NHS CONFEDERATION RESPONSE TO THE EMERGENCY ADMISSIONS MARGINAL RATE REVIEW (JUNE 2013)

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1 NHS CONFEDERATION RESPONSE TO THE EMERGENCY ADMISSIONS MARGINAL RATE REVIEW (JUNE 2013) 1. ABOUT THE NHS CONFEDERATION 1.1 The NHS Confederation is the only body to bring together the full range of organisations that make up the modern NHS to help improve the health of patients and the public. We are an independent membership organisation that represents all types of providers and commissioners of NHS services. We speak for the whole of the NHS on the issues that matter to all those involved in healthcare. We also reflect the diverse views of the different parts of the healthcare system. 1.2 We welcome the opportunity to contribute to Monitor and NHS England's call for evidence, as part of their review of the marginal rate for emergency admissions. Managing demand for urgent and emergency care is undoubtedly a major issue for our members. The way urgent and emergency care services are commissioned and reimbursed is cited frequently by members as a factor impacting on their ability to respond effectively to increasing or changing patterns of demand. We believe this review, and the transfer of responsibility for the NHS payment system to NHS England and Monitor from 2014, will offer an important opportunity to address the concerns that many of our members have and to develop an approach that achieves greater quality and value across the whole system. 2. GENERAL COMMENTS 2.1 Monitor and NHS England have asked three overarching questions as part of this call for evidence and we are keen to respond to these directly at the start: What has happened? - Our provider members have told us that demand for urgent and emergency care continues to rise and, as a result, they have concerns about the capacity and ability of services to maintain and improve quality standards. Their observations are supported by evidence from national data. The rise in emergency admissions is causing particular concern across our membership and is indicating a higher level of acuity in patient needs and the lack of appropriate care outside of hospitals Has the marginal rate for emergency admissions helped? - The overall impact of the marginal rate is difficult to assess, but growing levels of emergency admissions in the last three years indicate that it has probably not had the impact that was hoped for. This could however have more to do with its application and not necessarily the logic behind it. At least in some parts of the country, what it seems to have done in practice is transfer a large degree of risk for emergency care onto acute providers, by reducing their income for emergency patients above the baseline, without delivering noticeable benefits of effective demand management through investment in community-based services Could the approach be improved? - Monitor, NHS England and local commissioners need to develop payment systems that include effective incentives for improving the quality of care and achieving value. In theory, the marginal rate does not run counter to these objectives, but its application across the system doesn't seem to have so far supported it. We would like to see greater transparency 1

2 in how funds released by the application of a marginal rate are invested and support an approach where local commissioners and all types of providers work jointly to establish services outside of hospitals that the whole system can rely on in an emergency. 2.2 Our response reflects the concerns our members have raised in relation to the marginal rate for emergency admissions, but also addresses issues about urgent and emergency care more generally. The latter should provide the context for our comments on the funding mechanism itself. However, before these are outlined we would like to recognise three important intentions of the marginal rate that have been welcomed and should not be lost in any reforms: It acknowledges the significant challenges in urgent and emergency care - Recent attention on the pressures to deliver effective urgent and emergency care echo what we and our members have been saying for a while now. Problems at A&E departments indicate an inability for the service to manage the flow of patients across and between our organisations, which needs to be addressed as a priority It identifies demand management strategies outside of the hospital as the main solution in dealing with this challenge - There is an imbalance in the investment of primary, community and social care, compared to hospital care. We need to develop services outside of the hospital to help reduce demand at the front door of A&E and to improve discharge out of the back door, which will free up the capacity needed in hospitals to deal with the increased acuity of patients It creates a mechanism for resources to be shifted and investments to be made in community care - One of the main challenges in managing demand out of hospitals is finding the resources to invest in community-based schemes. In a no-growth health funding environment, the only real way to make investments is to shift resources so as to deliver greater value from the funding available. The marginal rate not only creates a mechanism to do this, but does it in a way that should encourage the whole system to work collaboratively in devising solutions. 2.3 However, despite these good intentions our members report that the implementation of the marginal rate for emergency admissions has realised limited benefits. In particular, we would highlight three main limitations in its application, which are identified in more detail throughout this response: Lack of transparency - The way that the funds from the marginal rate have been collected and reinvested hasn't been clear. Many of our members express scepticism as to the reallocation of funds and have concerns about the lack of involvement that local commissioners and all types of providers have had up to now Patchy impact on demand - There are examples where demand management strategies funded by the marginal rate have delivered benefits to patients and the local community. However, the impact across England has so far been varied and emergency admissions have continued to grow at a national level It can only deal with a specific part of the system - The relationship between the acute sector and community care is a vital part of the solution to challenges in urgent and emergency. However, the capacity of both primary and 2

3 social care will also have an impact. The latter in particular has been limited by significant cuts in local government funding that has seen the provision of adult social services restricted, which may diminish the impact of NHS-funded interventions The response now develops some of these conclusions in more detail and presents evidence that we have received from our members, as well as referencing data more widely available to support these assertions. In particular, there are five main points we want to emphasise, in describing the context for this review, which are that: Our provider members are seeing more patients with more acute conditions in their urgent, emergency and unscheduled care facilities They are concerned that the quality of urgent and emergency care services is falling as a result of this increasing demand There is a need to improve the low awareness of and confidence in the potential for alternative community-based services to help manage demand differently There must be a whole system approach to tackle this issue effectively, which allow local decision-making to guide approaches that are most appropriate and effective 3. Our provider members are seeing more patients with more acute conditions in their urgent, emergency and unscheduled care facilities 3.1 The pressure on urgent and emergency services is significant and NHS leaders continue to highlight concerns about the capacity of A&E departments. Our members indicate to us that more people are seeking unplanned care and the data on attendances in unscheduled care settings would support this. National statistics show a 31 per cent increase in A&E attendances over the last ten years, which equates to over five million more patients turning up at A&E since 2003 (see graph 1). In the last three years, this rate of increase has slowed slightly but there has still been a 1.6 per cent increase that means an extra 300,000 patients since 2010 (see graph 2). Data also suggests significant longterm increases (94 per cent) in attendances at Type 2 and 3 (or minor ) A&E units 2, although in the last three years this has reduced slightly. 1 National Audit Office (2013) - Financial sustainability of local authorities 2 Type 2 and 3 A&E units are those that treat single specialties or minor illness/injury, such as minor injury units and walk-in centres. These units are often, but not necessarily, co-located with a major A&E. 3

4 Graph 1: A&E attendances, ,000,000 20,000,000 15,000,000 10,000,000 5,000, Type 1 Types 2 and 3 Graph 2: A&E attendances, ,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000, (Q1) (Q2) (Q3) (Q4) (Q1) (Q2) (Q3) (Q4) (Q1) (Q2) (Q3) (Q4) Type 1 Type 2 and 3 Total 3 Department of Health/NHS England (2013) - Weekly A&E Activity, now available at: 4 Department of Health/NHS England (2013) 4

5 3.2 While the upward trend in activity seems clear, the reasons for this are less well understood. The significant increase in attendances at minor A&E units over the last ten years could represent the treatment of previously unmet need, or the effect of supplyinduced demand. While the more recent plateau in these figures might be a consequence of the closure of some walk-in centres, as is being suggested by some commentators 5, it could also reflect changing expectations, preferences and needs of patients. Similarly, it is difficult to establish a clear causal link between the rise in A&E attendances and the availability of primary care out-of-hours services. 6 Certainly, attendances would be expected to rise if there was reduced access to primary care out-of-hours, but it is still not clear from the available data the extent to which such attendances have actually risen outof-hours, or whether and how far the availability of primary care services has been reduced. In many parts of the country, opening hours for GP practices have actually been significantly expanded in recent years as a result of, for example, the development of primary care centres and practice federations As well as more people attending A&E departments, there are also more people being admitted to hospital as a result. National data on emergency admissions, for which the marginal rate is applied, shows a long-term increase of 50 per cent since 2003, which means over 1.25 million more people admitted from major A&E departments in the last ten years (see graph 3). Emergency attendances are the main source of admissions in hospitals and so a rise in the former may explain in part the increase in the latter. However, the ratio between emergency admissions and attendances at Type 1 units 8 has also risen from 19.5 per cent in 2003 to 26.1 per cent in 2013 (see graph 4). Graph 3: Emergency admissions, (Q1) (Q2) (Q3) (Q4) (Q1) (Q2) (Q3) (Q4) (Q1) (Q2) (Q3) (Q4) 5 "Labour: 'False economy' to close walk-in centres" in ITV.com (31/05/13). 6 "GPs blamed for crisis in out-of-hours health care" in The Telegraph (24/04/13) 7 Royal College of General Practitioners (2008) - Primary Care Federations: Putting patients first 8 Type 1 units are consultant-led and provide 24 hour services with full resuscitation facilities 9 Department of Health/NHS England (2013) 5

6 Graph 4: Ratio percentage of emergency admissions to attendances at Type 1 units Data suggests a link between growing emergency admissions, as a percentage of attendances, at different times of the year. Each year, since 2003, there are noticeable peaks between Q3 and Q4 (October to March), although in the last few years this has begun to flatten out slightly (see graph 5). In comparison, there doesn't appear to be a significant variation in attendances during these periods, in fact the average increase in attendances between the busiest and quietest quarters last year would equate to around an extra nine patients per unit per day. This would indicate that seasonal pressures apply more to the acuity of patients and the need for more patients to be admitted from emergency departments, rather than simply an increase in demand at the front door. 10 Department of Health/NHS England (2013) 6

7 Graph 5: Ratio of emergency admissions to attendances at Type 1 units Our members report that the rising rate of emergency admissions, over and above the increase in attendances, is the result of increasing acuity in the needs of patients presenting at emergency departments - particularly in winter times. Alternative explanations have been proposed elsewhere with, for example the rise in short-stay admissions, pointing to a reduction in thresholds for acute admissions rather than an increase in acuity. 12 Evidence suggests that 90 per cent of emergency admissions stay for less than two weeks and these account overall for 45 per cent of bed days However, the emergency marginal rate, which sees Tariff prices capped, means that there are unlikely to be financial incentives to lower the threshold for acute admissions. There have been suggestions that emergency services generate a degree of supplierinduced demand and, even with a cap on Tariff prices, providers are incentivised by the 11 Department of Health/NHS England (2013) 12 Nuffield Trust (2010) - Trends in Emergency Admissions in England The King's Fund (2011) - Emergency bed use: What the numbers tell us 7

8 marginal revenue to take on more business. 14 We cannot however see a strong basis for this claim and our provider members are telling us that they are keen to reduce the number of emergency admissions, not increase them. Commissioners have indicated that they see a link more generally between Payment by Results and the incentive to increase acute activity, which might impact on the business models and approaches adopted by providers in relation to elective care, but seems less relevant for emergency care given the application of the marginal rate The lack of financial incentives to admit suggests a need to better understand the clinical reasons for increasing admissions. The growth in the number of patients presenting at emergency departments with very acute conditions may be connected to long-term trends such as an ageing population or the impact of unhealthier lifestyles. However, there may be other factors impacting on these trends at the moment which need to be explored. The pressure to meet the four hour waiting targets has been cited as a potential cause of short-term admissions, although recent trends in performance against this target suggest current pressures are over-riding any incentive this creates to admit. 3.8 Emergency consultants need to make risk-based decisions as to whether it is appropriate to admit an emergency patient, but the way they manage this risk will depend on a number of factors. One important factor is the availability of beds and evidence shows that bed numbers in England are continuing to fall (see graph 6). Between 1997 and 2010, the number of beds dropped by 18.2 per cent, although this would have been balanced in part by a reduction in average length of stay from 9.1 to 5.9 days. 16 Evidence also tells us that patients over the age of 65 on average have a longer length of stay and they account for 48 per cent of long-term emergency admissions. 17 Fewer beds means less capacity to admit, which highlights the need for more capacity outside the hospital to support these risk assessments. 14 Public Accounts Committee (2013) - Uncorrected Transcript Of Oral Evidence: Progress In Delivering NHS Efficiency Savings (14/01/13) 15 NHS Confederation (2013) - Ambition, challenge, transition: reflections on a decade of NHS commissioning 16 Department of Health (2011) 17 The King's Fund (2011) - Emergency bed use: What the numbers tell us 8

9 Graph 6: Average daily number of available beds, by sector, England, to They are concerned that the quality of urgent and emergency care services is falling as a result of this increasing demand 4.1 As noted above, some studies point to the pressure to meet the four hour waiting target as a potential cause for increases in short-term admissions. It has been suggested to us that this is less of a factor as the pressure on emergency departments grows, which is reflected somewhat in recent performance against this target. 19 Since the threshold for patients waiting longer than four hours was reduced from 98 per cent to 95 per cent at the provider level, performance has diminished to this new limit (see graph 7). This is perhaps unsurprising given that the threshold was reduced for clinical reasons and is not necessarily symptomatic of a drop in quality. The more recent drop to below the threshold, for example on average across the FT sector, is however concerning and is, in our view, indicative of the pressures on urgent and emergency care services. 20 A recent survey of directors of finance further illustrates the concern among NHS leaders as to the ability to meet the four hour target in the future Department of Health (2011), figures from DH evidence to Health Select Committee 19 Sibly et al (2007) - Short stay emergency admissions to a West Midlands NHS Trust: a longitudinal descriptive study, Monitor (2013) - Performance of the Foundation Trust sector (Year ended 31 March 2013) 21 The King's Fund (2013) - How is the health and social care system performing? 9

10 Graph 7: Proportion of patients waiting more than four hours in emergency departments from arrival to admission, transfer, or discharge Furthermore, other measures of quality highlight concerns. Between 2001 and 2011, the numbers of emergency patients being readmitted increased from 379,547 to 648,147, a rise of more than 70 per cent (see graph 8). Throughout this period, the highest proportion of emergency readmissions were among patients aged 75 years old and above, ranging from 11 per cent in 2001 to 15 per cent in Taken from: Appleby, John (2013) - "Are accident and emergency attendances increasing?" in British Medical Journal (07/06/2013) 10

11 Graph 8: Emergency readmissions, We are concerned about the impact that the pressures on urgent and emergency care are having on the ability of providers to maintain quality standards of care. We are also keen to support the NHS to deliver a more consistent service throughout the week. Like many hard working frontline staff in the NHS, we have been ringing the alarm bells about urgent care services struggling to meet the demands of patients. The problems that longer waiting times in A&E highlight are an inability of the service to manage the flow of patients across and between our organisations. In particular, it reveals the imbalance of investment in primary, community and social care compared to hospital care. 5. There is a need to improve the low awareness of and confidence in the potential for alternative community-based services to help manage demand differently 5.1 Our research highlights that addressing the imbalance of investment in primary, community and social care compared to hospital care will require a greater awareness of the value that these services can deliver. 24 Community and home-based health services in particular can often be unseen and this has caused concerns in some local communities about how they can be used more to support care in hospitals. If awareness of community services is low, people are likely to be less enthusiastic about a new model of care that moves care to them. More is needed to emphasise the care that can be provided in the community and highlight how it can deliver the same if not better outcomes for many conditions compared to the hospital. A distinct vision is needed to communicate what 23 Information Centre, dataset NHS Confederation (2013) - Changing care, improving quality 11

12 community services can offer patients in practice and highlight how they can effectively manage demand (see case study 1). 5.2 As outlined in our recent briefing, the community health sector is already driving the transformation of local care systems. 25 Innovative community healthcare providers, including stakeholders such as charity and social enterprises, are enabling people to stay healthy and independent and avoid crises that lead to unplanned hospital admissions. They enable staff to develop a holistic view of the needs of each individual and provide personalised continuous, rather than episodic, care. This sort of care is much better for the growing number of people with long term conditions and can help better manage those conditions, which in turn will help reduce unnecessary hospital admissions. Central to the community health model are prevention, early intervention and enabling timely discharge or transfer from hospital to improve recovery. Community health is moving the focus away from traditional models of healthcare in acute settings to nurse-led rehabilitation in, or closer to, peoples' homes, the provision of 'hospital at home' services such as diagnostics and chemotherapy, and community-based end of life care (see case study 2). 5.3 While there are good examples of innovative initiatives across the NHS, more needs to be done to ensure best practice is widely adopted. Often the main challenge in doing this is realising the resources needed to invest in services outside of the hospital and highlighting clearly to the public the benefits of this. The marginal rate offers an effective way of performing the former, but has been lacking in delivering the latter. Strategies to manage emergency demand, funded by the marginal rate, are not being shared both locally and nationally. In particular, there appears to be a lack of transparency at the local level about the funds being made available and this is raising concerns as to whether investments are being made. In particular, some of our commissioner members have raised concerns about the lack of certainty as to the reinvestment of funds locally into demand management strategies by Strategic Health Authorities. This will needed to be addressed in the future by the Local Area Teams of NHS England to ensure that the whole system is engaged in the solution to rising unplanned demand. 5.4 Another concern about the marginal rate that many of our provider members highlight is the destabilisation of their budgets. Many providers are running their A&E departments at a loss, which often means they are required to cross-subsidise within their organisations. This can put these services on a less sustainable footing and push some providers closer to a financial cliff edge. Many of our members feel the marginal rate is too punitive because it reduces their income on services in which demand continues to increase out of their control. Evidence that we have been shown from a local survey of acute providers shows that from more than 560,000 admissions in a year around 50,000 patients are effectively treated for free, at a cost of 103 million to the providers. 5.5 The focus of the marginal rate up to now seems to have been more on its ability to reduce demand for emergency services in hospitals by way of disincentive. As highlighted earlier, we are not convinced of the argument for supplier-induced demand for financial reasons in emergency care and so believe the focus now needs to shift towards using the resources it raises to invest directly in managing the demand that is there (see case study 3). A more transparent and collaborative approach in doing this will help to ensure that resources are spent in reflection of local needs and in a way that appropriately shares 25 NHS Confederation (2013) - Transforming local care: community healthcare rises to the challenge 12

13 risks and benefits across the system. We note the role of newly-formed clinical commissioners in doing this and highlight their power to convene providers in the local community, in addition to the support they can access from health and well-being and urgent care boards, as important tools in reforming how the system works in the future. 6. There must be a whole system approach to tackle this issue effectively, which allow local decision-making to guide approaches that are most appropriate and effective 6.1 The NHS needs a change in culture to make managing demand a top priority for all parts of the system. This will need to be a whole system effort, where proper management of unscheduled episodes happens along the whole continuum of care, supported by well developed communication channels among all the parts of the system. Information gathering and sharing across the system is thus paramount, especially along those fault lines where different parts of the system interface. However, it requires a change in working patterns - recognising weekends and evenings as normal working times - and service delivery planning. It is a shift which needs to be driven by quality and safety in patient care, and not overtime rates. Investing in good-out-of-hours services will help this. 6.2 Proper discharge planning can have a positive impact and will involve different parts of the system - internal hospital teams, ambulance services, social care and family carers. It can also reduce the risk of re-admission within 30 days following discharge. Properly coordinated, person-centred services provided closer to home can better care for the health of people, rather than dealing with the sickness of patients when they arrive at a hospital. Some progress has been made on transferring care into the community but more must be done and we welcome Bruce Keogh's review into this issue. There needs to be renewed efforts at national level to enable services other than emergency departments to better deal with unscheduled care episodes, locally and safely. 6.3 The NHS payment system provides a mechanism by which the right incentives are set across the system. While we don't believe the marginal rate has been effective at establishing a disincentive to admit, which can often be out of the provider's control, it will have certainly created an incentive to work across the system in finding a solution. We need a payment system that helps to encourage better joint working, more focus on intervention and greater investment in community services, all of which would relieve the pressures on urgent and emergency care. Various payment tools can be used, beyond simply the marginal tariff, to achieve this, but current mechanisms seem to have been developed in an ad hoc way to address various issues and plug particular gaps across the system. 6.4 While this is understandable, we believe the renewed focus by both Monitor and NHS England to reform how services are paid for represents an opportunity to take a more strategic approach toward incentives in the NHS as a whole. We urge them to develop incentives that will facilitate risk sharing across the system and give local leaders the freedom to assess what is needed in their area and the flexibility to develop local incentives. 6.5 We also recommend that they give sufficient consideration to local autonomy and flexibility in assessing the needs of their population. Clinical commissioners need the freedom to work with providers to make local decisions about local services. It should be 13

14 considered whether this means it would be better for local CCGs to hold the funds recouped from the marginal rate and use them to react quickly to develop a solution to the problem locally. It is in the interest of both providers and commissioners for emergency admissions to be reduced. NHS England's area teams must behave in a way that enables local commissioners to work effectively with their providers to achieve this. 6.6 There is probably also a need to make the baseline, upon which the marginal rate is based around, more accurate and reflective of what is actually happening in local services. Concerns have been raised with us about the current baseline and suggestions are that it is by now too historic. Case study 1: Birmingham Community Healthcare NHS Trust Birmingham Community Healthcare NHS Trust has developed a model of care that enables rapid, 24-hour access to community services in an attempt to reduce emergency hospital admissions. It is available to all patients over the age of 17 in need of immediate assessment and at high risk of hospital admission. A 24/7 single point of access for urgent and non-urgent referrals signposts patients to the appropriate care for their condition. For urgent care, a rapid response and advanced assessment at home is delivered within two hours. For non urgent care, multi-disciplinary teams respond within 48 hours. The trust is now meeting its target of 100 per cent of referrals having a nurse respond within two hours. The single point of access team is now taking over 500 calls a week, signposting all to appropriate services and putting responsive packages of care into 200 of those calls directly avoiding A&E attendance and acute hospital admissions. This is over 10,000 avoided admissions a year through that service. In addition to this, their integrated multi-disciplinary teams are receiving over 200 calls per day that are responded to within 48 hours, i.e. 1,000 referrals a week. Case study 2: Shropshire Community Health NHS Trust Shropshire Community Health NHS Trust is working on a new system for treating frail and complex patients that aims to work together with other providers to deliver an integrated care model for them. It has assembled a team that focuses on frail and complex patients identified as having a potential length of stay of less than 72 hours. The team helps patients in the emergency department of the local hospital to avoid having to be admitted, where appropriate, and assists in earlier discharge from the acute medical unit, where appropriate, if they have been admitted. Early results show reductions in admissions and a good percentage of patients being redirected back to their homes or to local community services. Case study 3: The North West London Integrated Care Pilot (ICP The North West London Integrated Care Pilot (ICP) was launched in June 2011 and brings together more than 100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age UK and Diabetes UK) to improve the coordination of care for a pilot population of people. The ICP was developed in response to variations in the 14

15 quality of care and a rising deficit across the local health economy. The clinicians involved decided two areas of focus for integrated care: people older than 75 years and those with diabetes. These groups were experiencing a high level of avoidable admissions and variable care, there was known best practice and improved outcomes would be measureable. The ICP developed a unique model of clinicians working together in multi-disciplinary groups within a multi-disciplinary system. The multi disciplinary group risk stratified the patients identified for the pilot, developed shared protocols for care across organisations, discussed these protocols and developed care plans with patients, mapped available care and addressed gaps in provision, introduced case conferences for patients with particularly complex needs or significant problems, and reviewed overall performance of the pilot. 7 million investment was provided by London SHA channelling the funds from the 30 per cent marginal tariff on 'excess' emergency admissions to hospital. This provided for an operational team, an information tool (to support risk stratification, care planning, sharing of medical information and evaluation), care coordination and incentive for providers to save. Some benefits have been seen relatively early in the pilot, though it is anticipated the full benefits would become apparent over a 5-10 year timescale. Based on analysis of the impact to date, the ICP hopes to reduce emergency admissions for people over 75 with diabetes by 10 per cent. Patients are also experiencing better coordinated care across different providers. The aspiration for the pilot is to scale up to the whole local population, focusing on the 20 per cent that drive 80 per cent of costs. If you have questions about this response or require clarification, please contact Paul Healy (Senior Policy and Research Officer) on paul.healy@nhsconfed.org. 15