Cancer Commissioning Toolkit (CCT)

Delivering Care In The Most Appropriate Setting – 21st October 2008

Reducing inpatients & moving to ambulatory care

How the toolkit can inform your strategyTeresa Moss

Director, National Cancer Action

Team

Agenda

• Background on inpatient care• CCT inpatient section and key questions answered by the toolkit

• How do we turn information into a local strategy for moving from an inpatient to ambulatory service

• How do we use the information to focus on different patient groups

• Lessons from NHS Improvement

Why focus on inpatient care?It matters to patients• Most patients have at least one

admission• Opportunity to improve patient

experience

England has higher bed utilisation for cancer than other countries

• Accounts for a large proportion of total cancer expenditure

• Opportunity to redirect resources

Inpatient care has received very little attention to date

We have mostly focused on referral to first treatment

NOT mentioned in NHS Cancer Plan or NICE Guidance

1

2

3

Statistics on cancer bed days reveal heavy bed usageCancer bed days

• Over 14,500 cancer patients are in hospital at any one time

• This equates to around 29 occupied beds per 100,000 population and around 435 for a network with a population of 1.5 million

• 60% of these beds are occupied by patients admitted non-electively

Cancer bed usage trends

Inpatient admissions have risen by 25% in the last 8 years (625,000 to 785,000)

Emergency inpatient admissions have risen fastest – an increase of 47% in past 8 years (equivalent elective increase is 8.6%)

Average length of stay has reduced but bed days for cancer are rising by 1% each year

• Emergency bed days rising by 2.5% p.a.• Elective bed days reducing by 1% each year

Cancer accounts for 12% of all bed days

HES Total Cancer %

FCEs (Inpatient) Emergency

4,565,021

409,228 9%

FCEs (Inpatient) Elective

5,560,362

558,386 10%

Bed days 44,358,492

5,263,210 12%

HES cancer activity - % total activity (excluding mental health)

Strategies for reducing inpatient admissions and bed use

• Focus on different categories of patients– Patients admitted electively for surgery– Patients admitted electively for oncology /

haematology– Patients admitted as an emergency due to side

effects of treatment / progressive disease– Patients presenting / admitted as an emergency

who are subsequently diagnosed with cancer

How do we turn information into an inpatient to ambulatory care strategy?

Define who needs to be engaged + Define who will drive the project

Trusts are motivated to reduce bed days

PCTs are motivated to reduce inappropriate admissions, bed days

over trim points

Clinical engagement is essential

User perspective is essential

Network team / service improvement skills essential

What do we know about current inpatients (quantity and cost)?Analysis of Hospital Episode

Statistics (HES) provides information on Bed utilisation

Elective vs. emergency splits

Utilisation by tumour group

Admissions by specialty

Cost (applying HRGs to admissions)

CCT Inpatients section – Moving towards ambulatory care

The CCT Inpatient chapter is divided into 3 key sections

Provider activity and efficiency reports

Inpatient activity by resident population

Quality reports

Local bed use can be analysed at a Hospital Trust or PCT level

How many beds in the hospital / trust are

occupied by patients to due cancer on any one day

(emergency and elective)?

Key questions answered in the

toolkit 1

1) Data compiled by trust, “provider” network, “provider” SHA

How many bed days / beds does this amount to each

year (emergency and elective)?

How many emergency / elective episodes (FCEs) of the total trust activity are

due to cancer each year?

What is the difference in bed usage across the tumour types for all of the above?

Which specialities are looking after patients with

cancer?

How do lengths of stay compare with elsewhere?

Cancer inpatient care in local NHS(F) trusts

What is the approximate income from cancer

inpatient care?

Local bed use can be analysed at a Hospital Trust or PCT level

How does our population use of emergency bed

days / FCEs compare with elsewhere?

Key questions answered in the

toolkit

How many of the PCT’s / network’s resident

population are in hospital due to cancer on any day (emergency and elective

per 100k population)?

How many excess cancer bed days

(emergency/elective) over trim point is the

PCT funding?

How many emergency /

elective episodes (FCEs) are due to cancer each year?

What PCT activity and cost is going to each trust by

tumour?

Inpatient care for PCT / Network resident population

Strategies for reducing inpatient admissions and bed use

• Focus on different categories of patients• Patients admitted electively for surgery• Patients admitted electively for oncology /

haematology• Patients admitted as an emergency due to side

effects of treatment / progressive disease• Patients presenting / admitted as an emergency

who are subsequently diagnosed with cancer

How do we turn information into an inpatient to ambulatory care strategy?

Reducing elective surgical lengths of stay

• Key actions trusts can take–Develop pre-admission systems with

advanced discharge planning–Define timed care pathways, with proactive

daily decision making and clear escalation triggers

–Team approach to care, empowered to discharge, supported by protocol National priorities are to move to

• Day case / 23 hour breast mastectomy

• Laparoscopic colorectal surgery with an enhanced recovery programme (national programme)

Reducing breast surgery lengths of stay – how the CCT can help

you

Breast inpatient Bed

Saver Calculator example

Average Length of Stay by Procedure

Compare ALOS against other trusts and then use the Bed Saver Calculator to determine the cost saving of ALOS

reduction

Trust

(Trust \ Average)

Illustrative

Reducing elective oncology admissions• Medical oncology, clinical oncology,

haematological oncology elective admissions account for 25% of all cancer elective admissions

• Key questions are–Is an inpatient admission necessary (PCT)–Is the LOS appropriate (Trust)

Examples of key actions

• Agree a list of regimens that can / should be given on an outpatient basis

• Develop models of giving long infusions (chemo / hydration) on an outpatient basis

• Introduce “on-call oncologist” with daily ward rounds to reduce delays in discharge

Reducing elective oncology admissions – how the CCT can

help you

Illustrative

Inpatient bed occupancy and change over time

Reducing emergency admissions for patients with known cancer Key questions

• How does emergency bed use for cancer compare with elsewhere?

• Is use increasing (emergency FCEs / emergency bed days)?

• Are there long lengths of emergency stays?

• How many emergency admissions end in death compared to elsewhere?

Examples of key actions

• Develop protocols for supportive care to minimise side effects

• Monitor patients proactively (e.g. phone calls) and educate patients for early identification of problems

• Agree emergency symptoms pathway direct to an agreed location (not A&E) - where possible stabilise patient and treat in an ambulatory setting

• Establish links with hospice, community based teams, etc.

Reducing emergency admissions for patients with known cancer –

how the CCT can help you

Inpatient bed occupancy and change over time

Illustrative

Reducing number of patients admitted as an emergency who

are then diagnosed with cancer – diagnose promptly

Key questions

• Is the local health economy “fully engaged”?

• Are there emergency communication alert systems for GPs, A&E, etc. to gain rapid specialty assessment?

Examples of key actions

• Don’t admit to assess – Assess to admit (A&E, SAU, MAU)

• If possible stabilise and discharge patient / bring back on very urgent pathway

Commissioning for Reduced In Patient Care: The Levers

- National Guidance• A successful CRU strategy should consist of three elements:

1. Strategic use of information tools to diagnose where CRU should be targeted (e.g. by demographic, by

GP practice)

2. Ensure hospital admissions are

appropriate – right care in the right

place at the right time, every time

3. Ensure sufficient alternatives to

hospital admissions exist in community

or primary care, and divest in acute care appropriately

Diagnostic tools:• Utilisation reviews• PBC toolkits (e.g. MIDAS)• Ambulance control information

• LTC management• Care management• Disease management• Self management• Population-wide prevention

Alternative provision:• Crisis resolution teams in mental health• Long-term conditions strategies (case

management and self-care)• Tailored local intervention

Iterate e.g. UM information can be used in strategic community investment plans

National Guidance published: “Care and Resource Utilisation – Ensuring Appropriateness of Care”

Commissioning for Reduced In Patient Care: The Levers

- National ContractCRU linked to National Contract Specification

• For example:–A period of ensuring the new model works (e.g. 3 months)

–A target set in the PCT/Trust contract e.g. 5% reduction in first year, increasing thereafter

–Monthly monitoring of activity and routine meetings

–Prior approval schemes agreed–Contract penalties if appropriate

Commissioning for Reduced In Patient Care: The Levers

- PbR / Local Tariff• Examples of flexibilities to support

change:-–Tariff sharing–Unbundled tariff–Tariffs for telephone advice

Commissioning for Reduced In Patient Care: The Levers

- Conclusion• Change must be clinically appropriate• Change must be clinically driven• Performance and contractual levers

available to support implementation

Ann DriverDirector, NHS Improvement

How the toolkit can inform your improvement strategy

Identifying the opportunity for improvement

• The commissioning tool provides the starting point – the indicator

• Next step is to find out what lies beneath the numbers

• Find out why your LOS is X and bed days Y

• Don’t look at the numbers in isolation from the whole improvement picture for the patient

• Don’t jump to solutions without identifying the real problem

• How can you manage length of stay if you do not really know what the right length of stay is?

• Do not get complacent there is always room for improvement

Commissioning Guide/Tool provide the baseline position

and capture the impact of improvement

Patients admitted electively for

surgery

Patients admitted electively for

oncology / haematology

Patients admitted as an emergency

due to side effects of

treatment / progressive

disease

Patients presenting /

admitted as an emergency who

are subsequently diagnosed with

cancer

The Transforming Inpatient Care Programme

• Return to the basics of service improvement

• Scope the work – e.g. identify the top three tumours re bed days, emergency or elective

• Map the detailed pathway• Identify and understand the variation• Local baseline – a real-time snap shot• Baseline from different perspectives

–Patient experience: Patient tracking, diaries, discovery interviews

–Pathway efficiency: Identify the delays, duplication, non-value adding time for staff and patients

–Value for money

Identifying the opportunity for improvement

Patient Pathway – Before and After

IMPACT OF CHANGE

Pre-admission

Early discharge planning

No drains

Nurse led discharge

Moving from inpatient to 23 hour model

Total saving of 5 days

Comparative costs at City Hospital Birmingham – Breast cancer surgery, early discharge testing Illustrative

• Proactive length of stay management vs. reactive bed management

• Defined emergency pathways & entry points• Communication: rapid alert systems• Checking in while booking out model: setting

patient expectations• 6-23 hour delivery models• Shared symptom response strategies

(GP/Acute)• Clinical decision making models• Shared triage (A/E, Oncology)• Streamlining the elective pathway• Procedures in alternative settings• Enhanced recovery programmes• Changes in clinical practice

Opportunities to streamline & design new models of delivery

Testing Identified: Winning Principles

• Unscheduled (emergency) patients should be assessed prior to the decision to admit–Emergency admission should be the exception not the norm

• All patients should be on a defined inpatient pathways based on their tumour type and reasons for admission

• Clinical decisions should be made on a daily basis to promote proactive case management

• Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed

www.improvement.nhs.uk

This publication is available from 18th June 2008

Next Steps

• NHS Improvement / NCAT top priority – Transforming Inpatient Care Programme

• Local testing and spreading through Trusts / Networks

• Publications June 2008 at NHS Confederation

• Improvement Event late summer 2008• Looking for new test sites Primary Care /

Social care• Linking learning and capturing impact

with Cancer Commissioning Toolkit and NHS Improvement System

Transforming Inpatient Care Programme

Interested in becoming a test site contact, looking for primary, acute

and social care sites contact

Ann.driver@improvement.nhs.ukAngie.robinson@improvement.nhs.uk