Southend Estuary CCG provides one good example of how to deal with unplanned care issues when serving a challenging health population.

Southend Estuary has a strong track record in GP commissioning and has been a first wave pathfinder since 2010, leading the way on a range of service developments across the South East Essex primary care trust.

Southend Estuary CCG became a formal sub-committee of the PCT Board in May 2011 and immediately set about the task of dealing with the challenging unplanned care agenda.  Within the Southend Estuary area there are extremely challenging patient demographics:

  • A high volume of patients over the age of 65 - significantly above the regional average
  • 9 per cent of patients over the age of 80, many of whom are burdened with long term conditions
  • A high number of patients within the above groupings living alone

Unsurprisingly such a challenging patient demographic resulted in:

  • A high volume of unplanned care admissions with significant variability across practices
  • High volume of multiple short stay admissions. It was clear that a significant number of these were more amenable to primary and community care, yet they were still admitting to the hospital.

As a result system costs were rising and it was at this stage that under the leadership of CCG clinical director Dr Paul Husselbee the CCG decided to take immediate action 

The first step was to understand in more detail the individual patient journey and the group quickly commissioned the support of PI benchmark and Southend Borough Council in implementing the Caretrak information system. The system provided the CCG with the granular level of analysis it required to face this challenge head on.

James Roach the chief operating officer of the CCG said, “We were fortunate that Southend Borough Council invested jointly in the system with us and it provided us with some interesting findings.” There were, said Mr Roach, individual  patients who over the course of a one year period cost the health and social care system in excess of £ 36,000.

Mr Roach added the system provided an excellent visual overview of the patient journey. He and his team were reviewing examples of patients who in a one year period had attended A&E and had subsequently admitted eight times to a hospital bed in a one year period.

The CCG started to get all its GPs involved in reviewing this information at practice level. According to Dr Husselbee this review ignited an interesting debate amongst the GP leads at Board. Dr Sarah Zaidi a GP partner at a thriving local practice was appointed as the lead for this programme of work for the CCG.

“It was clear once I started this project that we had to focus on three key areas,” said Dr Zaidi. “Ensuring we were targeting the right patients using risk stratification and that practices were beginning to revive regular reports on identified ‘high intensity users’; that we continued to build upon and enhance the emerging community model in partnership with the local acute hospital, social care and community nursing; that we engaged GPs from the outset and encouraged them to develop their own practice level MDTs with allocated social care and community health care input.”

Using Caretrak and with the support of the community geriatrician, community matrons and social care, Dr Zaidi began to develop a range of criteria against which the system would generate reports on identified patients. The criteria for selection was:

  • Two or more unplanned admissions in the last six months (particularly if admissions were recurrent for the same reason)
  • Increasing fraility / falls
  • Evidence of cognitive problems (acute or chronic)
  • Inadequate social support at home
  • Multiple long term conditions (especially progressive chronic conditions such as dementia, Parkinsons, end stage cardiac or respiratory disease)
  • Multiple medications

Dr Husselbee felt that these practice level reports were a significant step as all GPs had a real appetite for reducing unnecessary unplanned admissions and this type of report enabled them  to focus on the right patients and case manage accordingly.

Dr Zaidi felt that the next step, once practice level awareness and accountability around the unplanned care agenda were increased, was to ensure that the systems was supportive of the process and played its part. “We were fortunate in that the emerging community model was beginning to take shape and meet the needs of the GP community,” added Dr Zaidi.

In partnership with Dr Liakas, a consultant geriatrician from Southend University Hospital, Dr Zaidi re-established the community geriatrician programme across South East Essex. This included:

  • The establishment of a a specialist weekly community MDT meeting where all practionners across health and social care are present and discuss and manage a range of complex cases.
  • Specialist “in reach” support to a range of nursing and residential homes which has had a significant impact in reducing admissions from care homes.
  • The establishment of four community clinics
  • Clear deferral guidance for admission avoidance circulated to all GPs on a one page laminated sheet

All of these schemes we underpinned by the innovative single point of referral, launched by Southend Borough Council and South East Essex Community Services and hosted by South East Essex Partnership Trust, and provides GPs with one number to ring for discharge and admission avoidance purposes.

It was at this stage the CCG decided to launch our practice level MDTs. 

Dr Paul Husselbee said this approach had the full backing of the board and the full support of Southend Borough Council and community services. There was a shared vision and ambition to improve the services provided for patients and this was reinforced at stakeholder event in December 2011 when over 40 health and social care professionals met and agreed the approach moving forward.

Each practice now runs a monthly MDT meeting with the full involvement of an assigned social worker and community matron, the meeting is chaired by a GP and case manage a minimum of 15 patients a month, these patients are those identified as high risk of an acute admissions, using the risk stratification tool.

Each practice has a target of avoiding a minimum of five unplanned care admissions a month and this contributes to the overall CCG target of 600 unplanned care admissions to be avoided.

“We have been really fortunate to have the full support of social services and community healthcare in this endeavor and there has real energy across all practices to make it happen,” said Dr Zaidi.

The process has been live since November and whilst it is too early to assess overall system impact the area is beginning to see a reduction in short stay admissions, and reduction in admissions from nursing and residential homes as well as an increase in the volume of GP referrals to the range of alternative community schemes through the single point of referral. Dr Husselbee feels another notable impact of the scheme to date has been the commitment from GPs across the CCG to support this agenda and affect real change across the health system.