Reducing emergency admissions inquiry

Nearly one and a half million emergency admissions could be avoided with better preventive care outside hospitals. In 2016–17 there were 5.8 million emergency admissions to hospitals in England. Some 24% of the emergency admissions were avoidable if people had more effective community health care and case management to prevent them getting so unwell that they needed emergency hospital care. The proportion of avoidable admissions has been rising faster than the overall rate of emergency admissions since 2013–14. However, the NHS had not made the necessary investment to fund this kind of preventative work and the need to make short term savings means local areas have been overlooking investment in preventative services. Social services also help prevent people needing an emergency admission, and we find the combination of rising demand for social services and limited local authority finances particularly worrying. Recommendation: NHS England should identify gaps in capacity in primary and community health care and set out how it intends to fill those gaps. It should also consider the impact of pressures on social care provision on emergency admissions and use this understanding to inform discussions with the Ministry of Housing, Communities and Local Government and HM Treasury about the Green Paper on future funding of social care.

Rising bed occupancy rates further jeopardise hospitals’ ability to cope with emergency admissions. The average number of available hospital beds at any one time dropped by nearly 6% from 2010–11 to 2016–17. The use of hospital beds is also intensifying and hit a seasonal peak of 91.4% in the first three months of 2017 and NHS Improvement told us that hospitals are running at too high an occupancy rate. Most worryingly, in January, because of seasonal pressures caused by rising emergency admissions, the NHS postponed or cancelled numerous planned operations and as a result there were some 23,000 fewer operations in January 2018 than in January the previous year. While NHS England recognises that no-one wants to postpone planned operations, the Department considers that the NHS’s approach to dealing with pressures last winter was more strategic and gave greater certainty to patients, including cancelling operations in advance rather than on the day. However, this gives little comfort to patients whose operations were cancelled and we remain concerned that cancelled operations are a sign of failure in how the system is operating. Recommendation: NHS England’s and NHS Improvement’s regional teams should assess the capacity that hospitals need in terms of beds, staff and funding to deal with emergency admissions throughout the year. We have previously highlighted the need for Trusts to have greater certainty earlier in the year of additional funding to cope with winter pressures.

NHS England has not systematically engaged with the voluntary sector to understand fully the importance of its support in reducing emergency admissions. The voluntary sector can play an important role in supporting health and social care teams to look after people in the community. Yet NHS England has not always actively involved the sector in efforts to reduce emergency admissions. We heard some evidence from our NHS witnesses of how the voluntary sector gets 6 Reducing emergency admissions involved, such as with the ambulance services, but only piecemeal examples. It is disappointing that there is no central understanding of the work of the voluntary sector in helping to reduce emergency admissions or how reliant Trusts may be on voluntary sector support, both paid and unpaid. Recommendation: The Department should encourage better sharing of best practice on how the voluntary sector supports health and social care efforts to reduce emergency admissions and understand the reliance the system has on the sector. It should report back to the Committee on this.

Without a better understanding of what works best to reduce emergency admissions, NHS England cannot prioritise resources effectively. NHS England is trying to reduce emergency admissions with various interventions in several different programmes, including the urgent and emergency care programme, new care models and the Better Care Fund. However, neither NHS England nor NHS Improvement know what is most effective at reducing emergency admissions. We recognise there is some good practice but it is still too piecemeal and varies regionally. Factors such as deprivation and demographics can affect levels of emergency admissions substantially in different areas. But, even after adjusting to take account of such factors, in 2016–17 the number of emergency admissions across England still varied between 73 and 155 admissions per 1,000 people. There is clearly significant local divergence of what is and what is not working in reducing emergency admissions. When challenged on the lack of evidence on the impact of particular interventions, NHS England does not seem to understand which particular interventions are working or why. This lack of understanding hampers improvement and prevents the cash-strapped NHS from targeting taxpayers’ money on the things that work best. Recommendation: NHS England and NHS Improvement should set out their plans for how and by when they will determine which interventions are most effective at reducing emergency admissions and how they will use any findings to ensure a more targeted use of resources and funding.

Poor data on daycase emergency care and readmissions stops NHS England knowing if its efforts to reduce emergency admissions are helping or potentially harming patients. In most cases, it is better for people, particularly older people, if they do not have to stay in hospital overnight. NHS England is trying to provide more emergency care without an overnight stay, which it calls daycase or ambulatory emergency care, which is both more appropriate for some patients and also frees up beds. Certainly a large proportion of the growth (79%) in emergency admissions was caused by people who did not stay overnight. However, hospitals record this kind of emergency care inconsistently; some record these patients as admissions and some record them as outpatients. The inconsistent recording prevents NHS England knowing to what extent patients are being spared an unnecessary overnight stay in hospitals, and may also allow hospitals to game admissions to receive higher payments. There are similar problems with the data on readmissions, which NHS England has not been recording. One study suggests that in the last five years there has been a 22.8% increase in people being readmitted back to hospital. Readmission rates are not necessarily a worrying sign; they can reflect improving clinical practice and show the success of the NHS in helping people recover from illness or injury. But Reducing emergency admissions 7 a readmission can also be the result of previous poor clinical judgement. However, a lack of data prevents NHS England knowing how many people are readmitted back into hospital in an emergency. Without good data, NHS England cannot assess if readmission rates are at harmful levels. Recommendation: NHS England and NHS Improvement should improve data they collect and that hospitals record so that by the end of 2018 care can be tracked and publicly reported, together with a clear statement of what is a harmful level of readmissions for people’s care. 8 Reducing emergency admissions 1 Management of emergency admissions

Clearly, there are gaps in the provision of these alternative forms of care. Earlier this year the National Audit Office reported that sustainability and transformation partnerships were overlooking investment in these types of preventative services in order to make savings in the short term.9 Research also showed shortfalls in investment 1 Report by the Comptroller and Auditor General, Reducing emergency admissions, Session 2017–2019, HC 833, 2 March 2018 2 C&AG’s Report, para 3 3 C&AG’s Report, para 6 4 Q 12; C&AG’s Report, para 6 5 C&AG’s Report, para 10 6 Q 12; C&AG’s Report, para 6 7 Q 12 8 Q 83 9 C&AG’s Report, Sustainability and transformation in the NHS, Session 2017–19, HC 719, January 2018 Reducing emergency admissions 9 in ‘intermediate care’. This type of care consists of health, community and social care services outside hospitals that help bring about faster recovery from illness and maximise independent living, particularly for elderly people.10

Despite the importance of community health care, at the time of our evidence session there was not a clearly defined plan for how the £10 billion of annual spend on community care could be better used to manage current and future demand. NHS England’s proposals for programmes to focus on community care had stalled.11 NHS England was aware that the ever-increasing gap between the need for social care and the availability of social care would put extra pressure on hospitals. Despite this, NHS England had not estimated of the impact of social care spending on the NHS.12 The Department and NHS England both acknowledged the financial pressures on social care. The Chief Executive of NHS England commented that “I think everybody agrees … that there needs to be a sustainable solution for health and social care funding and that is growing increasingly urgent.”13 Bed occupancy

The average number of available general and acute beds in hospitals fell by 6,268 (5.8%) from 2010–11 to 2016–17. The intensity of the use of those beds, shown by bed occupancy rates, has increased and hit a seasonal peak of 91.4% in the first three months of

NHS England acknowledged that no-one—the patient, the surgeon, the hospital board, the chief executive—wants to postpone or displace elective operations but that the emergency patient will take precedent.17 The Department considered that there was a more strategic approach to postponing operations this winter, rather than individual trusts postponing as winter progressed. It told us that this strategic approach gave greater certainty to patients and enabled trusts to redeploy staff to deal with emergencies.18 NHS Improvement acknowledged that it would need to do more work than in the past to look at the capacity of each hospital and that it hoped to reduce bed occupancy significantly from levels currently seen.19 10 C&AG’s Report 11 C&AG’s Report, para 3.9 12 C&AG’s Report, para 2.14 13 Qq 79–81 14 Q 27; C&AG’s Report, para 3.2 15 Q 30 16 Q 24 17 Qq 27–28 18 Qq 30–32 19 Qq 27–28 10 Reducing emergency admissions Engagement with the voluntary sector

The voluntary sector could be a powerful force in helping to keep people out of hospital, particularly to support health and social care teams looking after people in their homes and communities. Volunteers could help ease pressures on busy health and social care professionals. We challenged NHS England on the apparent lack of emphasis on engaging the voluntary sector in reducing emergency admissions. NHS England told us that the Department had supported the voluntary sector over several years, particularly as part of the “discharge to assess model” in making sure that people who go back into the community have support. It also told us that, when an ambulance is called to attend an elderly patient who lives alone or in warden-controlled accommodation, paramedics can contact the “single point of access”, who can mobilise the voluntary sector rapidly to come and be with the patient when the patient does not need conveying to hospital. NHS England also said that, in several parts of the country, voluntary sector groups could make referrals into the “single point of access”.20

However, there remains plenty of scope for the Department and NHS England to engage with the voluntary sector much more systematically and consistently on this issue, over and above what it is doing with the ambulance services. There seems to be no national ambition to engage with the voluntary sector proactively and to best effect at the local level. NHS England gave us a commitment to look far more proactively at the role the voluntary sector can play. It also commented that some, albeit a modest amount, of last winter’s money had gone to support the Red Cross with its hospital discharge and support scheme, and mentioned that the Greater Manchester area had entered into a memorandum of understanding and partnership agreement with nearly 15,000 voluntary organisations.21 20 Qq 69–70 21 Q 71 Reducing emergency admissions 11 2 Understanding what works The evidence base

Providing cost-effective alternatives to emergency care needs input from across the health and social care system. NHS England, and its partners, have set up several programmes which aim to reduce emergency admissions through working with different parts of the care system: The urgent and emergency care programme aims to improve emergency and urgent care and ease the pressure on the emergency system; the Better Care Fund aims to integrate health and social care, the new care models aim to integrate primary and hospital care; and NHS RightCare and Getting it Right First Time try to help local areas understand how their performance compares with other similar places.22

NHS England could point to some indicators of success in these programmes, for example, the new care models showing, on average, a slowdown of growth in emergency admission rates.23 However, NHS England has not been able to unpick what particular interventions in these programmes work best to reduce emergency admissions. In fact, the interventions are not always based on what works well in practice. The evidence base for these interventions are mixed and, in some cases, quite poor.24 Without an understanding of what works, NHS England cannot target its efforts to improve and get the most effective use of taxpayers’ money.25

Factors such as deprivation and demographics can have a major impact on emergency admissions rates. Even when these factors are taken into account at local level, the number of emergency admissions in England in 2016–17 varied considerably, between 73 and 155 admissions per 1,000 people.26 NHS England told us about a programme called Getting it Right First Time which is a clinically-led programme that looks at variation within hospitals and began by looking at surgery. NHS England believes that it will contribute to the identification of clinical best practice within hospitals.27 However, we were unconvinced that NHS England was drilling down enough to find out the real reasons for these differences in the populations, and sharing this understanding with NHS teams.28 When challenged on the lack of evidence of the impact of particular interventions, NHS England does not seem to understand which particular interventions are working or why. Without a good understanding of what causes these variations, NHS England and its partners do not know whether local social and health care practices are causing different rates of emergency admissions than elsewhere.29 Poor data

In most cases, a shorter stay in hospital is best for people, particularly the elderly, as they lose mobility quickly if they do not keep active, and their ability to do everyday 22 C&AG’s Report, paras 2.3–2.9 23 Qq 50, 51 24 C&AG’s Report, para 3.26 25 Qq 43–47 26 C&AG’s Report, para 3.24 27 Q 68 28 Qq 68–69 29 Qq 62–69; C&AG’s Report, para 3.24 12 Reducing emergency admissions activities can reduce quickly while in hospital.30 NHS England and NHS Improvement are trying to promote a model of emergency care, known as daycase or ambulatory emergency care, in which people are admitted to hospital but do not stay overnight. NHS England explained that this model of care can take many forms including a specific “ambulatory care” facility on the hospital emergency floor or a team that specialises in frail patients.31 It considers that this type of care is one of the positive steps it is taking to manage patients closer to their home and in a way that is better for patients.32

However, hospitals do not record daycase emergency care consistently. Some hospitals record these patients as an emergency admission while others record them as outpatients.33 There is no guidance as to how hospitals should record these patients and NHS England acknowledged that the system was not set up to enable hospitals to record this care consistently.34 This inconsistency creates two problems. First, it prevents NHS England knowing how successful its efforts are in providing what it considers better care for certain patients, and whether patients are being spared an unnecessary overnight stay in hospital. Second, it carries the risk that hospitals may game the data to get higher payments through the tariff system, which pays hospitals more for emergency admissions than for outpatients.35 We asked NHS England about the danger of gaming the system. It responded that clinicians are rarely aware of how the tariff works and would treat the patient in the best way possible. It accepted that the data needed improving and pointed to a pilot it has started in six areas to improve data on daycase emergency care.36

There are similar problems with the data on the numbers of people being readmitted to hospital. Readmissions can indicate the success of the NHS in helping people to recover from illness or injury. They can happen for many reasons and may not always be preventable.37 NHS England told us that clearly there have been occasions when people have been discharged from hospital too soon, or where the community and social care they needed was not in place as expected.38 However, NHS England explained that readmissions are not always a bad thing and may result from a push to get people out of hospital as quickly as possible given the health problems associated with long stays in hospitals.39

However, the NHS does not record data on readmissions and so is unaware if readmission rates are approaching levels that could be harmful, and be an indicator of failures in care. We challenged NHS England to be clearer about when a readmission was a positive indicator or a result of poor judgement, but there is evidently more work needed to give this clarification.40 A report by Healthwatch England in October 2017 on data from 72 trusts estimated that readmission rates have risen as much as 22.8% between 2012–13 and 2016–17.41 30 Q 18; C&AG’s Report, para 1.7 31 Q 13 32 Q 12 33 Qq 13–16; C&AG’s Report, paras 13, 3.32 34 Qq 13–16; C&AG’s Report, para 3.32 35 Qq 12–16 36 Q 16 37 C&AG’s Report, para 3.3 38 Q 18 39 Qq 17–19 40 Q 26 41 C&AG’s Report, para 3.4 Reducing emergency admissions 13