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Why evidence-based, patient-centred care is the key to cutting NHS costs

Now more than ever, the pressure is on for hospitals to make efficiency improvements, not only to help the NHS meet its cost savings target of £20bn by 2014-15 but also to adapt to changes in the way that tariffs are organised and to meet the challenges of the changing healthcare market, writes McKesson’s director of care management Matthew Hunt.

As we know, the marginal rate of tariff payment for emergency admissions above baseline thresholds will be maintained and the national tariff efficiency requirement will be set at 4 per cent in order to drive the necessary efficiencies in the provider sector.

This introduction of capped or marginal tariff payment means that, unless there are changes such as improved throughput, many hospitals will almost certainly see a drop in their income.

Hospitals are being forced to make tough decisions to stem emergency admission and the use of evidence-based tools can support this decision making process.

However, it’s not just hospitals that can benefit from evidence-based tools. Structural changes being introduced means there is a role for these tools at every level of the NHS.

Targeted healthcare

Patients are not foolish. They often know what’s wrong with them, what they need, and they know if they go straight to their local A&E they will receive treatment – society is also expecting patients to take more responsibility for the treatment they receive.

However, the idea of hanging around for hours, going through a tranche of unnecessary checks and procedures when they know that this choice is taking resources away from more needy patients, means it is rarely the preferred option, but often the only viable option open to them at that moment in time.

Despite this, A&E admissions are rising, placing an increased financial and time pressure on an already stretched healthcare system.

In a bid to force hospitals to find solutions, NHS chief executive David Nicholson announced that acute trusts are to be paid only 30 per cent of the NHS tariff for emergency activity above their 2008-09 levels next year.

At the same time, tariff prices will not be increased to allow for inflation, which puts hospitals under further pressure, and leaves increases in hospital costs, such as fuel, to be covered by new hospital efficiency savings which will need to be at least 3.5 per cent.

In addition, in a bid to devolve NHS power from Whitehall to patients and professionals, and to “move the focus of healthcare management to quality of care”, through Equity & Excellence: Liberating the NHS the government announced wide-ranging changes in the way the NHS is organised. These changes are intended to put the NHS “on a sustainable footing” so that everyone in the system, from the DH to GP groups, is accountable for the best use of funding.

The implementation of clinical evidence-based tools to gather information at every level from trust to doctor’s surgery will greatly assist in making informed commissioning decisions. These tools provide data about the extent to which resources are used appropriately, to identify gaps in the provision of service and therefore guide commissioners on how services might be better designed and delivered.

Using clinical evidence-based tools to make informed decisions

When under pressure, knee jerk decisions to slash department’s costs by reducing staff can sometimes be made. The NHS must avoid this reaction and instead realise the importance of ensuring that any changes are made intelligently and based on hard evidence. Using clinical evidence-based tools enables informed decision-making, while maintaining the quality of care provided to patients.

Indeed, clinical evidence-based tools can not only fulfil the patient’s desire for personalised care that fits their particular condition, but they too fit the hospital’s agenda of cutting costs and reducing admissions by providing evidence that will guide decisions to both avoid and identify unnecessary admissions.

Appropriate levels of care – the evidence

According to McKinsey, 40 per cent of patients in the typical hospital simply do not need to be there – most significantly because of delays in receiving hospital tests or therapies and a lack of suitable care facilities in the patient’s own home or community. McKesson’s findings go further than this with their audits revealing instances closer to 70 per cent where patients were in hospital unnecessarily.

Too many patients fall into an inappropriate level of care; some find themselves on acute wards waiting for a social services assessment or a discharge plan, two thirds of patients with long-term conditions are inappropriately admitted to hospital when they could be better served through alternative models of care, many patients stay on a hospital ward because sub-acute care in intermediary care beds or step down facilities do not exist in their local area and some GPs are sending patients for expensive hospital scans when diagnostic tools could have identified that this was an unnecessary procedure.

The use of clinical evidence-based tools could see these issues become a thing of the past, decisions become more robust and transparent, and more consistent across the organisation. This in turn supports care planning and resource utilisation, providing the hard evidence to tackle bottle-necks in the system.

Hospitals in the US have been using such tools for decades in order to support decisions about individual patients in its largely insurance-based healthcare system – and their findings are now becoming relevant on this side of the Atlantic.

Interestingly, in a UK review of acute care activity levels, it was found that patients that did not meet the criteria for an acute admission or continued stay resulted in patients occupying an acute bed for a total of over 1,500 variance (bed) days over a three-month period. With a cost on average of over £400 per day to keep a patient in a hospital bed, this confirms that there are huge savings to be made by simply ensuring patients have access to and are able to receive the appropriate level of care. Over a year this equates to over £2.4m in savings to be made on average.

With such tools, gaps in care can easily be identified – where there is under-funding, or over-funding; where the alternative services are not available and where more community/step-down care beds are needed. And the fact that these tools will log all outcomes helps to establish the business case.

Change must come, where healthcare moves away from a one-size-fits-all approach to a patient-centred approach that provides the most appropriate level of care for the individual patients needs. The current system is simply not working. It’s not about just slashing hospitals or beds regardless, in an effort to cut costs. It’s about making the changes in an intelligent, evidence-based way; standardising levels of care; ironing out inconsistencies and reorganising services around the patient.

By using evidence-based decision support tools to aid this decision-making process organisations can not only cut out a lot of expensive, avoidable costs in the system but also provide the right care to the right patient at the right time.

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