CASE STUDY: Nottinghamshire uses data solution to build cost-effective, patient-centric services

About the trust

NHS Nottingham City and NHS Nottinghamshire County, formerly two separate primary care trusts, have been working as a cluster since April 2011. Prior to this, they had been divided into six Practice-based Commissioning (PBC) clusters and last year each of these clusters became a Clinical Commissioning Group (CCG). NHS Nottingham City and Nottinghamshire County is now responsible for the healthcare of around one million people in the East Midlands.

The problem

In 2010, while operating as NHS Nottinghamshire County PCT, work had begun to assess capacity in the local health system and how patients were using health services, particularly in acute care. High levels of unplanned acute admissions in the region had been placing great strain on resources at the two acute providers in the county. Unplanned admissions were steadily increasing and it was widely accepted that this was not sustainable.

We have since transformed the service to the extent that in the past three months we have had no delayed transfers of care from the community hospital

“It had become clear that if we didn’t tackle the critical levels of unplanned admissions into our acute trusts, the service wasn’t going to be affordable in the future,” said Fiona Callaghan, head of pathways and improvement at Nottingham North and East Clinical Commissioning Group.

“We needed to understand usage trends across all the different areas of care and to identify solutions to the problem. Did we need to raise awareness of other primary care services? Should we be putting a GP ‘front door’ at the hospitals? Did we need new community-based services or additional social care services? Was there a call for step-up or step-down facilities? There were lots of ideas, but no depth of information on which we could determine the way forward.

It had become clear that if we didn’t tackle the critical levels of unplanned admissions into our acute trusts, the service wasn’t going to be affordable in the future

“As the reality of the financial challenges in the NHS began to emerge, we knew the likelihood of us having to reduce beds in the future was very real. But we also knew that we were unlikely to be able to do that with the existing volume of admissions at that time. We needed to create an evidence-base to show us how the acute sector was being used by our population and the clinical decisions that underpinned that usage.”

The solution

In August 2010 the primary care trust teamed up with East Midlands Procurement and Commissioning Transformation (EMPACT) – an NHS venture set up to help commissioners and providers in the region to deliver improvements and meet local challenges – to become one of the early implementers of an innovative Utilisation Review (UR) programme.

The programme was designed to provide a review of objective clinical evidence to guide decision-making and change. Its wider aim was to understand pressures in the healthcare system and produce detailed information that identified gaps in levels of care and provided an evidencen base upon which commissioners, clinicians and service improvement leads could base critical decisions.

As the reality of the financial challenges in the NHS began to emerge, we knew the likelihood of us having to reduce beds in the future was very real. But we also knew that we were unlikely to be able to do that with the existing volume of admissions at that time

The UR programme deployed McKesson’s InterQual clinical decision support software – a solution chosen by EMPACT following a thorough procurement process. InterQual gives commissioners and providers a strong evidence base upon which they can determine whether patients are receiving the right level of care at the right time and in the right setting.

The tool draws on a repository of clinical content – generated by critical assessment of the best medical evidence from literature and validated by a global panel of practicing clinicians – to provide healthcare professionals with guidelines to indicate whether a patient’s admission into hospital and their length of stay is appropriate for their individual condition. The software recommends the appropriate level of care and, where this is not being met, allows organisations to record the variances and provide the reporting necessary to understand the gap and act upon it.

“InterQual allows you to measure clinical care at a particular level and assess its appropriateness, which was precisely what we needed to do in Nottinghamshire,” said Callaghan. “We wanted to establish two things; how many patients were being treated in the hospital who could actually be treated in an alternative setting, and for those who had been appropriately admitted, at what point should they go to an alternative level of care? Were patients staying in hospital for the most appropriate length of time?”

There were lots of ideas, but no depth of information on which we could determine the way forward

InterQual can be used in two ways. A snapshot approach allows utilisation reviewers to work onsite alongside clinicians to assess previous admissions and retrospectively validate decisions. The embedded approach enables real-time use of the InterQual solution by clinicians at the point of care.

NHS Nottinghamshire County PCT and EMPACT opted to conduct a series of snapshot reviews of its acute trusts, focusing on admissions and continued stay. These were followed up with a snapshot review of the region’s community hospitals.

We were housing patients at the hospital because we didn’t have the systems in place to get them out

Peter Huskinson, director of commissioning services at EMPACT, said the snapshot approach has helped clinicians in the region meet some of their QIPP objectives.

He added: “Using InterQual, our clinical UR team works with local clinicians and commissioners to measure the quality of care delivery against the evidence-based protocols. Clinical variation can be identified and addressed with current practice benchmarked across the region.

“Because levels of care are clearly defined in InterQual, it means providers and commissioners can use these definitions as a footprint for QIPP, clinical, service and commissioning changes. They provide much greater assurance about improving the quality of care than in traditional cost improvement programmes. Auditable confidence that care will be better for patients, delivers a major benefit to the NHS.”

The results

The snapshot reviews of the acute trusts have provided the PCT/CCG with an evidence base that showed a proportion of patients didn’t need to be in the hospital setting. In addition, they highlighted that a number of patients could have been discharged earlier, or offered treatment in a community setting. Data revealed that in one of the trusts, 23% of inpatients did not warrant acute care at that time – mirroring the national trend cited by the NHS Confederation.

The community hospital snapshot review has helped transform not only health services, but also the region’s relationship with social care.

“It became clear that we were not using the community hospital’s inpatient facility appropriately,” said Callaghan. “The review showed that patients were not being discharged effectively and that a large proportion of patients could have been better treated at home. We were housing patients at the hospital because we didn’t have the systems in place to get them out. Consequently, we began to negotiate with our social care providers so that we could reduce the number of patients that were stuck in hospital awaiting the right social care package. We have since transformed the service to the extent that in the past three months we have had no delayed transfers of care from the community hospital.”

As a direct result of the UR programme, the community hospital has reduced the number of unused beds by 24, while maintaining the quality of care for patients.

By using InterQual, we now have a much more holistic intelligence about our local health economy and we can base commissioning decisions on evidence, rather than guesswork

Callaghan said: “The InterQual tool was everything to us. Without it, we wouldn’t have understood the levels of care our patients were getting and how many people were still in our hospitals despite not needing that level of care. It gave us an evidence base that suggested that if we had the right services in the right places, we wouldn’t need the number of beds we had got in the hospital setting. That was a real driver for us to try and shift care into the community where appropriate.”

On the wider impact across the East Midlands region as a whole, Huskinson said: “Results show that up to 1 in 4 people admitted to acute settings can be cared for without an acute admission and of those who are appropriately admitted the UR also identifies patients who can be discharged to other settings. Regionally this equates to 28-52% of hospital bed days for these patients that can be freed up through this approach. Our snapshot URs have resulted in aligning services and delivering more efficient services and savings while still ensuring best practice and high-quality patient-centred care is maintained.”

The future

NHS Nottingham City and Nottinghamshire County cluster will shortly use the embedded InterQual tool with its providers in intermediate care. “The whole exercise is about integrated care, rather than focusing on individual services,” said Callaghan. “We’re looking at things right across the health system to get a good understanding of how our services are being used so that we can make appropriate commissioning decisions. By using InterQual, we now have a much more holistic intelligence about our local health economy and we can base commissioning decisions on evidence, rather than guesswork.”