How to reduce emergency admissions – notes from a PwC round table

Earlier in January I spoke at a round table discussion with around 20 acute trust chief execs and CCG leads organised by PricewaterhouseCoopers. The subject of the discussion was how to reduce emergency admissions, and here are some of the key points that came up in discussion.

There are tremendous opportunities in the new clinical commissioning arrangements to provide a much stronger clinical focus on commissioning and provision. Several people described transformative relationships between GPs and consultants. GPs have been given more power and influence. Our consultant colleagues have become seriously disempowered over recent years and they need to get more influence back too.

The purchaser-provider split remains a major block to providing integrated services. Some trusts are negotiating block contracts (despite Monitor). The success of CCGs may in some respects depend on their ability to work round NHS regulations where they seem to get in the way.

All changes take a long time. New schemes are often assessed and abandoned prematurely because of a rush to show change. This is partly because successful system change is often built on existing effective personal relationships, e.g. between senior managers.

The variation in hospital utilisation is partly driven by differences in rates of admission and partly by variation in length of stay. In general, length of stay has proved easier to change than admissions.

Patients are often admitted because it’s the least risky thing to do. It helps to have the most senior people at the front door (e.g. urgent care consultants on till late evening at least). Senior doctors are better at acting as ‘risk sinks’.

The move to have more consultant presence in A&E has not been matched in GP out of hours care where triage tends to be done by inexperienced people. Will CCGs seek to commission more appropriate out of hours care (e.g. from experienced local clinicians)?

Admission rates go up when A&E is under pressure. When the hospital is under pressure too, then patients tend to get admitted to inappropriate wards with further negative knock-on consequences.

There’s a lot that could be done in primary care – e.g. having all home visits phoned back within 30 minutes by an experienced GP, making sure that visits that might possibly require an admission are done right at the beginning of the day, providing better continuity of care.

People at the meeting were generally pretty sceptical of risk stratification / multi-disciplinary team meeting approaches as being likely to reduce costs or utilisation, though they may improve care.

The ambulance service is important and often left out of commissioning discussion – e.g. being able to get old people home from A&E in the evening.

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