HSJ’s round up of the day’s must read stories and debate

Zero day to hero

Two thirds of the growth in emergency admissions in recent years has been for patients who are discharged without an overnight stay, HSJ analysis has revealed. 

The rising proportion of “zero day” admissions is currently the subject of discussion at the highest levels of national bodies, which are trying to determine how many of the admissions are necessary and whether providers are being paid appropriately for them.

HSJ bureau chief David Williams has examined the issue. He writes: ”The vital question that NHS Improvement and NHS England need to be able to answer is: should zero day admissions be rising as fast as they are?

“No one believes that all zero day admissions are unnecessary, but opinion is split on whether all of the growth is justified.

“Optimists argue that short stay emergency admissions are being driven by ever more appropriate and more efficient forms of care: that people who otherwise would have been kept in overnight unnecessarily are leaving after a few hours. Thanks to trusts’ investment in ambulatory urgent care, the argument goes, ward capacity is kept free for the patients that really need it, while those patients who just need a few tests or a bit of observation get to go home sooner.

“That argument is most commonly heard from providers, and emergency care leaders.

“The counter, which comes more from the commissioner side, questions whether all those admissions are appropriate, and whether trusts might be being overpaid for some of them. For example, not all zero day admissions are alike: a patient discharged in under two hours probably needed less treatment than someone who was kept in for eight hours. Commissioners may sensibly ask whether all those two hour admissions were really necessary at all. The average tariff rate is £600 per emergency admission. Is that too much for those ultra short stays?”

Read the full analysis

Vanguard performance revealed

NHS England has gone eerily quiet about its new care model vanguards which, you will recall – if your memory stretches as far back as 2015 – were a Five Year Forward View centrepiece.

HSJ has not forgotten, anyway, and behind the scenes national officials are still measuring the performance of the multispecialty community providers and primary and acute care systems.

We reveal a recent cut of their performance against NHS England’s two key vanguard “efficiency” metrics.

These indicate that they have, overall, outpaced the rest of the field in containing emergency admissions growth; but are not standing out from the crowd when it comes to reducing how much their populations use hospitals overall, as measured by bed days.

NHS England maintained its radio silence and declined to comment, leaving others to theorise on what this might all mean.

A very important point is that a relatively short measurement period, from 2014-15 to 2017, may not be long enough to distinguish any real intended impact of vanguards from external factors, unexplained fluctuation or data artefact. 

One theory could be the impact of the zero-day issue described above. Vanguards may be eliminating some of these or have stopped recording them as admissions – which would reduce admission growth but not bed days.

Mulling the gap on emergency admissions and bed days, one HSJ reader commenting anonymously suggests that, while new care model teams – primarily community focussed – are set up to influence out-of-hospital pathways, they have no control once a patient is in the acute system.

Bed days, as measured in the dashboard, are reducing overall at a national level. That seems to be good news since the system is trying to contain acute demand – but is a bit baffling given the mood music that these efforts are failing.

One driver of this – some have speculated – may be the intense (and to some extent successful) focus on reducing delayed transfers over the past 12 months, another might be slowing elective admission growth.

Perhaps vanguards haven’t been as focussed on getting patients out the back door – for vanguards this has not been signalled as much as a priority as admission avoidance and the health and wellbeing of their populations.