A three part analysis can help the commissioning body calculate the growth and reduction in emergency admissions, focusing on how total healthcare activity may be reduced, writes Simon Rowe

’How many bananas did you not buy today sir/madam?’ If someone, armed with a clipboard, approached you in a supermarket and asked you this, what would your response be?

Would it be to consider it an interesting question, one that really considers what you have brought today, and what you did not? Or would you think what a silly question, it would have only been logical to ask how many bananas, if any, did I buy today.

Within NHS commissioning there is an overwhelming need to keep asking managers and clinicians alike a question that is the same as that for bananas: how much healthcare activity, such as emergency admissions, did you prevent today?

NHS context

In the NHS there is a need to deliver financial efficiencies. For areas of healthcare activity, such as emergency admissions, the need to deliver financial efficiency translates to a reduction in these types of activity.

This is whether we are talking about MCP, STP, QIPP, or any other acronym the NHS can throw at us. A reduction in expenditure requires fewer units of total activity from one year to the next.

How can the NHS prevent the illogical and solely focus on how total healthcare activity may be reduced?

Yet within NHS commissioning projects funded to reduce activity, such as emergency admissions, are not necessary tested against whether a reduction in total activity can be achieved. This is often shown in the commissioning discussions that ensue when there is a growth in emergency admissions.

Project leads may point to a growth in a prevention of admissions within a specific clinical area, with the subsequent assertion that the growth in total activity would have been greater without the prevention of admissions.

Such an assertion brings one back to bananas, and a subsequent question: how can you count something that has not happened? In short you cannot. A shopper cannot count how many bananas they did not buy, only those that they did.

In the same manner a clinician or manager cannot count how many emergency admissions they prevented for asthma, say, only how many admissions there have been.

Only counting activity that occurred

So how can the NHS prevent the illogical and solely focus on how total healthcare activity may be reduced?

Part one

Let’s say that an NHS commissioning body seeks to reduce total emergency admissions in the 2017-18 financial year by 5 per cent, and that this is to be achieved at reducing admissions for ‘Simon’s disease’. The commissioning body would then need to understand what reduction in admissions (for ‘Simon’s disease’) would be required to produce a 5 per cent reduction in total emergency admissions.

For areas of healthcare activity, such as emergency admissions, the need to deliver financial efficiency translates to a reduction in these types of activity.

From knowing in a previous year that 16 per cent of emergency admissions were for Simon’s disease, it is then straightforward to see that a 31.3 per cent reduction in these admissions would be required for a 5 per cent reduction in the total. (This is because 5 is nearly a third of 16.)

The NHS commissioning body would not need to stop there, though. It could then ask what are the risks associated with signing off a single project to achieve a 5 per cent reduction in total admissions?

Part two

If 16 per cent of emergency admissions are for ‘Simon’s disease’ then 84 per cent are not. So even if a 31.3 per cent reduction in admissions for ‘Simon’s disease’ is achieved then there can be no simple assertion that there is then a 5 per cent reduction in the total.

This is because a 5.95 per cent increase in admissions for something other than ‘Simon’s disease’ would completely cancel out a 31.3 per cent reduction in admissions for Simon’s disease.

So even if a project on reducing emergency admissions for Simon’s disease was fully successful, a 5 per cent reduction in total activity would not have been achieved.

And these figures are before one considers how the requirement for a project on Simon’s disease may change throughout 2017-18.

Part three

Imagine – fast forwarding to July 2017 – that total emergency admissions have been forecast to grow by 2 per cent throughout 2017-18, with the consequence that there is now a required 7 per cent reduction in the total.

Project leads may point to a growth in a prevention of admissions within a specific clinical area, with the subsequent assertion that the growth in total activity would have been greater without the prevention of admissions.

This then means that the project now has to reduce admissions by 43.8 per cent. (7 is over four-tenths of 16.) But unfortunately this assumes that there are 12 months in which to achieve this reduction.

As there are only nine months left of the year – and less available activity left to prevent for ‘Simon’s disease’ - then the actual required reduction jumps by a factor of 1.33 (12 months divided by 9), from 43.8 per cent to 58.3 per cent.

Concluding points

Without this type of analysis the commissioning body would not know that at least a 31.3 per cent reduction in admissions is required, but this could easily become a 58.3 per cent reduction.

And most importantly of all, as an objective on reducing actual admissions is not being realised, it may simply talk about prevented admissions for ‘Simon’s disease’.

Simon Rowe is senior commissioning manager at Wakefield Clinical Commissioning Group