Clinical Utilisation what s that?

Transcription

1

2 Can we really ensure patients are treated in the right place at the right time? MO

3 Wasted resources the scale of the problem It has long been suspected that a significant proportion of secondary care patients in the NHS are in hospital unnecessarily. Various reasons are put forward to explain the situation, some of the most popular being: Diffi culties accessing social and primary care lead to discharge delays An increasingly elderly population, and more long-term conditions, inevitably lead to strain on the system and more frequent fl yers equals more bed blockers The four hour A&E target, coupled with rising demand at the front door, increases pressure on hospitals to admit patients who do not need to be treated in hospital. All of which is eating up precious resources and costing the NHS millions. The diffi culty lies in identifying the true scale of the problem and the real causes behind it. What size should an A&E department actually be? How many acute beds do we really need? And how do you prevent a triage service from becoming a revolving door? Clinical utilisation offers answers to these questions and clues to solving some of the problems they highlight. How can it help? As far back as 2006 the Department of Health recognised the potential value of addressing clinical utilisation (see Care and Resource Utilisation, Ensuring Appropriateness of Care, December 2006). There are a number of utilisation strategies and tools that can be employed to assess appropriateness of care, but the most effective ones all have two central elements: 1. Evidence based clinical criteria applied to real patients as the basis for evaluating the needs of a population 2. Scientifi c, statistically reliable, analysis to determine precise service requirements In simple terms, the clinical evidence answers the questions: Should this patient be where they are? and If not, where should they be and why are they here? The statistics allow for extrapolation over time in order to understand: What services does this population require? What capacity is needed? Where, and how, should services be provided? In short, clinical utilisation management is the ideal way to ensure that patients receive the right treatment, in the right place, at the right time. So much for the theory. 01

4 How does it actually work in practice? In secondary care, most utilisation programmes begin with an initial review or audit across a particular clinical area or specialty in order to identify the scale of any problem and establish a baseline from which to work. Clinical teams trained in the use of case review tools and criteria assess patients, either in real time or retrospectively, and determine whether admission to an acute bed was warranted. By using precise clinical criteria that are mapped to different care settings, it can also be determined at what point the patient should be discharged or transferred to an alternative service. The results of such audit vary widely across the NHS, but identifying inappropriate admission rates of 25% are not uncommon. Equally, for non-elective admissions, utilisation review has been shown in some specialty areas there are hospitals where between 50% and 75% of the hospital patient population on a given day should have been discharged or transferred. Of course it s true that the situation varies across the country and that things are generally not quite so bad in the summer months, but if you examine enough clinical utilisation data it leads to some startling conclusions: There are hospitals where, on any given day, half of their patients should not be there and a quarter should never have been admitted in the fi rst place. The implications for the NHS as a whole are staggering. Implementation in Admission Process Ongoing Reviews of Inpatient Stays Admission Decision Decision Appropriate Inpatient stay Discharge Co-ordination Benefi ts Benefi ts Improved consistency of admission decisions and admission destinations Reduction in avoidable admissions Reduced number of inappropraite early admission surgical specialities Improved discharge processes Reduced length of stay Reduction in required inpatient beds, particularly in mediacal specialties What else can it do? Clinical utilisation defines clinical criteria specific to service settings. It can therefore be used to inform admission; transfer and discharge criteria and improve pathways and outcomes for patients. Similarly it can be used as a discharge planning tool and in areas where this has been done length of stay reductions and inappropriate hospital bed days have been seen to reduce considerably. For example, in Nottinghamshire where the community hospital reduced the number of unused beds by 24 while maintaining the quality of care for patients 1 Clinical utilisation can also be used to build a picture of service use (in terms of bed days) and capacity requirements across a whole health system. To this end it has been employed in primary care and community hospital settings in attempts to understand service capacity requirements across whole health economies _patientcentric_services/81173

5 But it s American isn t it? These utilisation management techniques came to us from the States where there is of course a very different health care system. Or is there? The conspiracy theorists would have it that in America, a computer is used to determine whether you are entitled to be in hospital, and if not you are dumped on the street. From there, it s a short hop to it could happen here! Nonsense, of course. The Americans use clearly defi ned clinical criteria, based on best practice, to determine the most appropriate setting for a given patient in order to minimise the cost of providing quality treatment. Sound familiar? So why hasn t it cured the NHS? Three little words: investment, attitudes, systems Clinical utilisation requires some up-front investment in terms of tools, training and deployment. That said, the potential return in the form of reduced wastage and re-aligned resources is colossal. Attitudes need to change. Partly, in terms of doing away with old fashioned ideas about how and where we treat and manage patients: we ve always done it this way. Also, in terms of removing the vested interests and perverse incentives built into fi nancial systems: payment for outcomes instead of payment by results? For the true potential of clinical utilisation to be realised, the NHS must take a whole systems view of service delivery. Joined-up care needs to become more than just another political buzzword to the point where holistic pathways become a reality. For further information about issues raised in this paper, please contact Jason Nerval, jason.nerval@monmouthpartners.com,

6