Shifting care from the acute sector into the community has the greatest potential for improving quality while reducing costs but investment is still lacking. Michael McCourt reports on evidence to further support the case
Moving care from acute hospitals into the community, where appropriate, has been a consistent policy direction for years. Not only is this intended to deliver high quality care closer to (or in) the patient’s home, avoiding unnecessary stays in hospital, but it can also be achieved at a lower financial cost than the current approach. Yet despite these ambitious intentions the scale and pace of change has been relatively moderate.
The Five Year Forward View notes that the traditional divide between primary care, community services and hospitals remains largely unaltered since the birth of the NHS, which is increasingly a barrier to the personalised and coordinated health services that patients need.
There is general consensus that out of hospital care needs to become a much larger part of what the NHS does. Although there are examples of health and social care systems shifting in this direction up and down the country, evidence of the impact is variable.
Pennine Care Foundation Trust provides community and mental healthcare to parts of Greater Manchester, with a heavy focus on delivering services that support acute care avoidance. The trust commissioned economic consultancy Frontier Economics to undertake an evaluation of some of its intermediate care services to determine exactly what impact they were having on the system. The findings of the evaluation for two key services provide good evidence of the benefits to both patients and the healthcare system.
Enhanced intermediate care
Butler Green is an enhanced intermediate care facility in Oldham, commissioned by Oldham CCG. It provides enhanced recovery and rehabilitation to avoid hospital admission or reduce acute length of stay. Both primary care and secondary care can refer patients.
The facility has 28 beds, comprising 20 nursing beds and eight clinically enhanced beds, and operates an ambulatory IV therapy clinic, urgent response to patients at home, A&E therapy in-reach and a GP helpline.
The study found that in 2014/15, Butler Green:
- Treated 1,235 patients
- Achieved 977 acute deflections from acute ward admissions
- via A&E
- Deflected 5,268 bed days from acute care and achieved a 98 per cent Friends and Family Test score l Delivered potential annual acute cost savings of £2.8m. This is equivalent to an annual saving of around £100,000 per bed per year.
At a cost of £1.9m per year, this suggests a potential net saving to the health system from Butler Green of £0.9m per year under cautious assumptions.
Care is delivered by a multi-disciplinary team of health and social care professionals, including nurses, physiotherapists, occupational therapists, social care workers and GPs. Staff are also trained in mental health interventions.
As part of the study, an evidence-based approach to estimate the scale of activity deflected from acute settings and the associated potential for acute cost savings from Butler Green was used (see table below).
Pennine Care operates a 20-bed unit in Stockport, providing a step-down from acute care for people aged over 65 who are experiencing delirium. The trust also operates a psychiatry liaison service based on Birmingham’s rapid assessment, interface and discharge (RAID) model, which places mental health practitioners on older people’s acute wards.
The team identified that many of the patients on the wards were being kept in hospital because of their acute confusion, which could more appropriately be treated in a non-acute environment by mental health experts. As a result, the trust worked with commissioners at Stockport CCG to set up the new facility in 2014, known as Saffron Ward.
The new ward means patients with delirium can be cared for in the community by an integrated mental health team, including GPs, occupational health therapists, physios and specialist nurses. Discharge and packages of care are organised by a social worker working within the integrated mental health team to ensure the discharge is safe and avoids re-admissions.
The RAID team works on the acute wards to identify suitable patients who can be stepped down to Saffron, helping to reduce acute length of stay and alleviate bed pressures.
The study found that in 2014/15, Saffron Ward:
- Reported a 92 per cent occupancy rate in its first year
- Deflected 5,700 bed days from acute care and achieved a 98 per cent Friends and Family Test score
- Delivered potential annual acute cost of £1.3m. This is equivalent to saving over £1,000 per patient per week relative to the patient being in hospital.
With a cost of running Saffron of £1m per year, this implies a net saving to the health system of £0.3m per year under cautious assumptions.
The same methodology was used to evaluate the impact of Saffron Ward, estimating the scale of activity deflected from acute settings and the associated potential annual acute cost savings (see table above).
Kat Deyes, who led the Frontier analysis, says: “The evidence from the Pennine Care study shows a strong case for integrating physical health, mental health and social care services around patient needs and delivering them in the community. To scale this up more widely and complement necessary acute care, the key will be to gather evidence more systematically about what works and under what conditions, to inform decision makers.”
A significant number of people receiving patient care in hospital every day could be cared for at home or in other non-acute settings. If addressed, this has the potential to release significant efficiencies.
Assuming that a standardised community offer across a conurbation like Greater Manchester would deflect 2,500 patients on any given day, it could conservatively save 912,000 bed days a year, equating to £250m of acute sector savings. Taking this down to an average locality, of which there are 10 in Greater Manchester, there is the potential that £25m per annum could be saved in acute care locally.
Of course, there are a number of constraints that would need to be addressed before these benefits could be realised, such as the varied levels of investment in community services and variation in community capacity and capability, as well as differences in commissioning intentions.
However, a programme such as Greater Manchester Devolution presents the ideal opportunity for community care to be the biggest game changer in town.
Michael McCourt is chief executive of Pennine Care Foundation Trust.