Healthcare: Ensuring Patients are Treated in the most Appropriate Clinical and Care Settings

The operational efficiency and effectiveness of A&E and long-term increases in hospital discharge delays are two of the major operational inefficiencies in the NHS, both nationally and in Nottinghamshire.

As a result of Professor Murphy’s previous experiences (including membership of the boards of Nottingham and Nottinghamshire Primary Care Trusts), NTU was commissioned to undertake two complementary research projects at the two major hospitals serving Nottingham and Nottinghamshire.

NTU’s research findings and recommendations significantly improved two major contemporary operational challenges in the delivery of UK healthcare services, namely overcrowding in Accident and Emergency (A&E) and delayed discharges from hospitals (sometimes known as ‘bed blocking’). As a result, significant improvements were made to:

• A&E capacity, patient flow, treatment targeting, and clinical and non-clinical outcomes at the Queens Medical Centre’s (QMC) in Nottingham with bed capacity/availability up 57% to 550.
• At Kings Mill Hospital in Mansfield, there were significantly reduced delays in discharges leading to significantly reduced costs to the NHS, to Social Services and to welfare providers, as well as to substantial benefits for patients.

A&E, Queens Medical Centre

Nottingham University Hospitals Trust (NUHT) is the 4th largest acute hospital trust in the UK and the largest outside of London.Despite implementing multiple innovations, and system improvements they consistently failed to meet governments the ‘4-hour’ waiting target between 2004 and 2016. In response NUHT and the Nottingham Clinical Commissioning Group produced an operational plan for urgent/emergency care, which identified four improvement projects based around 4 major user groups of A&E. The commissioners had sufficient detailed information and predictive models for three of these groups and commissioned NTU to investigate the fourth.

People between the ages of 19-29 are infrequent and intermittent users of NHS services, but they are also among the least efficient users and most difficult to assess or predict. QMC had over 60,000 students and 70,000 non-students in this age cohort in its catchment and this  cohort are the biggest ‘over-attenders’ of A&E and represent approximately 20% of attendances. NTU analysed data from multiple sources including the hospital, the ambulance service, GPs, third sector providers and local authorities. The team held focus groups with the target population and over 20 interviews with key staff from A&E, GPs, NHS111 and key stakeholders.

The research found attitudes and behaviour materially and surprisingly different from the previous 10-year cohort, upon which services had largely been configured at the time. It identified the sources and reasons for over attendances as:

• Poor knowledge of alternative out-of-hospital provision
• Misdiagnosis of severity of conditions (by patients and advisors)
• Unwillingness to ‘wait’ for services such as GP, out of hours, or 111
• Use of risk averse on-line algorithm-based advice
• A spike in alcohol and drug abuse presentations.

NTU found over 60% were self-referrals, that 70% were in the four lowest triage categories of severity, that 80% were in the ‘mostly healthy’ group with 80% discharged after treatment. These were all considerably in excess of any other groups and the averages for all patients.

Reducing delayed discharges at Kings Mill Hospital (the ASSIST project)

The cost to the NHS of treating patients in hospitals no longer needing acute care were estimated by the National Audit Office at £820 million p.a. (in 2015), with £16m being the pro-rata costs for Nottinghamshire. Building on our previous research and experience, Nottingham Business School (NBS) was commissioned by a multi-agency consortium from Health and Local Government to research, design and evaluate a scheme to reduce delayed discharges from the Kings Mill Hospital, in Mansfield. The NBS team developed bespoke databases and an evaluation process, collected and analysed financial and performance data, and acted as ‘critical friends’ and advisors to the project. The 3-year research study found increased use of the ‘ASSIST’ service in Mansfield; significantly increased year on year savings (to both the NHS and adult social care), with falling costs and improved patient outcomes and a rising return on investment ratio that had reached  over 650% by the end of the study.

Improved patient flow and treatment in A&E and alternative settings

NUHT is the single acute service provider for 2.5 million people. NTU’s recommendations have been implemented both by the hospital and by local NHS bodies, providing out-of-hospital healthcare.

QMC was dealing with over 500 patients per day in an area designed to treat a maximum of 350 at the time of the study. As a direct result of NTU’s research, the NHS and service providers in and out of hospital (including A&E, GPs Pharmacies, NHS111 and Out-of-hours services) adopted strategies to alleviate these capacity problems and improve outcomes. They improved triaging, reduced unwarranted presentations, and improved case mix and patient flow into A&E both before and at presentation.

Young adults generally had poor knowledge of alternative provision; students had poorer knowledge than residents with young overseas students the poorest-informed. GPs, and pharmacists redesigned and targeted their treatment practices and advice to the different groups, particularly around severity, and the availability of on-line services and telemedicine.

Nottingham has a ‘young’ population with 28% of its population between 18 and 29; against the national average which is 16%. In addition to changes in the services for students changes were made in equivalent treatment practices, service reconfigurations and out-of-hours services serving the non-student community and were also incorporated in the major new NHS/Local Authority service centres at Clifton Cornerhouse, Mary Potter, Bulwell Riverside, and St Ann’s. A sharp spike in unwarranted alcohol and drug presentations, following the opening of the new QMC hospital stop on the new tramline, was also reversed by changing police, drug and alcohol services practices in the city centre.

This significantly increased capacity for patients genuinely needing A&E with the redirection or signposting of other patients to more appropriate treatment settings. However, these changes did not completely resolve the capacity issue and in December 2018, QMC was awarded £11.9m as a result of a portfolio of evidence (including NTU’s findings), to revamp and extend A&E, which was completed in 2019. The project featured in the Health Foundation report “Transformational change in NHS providers”.

Significantly reduced hospital discharge delays

The ASSIST service in Mansfield was commissioned by the NHS trusts and local authorities in central Nottinghamshire (serving approximately 300,000 population). NTU was commissioned to design develop and evaluate the service by creating databases, systems, evaluation metrics and advice to  the development team. To facilitate wider adoption, NTU also identified critical success factors for such services as well as identifying areas (including Nottingham City), where such schemes had the most potential to be effective and also identified areas where there was little potential.

The multi-agency ‘returns on investment’ delivered savings to the public purse of 130% in the pilot phase, 300% in year 2, and 650% in year 3. This excluded benefits to patients, which would have significantly increased the return on investment although the latter were impossible to capture or measure in the circumstances. Of those that could be measured it  resulted in:

• increasing return on investment (£1.3 m system savings in 2016)
• reduced delays in discharges (6,700 bed days in 2016)
• reduced avoidable admissions (saving £235,053)
• improved collaboration between health and social care
• accelerated adaptations and re-housings
• improved patient outcomes (illustrated by case studies).

Following stage 2, ASSIST was shortlisted for multiple national awards, and won the prestigious Shared Learning Award at the 2017 National Institute for Health and Care Excellence (NICE) national conference, thus giving it an international profile. It has featured on the NICE Shared Learning database ever since. The scheme, or parts thereof, have been replicated or used as a model in all parts of the UK, including a scheme in Nottingham, which by 2019 was reporting savings of £5.4m and £11.42 benefits for every £1 invested.

Following the NICE award, the scheme formed part of the national ‘hospital-at-home’ initiative and was evidence for the UK Parliaments “Delivering Core NHS and Care Services during the Pandemic and Beyond”. Its continuing impact is demonstrated in the annual Adult Social Care Surveys by NHS between 2016-to-date and on the ‘Housing to Health and the coronavirus pandemic webpages’.

• Harradine, D., Prowle, M. and Murphy, P., 2015. Interim report: an examination of the preadmission decision making factors resulting in pressure on A&E at NUHNHST. Nottingham: Nottingham NTU.
• Harradine, D., Murphy, P., Valero-Silva, N. and Prowle, M., 2016. An examination of the reasons that result in Emergency Department attendances, in contrast to alternative care and diagnostic options, for a defined Millennials/Generation Y population in Nottingham. Nottingham NTU.
• Murphy, P., 2013. Public health and health and wellbeing boards: antecedents, theory and development. Perspectives in Public Health, 133 (5), pp. 248-253.
• Ferry, L., Murphy, P. and Glennon, R., 2019. Health and Social Care. In: P. Murphy, L. Ferry, R. Glennon and K. Greenhalgh, eds., Public service accountability: rekindling a debate. Cham, Switzerland: Palgrave Macmillan, pp. 75-90.
• Murphy, P., Harradine, D. and Hewitt, M., 2020. Evaluation of an early discharge from hospital scheme focussing on patients’ housing needs: The ASSIST Project. Health and Social Care in the Community DOI: 10.1111/hsc.12977.
• Murphy, P. and Harradine, D., 2017. Better Together: the ASSIST hospital discharge scheme. In: National Institute for Health and Care Excellence (NICE) Conference, Liverpool Arena, Liverpool, 18th-19th May 2017