Reinvestment of Emergency Admission Monies
Introduction:
The way hospital trusts are funded for the work they undertake is determined by a national
payment system called ‘Payment by Results Tariff’. In 2008/09 rules were set which meant
that an assessment was made of the volume and cost of emergency admissions for each
hospital. Following this any emergency admissions over and above this threshold would
only be paid at 30% of the nationally agreed tariff. This was designed to ensure that there
was an incentive for hospital trusts to work with commissioners to design a system which
meant that emergency admissions were managed at a rate which did not significantly
increase on 2008/09 levels.
The intention was that the remaining 70% of the monies were reinvested in demand
management schemes which would help the system to manage through alternatives to
admission to hospital.
2014/15
In 2014/15 local health and social care systems set up ‘urgent care working groups’.
These groups were established to oversee the urgent care system locally with a view of
developing an urgent care strategy, supporting management and delivery of the
emergency care standard and whole system response in times of pressure. AWC CCG
and ANHSFT are part of the Bradford, Airedale, Wharfedale and Craven Urgent Care
Working Group. The membership is made up of commissioners, providers, local
authorities and Healthwatch in their role as patient advocates, the group is clinically led
and chaired by a local GP.
Everyone Counts Planning Guidance 2014/15i advises that Clinical Commissioning
Groups should engage with their providers and agree through the urgent care working
group a plan which set out appropriate use and reinvestment of the 70% threshold monies
and publish such plans on their website.
In 2014/15 the value of the 70% monies for admissions which occurred at Airedale
Foundation trust in 2013/14 (over the 2008/09 threshold) is £1.1 million
In 2014/15 ANHSFT also received £1.4m of funding from NHS England to support delivery
of the emergency care standard.
The following sets out the plans for use of this funding. These plans were agreed at the
urgent care working group meeting 10th April 2014
Lynne Hollingsworth. Head of Service Development 14th April 2014
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Airedale NHS Foundation Trust
Emergency Care Threshold Monies – 2014-16
Context
This paper details the investment and expenditure associated with the above that Airedale
NHS Foundation Trust made in 2013-14. Whilst it is recognised that the allocation of the
threshold monies by the CCG are non- recurrent as can be seen from the paper Airedale
NHS Foundation Trust have been required to invest on a recurrent basis to secure a safe
and effective service on behalf of patients. In addition to this it has been necessary to
invest in non- recurrent spend over and above the value of the threshold monies.
Information re this is provided in the paper too.
The specific elements of the recurrent investment are well known to commissioning
colleagues and the analysis of the benefits have been shared at various points via the
Urgent Care Working Group in AWC. Infrastructure of this type to support the
transformation of emergency and urgency pathways in secondary care is required on an
on-going basis. It is not feasible with the challenges in securing an appropriate workforce
and the continued increase in non- elective admissions to deliver this consistently unless
the investment is recurrent. This paper is requesting that the threshold monies for 2014-15
are used as a contribution to these recurrent developments.
These developments are in addition to a wide range of work with partners across the
health and social care economy that is focused on admission avoidance, supporting frail
and older people with long terms conditions in their place of usual residence where safe to
do so and the use of technology.
Recurrent investment in the service models for emergency and urgent care at
Airedale NHS Foundation Trust
1. Investment in Ambulatory Care Unit (ACU) and Short Stay Beds /Acute Medical
Unit and the Surgical Assessment Unit (SAU). This includes additional
consultants, GP advice line provided by Acute Physicians and Advanced Nurse
Practitioners.
GP advice line - triages GP admissions direct. This has delivered a 30% change in patient
flow resulting in an inpatient admission being avoided. 10% of the calls are dealt with by
advice only and a further 20% of the calls result in attendance to same day ambulatory
care setting with patients being discharged same day. This is adding significant value and
it one of the critical success factors of delivery of the 4 hour ECS since its introduction in
February 2013.
• Increased consultant cover on AMU. 7 day cover – Mon- Friday is 8 am until 9 pm and
Saturday and Sundays from 8am until 8pm. This has enhanced not only the quality and
experience of the service for patients on the AMU but has also contributed to a further
reduction in Length of Stay for Non- Elective patients across Medicine and Older
People’s services.
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• Short stay pathways have reduced average LOS by 0.5 days.
• Ambulatory care pathways have reduced the need to admit patients who can be seen as
ambulatory e.g. DVT, PE, chest pain. There is scope to increase the number of
ambulatory pathways which is work that will be on-going during 2014-15.
• SAU opened in May 2013 - surgical patients are assessed for admission avoiding
inpatient admission where feasible and contributing to a reduction in LOS across the
surgical group of 0.4 days in 2013-14.
2.
Additional beds on ward 1 (now ward 4).
There was a requirement to increase the number of beds in the department for Elderly
Medicine with a focus on Frail, Elderly and patients with Dementia. This has included
investment in additional nursing and therapy staff as well as investment of capital monies
to upgrade Ward 4’s environment. This is a significant improvement of Ward 1 and the
environment and increase in capacity is effective in supporting older people. This was
required following an increase in NE spells in the over 80s in 2012 -13 which has been
observed again in 2013-14. It would not be feasible to manage the service safely at the
current time without this additional capacity given the continued increase in GP nonelective admissions. This information has been shared with AWC CCG including the detail
of GP admissions at a practice level.
3. Investment in additional Emergency Care Consultants to deliver Consultant
presence in the ED from 8am – 12 Midnight -7/7.
This is required to provide an adequate response to the impact of national shortage of ED
middle grade Drs in order to deliver 24/7 services. Increasing the consultant
establishment will allow the Trust to deliver 16 hour consultant cover 7 days a week which
is consistent with the guidance in the Bruce Keogh work re Emergency and Urgent Care.
Whilst not all of these posts are yet recruited too on a substantive basis (2 gaps) they have
been secured via additional shifts from Airedale NHS Foundation Trust Consultants and
Locum/Agency Consultants. This has been another critical success factor in terms of the
delivery of the 4 ECS since August 2013.
4. Advanced Nurse Practitioners (ANPs)
Airedale NHS Foundation Trust has a programme that is focused on the introduction of
ANPs as an effective substitute for junior doctors where this is clinically appropriate.
Investment in 2013-14 in 6 wte ANPs who are working within the footprint of ED, ACU and
AMU. They were in part funded via the threshold monies given the focus of their activity in
urgent care pathways.
They are continuing to develop through their formal training programmes with 2 of the 6
practitioners now able to substitute junior doctors on call. The remainder are due to
complete their education preparation in summer 2014.
They are of significant value given the continued pressures coupled with the gaps in the
junior doctor workforce. This model of workforce will deliver improvements in consistency
and sustainability of service as well as provide equivalence in terms of value for money.
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NB - all the above have been subject to Trust Board level business cases
throughout 2012-14.
The detail of the expenditure associated with these schemes is in Table 1.
Additional pressures and non-recurrent expenditure in year to respond to
Emergency Work.
From mid December 2013 through to April 2014 there has been an increase in NEL spells
of 15% over the same period as last year. The details of this have been shared with AWC
CCG. It is evident that this is being driven by an increase in GP admissions as opposed to
an increase in ED admissions .This increased demand has been a significant challenge to
capacity across both Medicine and Surgery at Airedale NHS Foundation Trust and as a
consequence we have been required to deliver a number of actions on top of the Winter
plan and the recurrent changes to respond. These are detailed below:
1. Additional Medical agency staff to cover middle grades. As well as covering gaps in
middle grades in ED we have also put on additional shifts during weekends and
evenings to manage demand and secure delivery of the 4 hour ECS for patients.
2. ENP agency costs to cover weekends from December. Emergency Nurse Practitioners
have been running our minor injuries in ED which release Dr capacity to deal with more
seriously ill patients. This has been required whilst we expand the scope of practice
and number of ENPs in our substantive workforce.
3. Additional locum costs in A&E to cover consultant expansion. Due to delays in the
recruitment process for A&E consultants and also to cover a consultant maternity leave
it has been necessary to utilise locum consultants. Whilst the money for this has been
invested on a recurrent basis ( see 3 above ) the costs of having to secure this via
Agency and premium rate payments to existing personnel are in excess of the
substantive budget.
4. Additional twilight nurses in ED to support flow from November. Although ED
attendances have not increased compared to last year, there has been a
disproportionate number of attendances during the evening until midnight. Additional
nurses have been required to meet this demand.
5. Increase agency to cover vacancies and sickness above expected. Junior Dr sickness
and vacancies across the medical wards has been much higher than in previous years
meaning an increase in agency costs.
6. Transfer team/Pack up and go team Nov-May. These teams facilitate patient flow from
ED to AMU and from AMU to the base wards has had a positive impact on flow and
enabled the number of breaches through bed holds to be significantly reduced during
the winter months in 2013-14.
7. AMU additional nursing Jan-March. This has been required to keep the busy AMU safe
and to meet the increase in demand especially during the evening and at weekends.
8. Orthopaedic additional beds to service increased surgical & orthopaedic NEL spells.
Increased NEL spells during December-March have also been a feature in
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orthopaedics and surgery. This has impacted on the overall number of beds available
in hospital that can be used for medical, ortho and surgical NEL admissions.
The detail of this expenditure is in Table 1
Table 1
Emergency Investment Recurrent infrastructure
£
Investment in the CAT/AMU
Additional beds ward 1
Additional Consultant doctors 3 in AMU
A&E Consultants 2.65
short stay Beds
ANP 6 wte
Surgical assessment
500,000
180,000
300,000
300,000
180,000
160,000
250,000
Total
1,870,000
Additional pressures in Year to service
Continued increased Emergency Work
Additional Medical staffing agency to cover middle
grades
ENP agency costs for weekends from December
Additional Locum costs in A&E to cover consultant
expansion
Additional Twilight nurses in A&E to support flow
from November
Increase agency costs to cover vacancies and
sickness above expected
Transfer team Pack and go Nov to May
AMU additional nursing Jan to march
Orthopaedic additional beds to service increased
Surgical Emergency still awaiting info
527,000
108,000
42,000
30,000
60,000
20,000
20,000
Total
807,000
Total Costs
2,677,000
Stacey Hunter. Director of Operations - April 2014.
i
Everyone Counts Planning Guidance 2014/15
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