Reducing avoidable emergency admissions · conditions where early intervention can prevent...

Reducing avoidable emergency admissionsAnalysis of the impact of ambulatory care sensitive conditions in England

Turning data into decisions Our aim at Dr Foster is to equip healthcare organisations to make better and faster decisions on the quality and value of connected healthcare. We do this by working with our clients to deliver easy to use and role-relevant solutions that deliver actionable insights – insights that play a significant role in driving decisions.

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Executive summary

By looking in detail at avoidable emergency hospital admissions – patients with

ambulatory care sensitive conditions (ACSCs) who are admitted to hospital – our

aim is to help NHS organisations understand how they can address the challenges

they present and, by establishing where variations exist, where to direct resources

to target the most affected groups.

Better management of patients with ACSCs has been a significant focus for the NHS for many years.

ACSCs are both costly to the NHS and expose patients to unnecessary clinical risks. In addition,

addressing ACSCs can help to meet several objectives outlined in the 2019 NHS Long Term Plan.

Despite efforts to tackle the number of emergency admissions, ACSCs currently make up 23 per

cent of all emergency admissions and, despite taking into account the growing population, the rate

of ACSC admissions rose by 9 per cent between April 2013 and March 2018. This increase is

alarmingly high considering many of these admissions can be prevented through effective primary

and community care.

This report highlights which ACSCs are contributing most to this high rate of admissions, finding

that (1) influenza and pneumonia, (2) pyelonephritis and kidney/urinary tract infections, (3) chronic

obstructive pulmonary disease (COPD), (4) dehydration and gastroenteritis, and (5) ear, nose and

throat infections are the top five conditions by volume of emergency admissions. Over five years,

emergency admissions for influenza and pneumonia and ear, nose and throat infections increased

by 58 per cent and 30 per cent respectively.

The report also highlights that substantially more emergency admissions for ACSCs occur on an

average weekday than on a weekend day, possibly owing to ‘the weekend effect’. It suggests that

there may be limited primary or community care service availability on the weekend, meaning that

there are more attendances in the emergency department but these admissions are restricted to

very severe cases at this time.

We have reviewed population demographics to identify which groups are more likely to be admitted

for ACSCs, and enable evidence-based plans to be delivered for targeted intervention. Under-fives

and over 65s showed the highest rates of admission.

The analysis compared rates of emergency admissions for ACSCs across sustainable

transformation partnerships (STPs) in England, finding a strong correlation between deprivation and

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emergency ACSC admissions. It suggests that socioeconomic factors are a significant influence on

the likelihood of advancing ACSCs, with adults in more deprived areas more likely to be admitted for

diabetes, COPD, and hypertension, and children in more deprived areas more likely to be admitted

for chronic conditions such as asthma. Considerable variation between the north and south exists

and may point to health inequalities due to factors other than socioeconomic ones, such as a

greater disparity between primary/community and secondary care services, health service

accessibility or wider determinants of health such as lifestyle and vulnerability.

Interestingly, the complexity of patients was not found to be an important factor in determining the

likelihood of admission, with nearly half of all emergency ACSC admissions (48 per cent) having a

comorbidity score of 0. This indicates that the majority of patients could be treated out of hospital

in the primary or community care setting.

Savings in both bed days and tariffs could be achieved by addressing the issue of ACSCs

admissions. We estimate national savings of £125 million could be made. The report includes a list

of STPs and potential tariff savings if emergency admissions for ACSCs were reduced to the STPs’

expected values1 and a list of potential bed day savings if the cumulative lengths of stay for

emergency ACSC admissions were again reduced to their expected values1.To help STPs better

manage patients with ACSCs and reach these national benchmarks, the report makes several

recommendations:

• Use data for targeted intervention

• Identify high-risk patients early

• Focus on health inequalities

• Reduce unwarranted variation

• Build relationships with local partners

• Support and inform the population

• Encourage self-management

Following these recommendations can lead to an improved healthcare system with a focus on

population health and health inequalities, reduce the growth in demand for emergency care through

better healthcare integration and prevention and help the NHS achieve the objectives of the Long

Term Plan.

1 Expected value for each STP based on the national rate, calculated using indirect standardisation adjusting for age, sex and deprivation.

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Introduction

Better management of patients with ambulatory care sensitive conditions (ACSCs)

has been a significant focus for the NHS as it can lead to a reduction in avoidable

emergency admissions, which are costly and also expose patients to otherwise

unnecessary clinical risks. In the NHS Long Term Plan there were a number of

themes relating to the better management of ACSCs and this has been a catalyst

for further effort.

ACSCs can be chronic conditions where early intervention can help prevent exacerbation; acute

conditions where early intervention can prevent progression; or conditions where immunisation can

prevent disease.i Effective care and active management of ACSCs should help to avoid hospital

admissions.ii

When a hospital has a high proportion of emergency admissions for ACSCs, it can be a result of

primary or community care services in the area not working effectively to prevent conditions from

developing. Socioeconomic factors have also shown to be influential in the rate of emergency

admissions for ACSCs.

Figure 1 shows how addressing ACSCs is linked to objectives outlined in the NHS Long Term Plan.

Given the significance of admissions for ACSCs, we felt a more extensive analysis was required to

help the NHS understand how it can begin to address the challenge and to establish whether there

were variations (e.g. demographics, geographical) that could help the NHS better direct its

resources and target the most affected groups.

https://www.longtermplan.nhs.uk/

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Figure 1 – Objectives in the NHS Long Term Plan relating to ACSCs

Table 1 shows a list of 20 defined ACSCs (amended by Dr Foster in February 2019 based on the NHS

Outcomes Framework): iii

Table 1 - List of 20 ACSCs classified into relevant groups

Vaccine-preventable Chronic Acute

• Influenza and pneumonia • Other vaccine preventable

• Asthma • Congestive heart failure • Diabetes complications • COPD • Angina/ischemic heart

disease (IHD) • Iron deficiency anaemia • Hypertension • Other cardiovascular

diseases • Mental and behavioural

disorders

• Dehydration and gastroenteritis

• Pyelonephritis and kidney/urinary tract infections

• Perforated/bleeding ulcer • Cellulitis • Pelvic inflammatory

disease • Ear, nose and throat

infections • Dental conditions • Convulsions and epilepsy • Gangrene

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National overview of emergency

admissions for ACSCs

HOW HAS THE PREVALENCE OF EMERGENCY ADMISSIONS FOR ACSCS CHANGED OVER TIME?

Figure 2 shows that ACSCs continue to be a major cause of emergency admissions

in hospitals. In FY 2017/18, there were 1.36 million emergency admissions for

ACSCs. Over five years, the number of emergency admissions for ACSCs increased

by 12 per cent, equivalent to 151,067 more preventable emergency admissions

nationally in FY 2017/18 versus FY 2013/14.

Increases in emergency admissions are expected as the

demand for secondary care services rises with a growing

population. However, even when taking the growing

population into account, the rate also increased between

April 2013 and March 2018 by 9 per cent. Encouragingly,

the rate of ACSC emergency admissions has stabilised at a

rate of 23.2 emergency admissions per 1,000 population

over the last two financial years but this rate is still

alarmingly high considering these admissions are preventable with improved out-of-hospital

patient care and active management of these conditions.

23% ACSCs make up 23% of all

emergency admissions

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Figure 2 – Number and rate of emergency admissions for ACSCs trended over five years

Source: Hospital Episode Statistics (HES) and Office of National Statistics (ONS)iv. Data period: 1 April 2013 to 31 March 2018.

WHAT CONDITIONS ARE SIGNIFICANT CONTRIBUTORS TO ACSC EMERGENCY ADMISSIONS AND

HOW HAVE THESE CHANGED OVER TIME?

To reduce the number of ACSC emergency admissions, it is important to understand which ACSCs

are the biggest contributors to emergency admissions so that these groups can be targeted.

Figure 3 shows that emergency admissions for influenza

and pneumonia and ear, nose and throat infections

increased sharply in FY 2017/18. Over five years, the

number of emergency admissions for these two conditions

increased by 58 per cent and 30 per cent respectively.

Conversely, pyelonephritis and kidney/urinary tract

infections decreased by 10 per cent over the five years.

1,211,456

1,285,176 1,301,788

1,354,104 1,362,523

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41% The top three ACSCs

make up 41% of all ACSC


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Figure 3 – Number of emergency admissions for each ACSC for five years

Source: HES. Data period: 1 April 2013 to 31 March 2018.

DO ACSC EMERGENCY ADMISSIONS HAPPEN MORE ON A WEEKDAY OR WEEKEND?

Figure 4 shows that, on average, there are substantially more emergency admissions for ACSCs on a

weekday than on a weekend day for all ACSC groups – acute, chronic and vaccine preventable. This

observation has also been identified for all emergency admissions (not only ACSCs) and is possibly

related to the ‘weekend effect’.

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Figure 4 – Daily rate of emergency admissions for ACSCs on a weekday versus the weekend in FY 2017/18

Source: HES. Data period: 1 April 2017 to 31 March 2018.

The ‘weekend effect’ is a phenomenon in healthcare whereby patients admitted at the weekend

have a greater mortality versus those admitted on a weekday. Research suggests this may be owing

to limited health service availability at weekends (for example, certain community services or GPs

being closed) which could cause more attendances in emergency services. With more attendances,

it is possible that there is a stricter admission criteria for patients, limiting admissions to the more

severe patients. So, the probability of being admitted on the weekend is potentially lower but the

likelihood of mortality is higher.v

The significant disparity in the number of emergency

admissions for ACSCs on a weekday versus the weekend is

concerning since this is likely due to ACSC patients having

restricted access to health services on the weekend. With

limited primary or community care services available to

manage or treat the conditions combined with a potentially

higher threshold of severity for admissions, ACSC patients

may become increasingly ill over the weekend, leading to

more emergency admissions during the week.

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Weekday Weekend

1,723 In 2017/18, a typical

weekday had 1,723 more


for ACSCs than a day on

the weekend

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National variation in admission rates for

ACSCs

HOW DO THE RATES OF EMERGENCY ADMISSIONS FOR ACSCS VARY ACROSS ENGLAND?

The NHS supports multiple initiatives which aim to reduce unwarranted variation

in outcomes across England.vi The heat maps in Figure 5 show the variation in

emergency admission rates for overall, acute, chronic and vaccine preventable

ACSC groups by STP.2

Figure 5 – Heat maps showing the variation in the rate of emergency admissions for ACSCs in FY 2017/18 (adjusted for age, sex, and deprivation)

2 Clinical commissioning group-level heat maps are available online at www.drfoster.com/news

Figure 5a – overall ACSCs

Figure 5b – acute ACSCs

https://www.drfoster.com/news

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Source: HES and ONS. HES data period: 1 April 2017 to 31 March 2018. ONS STP boundary file based on latest release: February 2017. Records with unknown age, sex or output area information are excluded. Indirect standardisation used adjusting for age, sex and deprivation (IMD).

The overall variation in the admission rate for all ACSCs (Figure 5a) shows that the north and the

centre of England have the highest rates of emergency admissions for ACSCs after adjusting for

age, sex and deprivation. For all ACSC groups, the north of England consistently has considerably

higher admission rates, suggesting the well-documented north-south divide in health inequalities is

prevalent in emergency ACSC admissions. Our analysis adjusted for deprivation (IMD), therefore it is

possible that the health inequalitiesvii are due to other factors such as a greater disparity between

primary/community and secondary care services, health service accessibility or the wider

determinants of health not included in the IMD such as lifestyle and vulnerabilityviii.

The north-south divide inevitably has an impact on economic productivity in the north. A recent

report commissioned by the Northern Health and Science Alliance investigated the effects of health

inequalities on productivity in the region and found that tackling health inequalities between the

north and south could add an extra £13.2bn into the economy. ix

The maps also show that there is greatest unwarranted variation in the admission rates for acute

and vaccine preventable ACSCs and less variation in admission rates for chronic ACSCs. With

influenza and pneumonia (vaccine preventable) being the highest-admitting condition in England

and pyelonephritis and kidney/urinary tract infections (acute) being the second highest, these

conditions should be primarily targeted for reduction in regions having higher standardised

admission ratios (SARs).

Figure 5c – chronic ACSCs

Figure 5d – vaccine preventable ACSCs

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HOW HAS THE VARIATION IN ADMISSION RATES CHANGED IN FIVE YEARS?

Comparing Figures 6a and 6b below, there has been a slight increase in the variation of admission

rates across England since April 2013.

Figure 6 – Heat maps showing the variation in the rate of emergency admissions for all ACSCs (adjusted for age,

sex and deprivation)

Figure 6a – FY2013/14

Figure 6b – FY 2017/18

Source: HES and ONS. HES data period: 1 April 2013 to 31 March 2018. ONS STP boundary file based on latest release: February 2017. Records with unknown age, sex or output area information are excluded. Indirect standardisation used adjusting for age, sex and deprivation (IMD).

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Typical characteristics of emergency

admissions for ACSCs

HOW LONG AND HOW FREQUENT DO THESE ADMISSIONS TEND TO BE?

Frequency of emergency admission is one of the areas we investigated as part of

our analysis into ACSCs. We found that most patients are not regularly admitted in

an emergency for ACSCs. Figure 7 shows that 83 per cent of patients had a single

emergency ACSC spell in FY 2017/18.

Figure 7 – Distribution of the number of emergency admissions for ACSCs patients in FY 2017/18

Source: HES. Data period: 1 April 2017 to 31 March 2018. Records with unknown age, sex or output area information are excluded.

Figure 8 shows that 54 per cent of emergency admissions for ACSCs had a length of stay of two days

or less. We found there is a relatively large spread, with a small percentage of admissions (just 3 per

cent) having a length of stay of over 30 days; accounting for 27 per cent of the total bed days in

FY 2017/18. Only 1,520 admissions had lengths of stay of 100 days or more but this small proportion

accounted for 3 per cent of the total bed days.

858,565

125,151 30,494 10,325 8,619

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Number of ACSC admissions per patient

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Figure 8 – Length of stay profile for emergency ACSC admissions in FY 2017/18


WHICH PATIENTS ARE MOST AFFECTED BY ACSCS?

To reduce emergency admission for ACSCs, it’s important to understand the types of patients most

often affected, so that evidence-based plans can be developed for targeted intervention. We used

segmentation analyses to identify which groups of patients are most affected by ACSCs nationally.

We segmented emergency ACSC spells by age, sex, complexity and deprivation and the results are

shown below.

Grouping the admissions by age and sex, Figure 9 shows

that under fives and over 65s have the most emergency

admissions for ACSCs, with admissions for 65s accounting

for over half (52 per cent) of all ACSC admissions. There

were higher admissions for women between the ages of 15

and 50 and above 80 years old, though more males affected

in the 0-4 age group. The higher prevalence of spells for

females in the over-80 population is largely due to females

living longer than males.x

0

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300

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Num

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f em

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s (Tho

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Length of stay (days)

12% In FY 2017/18, females

had 12% more


for ACSCs than males

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Figure 9 – Number of ACSC emergency admissions by age group and sex


The complexity of patients is an important factor to consider in enabling effective planning of

services and accurate resource estimates. We investigated patient complexity using the Charlson

comorbidity score3 associated with each emergency ACSC admission. Figure 10 shows that nearly

half of all emergency ACSC admissions (48 per cent) had a comorbidity score of 0, indicating that

the majority of admissions were not associated with complex patients. This finding suggests that

these patients should be treated out of hospital in the primary or community care setting.

3 Charlson comorbidity score based on weightings derived by Dr Foster.

0

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Age group

Female Male

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Figure 10 – Complexity profile of patients admitting in an emergency for ACSCs


It is well established that deprivation is linked to health outcomes, influenced by many factors

including education, working conditions, food poverty and poor housing. Our analysis shows a

strong correlation between deprivation and emergency ACSC admissions, with both the number and

rate of emergency ACSC admissions climbing as the level of deprivation increases.

Figure 11 – Rate of emergency admissions for ACSCs per 1,000 population split by deprivation decile in FY 2017/18

Source: HES. Data period: 1 April 2017 to 31 March 2018. Records with unknown age, sex or output area information are excluded. Index of Multiple Deprivation decile derived from 2015 scores based on 2011 lower super output area (LSOA) boundaries published by the Department for Communities and Local Government.

620,182

211,590

125,930132,66376,429 61,510 37,015 17,392 8,551 3,782 1,531 504 202 47 18

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Charlson comorbidity score2

32.4

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R² = 0.92

10

15

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IMD decile (1=most deprived; 10=least deprived)

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A deeper dive into deprivation

The determinants of health are social, economic and environmental. These factors

largely depend on physical, social and personal resources that shape the

circumstances of daily life. Variation in these determinants is considered the

principal cause of health inequalities.xi

Previous research suggests that socioeconomic status is a significant factor in the likelihood of

developing ACSCs such as diabetes, COPD, and hypertension as an adult.xii Additionally, children

born into poverty are more likely to suffer from chronic conditions such as asthma as well as diet-

related problems such as tooth decay, malnutrition, obesity, and diabetes.xiii Access to primary and

community care is also a defining factor in an individual’s health throughout their life and is

particularly relevant in the development and/or management of ACSCs. It may be, therefore, that

access to care services in areas of deprivation needs to be improved.

We analysed the drivers and economic impacts of deprivation further after finding a strong

correlation between the admission rate for emergency ACSCs and deprivation (Figure 11). Our

analyses use the Index of Multiple Deprivation (IMD) which measures local areas relatively by seven

determinant factors:xiv

• Income

• Employment

• Education, skills and training

• Health deprivation and disability

• Crime

• Barriers to housing and services

• Living environment

HOW DOES DEPRIVATION AFFECT THE ADMISSION RATES FOR EACH ACSC?

For most ACSCs, the level of deprivation has a significant impact on the rate of emergency

admissions as shown in Figure 12. The chronic condition COPD has the largest range in admission

rates between the most deprived (4.41 admissions per 1,000) versus least deprived (1.12

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admissions per 1,000). Other conditions with relatively large ranges in admission rates by

deprivation decile are influenza and pneumonia; ear, nose and throat infections; asthma;

dehydration and gastroenteritis; and pyelonephritis and kidney/urinary tract infections. These

conditions should be the primary focus for reducing health inequalities.

Figure 12 – Variation in the rate of emergency admissions per 1,000 population for each ACSC by IMD decile

Source: HES. Data period: 1 April 2017 to 31 March 2018. Records with unknown age, sex or output area information are excluded. IMD decile derived from 2015 scores based on 2011 LSOA boundaries published by the Department for Communities and Local Government.

CLOSING THE GAP: HOW HAVE THE ADMISSION RATES FOR MOST VERSUS LEAST DEPRIVED

DECILES CHANGED OVER TIME?

A comparison between FY 2013/14 and FY 2017/18 shows that admission rates for each deprivation

decile are on the rise at a fairly equal rate. This means there is still a large disparity in care between

the least and most deprived groups. A focus for the future is to narrow the gap, working towards a

horizontal trend line across the deprivation deciles.

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Figure 13 – Comparing admission rates by deprivation decile for FY 2013/14 versus FY 2017/18


HOW DOES DEPRIVATION AFFECT THE NATIONAL TARIFF RATES FOR ACSC EMERGENCY

ADMISSIONS?

Our analysis found that the most deprived population

had the highest tariff for emergency ACSC admissions,

making up approximately 13 per cent of the total. As

shown in Figure 14, the most deprived decile (decile 1)

costs on average £66 per person (population) 4, a total of

an estimated £0.37 billion for the most deprived

population in FY 2017/18. It costs £39 per person

(population) in the least deprived decile.

4 Tariff per person (population) = Sum of tariff for all spells in deprivation decile x

Estimated population of deprivation decile x

R² = 0.9327

R² = 0.92

0

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IMD decile (1 = most deprived; 10 = least deprived)

FY 2013/14

FY 2017/18

£2.83 bn The national tariff for

emergency ACSC

admissions is estimated at

£2.83 billion for FY 2017/18

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Figure 14 – Tariff per person (population) split by deprivation decile


While the tariff per person is highest for the most deprived population (Figure 14), it is interesting

that the cost per admission5 is distinctly lower for most deprived decile as shown in Figure 15

below. This could be because the most deprived decile has more admissions and so has

proportionally more inexpensive admissions than the less deprived groups. This disparity is also

linked to life expectancy where the less deprived patients live longer and so tend to be more

complex, elderly patients.xv

5 Tariff per admission = Sum of tariff for all spells in deprivation decile x

Sum of spells in deprivation decile x

£0

£10

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1 2 3 4 5 6 7 8 9 10

Tarif

f per

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IMD decile (1=most deprived; 10=least deprived)

Observed tariff per person

Average tariff per person

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Figure 15 – Tariff per admission split by deprivation decile


£1,600

£1,700

£1,800

£1,900

£2,000

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1 2 3 4 5 6 7 8 9 10

Tarif

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adm

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IMD decile (1=most deprived; 10=least deprived

Observed tariff per admission

Average tariff per admission

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Savings opportunities for STPs

WHICH STPS HAVE THE GREATEST POTENTIAL FOR BED DAYS AND TARIFF SAVINGS?

We examined the potential opportunities for the NHS on a regional level. These are

the savings that could be achieved by addressing admissions for ACSCs and are

presented as estimated tariff savings and estimated bed day savings by STP

region. This analysis is also available at clinical commissioning group (CCG) level –

to find out more visit www.drfoster.com/news

The savings opportunities by STP are shown in Figure 16.

Figure 16 – Evaluation of savings opportunities by STP based on FY 2017/18 data

Source: HES. Data Period: 1 April 2017 to 31 March 2018. Records with unknown age, sex or output area information are excluded.

https://www.drfoster.com/news

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WHAT TARIFF SAVINGS ARE POSSIBLE FOR EACH STP?

Table 2 shows the list of STPs with potential tariff savings if emergency admissions for ACSCs were

to be reduced to the national benchmark (see Appendix 2 for full list). Nationally, this accumulates

to a total of £125 million potential savings.

Table 2 – Table ranking STPs by estimated tariff savings (STPs that have no savings opportunities have been

excluded)

Ranking STP Standardised admission ratio

Observed tariff per 1,000 population

Estimated tariff saving

1 Cumbria and North East 117.23 £62,538 £28,639,299

2 Greater Manchester 116.21 £55,387 £21,876,931

3 Cheshire and Merseyside 108.30 £59,912 £11,340,230

4 West Yorkshire 108.84 £52,485 £10,733,825

5 Milton Keynes, Bedfordshire and Luton 123.76 £54,991 £9,908,806

6 Lancashire and South Cumbria 108.33 £55,116 £7,105,033

7 Staffordshire 112.08 £53,024 £6,433,896

8 Northamptonshire 118.31 £56,897 £6,379,690

9 South West London 106.18 £49,179 £4,258,576

10 Frimley Health 113.56 £42,784 £3,776,793

11 Humber, Coast and Vale 104.65 £55,036 £3,374,247

12 Derbyshire 105.72 £57,516 £3,160,613

13

Buckinghamshire, Oxfordshire and Berkshire West 104.21 £42,180 £2,882,541

14 Hertfordshire and West Essex 102.69 £52,067 £1,998,974

15 Surrey Heartlands 104.65 £50,305 £1,895,715

16 Birmingham and Solihull 100.98 £49,865 £568,920

17 Shropshire and Telford and Wrekin 101.51 £53,018 £389,864

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HOW MANY BEDS DAYS CAN BE SAVED IN EACH STP?

Table 3 shows the list of STPs with potential bed days savings if the cumulative lengths of stay for

emergency ACSC admissions were to be reduced to the national benchmark (see Appendix 2 for full

list). The total that could be saved nationally is 381,350 bed days.

Table 3 – Table ranking STPs by estimated bed days savings (STPs with no bed days savings opportunities are

excluded)


Observed tariff per 1,000 population

Estimated tariff saving

18 Bath, Swindon and Wiltshire 100.80 £48,165 £349,724

19 South Yorkshire and Bassetlaw 100.13 £56,185 £111,763

20 Coventry and Warwickshire 100.16 £48,837 £70,842

21 Leicester, Leicestershire and Rutland 100.13 £43,856 £62,907


Observed bed days per 1,000 population

Estimated bed days saving

1 Cumbria and North East 117.23 169.64 53,144

2 Northamptonshire 118.31 172.75 39,041

3 Greater Manchester 116.21 143.69 37,342

4 West Yorkshire 108.84 144.25 32,385

5 Cheshire and Merseyside 108.30 163.09 32,102

6 Hertfordshire and West Essex 102.69 132.48 31,778

7 Milton Keynes, Bedfordshire and Luton 123.76 136.25 27,151

8 North West London 94.20 118.30 23,336

9 South West London 106.18 107.98 19,409

10 Hampshire and the Isle of Wight 88.77 140.31 16,864

11 South East London 88.42 110.48 14,822

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Observed bed days per 1,000 population

Estimated bed days saving

12 Staffordshire 112.08 148.77 12,394

13 Coventry and Warwickshire 100.16 137.77 11,792

14 Frimley Health 113.56 110.63 10,407

15 Bath, Swindon and Wiltshire 100.80 126.29 4,546

16 Humber, Coast and Vale 104.65 147.29 4,324

17 South Yorkshire and Bassetlaw 100.13 149.47 2,961

18 Surrey Heartlands 104.65 112.79 2,659

19 Lancashire and South Cumbria 108.33 149.07 1,927

20 Birmingham and Solihull 100.98 139.67 1,826

21 Bristol, North Somerset and South Gloucestershire 93.92 123.59 1,140

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Conclusions

ADMISSIONS

We found that the emergency admission rate for ACSCs increased by 9 per cent over the past five

years but remained stable between FY 2016/17 and 2017/18. The top three ACSCs are influenza and

pneumonia, pyelonephritis and kidney/urinary tract infections and COPD, and these make up 41 per

cent of all emergency ACSC admissions. Emergency admissions for ACSCs occur considerably more

frequently on weekdays than on weekends.

VARIATION

Our mapping analyses showed that there is significant variation in the SARs for emergency ACSCs

across England, with the north and centre of England having particularly high rates. The maps

showing the SARs for the acute and vaccine preventable ACSC groups have the highest level of

unwarranted variation across the country. The five-year comparison suggests that there has been a

slight increase in the variation in the SARs since FY 2013/14, with the north and centre of England

consistently having higher SARs.

CHARACTERISTICS

Patients admitting in an emergency for ACSCs tend to be low-intensity users of emergency services

and have a relatively short length of stay. The spread in length of stay across the country is large,

however, with 1,520 admissions having lengths of stay of over 100 days and making up 3 per cent of

the total bed days. The very young and elderly populations are affected most by ACSCs. Females

generally have more admissions than males (except among 0-9-year-olds). Most admissions are

associated with patients of low complexity, having no comorbidities and therefore should be treated

out of hospital in the primary or community care setting.

DEPRIVATION

We found that deprivation has a significant impact on the rate of emergency admissions for ACSCs,

increasing as the level of deprivation increases. The largest variation by deprivation decile is

observed for the ACSCs COPD, influenza and pneumonia and ear, nose and throat infections. A five-

year comparison shows that ACSC admissions rates for each deprivation decile are increasing fairly

equally, with negligible change in the large disparity between the least and most deprived groups.

This large disparity in admission rates leads to a disparity in the tariff rate across the deprivation

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deciles. The tariff per person (population)6 increases from most to least deprived, where a person in

the most deprived population costs, on average, £66. Cumulatively, the most deprived population

account for 13 per cent of the total cost of emergency ACSCs. The total national tariff for emergency

ACSCs was £2.83 billion in FY 2017/18.

Interestingly, the cost per admission7 for emergency ACSCs is lowest for the most deprived group

and increases as the level of deprivation decreases. This trend is likely owing to a multitude of

factors, including higher numbers of less-expensive admissions among the most-deprived group as

well as more complex, elderly patients admitting in the least-deprived group which cost more.

SAVINGS

Our analysis found that significant tariff and bed days savings are possible for STPs in England. The

STPs with the greatest overall potential savings in FY 2017/18 were Cumbria and North East,

Greater Manchester and Cheshire and Merseyside. In total, if all potential savings goals were met,

the NHS could save over £125 million and over 381,350 bed days nationally.

6 Tariff per person (population) = Sum of tariff for all spells in deprivation decile x

Estimated population of deprivation decile x

7 Tariff per admission = Sum of tariff for all spells in deprivation decile x

Sum of spells in deprivation decile x

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Recommendations

USE DATA FOR TARGETED INTERVENTION

As commissioners work towards building integrated care systems, we advise that leaders use data

to understand their local populations better using tools like population segmentation.

Segmentation enables informed service planning and the delivery of targeted care to local

populations which can then be scaled up. This is in line with the NHS ambition, outlined in the Long

Term Plan, for local organisations to focus on population health, identifying the greatest needs of

the population and aligning NHS services to meet them. This analysis has reinforced the importance

of understanding the demographics and complexity of the affected population so that action can be

taken. Our results show that the NHS should target elderly females, very young males and more

deprived people with ACSCs for out-of-hospital treatment in order to reduce pressures on

emergency services.

IDENTIFY HIGH-RISK PATIENTS EARLY

Commissioners and GP practices should work to actively identify those ACSC patients who may

require more effective support and intervention within primary care to prevent or reduce the

escalation of an ACSC to a hospital admission where possible. Risk stratification could aid the

development of a priority system for patients. This work in primary care will be supported by the

new ‘shared savings’ scheme for primary care networks, which allows them to benefit from reducing

avoidable A&E attendances, admissions and delayed discharge.

FOCUS ON HEALTH INEQUALITIES

The government should assess whether current resources are sufficient to address the gap in

health inequalities, taking into account the effects of the wider determinants of health. The NHS

plans to set out ‘specific, measurable goals for narrowing inequalities’ through service

improvements and this year all local health systems will be expected to set out how they plan to

tackle health inequalities, with targets for 2023/24 and 2028/29. This will require targeted use of

resources for areas with the greatest levels of deprivation.

REDUCE UNWARRANTED VARIATION

The NHS should continue supporting programmes that aim to reduce unwarranted variation in

health outcomes across England. Our analysis found significant variation in admissions rates for

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ACSCs across the country, which inevitably affects patient outcomes, costs and productivity. It is

advised that primary and community care services in the north and centre of England be examined

to understand why these areas are affected by ACSCs more than the rest of England and that the

variation be monitored regularly in the future.

BUILD RELATIONSHIPS

Local government services should work together to maximise outcomes with limited resources.

Leaders should assess whether a redistribution of resources between services would prove

beneficial for the community as a whole.

SUPPORT AND INFORM THE POPULATION

Local health organisations should consider carrying out targeted ACSC-related campaigns to ensure

that patients are being effectively supported and signposted to the relevant primary care services.

This would ensure greater continuity of care for patients, whilst also helping to reduce unnecessary

admissions and the costs associated with emergency secondary care.

ENCOURAGE SELF-MANAGEMENT

We’ve explored how the wider determinants of health are important factors affecting the well-being

of people. Education is an important factor, therefore the NHS should educate and empower

patients to manage chronic or long-term conditions themselves at home. This is particularly

relevant to ACSCs such as COPD, diabetes, and asthma. Effective interventions for COPD include

smoking cessation services, the step-wise approach to drug therapy (as outlined in the NICE

guideline for COPD), pulmonary rehabilitation, and influenza vaccination.xvi Adequate resources

need to be provided for these interventions, particularly in more deprived areas where smoking is

more prevalent.

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Appendix 1 – NHS Outcomes

Framework Indicators

The NHS Outcomes Framework (NHSOF) has two indicators relating to ACSCs: xvii

1. NHSOF 2.3.i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (all

ages) – this indicator measures how many people with long-term or chronic conditions, who

should not usually require hospitalisation, are admitted in an emergency.xviii

2. NHSOF 3a. Emergency admissions for acute conditions that should not usually require

hospital admission – this indicator measures the number of people admitted to hospital in

an emergency with acute conditions that could have been avoided with better care. This

indicator aims to target out-of-hospital care.xix

The ICD10 codes provided by the NHSOF were used to specify the ACSCs listed in Table 1 and

reviewed by Dr Foster’s team.

Dr Foster acknowledges that there is variation in coding and recording practices around the country.

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Appendix 2 – Tables of STPs showing

opportunities

Table 4 – Complete table of STPs ranked by SARs showing tariff and bed days savings opportunities

STP Standardised admission ratio

Estimated bed days savings

Estimated tariff savings

Milton Keynes, Bedfordshire and Luton 123.76 27151 £9,908,806

Northamptonshire 118.31 39041 £6,379,690

Cumbria and North East 117.23 53144 £28,639,299

Greater Manchester 116.21 37342 £21,876,931

Frimley Health 113.56 10407 £3,776,793

Staffordshire 112.08 12394 £6,433,896

West Yorkshire 108.84 32385 £10,733,825

Lancashire and South Cumbria 108.33 1927 £7,105,033

Cheshire and Merseyside 108.30 32102 £11,340,230

South West London 106.18 19409 £4,258,576

Derbyshire 105.72 0 £3,160,613

Surrey Heartlands 104.65 2659 £1,895,715

Humber, Coast and Vale 104.65 4324 £3,374,247

Buckinghamshire, Oxfordshire and Berkshire West 104.21 0 £2,882,541

Hertfordshire and West Essex 102.69 31778 £1,998,974

Shropshire and Telford and Wrekin 101.51 0 £389,864

Birmingham and Solihull 100.98 1826 £568,920

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STP Standardised admission ratio

Estimated bed days savings

Estimated tariff savings

Bath, Swindon and Wiltshire 100.80 4546 £349,724

Coventry and Warwickshire 100.16 11792 £70,842

Leicester, Leicestershire and Rutland 100.13 0 £62,907

South Yorkshire and Bassetlaw 100.13 2961 £111,763

Suffolk and North East Essex 98.53 0 £0

The Black Country 98.13 0 £0

Gloucestershire 95.70 0 £0

Kent and Medway 94.94 0 £0

North West London 94.20 23336 £0

Mid and South Essex 93.93 0 £0

Bristol, North Somerset and South Gloucestershire 93.92 1140 £0

Dorset 92.84 0 £0

Somerset 92.73 0 £0

Cambridgeshire and Peterborough 92.15 0 £0

Nottinghamshire 89.85 0 £0

Hampshire and the Isle of Wight 88.77 16864 £0

Devon 88.73 0 £0

South East London 88.42 14822 £0

Sussex and East Surrey 86.72 0 £0

Norfolk and Waveney 86.51 0 £0

North East London 85.02 0 £0

Lincolnshire 83.43 0 £0

Herefordshire and Worcestershire 81.27 0 £0

North Central London 79.85 0 £0

Cornwall and the Isles of Scilly 77.38 0 £0

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Appendix 3 - Methodology

Hospital Episode Statistics (HES) is the primary data source used in this analysis. Copyright © 2019.

Reused with the permission of NHS Digital. All rights reserved.

The datasets, respective data exclusions and time periods used are noted below each figure. All

analyses are carried out by financial year.

Standardised rates are calculated by indirect standardisation. The benchmark is calculated as the

national rate for each stratum of age, sex and deprivation (IMD). This rate is then multiplied by the

local population’s stratum to obtain the expected value for the stratum. The observed and expected

values are aggregated and presented as ratio of observed-to-expected per 1,000 population.

Savings are also calculated using indirect standardisation based on the difference between

observed and expected values.

Bed days savings are calculated by:

Estimated bed days saving = observed bed days − expected bed days

Where observed bed days is the sum of the length of stay of each spell in the region; expected bed

days is the national rate of bed days applied to the population of the region, indirectly standardised

for age, sex and deprivation.

Tariff savings are calculated by:

Estimated tariff saving = estimated activity saving x average tariff per activity*

Where

Estimated activity saving = observed activity – expected activity

Observed activity is the sum of the spells in the region; expected activity is the national rate of

admissions applied to the population of the region, indirectly standardised for age, sex and

deprivation.

And

Average tariff per activity* =Observed tariff in region

Observed activity in region

The tariff used is the Payment by Results tariff with market forces factor from the year 2017/18

based on the healthcare resource group.

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References

i https://www.england.nhs.uk/wp-content/uploads/2014/03/red-acsc-em-admissions-2.pdf

ii Emergency hospital admissions for ambulatory care-sensitive conditions: identifying the potential

for reductions, The King’s Fund, 2012

iii https://digital.nhs.uk/data-and-information/publications/clinical-indicators/nhs-outcomes-

framework

iv https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populatione

stimates/datasets/lowersuperoutputareamidyearpopulationestimates

v https://www.ncbi.nlm.nih.gov/pubmed/27255144 vi https://www.england.nhs.uk/rightcare/2017/01/04/matthew-cripps-3/

vii https://www.england.nhs.uk/about/equality/equality-hub/resources/

viii https://fingertips.phe.org.uk/profile/wider-determinants ix http://www.thenhsa.co.uk/2018/11/major-new-report-connects-norths-poor-health-with-poor-

productivity/

x https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpe

ctancies/bulletins/healthstatelifeexpectanciesuk/2015to2017

xi https://fingertips.phe.org.uk/profile/wider-determinants

xii Health at a price: Reducing the impact of poverty. BMA, June 2017 xiii Health at a price: Reducing the impact of poverty. BMA, June 2017

xiv https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data

/file/579151/English_Indices_of_Deprivation_2015_-_Frequently_Asked_Questions_Dec_2016.pdf

xv https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities

/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationimd/2015to2017

xvi Reducing avoidable emergency admissions, NHS Ayrshire and Arran, 2015 xvii https://www.england.nhs.uk/wp-content/uploads/2014/03/red-acsc-em-admissions-2.pdf

xviii https://digital.nhs.uk/data-and-information/publications/clinical-indicators/nhs-outcomes-

framework

xix https://digital.nhs.uk/data-and-information/publications/clinical-indicators/nhs-outcomes-

framework

https://fingertips.phe.org.uk/profile/wider-determinants

For more [email protected]+44 (0) 20 7332 8800www.drfoster.com

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