1. June
Urgent Care in
Derby 2010
Rakesh M
R k h Marwaha h
Director of Performance and Knowledge Management
Ian Hays
Senior Knowledge Officer
g

2. Contents
 About Derby
About Derby
 The Problem
 Evidence Gathering
 Actions / Outputs
Actions / Outputs
 Summary

3. About NHS Derby City
 Integrated organisation since 2004
 Population served c291,000 (census c243,000)
 Resource allocation c £447m
Resource allocation c £447m
 HCC results Good for quality, Good for use of resources
 69th most deprived local authority out of 354
 Significant internal variance: Derby contains Lower Level
Super Output Areas listed in both the most deprived 20%
S O t tA li t d i b th th t d i d 20%
and the most affluent 20% in England

4. About NHS Derby City

5. Contents
 About Derby
About Derby
 The Problem
 Evidence Gathering
 Actions / Outputs
Actions / Outputs
 Summary

6. The Size of the Problem
Non Elective Admissions and A&E Attendance Cost per Non Elective Admission
Trends
ndances
Emerge
82000 36000
2009/10 -
ency Admissions
A&E Atten
80000 35000 £1730
78000
34000
76000
33000
s
74000
32000
72000
2008/09 -
31000
70000 £1510
30000
68000
Total Cost
29000 2007/08 -
66000
Annual A&E Figures Annual NEL Adms £1500
64000 28000
2005/06 2006/07 2007/08 2008/09 2009/10 Total Activity
 12.5% growth in A&E Attendances in last five years  Significant increase in cost per patient for non
 14% growth in emergency admissions in last five years
14% growth in emergency admissions in last five years elective admissions due to tariff price change, HRG
elective admissions due to tariff price change HRG
4 and Length of Stay costs

7. The Size of the Problem ‐ Comparator
PCT in East Midlands peer group
PCT i E t Midl d
PCT 1 116
PCT 2 123
PCT 3 124
Non‐ elective PCT 4 128
PCT 5
PCT 5 128
admissions are high
d i i hi h PCT 6 129
compared to peers PCT 7 148
Derby City 174
and benchmarks
PCT 9 213
+22%
Ø 143
PCT in ONS peer group
PCT 1 138
Non‐elective admissions per 1,000 weighted PCT 2 138
population, 2008/09 PCT 3 149
PCT 4 151
PCT 5 152
Derby 174 PCT 6 154
PCT 7
PCT 7 161
PVT 8 162
East Midlands 136 PCT 9 163
PCT 10 174
Derby City 174
ONS 154
+12%
Ø 156
7
SOURCE: Dr Fosters data 2008/09; 2007 weighted pops ONS, Business Intelligence Unit

8. Contents
 About Derby
About Derby
 The Problem
 Evidence Gathering
 Actions / Outputs
Actions / Outputs
 Summary

9. Examining Urgent Care
Where
When
Who
How
Why
?

10. Examining Urgent Care – GP Audit
 One area identified of
particular concern was the
particular concern was the
rise in conversion rate from
A&E attendances to
emergency admissions
emergency admissions
 GP Audit was carried out
to check validity of GP direct
admissions
Findings:
 The GP Audit of Emergency Admissions carried out in March 2009 found
that of 378 recorded admissions, 70 (19%) were assessed as avoidable.*
that of 378 recorded admissions 70 (19%) were assessed as avoidable *
*Performance and Knowledge Management Directorate (2009) GP Audit of Emergency Admissions Derby Hospitals Foundation Trust

11. Examining Urgent Care ‐ MCAP
Resource Utilisation (Bed Census) Audit
A panel of nurse reviewers used the Oak Group Criteria to review :
i. all non‐elective patients admitted between 16‐22 August 2009
ii.
ii all patients in a care bed with an in‐hospital length of stay of five days or more.
all patients in a care bed ith an in hospital length of sta of fi e da s or more

12. Examining Urgent Care ‐ MCAP
Resource Utilisation (Bed Census) Audit
A panel of nurse reviewers used the Oak Group Criteria to review :
i. all non‐elective patients admitted between 16‐22 August 2009
ii.
ii all patients in a care bed with an in‐hospital length of stay of five days or more.
all patients in a care bed ith an in hospital length of sta of fi e da s or more
25% (16) were assessed
25% (16) were assessed 34% of patients with a stay of five
34% of patients with a stay of five
as not qualifying for an days or more were assessed as
acute admission not qualifying for such a stay
29% of all non‐elective bed days in Between 44% ‐ 63% of
Derby are within Medicine for the
Derby are within Medicine for the acute bed days are
acute bed days are
Elderly inappropriate (UK studies)

13. Contents
 About Derby
About Derby
 The Problem
 Evidence Gathering
 Actions / Outputs
Actions / Outputs
 Summary

14. Current Status
Service
S i  Rightcare – over 400 patients registered ££saved
Rightcare over 400 patients registered, ££saved
 100% of Practices extended hours
Avoidance  Social Marketing – Outreach team
Admission  Service Navigation ‐ 4 diverts/day, ££
 IV Therapy, DVT & Catheter ‐ ££cash released
h h h l d
Avoidance  MAU Triage – New clinical model implemented
 Transitional Beds = 510 Emergency & 3129 rehab bed
Community days saved
 Early supported discharge – ££saved
y pp g
Service  Continuing Care costs falling in opposition to other East
Mids PCTs

15. Contents
 About Derby
About Derby
 The Problem
 Evidence Gathering
 Actions / Outputs
Actions / Outputs
 Summary

16. Tier 1 Service
Tier 2 Service
Summary Tier 3 Service
Tier 4 Service
Referral Management / Follow Up
Primary
Care
10 Point Plan
10 Point Plan
Primary Care
Foundation ACUTE
Service Navigation Team –
RightCare EXPANDED AND HOSPITAL
earlier discharge (MCAP audit
A&E, Mental Health, Social,
ENHANCED Intermediate & Continuing
Care, Voluntary Sector)
Long Term Conditions
L T C di i
HOME COMMUNITY
Staying
Referral admissions
standardisation SERVICES New model for ACS conditions –
earlier discharge
Healthy Enhanced Step Up/Down & Comm
Service Navigation Intermediate Care Services
(phase 2) EMAS DHFT Review MAU(CDU)
DEMAND
p
Duty Doctor MANAGEMENT Improved resource Utilisation
Walk In Centre Review
SELF CARE Social Marketing
Discharge Planning
Expert Patient Programme Campaign
Rapid 1 hr Community Response team New Patient flow team
Health Coaching
RightCare
Falls, Stroke,
Falls Stroke Care of the Elderly
Care of the Elderly
Welcome Pack for New Respiratory pathway
Trauma, Alcohol Physician in A&E/MAU
Entrants
Evening suspected DVT service
Contracting
Catheter service pathway
IV therapies service
Transitional / Intermediate Care
INTEGRATED CARE MODEL

17. Summary
 Problem
 14% growth in admissions
 5% increase in activity with 19% rise in cost (Tariff cost, HRG4 and LOS)
 E id
Evidence
 Systematic and triangulated evidence gathering from external audits
 Benchmarking
g
 Actions
 Defining Knowledge reports to Board
 Plans, implement, robustly performance manage, continuously improve
 Robust transformation and contract management with providers
 Outputs
Outputs
££savings delivered to date with On Target Savings of ££savings

18. QUESTIONS