Can CCGs curb emergency admissions?
Cutting emergency admissions is at the core of QIPP targets and the quality premium. But how much control can CCGs really have on the ever rising numbers? Alisdair Stirling reports
The full extent of the inexorable rise in emergency admissions was laid bare in research published by the Nuffield Trust in November. It showed that between April 2001 and March 2011, the number of admissions for chronic conditions such as congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension rose by 40%.
Around 65% of hospital bed days are now an emergency admission, according to Dr Sarah Purdy, reader in the academic unit of primary care at the University of Bristol. And earlier last year, figures obtained by Pulse showed admissions between April and July were 60,000 higher than the same period in 2011 (1,786,341 compared with 1,723,399).
What makes these figures even more troubling is that they come at a time when much noise has been made by the Department of Health, raising the profile of emergency admissions. The 2010 QIPP initiative, for example, set GPs a target of cutting unscheduled admissions for long-term conditions by 20% by the end of 2013.
And some clinical commissioners have worked very hard on solutions – community matrons, GPs in A&E, risk stratification tools and focus on frequent fliers – but with variable success.
Dr Purdy is about to publish research that suggests the much-vaunted case management approach, via community matrons, has done little to cut emergency admissions. She said: ‘Despite the implementation of a large number of programmes, the numbers are growing rapidly year on year.’
A recent Cochrane review of GPs in A&E found while GPs treating non-urgent patients used fewer healthcare resources than emergency physicians, there was insufficient evidence on reducing costs and overcrowding to prove benefit.
Unpicking the problem
Professor Martin Roland, professor of health services research at the University of Cambridge, published a key article in the BMJ last year, laying out the complex multi-factorial nature of the rise in emergency admissions.
He cited the acute trust target introduced in 2004 that patients must wait no longer than four hours and the 2006 incentive for hospitals to improve their emergency admissions data, as contributing towards the upwards ramp on the emergency admissions graph.
Professor Roland also argued that an over-emphasis on frequent fliers – plus the erroneous assumption that we ‘know what to do’ about admissions – has prevented more targeted, flexible solutions.
His paper concluded that managers (and now CCGs) need to focus on evidence-based strategies tailored to local circumstances, if they want to bring emergency admissions down.
Dr Purdy appears to be on the same page as Professor Roland, saying it is difficult to define an unnecessary admission. ‘Social factors – such as living alone – mean one person will be admitted and another won’t.’
She cites new end-of-life services in Somerset and the integration of health and social care into Torbay Care Trust as examples that demonstrate emergency admissions can be reduced, but Dr Purdy adds much depends on local relationships.
A new CCG approach
Dr Agnelo Fernandes, Croydon CCG’s assistant clinical chair and the RCGP’s national urgent and emergency care lead, believes CCGs need to consider all the approaches at their disposal.
’If CCGs are going to succeed they need to act differently from PCTs. A much more strategic approach across health and social care in hospital and in the community is needed with a focus on co-ordinating
a fragmented system. A transformational approach is needed across all services for urgent and emergency care. CCGs will only make a difference if they are brave enough to radically change the whole system simultaneously rather than tinkering around the edges or adopting a blinkered but excessive focus mainly on A&E.’
For Dr Purdy, the challenge is to make sure CCGs have access to all the available evidence on what works. ‘I spoke to GPs and consultants recently and they were not aware of the evidence on co-ordinating end-of-life care, for example. It’s really important that we all make use of all the evidence.’
Professor Roland believes the whole-system approach Dr Fernandes advocates is to some extent built into GP commissioning via CCGs. ‘The change in management system provides an increased opportunity for a clinical discussion between specialists and GPs to improve the way they do things. Locally, our CCG is having detailed discussion with specialists and I think more widely, there is a new type of discussion about how to improve the whole system – including new types of contract. It’s not a panacea but there is potential for a positive outcome. GPs can see things that need doing locally to reduce emergency admissions and can liaise with consultants over how to bring that about. For example, because of GP input, more hospitals are looking at providing consultant cover for more of the day. Junior doctors are likely to admit
a patient. Someone senior at the front door can help reduce emergency admissions.’
Dr Purdy agrees: ‘Things like Choose and Book mean that GPs don’t always have the one-to-one discussions with consultants that they used to. But locally we’ve got initiatives like Dial-a-Consultant, where GPs can speak to a cardiologist about a patient, which may prevent an unnecessary admission. Also, continuity of out-of-hours care is improving with use of IT and that can help prevent admissions.’
Dr Mike Dixon, interim president of NHS Clinical Commissioners, also sees evidence of an early change in approach. ‘There’s quite a lot happening. CCGs are pioneering high-intensity nursing, hospital at home and night-sitting initiatives that are having an effect on emergency admissions. And once CCGs get their feet fully under the table, they will want to analyse referrals in detail. Closer discussion between primary and secondary clinicians will ensue and we’ll see social services working with commissioners to tackle local reasons for unnecessary admissions.’
So if CCGs are already adopting a more flexible approach and – in some cases – getting to the bottom of the local causes of unnecessary emergency admissions, what of the top-down, target-led approach the Government is pursuing? It’s now clear that one-quarter of the anticipated £5 per head quality premium for CCGs will relate to cutting emergency admissions.
Professor Roland is against rewards for individual GPs: ‘It’s unclear that will be helpful and it could have an inappropriate impact.’
Latest information on the premium suggests it will be paid to CCGs with the stipulation that they use the funds to improve services. But even so, Dr Dixon thinks its effects will be limited: ‘I think this will concentrate CCG – and GP – minds to some extent. It is clearly a large part of the quality premium and therefore visible as a success factor for the CCG and its practices. That doesn’t mean that this isn’t an issue that needs taking seriously and I suspect most CCGs would focus on this, especially if they benchmarked badly on it, whether it was part of the quality premium or not.’
Dr Purdy is also unconvinced that quality premiums or the QIPP targets will have any real impact. ‘This is a really big challenge for commissioners, so I think CCGs have got to pick one area like end-of-life care where there is good evidence and focus on that.’
Emergency admissions may be able to be put into simplistic targets by the centre but finding solutions to the inexorable rise will be a complex journey for CCGs, requiring localism and integration within the NHS and beyond.
⦁ RCGP commissioning guidance for urgent and emergency care tinyurl.com/rcgpemergency
⦁ National ‘Silver Book’ on care standards for older people having urgent care episode tinyurl.com/leasilverbk