NHS Digital publishes Hospital Episode Statistics, which provide data on the number of hospital episodes for patients in England. Each hospital episode relates to a period of care for a patient under a single consultant within one hospital provider. Therefore, the data relates to the number of episodes of care for admitted patients rather than the number of patients. A stay in hospital from admission to discharge is called a ‘spell’ and can be made up of one or more episodes of care.
In this section, data is presented on the number of completed episodes, called Finished Admission Episodes (FAEs), which is the first episode in a spell of care, and Finished Consultant Episodes (FCEs), which is a continuous period of care under one consultant.
Finished Consultant Episodes
Figures for Bexley show that there were 79,717 FCEs recorded in 2016/17, an increase of 2.5% from the previous year and an increase of 46% from 2006/07 (54,587). For 2016/17, the five-year age groups in Bexley with the greatest number of FCEs were patients aged 70 to 74 (6,468), 75 to 79 (6,246) and 80 to 84 (6,116).
Figure 70: Finished Consultant Episodes in Bexley, 2016/17
There have also been significant increases in the number of Finished Consultant Episodes among the older age groups. Over the 5 year period 2012/13 to 2016/17, FCEs increased by 21% among those aged 70-74, 27% among those aged 85-89 and 44% among those aged 90 years and over.
Figure 71: Finished Consultant Episodes in Bexley (65+), 2012/13 to 2016/17
Finished Admission Episodes
Figures for Bexley show that there were 65,857 admission episodes recorded in 2016/17, an increase of 2.2% from the previous year and an increase of 29.3% from 2006/07 (50,941)
Emergency admissions to hospitals accounted for 23,060 (35%) of total admission episodes for Bexley residents in 2016/17. This is an increase of 0.6% from the previous year (22,915) and an increase of 57.4% from 2006/07 (14,646). Emergency admissions are not planned and happen at short notice because of perceived clinical need.
Total Finished Admission Episodes in Bexley, 2006/07-2016/17
Avoidable emergency admissions
Avoiding unnecessary emergency admissions and managing those that are admitted more effectively is a major concern, not only because of the costs associated with these admissions, but also because of the pressure and disruption they can cause to elective healthcare and to the individuals admitted. Ambulatory care sensitive conditions (ACSCs) are conditions where effective community care and case management can help prevent the need for hospital admission.
The NHS Outcomes Framework (NHSOF) includes two indicators that measure the rate of emergency admissions per 100,000 population for people of all ages:
NHSOF 2.3i: Unplanned hospitalisation for chronic ACSCs (all ages): This indicator indicates how successfully the NHS manages long-term or chronic conditions (such as asthma, diabetes, epilepsy, hypertensive disease, dementia and heart failure) where optimum management can be achieved in the community. Figure 73 shows that the number of persons with long-term or chronic conditions, admitted to hospital in an emergency, has fallen in Bexley from a rate of 940.3 per 100,000 population in 2003/04 to 579.1 in 2016/17. Whilst this is below the rate of admission for both England and London, Bexley’s rate has deteriorated over the last two years.
 Emergency admissions to hospital: managing the demand, National Audit Office, Oct 2013
Figure 73: Unplanned hospitalisation for chronic ACSCs
NHSOF 3a: Emergency admissions for acute conditions that should not usually require hospital admission: This indicator looks at conditions that should usually be managed without the patient having to be admitted to hospital such as ear, nose and throat infections, kidney and urinary tract infections as well as acute heart disease. Figure 74 shows that the rate of emergency hospitalisation per 100,000 population for patients with acute conditions that should not usually require hospital admission has increased in Bexley from a rate of 745.3 in 2003/04 to 1139.8 in 2016/17.
Figure 74: Emergency admissions for acute conditions that should not usually require hospital admission
Patient feedback on managing long-term conditions
In 2015/16, it was estimated that 31.4% of people aged 18 and over in Bexley have one long term condition, 12.9% have two long term conditions and 9.6% have three or more long term conditions.
Good management of long term conditions can reduce the frequency and necessity for non-elective admissions. This requires effective collaboration across the health and care system to support people in managing conditions and to promote swift recovery and reablement after acute illness.
Based on responses to one question from the GP Patient Survey, the proportion of people feeling supported to manage their long-term conditions in Bexley was 59.5% in 2016/17. This was below the England average of 64%.
Figure 75: Proportion of people who are feeling supported to manage their long-term condition
What are we doing about it?
Better Care Fund (BCF): The BCF is a programme spanning the NHS and local government, which creates a single pooled budget for health and care services. It aims to provide better outcomes for people who use health and social care services by helping to ensure that those services are more integrated and delivered closer to home. In Bexley, we have continued to invest in intermediate care services, care pathway improvements, and the delivery of personalised health and social care at home or in the community. Services have sought to prevent unnecessary hospital admissions, reduce lengths of stay, support timely discharge from hospital and avoid or delay permanent admission to residential and nursing care. In addition, services have been successful in maximising independence through reablement, equipment provision and Disabled Facilities Grant adaptations. This has helped to deliver a reduction in residential and nursing care home admissions, a reduction in delayed transfers of care, and enabled older people to remain living independently at home.
Local Care Networks: Bexley is developing three Local Care Networks, (LCNs), which align with the existing locality footprints of GP practices in North Bexley, Clocktower and Frognal. LCNs are a collaborative approach to health and care, which involve partners working together to plan and deliver services in an integrated way based on population need in each LCN. LCNs bring together health, community and social care workers, as well as the voluntary and community sector to provide care that is patient-centred, accessible and coordinated.
Bexley Care: On 1 April 2017, ‘Bexley Care’ – our new integrated care provider – was established. This brings together adult social care (London Borough of Bexley) and adult community and mental health services (Oxleas NHS Foundation Trust) into a single management structure with flexibility to use the combined health and social care resources across both organisations to deliver seamless and effective care and support. This includes integrated Rapid Response, Hospital Integrated Discharge, and Community Assessment and Reablement Teams that support urgent care needs, admission avoidance and facilitate timely and safe transfers of care. A bespoke service delivery model is being developed, which integrates the existing adult health and social services into three new teams aligned to Local Care Network geographies.
Queen Mary’s Hospital (QMH): At QMH in Sidcup, £30m has been invested to modernise the buildings and bring services up-to-date. NHS Bexley CCG and the Council are working with Oxleas and a range of providers to deliver a range of services to our local population. This includes an urgent care centre and GP out-of-hours service, children’s development service, outpatient clinics, and rehabilitation or intermediate care.
Reducing demand for acute care: NHS Bexley CCG and partners have continued to support a range of initiatives focused upon reducing demand for acute care. This includes enhanced access to primary care services 7 days a week, clinical support to the elderly living in nursing and care homes, and partnership working to redirect patients attending the Emergency Department to GP Hubs, which are open for extended hours. GP practices are identifying high risk patients and cases are discussed in Multi-Disciplinary Teams, which is helping to prevent admissions to hospital because of very pro-active management.
Urgent and Emergency Care Pathway: The urgent and emergency care services available to Bexley residents remain a key area focus. At a strategic level, the Council and NHS Bexley CCG have been involved in the local A&E delivery board(s). This is a partnership group formed of all the local healthcare providers to provide direction and co-ordination on the development of local emergency care services, and to address performance issues. At an operational level, NHS Bexley CCG has embedded a Patient Flow manager within the local Acute Trust to provide oversight and challenge on patient flow and discharge.
Transfer of Care Collaborative (ToCC): Launched in 2017/18, the ToCC is an initiative sponsored by NHS Improvement and adopted by local partners in the Lewisham, Bexley and Greenwich (LBG) system, which links to Lewisham and Greenwich NHS Trust. This initiative involves a system-wide, cross-authority approach through which system leaders and our teams are collaborating and working together to streamline care processes and pathways. This multi-agency, cross-authority approach brings further opportunities to use our collective resources across the system to better effect.
Quality, Innovation, Productivity and Prevention (QIPP) Schemes: The QIPP is a large scale programme implemented to transform the NHS through quality care improvement and efficiencies. In short, it aims to deliver a better service under a tighter budget. Work has been undertaken to explore potential QIPP opportunities using NHS RightCare intelligence tools, such as the Commissioning For Value/ RightCare packs, and to review best practice from other organisations. The CCG also continues to work with providers and partners to ensure delivery of efficient, quality services to the population of Bexley.
Care Market sustainability: We have undertaken market analysis to help inform our future commissioning and procurement plans. In 2018, uplifts in the domiciliary care rate are helping to guarantee capacity in the home care market. A full range of factors affecting supply side costs, including the National Living Wage and travel were taken into account. The fee levels were also benchmarked and informed by UK Home Care Association guidance.
Online services: In Primary Care, the patient online services – including access to appointments, prescriptions and medical records – are available across Bexley GP practices. Access to online consultation is fully rolled out and available to all practices. In November 2017, NHS Bexley CCG launched a 1 year pilot of NHS Online Bexley, which offers people in Bexley a new way to contact their local health services via a convenient app. This provides a self-care advice facility and access to their Patient Online account to manage appointments, order prescriptions and view their medical records or to request an online consultation. At the Urgent Care Centre in Queen Mary’s Hospital, tablets have been installed, which encourages patients to input their details using e-consult. This is then reviewed by Triage, enabling patients to be prioritised.
Linking data across health and social care: Connect Care – a local electronic record – is being implemented to allow important information from separate record systems to be viewed by staff directly involved in providing care (e.g., GPs, hospital staff, district nurses, and social workers) on a need to know basis. This will help them provide the most timely and efficient treatment.
What works and best practice?
National Audit Office Report – Reducing emergency admissions: The National Audit Office have examined the contribution being made by the main national programmes to the goal of reducing emergency admissions. This includes the Urgent and Emergency Care Programme, the Better Care Fund, New Models of Care, and the NHS RightCare programme. The programmes focus on integrating health and social care, improving access to primary care services, improving the performance of A&E departments and improving out-of-hospital care. Figure 76 outlines how they seek to address the root causes of and pressures driving increased emergency admissions.
The NAO report points out that, while there are some positive examples at a local level, the evidence base for these interventions is mixed. Although the rate of growth in emergency admissions has slowed slightly, the NAO report finds that there is limited evidence to show programmes have brought about that slow-down. The NAO points out that the NHS still has too many avoidable admissions and too much unexplained variation. This highlights the need to gather better data and evidence to understand the rise in admissions, the drivers behind the increase, and the impact of initiatives.
Nuffield Trust Report – Shifting the balance of care : A literature review by the Nuffield Trust provides insights from available evidence to help inform local strategies in STP areas. It aims to help areas identify the initiatives that may deliver the greatest benefits locally and the key contributors to successful implementation. It also highlights the considerable implementation challenges involved in shifting care out-of-hospital. This includes the possibility that some initiatives may be too small to shift the balance of care, whilst recognising that a more radical approach to designing and scaling up models will take time and resources. Where schemes have been most successful, they have: (i) targeted particular patient populations (such as those in nursing homes or the end of life); (ii) improved access to specialist expertise in the community; (iii) provided active support to patients, including continuity of care; (iv) appropriately supported and trained staff; and (v) addressed a gap in services rather than duplicating existing work.
NHS England Urgent and Emergency Care Programme: This programme aims to transform urgent and emergency care and ease pressure on the emergency system. Workstreams and priorities include:
- NHS 111 offering online triage, increased clinical input into calls and dedicated care home call lines staffed by GPs.
- Ambulance response programme introducing four categories of calls to provide a more appropriate response and enabling those with an immediate emergency to be prioritised.
- Urgent Treatment Centres to ease the pressure on hospitals and stream people away from A&E, where appropriate.
- Work with partners to support timely discharge and prevent admission through improved assessments undertaken in the right setting (e.g., Trusted Assessment; Discharge To Assess; Red Bag Scheme; Enhancing Health in Care Homes).
- GP access providing evening and weekend appointments.
New Care Models: NHS England’s Five Year Forward View set out plans to develop five new care models that integrate services around the patient. These models are:
- integrated primary and acute care systems – joining up GP, hospital, community and mental health services.
- multispecialty community providers – moving specialist care out of hospitals into the community.
- enhanced health in care homes – offering older people better, joined up health, care and rehabilitation services.
- urgent and emergency care – new approaches to improve the coordination of services and reduce pressure on A&E departments.
- acute care collaborations – linking local hospitals together to improve their clinical and financial viability, reducing variation in care and efficiency.
The models are being tested through 50 ‘vanguard’ sites but with variability in performance on emergency admissions. Individual reports show some positive results, for example, the Newcastle Gateshead care home vanguard, which has reported:
- 9% decrease in 999 calls resulting in conveyance to hospital, and an overall decrease in the number of 999 calls.
- 35% decrease in non-elective admissions for urine infection.
- 17% decrease in non-elective admissions for chest infections
- 26% decrease in oral nutritional supplement prescribing (15,000 fewer prescriptions).
- 11% increase in the number of patients dying in their place of choice.
Enhanced Health in Care Homes Framework: Learning from the six care home vanguard sites has informed the development of a framework for enhanced health in care homes. It is based on a suite of evidence-based interventions, which are designed to be delivered within and around a care home in a coordinated manner in order to make the biggest difference to its residents. In Bexley and across South East London, we are working to implement the Framework and share learning in order to improve the quality of care within care homes, ensure residents have access to the right health services, and reduce unnecessary conveyances and admissions to hospital.
 Polley, M., Bertotti, M., Kimberlee, R., Pilkington, K.,and Refsum, C., A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications, Social Prescribing Network, University of Westminster, June 2017
Social Prescribing: The University of Westminster have published a review of the academic literature on the impact of social prescribing. Social prescribing was associated with reduced use of health services by patients referred, including a 28% reduction in GP appointments (range 2% to 70%). Demand for hospital care also showed reductions. A&E attendance fell by an average of 24% (range 8% to 27%), emergency admissions fell between 6% and 36%, and most studies showed a reduction in outpatient referrals (up to 64% for patients engaged in social prescribing).
Figure 76: Interventions to prevent hospital admissions
What are the gaps?
Financial: The level of financial risk to the CCG and the Council is currently very high. Demographic changes from an ageing population and increased complexity of need continue to place significant pressure on the Council and CCG’s budgets.
Both the Council and the CCG have delivered significant transformation and efficiency programmes over a number of years but the scope for delivering further savings is diminishing. In 2016/17, Bexley’s gross expenditure on ASC was the fourth lowest in the country and represented a lower level of spend relative to comparator Boroughs, despite having a significantly older population.
Independent reviews have recognised that, whilst the CCG has robust systems in place for the identification and delivery of QIPP, the CCG has little further QIPP opportunity working alone. This raises the prospect of working collaboratively on QIPP schemes across the STP footprint and the need to support coordination of QIPP with neighbouring Boroughs.
In June 2018, the government announced proposals to implement a new long-term plan and multi-year funding settlement for the NHS. The priorities identified include delivering agreed performance standards, transforming cancer care, better access to mental health services, better integration of health and social care, and focusing on the prevention of ill-health. The Adult Social Care Green Paper in Autumn 2018 will set out the Government’s proposals to improve care and support for older people, including options to deliver a long-term, sustainable solution for funding adult social care. In the meantime, there is an urgent need to tackle immediate pressures in both health and adult social care.
Non-elective admissions: There is continued pressure on non-elective admissions to hospital when compared with previous years and acute over-performance remains a key area of risk. This is despite our investment as a system in out-of-hospital care and schemes to prevent hospital admissions. Pressures on acute care are now lasting throughout the year with seasonal surges in demand still occurring on top of existing high levels of activity. This means we face a significant challenge in achieving further reductions in non-elective admissions.
Capacity in the community to prevent emergency admissions and facilitate early discharge: Clinical skills are not always available in the community to meet demand, especially where specialist input is required (e.g., mental health and complex therapy needs). The National Audit of Intermediate Care has calculated that the capacity of intermediate care, which helps to prevent people going into hospital and facilitates their move out, needs to double to meet potential demand in England.
independence and reducing use of hospitals, Summary Report – England, November 2017
Market Sustainability: The care market is increasingly fragile. Key areas of concern relate to:
- Development of the market around transition of young people into adult services, including those with complex health needs, and supported living capacity. Through our Transforming Care Partnership Plan we are working with neighbouring boroughs and CCGs to develop the market across South East London.
- The long term sustainability of markets with high quality providers declining to tender on the basis of price.
- Homecare provision – increasing demand and workforce shortages.
- Extra Care Housing – No current extra care provision for older people in the borough but plans are being developed.
- Development of the market around high quality Dementia care, including those with complexity of needs to further support independence and resilience in the community.
Workforce: Recruitment and retention of a suitably qualified workforce remains a challenge. The National Living Wage has brought significant additional costs to the Council and providers but has also directly benefited front-line care workers by raising low wages in the care sector. The affordability of local housing is also recognised as a key factor impacting on the sustainability of the workforce.
Quality of Care: In July 2017, CQC ratings from inspections of active locations and registered providers in Bexley showed that 60% were rated as ‘Good’ and 40% were rated as ‘Requires Improvement’ (see Figure 97 in Section 14.4 for benchmark). This shows that further work is needed to raise standards and improve the quality of care home and domiciliary care provision in the Borough.
- Based on evidence of need in Bexley, continue to make the case to the Government for additional funding to tackle immediate pressures in both health and adult social care and seek a long-term, sustainable solution for funding adult social care from the Green Paper (expected Autumn 2018).
- Continue to make the case for greater flexibility within the BCF to prioritise preventative activity, which would help reduce demand for hospital services in the first place, as well as improve people’s health and wellbeing.
- Work with system leaders, partners and providers to implement the Borough’s plans for integrated care, including the Better Care Fund requirements, the Local Care Network Programme, and Bexley Care.
- Consider the opportunity presented by the Memorandum of Understanding on devolution in London to try out different approaches and develop solutions.
- Review the evidence on interventions that can have an impact on reducing emergency admissions and continue to explore QIPP opportunities, utilising Commissioning for Value Packs and other benchmarking tools.
- Where appropriate, work collaboratively on QIPP schemes and other initiatives across the South East London STP area, supporting coordination of initiatives with neighbouring Boroughs.
- Focus on improving patient and carer experience of out-of-hospital services and reduce variation in performance between GP practices; a poorer patient experience might discourage patients from using local services, such as their GP practice, resulting in presentations at A&E.
- Take advantage of new technology to support new ways of working and innovation in care delivery (e.g., telecare, telehealth, e-consult, Patient On-line, NHS Online Bexley, Connect Care).