost of £5,000 to the NHS. It’s not an uncommon occurrence but if each GP practice could avoid one admission like that a week the NHS could save £2bn a year. He suggests the answer is better integrated care, based around a practice population, and pulling in the services needed to support people closer to home.

As a first step it is vital to identify risk and target such services to the patients who are most at risk of an emergency admission. Data analysis is becoming increasingly important in understanding the likely shape of demand on services.
Risk stratification, both at a population level and within smaller groups such as those with particular conditions, can predict which patients are most at risk of admission to hospital and allow early intervention to prevent this.

Bupa has developed a risk stratification tool which brings together NHS data, demographics, and census data to pinpoint which patients are most at risk of admission. It uses GP and secondary care datasets to help the NHS plan service redesigns.

The tool is already in use in Worcestershire, where clinical judgment within GPs’ surgeries is then used to decide if they are appropriate for a virtual community ward approach.

The tool is a building block in a system which is designed to ensure people receive the right care in the right setting. Janet Austin, clinical services locality manager at Worcestershire Health and Care Trust, says: “Community matrons have a meeting with the practices to discuss the patients who have a high risk score. The matrons will then visit appropriate patients at home and discuss their needs. When we implemented the system two years ago we saw a dramatic fall in unplanned admissions.”

Once appropriate patients are identified, schemes - which can encompass nursing care, telephonic coaching, nutrition advice, and fitness monitoring - can be put in place to ensure they stay as healthy as possible. Integration is key to delivering this, as often patients will require a mix of health and social care services, and ones which are immediately responsive if a patient’s condition deteriorates.

Tiffany Hall, managing director of Bupa Home Healthcare, says the last 18 months have seen an upturn in interest in commissioning services which are intended to avoid unnecessary admissions for a range of long term conditions. With risk stratification expertise, and capability in both health and social care provision, Bupa is well placed to provide such services, often working closely with local NHS organisations.

In Somerset, Bupa is working with COPD patients to keep conditions stable in a groundbreaking scheme which could be applied to other long term conditions (see box). Patients get regular appointments, courses to educate them on self management and then a plan on how to cope if their condition unexpectedly deteriorates – such as emergency supplies of medicine.

But for some patients, home care may not be enough. They may require more intensive support for a short time, with the aim of ultimately returning home. Step-up care can help when they need, for example, more concentrated physiotherapist input but do not need to be in an acute hospital.

Inevitably some people will need the sort of care which can only be delivered in a hospital bed: but by making use of the community-based alternatives, NHS commissioners and providers can ensure the beds are there for those who really need them.