Kevin HudsonProgramme Manager,

Clinical Commissioning Information, NHS Somerset

Detailed Analysis of Emergency Admissions in Somerset

SummaryRESULTS

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2nd December 2011

Content of this Presentation

• Background, objectives, datasets & tools

• Summary of overall findings

• Some examples of detailed observations

– Observations relating to demographics of the patient population

– Observations relating to non-Acute settings and processes

– Observations relating to Acute Trust settings and processes

• Ongoing questions and next steps

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Background• Project initiated by the QIPP board to fully understand why emergency

admissions have increased in Somerset and quantify the causes.

• Steering group of senior directors, chaired by David Slack:– met weekly across October through conference call– attendees from PCT, Acute Trusts, Somerset Partnership and South West Ambulance.– Analysis led by Kevin Hudson and mediated through a Data Analyst Group across all

organisations.– Data Analyst Group subjected observations to peer review prior to discussion at the

steering group.

• Sought to achieve common story for Emergency Admissions in Somerset.

• Shared at visit of Intensive Support Team on 2nd November 2011

• Initiated further work and further communication.

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Objectives• To quantify and stratify the current trend in rates of emergency

admission in Somerset, and particularly in relation to Taunton & Somerset NHS Foundation Trust.

• To investigate potential correlating factors to the trend, and to attempt to quantify the relative influences of:– Changes in the demographics of the local population.– Changes in processes taking place in non-Acute settings – GP Practices, Out of hours

and ambulance trusts.– Changes in processes taking place in Acute settings.

• To further understand causes of A&E attendances and their link to emergency admissions (not part of these results, this work will follow).

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Data Sources used in this report(Listed as this analysis expands)

• SUS data from April 2008 re-costed at 2011/12 tariff. (Master Data Set). Received and uploaded for analysis.

• Timed admission data from Trusts

• Ambulance Activity data by patent and Practice

• Somerset Primary Link Activity (main emergency admission avoidance scheme)

• RISC system data on patients’ likelihood of a future unscheduled admission.

• Out of Hours activity data by Practice

• Practice performance data as used in QOF

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* ‘Admission Components’ (subsets that have been used to analyse the data)

• SUS data through the NERRT2 tool allows interrogation to Practice and Federation level of a number of components of Emergency Admission:

• Patient Demographics (“Admissions of”): Analysis for under 16s, 16-64, over 65s, 75s & 85s.

• Providing Trust (“Admissions to”): Analysis by each individual Trust providing to Somerset patients

• Method of Admission (“Admissions through”): A&E admissions, GP admissions, other admissions.

• Clinical Condition (“Admissions for”): Analysis by HRG chapter plus analysis of codes for ‘major / minor’ procedures and ‘with’ or ‘without complications

• Length of Stay (“Admission Stay”): Zero days, 1 day, 2-3 days, 4+ days.

• Time of Admission: including “in hours” and “out of hours”

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* Tools - NERRT2 (Overall Trend) (main analytical tool developed to review datasets – now on Dashboard)

• The front page of NERRT2 reports monthly recorded activity and reports variance for Financial Year to Date, 12 month growth, and growth from 2008/9:

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Admission Component Summaries

• One page report can be printed from the NERRT2 tool.

• Outlines admissions growth in all particular components.

• Can be set for Somerset overall and for any Federation or Practice.

• There is also a similar one page report to outline each Practice’s & Federation’s admission performance.

• Can be set for all admissions or for any of the individual admission components show opposite.

• Also shown graphically

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* Emergency Admission Trends(Raw Results – based on original / unadjusted SUS data)

• Analysis of SUS data has allowed the following ‘headline figures’ to be calculated• Somerset Trusts have agreed these reported growth statistics.

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* Performance against Contract(source – SLAM)

• Figures have been compared to planned (contractual) activity and variances are reported below:

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* Which reinforces the key objective of this analysis:

• Why have Somerset emergency admissions grown by 5.6% in the past year?

• What contributory factors can be identified in relation to this growth? What is the contributory amount of each of those factors?

And…

• Why have emergency admissions to Taunton and Somerset NHS Foundation Trusts grown by almost double this amount? (9.7% growth compared to 5.6% for Somerset)

• And again, what contributory factors can be identified in relation to this growth? What is the contributory amount of each of those factors?

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OVERALL FINDINGS

This has been a very detailed analysis (over 200 slides of results). However the key points that would be offered to readers are as follows:

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* Key Observations• Certain Components show ‘irregular’ or ‘step-change’ growth:

– Obstetrics, female reproductive system, Somerset PCT zero length of stay – 4% of admissions account for 21% of reported growth. – More work is required to understand these observations.

• Populations and age of patients have grown: – 31% of current year emergency admission growth (& 56% of growth since April 2008) can be

accounted for by changes in population and changes in the age of that population.

• A change of ‘Provider Mix’ is observable. – Patients in certain parts of Somerset that might previously have been admitted elsewhere

appear more recently to be admitted to Taunton & Somerset NHS Trust. – Of approx 1000 ‘additional admissions’ observed last year at T&S, 66% due to change in mix

and originate from patients attending Practices beyond the Trust’s ‘core catchment’– ‘Effect of Mix’ varies by HRG chapter: Significant for Cardiac Conditions & Musculo-skeletal

System. Less significant for Digestive System complaints.

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** Summary of Headline Figures

• From original “observed growth” of 5.6% in Somerset, 3.0% remains as ‘underlying’ or ‘unexpected’.

• For Taunton & Somerset, from original observed growth of 9.7%, 4.1% remains unexpected. For Yeovil, observed growth has increased.

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Summary of admission rates and growth by Federation

• The Federations with the highest admission rate are Taunton & W.Somerset• The Federations with the highest ‘underlying’ growth are Bridgwater and Taunton

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* ‘Underlying Growth’• The ‘underlying’ (unexpected) trend of emergency admissions has been calculated and

investigated further. Key observations include:

A less than average growth of admissions for patients over 55 years.o Particularly focussed in certain Federations.o Is this evidence of success of QIPP Schemes (or due to other factors)?

A higher than average growth of admission for patients under 55 years.

Growth of admissions of ‘under 55s’ particularly concentrated at T&S:o through both GP and A&E admission routes, particularly short lengths of stay.o focussed in ‘Digestive System’, ‘Male Reproductive’ & ‘Immunology...contacts with Health Services’.

High growth of admissions for children at Yeovil District Hospital (YDH)

Higher growth for patients ‘with complications’ compared to those ‘without’

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* Analytical Links to other sources

• Analytical links have also been made to other data sources:

A observed decline in the use and efficiency of Somerset Primary Link.

No observable correlation between growth of admissions & out of hours service.

No observable correlation between growth of admissions & patient’s abilities to access GP Practices.

Ambulance conveyance trends appear mirror overall observations including observed demographic differences and change in mix.

Nursing home analysis show differences in admission rates per home.

Timed data received from T&S show potentially useful information regarding growth of admissions at particular times of day.

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DETAILED OBSERVATIONS

The following detailed observations are perhaps worthy of further investigation and clinical debate...

Given the time constraints in any meeting, we can only just briefly touch on some of the observations made – but it is recommended that this evidence presented is understood in detail by any of those involved in the planning and execution of QIPP objectives for emergency care.

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CHANGES IN DEMOGRAPHICS OF LOCAL POPULATION

- Analysis of population and patient age changes in Somerset- Adjusting admissions for ‘natural’ changes in population and age- Detailed analysis of adjusted admissions for ‘unexpected changes’- Analysis of admissions of patients of different ages in different Federations

Effect on Emergency Admission of...

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* Admissions of Adults under 55(source pop’n growth adjusted NERRT2 / Practice Benchmarking Table)

• ‘Population growth adjusted’ admissions of adults under 55 has risen by 6.8%• Significant difference between Federations: Highest growth in, Taunton (17%), CLIC

(16%) & Bridgwater (14.2%)

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* Admissions of Adults over 55(source pop’n growth adjusted NERRT2 / Practice Benchmarking Table)

• ‘Adjusted’ admissions of adults 55 and over has risen by only 0.6%• Some difference between Federations: Drop in admissions in Central Mendip (-2.9%),

North Sedgemoor (-1.7%), Bridgwater (-0.8%), East Mendip (-0.3%).

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* Bridgwater admissions by age band (as an example of different rates of admission for different ages)

• Why is there significant differences in rate of growth of admissions before & after 55?• Is this evidence of success of Long Term Condition work? – or something else?• But if so, what is causing the increase in the under 55s which is masking LTC results?

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Note Weighted

Effect

* Key Growth components - adults under 55 • Strong ‘differential growth’ between T&S and YDH.• Equal growth through A&E and by GP Admission.• Highest growing HRG Chapters: Digestive system, Immunology... & contacts with

Health Services, Urinary Tract & Male Reproductive, Cardiac Surgery, Respiratory.

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* Key Growth components - adults over 55 • Potentially less ‘differential growth’ between T&S and YDH?• Growth through A&E but a decline by GP Admission.• Highest growing HRG Chapters: Cardiac Surgery, Immunology... & contacts with Health

Services, Respiratory, (Digestive system up on 1.9%).

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CHANGES IN PROCESSES AT NON ACUTE SETTINGS

- Somerset Primary Link- Out of Hours Service- Primary Care Access- Ambulance Service

Effect on Emergency Admission of...

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Somerset Primary Link (SPL) Analysis

• Analysis of SPL provided dataset shows a 19.2% decline in use of SPL.

• Also shows proportionately more patients going to DGHs.

• If a key SPL indicator is the proportion of patients admitted to DGHs, then a small diminution in service can potentially be observed (i.e. proportionally more patients admitted to DGHs):

– For the 12 months to July 2010, 73.6% of SPL referrals were admitted to DGHs

– For the 12 months to July 2011, 81.6% of SPL referrals were admitted to DGHs

• Somerset Partnership information team may wish to review this dataset.

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* NERRT2 – SPL Analysis by Outcome (source NERRT2 (SPL) / Trend Dashboard)

• SPL code 7 ‘outcome types’ (see below). Whilst with this dataset use of SPL has dropped by 19.2%, admissions to DGH have decreased by only 10.4%.

• This may warrant further investigation – indication of lessening of SPL effectiveness?

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* Out of Hours GP Correlation Analysis

• Growth of OOH GP per Practice compared to growth of Emergency Admission. Correlation Coefficient calculated.

• No significant correlation found to growth (or decline) of use of OOH GP service and Practice growth of emergency admissions – either overall or for admissions of “adults of working age”.

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* Practice Access Performance

• Practice access performance (via the quarterly GP survey) as of March 2011 and Jun 2009 compared to emergency admission growth reported for that Practice.

• No significant correlations have been observed for either growth of admissions against poor practice access or overall levels of admissions.

But

• A small / moderate correlation (R=0.34) has been observed when comparing Practice access performance against a measured rate of A&E Attendance for patients of that practice.

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* Residential Homes – RISC analysis (source RISC Nursing Home Analysis / CCG Information Dashboard)

• Reported generated following Federation requests. Now published on CCG Dashboard• Why is there disparity between the number of admissions / cost per resident?• Why does it seem that residential homes costing the NHS more than nursing homes?• Shared with Federations for further clinical analysis and local reflection.

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Analysis of South West Ambulance Data – Conveyances....

Data has been restated for all conveyances “from Somerset” (rather than “to Somerset”) as was previously reported.

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* Ambulance Data• Somerset Conveyance Data received from SW Ambulance Trust

– Analysed through NERRT2 to calculate latest trends– Admission Components also analysed and compared to SUS trends

• A reasonable correlation to Admission trends has been observed– Similar overall growth in conveyances to growth in admissions.– Similar increased growth for adults of working age.– Increased conveyances to T&S, fewer to YDH support notion of a ‘change in mix’

• Data also provides some new fresh insights to emergency admissions– Conveyances by Urgency & clinical condition.– Commissioning data for ‘see and treat’ and ‘hear and treat’ still to be analysed.

• The following slides illustrate the observations made...

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* Ambulance Conveyances v’s Demographics (source NERRT2 (ambulance) rev’d / Component Table)

• Conveyances of Children up by 13.7% and adults of working age up by 8.5%• Conveyances of the over 65s up by only 4.1%.• Shows the same pattern of growth as overall emergency admissions.

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Ambulance Conveyances v’s Destination (source NERRT2 (ambulance) rev’d / Component Table)

• Only data on conveyances to Somerset destinations received.• Although conveyances up by 6.5%, conveyances to T&S up by 9.4%, to YDH up by 5.6%.• Further evidence in a “shift in mix” towards T&S?

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Ambulance Conveyances v’s Urgency (source NERRT2 (ambulance) / Component Table)

• Red status conveyances up by 15.2%, Amber status up by 6.8%• Green status conveyances down by 0.8%• What can be inferred from this information?

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CHANGES IN PROCESSES ACUTE PROVIDERS

-Service Changes- HRG chapters with higher growth rates- Analysis of Length of Stay- “Major” v’s “Minor” procedures-Changes in Provider Mix-Analysis of Time of Emergency Admissions

Effect on Emergency Admission of...

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* Growth of Admissions by HRG Chapter (source NERRT2 (pop’n adjusted) / Component Table)

• Following HRG Chapters account for the highest rise in Emergency Admissions:• What is accounted for by Immunology....& other contacts with Health Services?• Digestive System, Cardiac Surgery and Respiratory account for next highest elements of

emergency admission growth.

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* Length of Stay (Under v’s Over 55)

• Significant differences in growth length of stay between over & under 55s.• Under 55s demonstrate strong admission growth for zero days, 1 day and 2-3 day

stays.• Over 55s demonstrate growth for 1 day stays but declines on 2-3 day and 4+ day stays.

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* ‘Major’ v’s ‘Minor’ HRG procedures (source NERRT2 (pop’n adjusted) / Component Table)

• HRG codes have been analysed depending on whether for ‘major’ or ‘minor’ procedures (as identified in the descriptive text) and ‘with complications’ or ‘without complications’

• Why does there appear to be more growth of admissions for ‘major procedures’ and ‘with complications’?

• Evidence of change in clinical Practice or changes in coding interpretation?

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* T&S Growth by demographic band (source NERRT2 (pop’n adjusted / T&S extract) / Component Table)

• Paediatric admission growth – 2.1%• Significant growth of admissions for adults under 55 – 18.8% growth. • Growth of admissions for adults over 55 – 3.3%.

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* T&S Growth components - adults under 55 • 27% growth through A&E, 10% growth through GP• Digestive System – 23% of all admissions, up by 28%.

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* YDH Growth by demographic band (source NERRT2 (pop’n adjusted / YDH extract) / Component Table)

• Significant Paediatric admission growth – 13.6%• Unlike T&S, emergency admissions of adults under 55 has declined – 5.3% down.• For adults over 55, decline of admissions is less (-2.7%). • Growth of admissions for adults over 55 – 3.3%.

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* YDH Growth components - children

• 28% growth through A&E, 5% growth through GP• Childhood & neonates – 77% of all admits, up by 7% / Undefined groups 11% of admits• Longer length of stays up by 22% (2-3 days) and 38% (4+days)

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Evidence supporting a “change in Provider mix” towards Taunton & Somerset.

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Usage of T&S - Practice Scatter Chart(Source: Jacq Clarkson, NHS Somerset Statistician) • Plotting T&S use across 2 periods shows more Practices of lower %age T&S use using T&S

more in the second time period (see red-dashed area)• Practice distribution is not spread equably around the x=y (expected) line (red line).

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* Quantify Movement in ‘Provider Mix’• Taking age / population adjusted data, calculate the additional admissions observed at

Taunton from Practices in Federations not necessarily expected to refer to Taunton.• Whilst a ‘diminishing list’ the top 20 Practice in this category suggest 66% of the observed

overall variance can be attributed to these Practices on the boundary of catchment areas.

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* Demographic component of ‘Additional T&S Admissions’

• These statistics (and those that follow) are after adjustment for population and age growth.

• Most of the additional admissions to T&S appear to be patients aged between 16 and 65.• Admissions of adults of working age has risen by 13.2% at T&S compared to 3.8% overall.• This component growth potentially accounts for 93% of the total observed difference.

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* HRG Chapter component of ‘T&S additional admissions’• 80% of the additional admission to T&S can be observed from 3 HRG Chapters:• Cardiac Surgery (30%), Digestive System (26%), MusculoSkeletal (23%)• 67% of Cardiac & Musculo variance explained by change in mix but only 51% of Digestive.

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Analysis of T&S data of time of Emergency Admission...

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* NERRT2 Variant ‘Admission Time Profile’ Analysis Tool• Importing timed data into NERRT allows presentation of admission profile in units of

‘admissions per half hour’ – weekdays by half hour periods, weekends by 3 hr time periods.

• Further Summarisation by 3 hour weekday intervals and ‘in hours’ and ‘out of hours’

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* NERRT2 Variant ‘Admission Time Profile’ Analysis Tool• Can also analyse movement in admission rate for same time segments. • This shows overall admission growth happens most between 14:00 & 20:30.• Little growth taking place in mornings, later evenings and weekends.

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Some examples of during what times of the day particular components of Emergency Admissions demonstrate highest levels of growth.

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• Most growth in admissions of adults of working age is taking place earlier in the working day – between 12:00 and 18:00

‘Time Profile’ growth of Admissions of patients of working age (17 – 64)

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• Although growth is less overall, most growth of elderly admissions is taking place later in the working day – 15:00 to 21:00

• Decline of admissions in late morning suggest later admissions .

* ‘Time Profile’ growth of Admissions of patients aged over 65

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‘Time Profile’ growth of Admissions through A&E. • Wide period of growth between 10:30 and 20:30. Less admission

between 20:30 and 23:00.

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* ‘Time Profile’ growth of Admissions through GP. • Overall referrals down by 5%. But evidence that GP admissions are also

now happening later in the working day.

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‘Time Profile’ growth of Admissions for Cardiac Surgery & Primary Cardiac Condition• Growth in admissions spread more evenly across the working day.• Reflective of the ‘immediate’ urgency of this clinical condition?

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* ‘Time Profile’ growth of Admissions for Respiratory System• Growth in admissions concentrated in later parts of the working day

(15:00 to 21:00). • Reflective of the ‘long term’ characteristics of this condition?

RECAP OF KEY OBSERVATIONS & ONGOING QUESTIONS

In Summary

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* Key Observations• Certain Components show ‘irregular’ or ‘step-change’ growth:

– Obstetrics, female reproductive system, Somerset PCT zero length of stay – 4% of admissions account for 21% of reported growth. – More work is required to understand these observations.

• Populations and age of patients have grown: – 31% of current year emergency admission growth (& 56% of growth since April 2008) can be

accounted for by changes in population and changes in the age of that population.

• A change of ‘Provider Mix’ is observable. – Patients in certain parts of Somerset that might previously have been admitted elsewhere

appear more recently to be admitted to Taunton & Somerset NHS Trust. – Of approx 1000 ‘additional admissions’ observed last year at T&S, 66% due to change in mix

and originate from patients attending Practices beyond the Trust’s ‘core catchment’– ‘Effect of Mix’ varies by HRG chapter: Significant for Cardiac Conditions & Musculo-skeletal

System. Less significant for Digestive System complaints.

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* ‘Underlying Growth’• The ‘underlying’ (unexpected) trend of emergency admissions has been calculated and

investigated further. Key observations include:

A less than average growth of admissions for patients over 55 years.o Particularly focussed in certain Federations.o Evidence of success of QIPP Schemes (or due to other factors)?

A higher than average growth of admission for patients under 55 years.

Growth of admissions of ‘under 55s’ particularly concentrated at T&S:o through both GP and A&E admission routes, particularly short lengths of stay.o focussed in ‘Digestive System’, ‘Male Reproductive’ & ‘Immunology...contacts with Health Services’.

High growth of admissions for children at Yeovil District Hospital (YDH)

Higher growth for patients ‘with complications’ compared to those ‘without’

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* ‘Other data sources’

• Trends and correlations to other data sources have also revealed:

A observed decline in the use and efficiency of Somerset Primary Link.

No observable correlation between growth of admissions & out of hours service.

No observable correlation between growth of admissions & patient’s abilities to access GP Practices.

Ambulance conveyance trends appear mirror overall observations including observed demographic differences and change in mix.

Nursing home analysis show differences in admission rates per home.

Timed data received from T&S show potentially useful information regarding growth of admissions at particular times of day.

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Recap of Key Results• Growth adjusted for ‘Service Changes’, population rises & change in mix.• Differences between patients aged over & under 55, also children.• Certain key clinical conditions demonstrating growth in those age bands.

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Federation Priorities• From NERRT 2 it is possible to review Admission Component summaries

for each Federation – which indicate components with highest growth.• Different areas of priority appear for different areas of Somerset.

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And in Summary it is possible to frame some key ongoing questions for those involved with Emergency Admissions in Somerset...

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Next Steps: Key Ongoing Questions• In addition to the quantification of components of emergency admission growth, this analysis has identified some

particular areas for further consideration and research:

1. What is causing observed ‘Service / Step Changes’ in Female Reproduction & Obstetrics?

2. Why is there a measured decline in the use of the SPL? Why do more SPL patients appear to go to DGHs?

3. Observations on Ambulance Analysis: What can be inferred from growth in conveyances and differential growth to different Trusts?

4. How much can the hypothesis of ‘change in mix’ explain observed differences between Trusts? o Can this hide other factors that may be having a particular effect in Taunton?

4. What can be inferred from the lower than average growth in admissions of the elderly and the localities where this is happening the most? o Is this evidence of LTC QIPP effectiveness?

5. What has caused higher than average growth in patients aged under 16 and those adults aged under 55? o Why do we observe growth particularly at T&S, through both A&E & GP admissions, and for Digestive System, Male Reproductive & ‘other

contacts with health services’?

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Key Ongoing Questions (cont)

5. What can be inferred from the lower than average growth in admissions of the elderly and the localities where this is happening the most? o Is this evidence of LTC QIPP effectiveness?

6. What has caused higher than average growth in patients aged under 16 and those adults aged under 55? o Why do we observe growth particularly at T&S, through both A&E & GP admissions, and for

Digestive System, Male Reproductive & ‘other contacts with health services’?

7. What can be inferred from detail study of growth of ‘Admission-Time profiles’ to improve the outcomes for admitted patients?

8. And Overall: How can we ensure that analytical observations are kept up to date and, most importantly, converted into clinical explanations?

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End of results

For further queries contact:Kevin.Hudson@somerset.nhs.uk01278 727 401 / 07717 530 220

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