Transcript Slide 1

NHS Yorkshire & the Humber
Monthly QIPP Resource Pack
October 2010
1
Introduction
This is the tenth QIPP monthly resource pack. The pack has three components:
CHILDREN’S SERVICES ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which
provides more detailed analysis on a subject relevant to QIPP. This month the hot topic is children’s
services. The analyses presented here are designed to offer insight and raise questions about variation
in performance. They need to be interpreted in the local context.
QIPP METRICS: We have developed a set of metrics to help understand system health in the tighter
financial climate. We will publish these metrics monthly although some of the indicators will only be
updated quarterly. The purpose is to offer insight and improve understanding of how the system
delivering with lower growth.
The next resource pack will be published week commencing 15th November. The hot topic will be
workforce. If you have any questions or comments on the pack, please contact Ian Holmes.
([email protected])
Children’s services - Overview
BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes
which have been developed locally and have potential to deliver better quality at lower cost. This
month the ‘better for less’ example focuses on children’s services.
2
1) Healthy Ambitions: Better for Less
3
Better for Less - Breastfeeding
Why breastfeeding?
Breastfeeding has been found to improve
the health of mother and child in the
short, medium and long term.
Breastfeeding provides infants with all the
nutrients they need for the first six
months of life.
Breastfeeding initiation rates in the UK are
amongst the lowest in Europe, rates in
Yorkshire & the Humber are below the
national average.
How can we provide Better for Less?
A comprehensive programme of activity
that spans acute and community sectors is
required to ensure that that women are
supported to breastfeed for as long as they
wish.
Better for Less - Breastfeeding
Breastfeeding reduces the risk of illness for
mother and child. Encouraging mothers to take up
breast feeding can reduce dependence on health
services in later life, resulting in NHS savings.
4
Better for Less - Breastfeeding
- A structured programme
UNICEF Breastfeeding Initiative (BFI)
provides a quality assurance scheme that
should be seen as the minimum standard
of care for acute & maternity services
with Yorkshire & the Humber.
- Training Staff
All health services and universities providing
training for midwives and health visitors
should achieve UNICEF BFI by 2014.
All areas should have a robust breastfeeding
peer support service in place.
Areas should take opportunities to influence
social norms in favour of a breastfeeding
friendly culture including within NHS
organisations and on NHS premises.
Patient benefits
Breastfed babies are less likely to develop
obesity, diabetes or childhood leukaemia.
There are also a range of other conditions
that breastfed babies are less likely to
encounter.
Better for Less - Breastfeeding
- Better Information
By improving the way that breastfeeding
information and support is provided to
women, they will be able to make an
informed choice of how they feed their
baby. We know that women are more
likely to consider breastfeeding if they
have more information about the
differences between breast & artificial
milk.
5
Better for Less - Breastfeeding
Financial benefits
Potential savings are linked to the
reduced risk of illness for mother and
child through the protective effects of
breastfeeding.
The full financial impact of these benefits
cannot be quantified, however an
estimation of a subset of savings through
the reduced incidence of childhood
gastroenteritis, otitis media and asthma
has been made.
Based on these conditions, NICE equate
that the NHS could save at least £5.6m over
4-5 years if breastfeeding prevalence at six
months was increased by 10%. This equates
to over £550,000 across our region.
In addition to the financial benefits
resulting from the reduced incidence of
other known associated diseases in children
and mothers, increasing breastfeeding rates
provide a significant savings opportunity to
PCTs.
For further information:
Jean Hawkins – Children’s and Families
services manager
[email protected]
Better for Less - Breastfeeding
Breastfeeding mothers are less likely to
develop type 2 diabetes, breast cancer,
ovarian cancer or suffer from postnatal
depression.
6
2) Hot topic: Children’s services
7
Contents
Overview
Children with long term conditions
Children with complex needs
Annexes
Children’s services- Contents
Variation in current patterns of care
8
Contents
Overview
Long Term
Conditions
Children
with
long term conditions
Children with complex needs
Annexes
Children’s services- Contents
Variation in current patterns of care
9
Overview
This information pack is the tenth in a series ‘hot topics’ that will be
While recognising that it may raise more questions than answers, we hope
it will stimulate thought and debate within organisations and health
communities. Clearly the data presented need to be interpreted in the
local context.
We would be delighted to receive comments on the contents together with
any ideas for further ‘children’s services’ analysis.
Children’s Services - Overview
produced by the SHA to support organisations in developing their
understanding of some of the challenges and opportunities presented by
the QIPP agenda.
10
Foreword from CEO sponsor
This resource pack focuses on the way that childhood ill health services are delivered across the region
and identifies areas where quality and value can be improved. A subsequent resource pack will provide
analysis of maternity and social care services for children.
In common with the rest of England only 15% of our children achieve NICE recommended levels of
diabetic control. Y&H has the highest rates of acute asthma admission for children. Improved control of
these conditions has the potential to improve quality of life and reduce admissions and inappropriate
use of A&E.
Healthy Ambitions identified the importance of prevention and early identification in improving the
quality of care received by children, particularly in a primary care setting, and the information in this
pack is designed to help build an understanding of the challenges faced locally and some of the
potential solutions.
The national Child and Maternity Health Observatory (ChiMat) is located in our region and provides
expert analysis on children’s services. They can be contacted at .
Chris Long, Chair of the Children’s Pathway Leadership Board.
Children’s services - Overview
The way that children receive and access services varies across the region and does not necessarily
reflect appropriate service usage. Around 27% of all those who attend A&E are children and nearly one
third of all calls to NHS Direct concern children. A&E attendance is often used as the default position
rather than due to necessity. Data from our region reveals 20-fold variation in A&E attendances by
children at practice level and 4-fold variation in hospital admissions rates by PCT. A small proportion of
children represent a large proportion of the costs, particularly those with long term and complex
conditions and present a significant challenge to the health service due to the bespoke nature of the
care needs.
11
Overview – Population profile
Population estimates Yorkshire & the Humber
2010
Source: ONS population projections
The age profile of populations
varies across our region with
children only representing 22% of
the population of East Riding but
28% in Bradford & Airedale.
Combined with variation in the birth
rates across PCTs the burden of
health care for children is not
evenly distributed.
Change in births per 1000 population: 2011 to 2016 & 2016-2021
Source: ChiMat, YHPHO
4.50%
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
2011-2016
2016-2021
Children’s services - Overview
There are almost 1.3 million
children (aged 0-19) in Yorkshire &
the Humber, representing almost
24% of the total population.
12
Overview - deprivation
There is wide variation across the region
in the proportion of children within a PCT
living in poverty*.
- A PCT wide practice audit in Leeds
found higher A&E attendances to be
correlated with higher levels of
deprivation.
35.0%
30.0%
England
Y&H
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Source: HMRC Child Poverty
Statistics as at 31st Aug 2008
- The requirement for health visitors is
lower in more affluent areas.
-Research suggests poorer control of
diabetic conditions in more deprived
areas.
*defined as families in receipt of child tax credits whose
reported income is less than 60% of the median income or
families in receipt of income support or job-seekers
allowance.
Children’s services - Overview
Evidence suggests differences in access to
health care services and treatment of
conditions by levels of deprivation:
Proportion of children (dependents under age 20) living in poverty*
13
Overview – Primary care health care spend
Estimated PCT expenditure per head (2009/10) by age group
The average cost of primary medical
services is high in young children (04) relative to other age groups (£207
on average).
600
On average pre-school children see
their general practitioner six times
each year. This age group consume a
larger proportion of Primary Medical
Services expenditure than they
represent in the population.
200
Primary medical services
400
300
100
0
0_4
5_14
15_44
45_64
65_74
75+
Source: Department of Health
Proportion of total population (2009) & expenditure (est
2009/10) attributable to each age group
Source: Department of Health
45%
share of PMS expenditure
40%
Share of population
35%
30%
25%
20%
15%
10%
5%
Children’s services - Overview
Average costs of primary care per
head of population in 5-14 year olds
are the lowest of any age group, less
than 5% of total expenditure despite
representing over 10% of the
population.
Prescribing
500
0%
0_4
5_14
15_44
45_64
65_74
75_84
85+
14
Overview – health care spend and age
7,000
6,000
5,000
4,000
However, a small proportion of children 3,000
2,000
account for a large proportion of the
costs within the cohort. Evidence from a 1,000
US study found that 54% of healthcare
0
costs are attributable to the 10% of
Source: Department of Health
children with the highest costs.
Proportion of total population (2009) & expenditure (est
(http://pediatrics.aappublications.org/cg
2009/10) attributable to each age group
i/content/full/118/4/e1001)
12%
Source: Department of Health
In England, two percent of children have
a chronic, life limiting conditions.
10%
8%
6%
4%
2%
0%
shares of HCHS Expenditure
Share of population
Children’s services - Overview
Costs of secondary care services are
generally low for children. Up to half of
infants attend A&E and about 16% of
children attend hospital in any one year.
Estimated PCT expenditure on HCHS services per
head (2009/10) by age group
15
Contents
Overview
Long Term
Conditions
Children
with
long term conditions
Children with complex needs
Annexes
Children’s services- Contents
Variation
Variation in
in current
current patterns
patterns of
of care
care
16
Since Healthy Ambitions, training for new GPs in
respect of competencies for children has improved
although variation remains in:
- referral rates
- use of A&E by children and young people
- admission rates
- re admission rates
- late referral for serious conditions
In response, the SHA is working closely with general
practitioners and others to define and articulate a
quality and outcomes framework. The framework
will describe the constituent elements of good
primary care and general practice for children and
young people.
A Structured Consensus Process method is being used
to ensure that this work is informed by a wide range
of stakeholders including general practitioners and
children and young people. The report of this work
will be published March 2011.
GPs per 100,000 population
Source: Healthy Ambitions
Children’s services – Provision of NHS Services
Primary care services – General practice
17
Health Visiting
Using deprivation scores, King’s College London have
recommended caseload numbers for children under 5
year of age per health visitor.
The Coalition government have stated that they aspire
to increasing health visitor ratio’s in line with the Kings
College modelling. Based on our levels of deprivation
Y&H may have to increase the numbers of health
visitors by 740. Based on average earnings this will
cost £6.4m. East Riding is the only PCT where current
ratio’s would not need to increase.
Health visitors will continue to focus on working with
vulnerable children and families whilst also taking on a
community development role, particularly in areas
supported by Sure Start Children Centres.
Population aged 0-4: Difference between Y&H actual
health visitor caseload and King’s College recommendation
250
200
150
100
50
0
-50
Source: ChiMat
Population aged 5-19: Number of children per school nurse FTE
6000
School Nursing:
There is two-fold variation in the ratio of children to
school nurses across PCTs.
5000
Community Nurses:
Workforce data is limited in terms of the numbers of
community nurses for children or specialist outreach
services. Workforce plans indicate little or no growth
despite the shift from secondary to primary and
community care.
2000
4000
3000
1000
0
Children’s services – Provision of NHS Services
Primary care services – Community services
Source: ChiMat
18
The quality of outpatient data in
the HES dataset is variable across
the region. For 11 PCTs in the
region where sufficient data
appears to be recorded, activity is
relatively evenly split by age
group.
Outpatient appointments by age (2008/09)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Across the region, the most
deprived 5th of the population
represent one third of outpatient
activity.
15+
10-14
5-9
0-4
Data provided by ChiMat. Source: HES
2008/09
Proportion of outpatient appointments by
deprivation quintile
2%
Y&H
11%
0%
28%
20%
26%
40%
33%
60%
80%
100%
Data provided by ChiMat. Source: HES
2008/09
Children’s services – Provision of NHS Services
Secondary care services – Outpatient activity
19
We have compared actual against
predicted secondary care
attendances based on regression
analysis.
Comparison of actual & predicted admissions rates by PCT
250
200
Predicted
Predictedaverage
averageper
perPCO
PCT
Actual
ActualAverage
averageper
perPCO
PCT
150
100
East Riding, Hull and Leeds PCTs
have actual admission rates lower
than predicted by the model.
Factors affecting predicted
admission rates include:
management of conditions,
perceived quality and satisfaction
with GP services, GPs per head of
population and distance from A&E.
50
0
Analysis undertaken by ChiMat
The average accuracy of the model in predicting
admissions rates is 85.8% . Where there are large
differences between actual and predicted rates, the
gap may reflect some factors not accounted for in
the model.
Children’s services – Provision of NHS Services
Provision of NHS services – Secondary care
20
Per person under age 19 there
are more than twice as many
elective procedures for children
in Wakefield relative to
Barnsley.
Elective procedures per 1,000 population aged 0-19 (2008/09)
70.00
60.00
50.00
40.00
30.00
20.00
10.00
Of procedures undertaken in
2008/09, 68% were from waiting
lists in Wakefield, compared to
just 12% in Barnsley, this is
100%
90%
likely to explain some of the Most deprived 20%
80%
60-80%
70%
variation in procedures per
60%
40-60%
50%
head
of
population.
40%
Data provided by ChiMat.
Source: HES 2008/09
Elective procedures by deprivation quintile
20-40%
30%
20%
10%
0%
Least deprived 20%
Hull
Barnsley
Doncaster
North East Lincs
Rotherham
Wakefield
Bradford & Airedale
N Lincs
Kirklees
Calderdale
Sheffield
Leeds
North Yorks & York
East Riding
The most deprived 20% of the
population of children in
Yorkshire & Humber account for
over one third of all elective
procedures carried out.
11%
0%
15%
20%
21%
40%
19%
60%
34%
80%
100%
Data provided by ChiMat.
Source: HES 2008/09
Children’s services – Provision of NHS Services
Provision of NHS Services – Inpatient activity
21
Nationally, there is evidence of the overuse
of certain procedures that may only derive
minimal benefit for patients.
There is wide variation in the use of
grommets nationally and across the region:
from 30% less procedures than expected in
North East Lincs to 51% more than expected
in Hull.
Tonsillectomy is another example, whilst
the procedure may be of modest benefit for
children experiencing severe recurrent
bouts of tonsillitis the benefit may be
outweighed by the risks of surgery.
Reducing activity in line with trusts
performing in the top quartile nationally
has the potential to generate savings of
£774,376 from grommets and £1.15m from
reduced tonsillectomies across the region.
160
140
120
100
80
60
40
20
0
Ratio of actual to expected level of surgery:
Myringotomy with/without grommets (Q3 2009/10)
Source: NHS Better Care
Better Value indicators
Rate of actual to expected level of surgery:
Tonsilectomy (Q3 2009/10)
160
140
120
100
80
60
40
20
0
Source: NHS Better Care
Better Value indicators
Children’s services – Provision of NHS Services
Provision of NHS services – Planned care
22
Nationally, 35 providers are deemed
eligible to provide specialised services
for children, four providers are in our
region.
2,000
1,500
1,000
Average number of operations (total) by trust per
year2006/07 to 2008/09
12-16
6-12
2-5
0-2
500
Over half of all operations for children
in Y&H are undertaken at Sheffield
Children’s Hospital.
Some Trusts undertake relatively few
planned operations but undertake a
high proportion of emergency activity
for children.
Work is underway in the region to
understand this activity in more detail.
Led by SCG, it is reviewing activity
data, compliance with national
standards and workforce analysis.
-
Provided by ChiMat
By trust, emergency operations as a proportion of all (average
proportion across all age groups) 2006/07 to 2008/09
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Provided by ChiMat
Children’s services – Provision of NHS Services
Provision of NHS services – Procedure volumes
23
Children account for 27% of all A&E attendances
across the region yet represent only 24% of the
population.
A&E attendances under 19 rate per 1000, Leeds April – Sept 2007
An 6 month audit of 112 practices in Leeds identified
variation in attendances per 1,000 population from
less than 10 to greater than 300. Further analysis
confirmed that higher attendance rates were in
areas of higher deprivation but even in practices
with comparable deprivation there were up to 4
times as many children directly accessing A&E
Services.
Use of A&E by children is often not for emergency
care and is the default position for concerned
parents.
Source: Report of Children’s pathway group
Percentage of children arriving at A&E by ambulance/helicopter
25%
20%
15%
The low proportion of children arriving by
ambulance at NLAG and Sheffield Children’s Hospital
10%
may reflect use of A&E for more minor concerns.
5%
Inappropriate admissions from A&E may occur due to0%
the lack of paediatric trained staff in A&E
departments. The Healthcare Commission (2007)
stated that 16-18% of hospitals provide insufficient
cover for paediatric emergencies at night.
Source: HES online
Children’s services – Provision of NHS Services
Secondary care – A&E attendances
24
There is almost two-fold variation in
the number of emergency procedures
per head of population across the
region.
There is significant variation across
the region in the proportion of
emergency procedures for the most
deprived children.
Emergency procedures per 1,000 population aged 0-19
90
80
70
60
50
40
30
20
10
-
Provided by ChiMat
A recent national report identified
that those families who live on the
margins of society, who are not
registered with a GP or who are
unaware of the range of services the
NHS provides use emergency services
more. (Kennedy, 2010)
Most deprived 20%
Emergency procedure volumes by deprivation quintile (2008/09)
Y&H
11%
16%
21%
20%
32%
Hull
Barnsley
Doncaster
North East Lincolnshire
Rotherham
Wakefield
North Lincolnshire
Bradford & Airedale
Kirklees
Calderdale
Leeds
Sheffield
North Yorkshire & York
East Riding
60-80%
40-60%
20-40%
Least deprived 20%
0%
20%
40%
60%
80%
100%
Children’s services – Provision of NHS Services
Provision of NHS Services – Emergency activity
Provided by ChiMat
25
Whilst there is not necessarily a
correlation between volumes of
elective and emergency activity for
children’s services, PCTs with high
levels of activity per head of
population should consider approaches
to managing down activity.
Sheffield and Leeds have tertiary
centres for children however Sheffield
has high volumes of elective and
emergency procedures compared to
low levels in Leeds.
85
Doncaster
80
Rotherham
Calderdale
Wakefield
North
Lincolnshire
20
30
North Yorks &
York
Leeds
75
Kirklees
70
Barnsley
High elective,
high emergency
90
Low elective,
low emergency
PCTs in South Yorkshire have activity
volumes greater than the regional
average for both elective and
emergency procedures.
Elective and emergency procedures per 1,000 population (2008/09)
Sheffield
65
40
60
Bradford &
55
Airedale
50
North East
Lincolnshire
60
70
Emergency
50
Hull
East Riding
45
40
Elective
Data provided by ChiMat
Children’s services – Provision of NHS Services
Provision of NHS Services – Inpatient procedures
26
Over half of PCTs in the region have
readmission rates for children greater
than expected (a ratio greater than 1)
given their population.
1.4
Ratio of actual to expected readmissions to hospital within 28
days of discharge (age 0-15), 2007/08
1.2
1
0.8
Leeds and Hull have readmission rates
20% less than expected, North
Lincolnshire and Doncaster have rates
20% higher.
0.6
0.4
0.2
Similar readmission rates in North East
Lincolnshire, North Lincolnshire and
Doncaster may reflect use of the same
provider for a large proportion of
services. The extent to which these
communities have out reach or
community support is also not clear and
needs further work to understand these
differences.
0
Source: NCHOD (2007/08)
Children’s services – Provision of NHS Services
Provision of NHS services - readmission rates
27
Contents
Overview
Long Term
Conditions
Children
Children
with
with
long
long term
term conditions
conditions
Children with complex needs
Annexes
Children’s services- Contents
Variation in current patterns of care
28
The most common long term conditions are asthma, diabetes and epilepsy. Although
emotional ill health and wellbeing are also often long term and have significant
debilitating factors in quality of life and should not be overlooked. Almost 75% of adults
with mental health problems first experienced mental health problems in childhood.
The severity of long term conditions varies from:
-relatively minor with little effect on daily living and quality of life and use of health
services, through to:
- children whose quality of life both in the immediacy of managing the condition on a day
to day basis is an additional burden through to the long term effects of school days lost,
frequent admissions to hospital and the effects of long term medical intervention.
Having a child with a long term condition puts additional restrictions on the family
including financial liabilities in terms of the cost of frequent appointments or restrictions
on family activities.
The Disease management information toolkit contains a range of information highlighting
PCT level variation and enabling benchmarking of information for children with long term
conditions. The tool is available through ChiMat:
http://www.chimat.org.uk/resource/view.aspx?QN=CHMTDMIT
Children’s services – Long term conditions
Long term conditions - Overview
29
1.1m children in the UK are currently
receiving treatment for asthma. The
causes of asthma are unknown but a
family history of asthma and allergies
and environmental factors are thought
to have an influence.
Many children with asthma have poor
control of their condition, often as a
consequence of poor compliance with
therapy. This may lead to
exacerbations of the condition and
hospital admissions.
Hospital admission rates for asthma per head of
population (age & sex standardised)
Children’s services – Long term conditions
Asthma - Overview
30
There is anecdotal evidence, supported by limited audit that National Clinical
Guidelines for the management of children with asthma is poorly adhered to.
As part of the Healthy Ambitions programme we are testing out the
effectiveness of Enhanced Services agreements in primary care to deliver
Gold Standard care for children with asthma
Enhanced Services Agreements are being trialled by 5 practices in Kirklees, 4
in Wakefield and 6 in Hull.
Standards include:
• Accurate diagnosis
• Timely reviews
• Longer appointments for reviews
• Detailed self management plans
• Follow up visits for children following admissions to hospital
Children’s services – Long term conditions
Asthma – Gold standard care
31
Children’s Services – Long term conditions
Asthma – A&E attendances, a practice audit (1)
NHS Kirklees undertook a practice
audit of paediatric Accident and
Emergency Attendances for Asthma
in 2009/10.
The results highlight variation from
0.9 attendances per 1,000 children
to almost 20.
As a result of this audit, NHS
Kirklees are offering resource
support to strengthen education
and training in primary care. Links
with public health have also been
established to provide education
around subjects such as smoke free
homes.
NHS Kirklees Paediatric A&E Attendances for
Asthma 2009/10
(Attendances per 1000 Practice Population aged 18 and under)
69
67
65
63
61
59
57
55
53
51
49
47
45
43
41
39
37
35
33
31
29
27
25
23
21
19
17
15
13
11
9
7
5
3
1
Average
0.0
5.0
10.0
15.0
20.0
32
high rate,
low distance
high rate,
high distance
20.0
- Practices further away from A&E
services tend to have below
average A&E attendance rates.
- Practices with high attendance
rates tend to closer than average
to A&E departments, but other
practices close to A&E managed to
maintain low attendance rates.
25.0
A&E attendances
Further investigation of the audit
data revealed the following
relationship between A&E
attendances and distance:
Paediatric Asthma A&E Attendances per 1,000 Practice Population
under 19 and Distance From Nearest A&E, NHS Kirklees 2009/10
15.0
10.0
0
2
low rate,
low distance
5.0
0.0
distance from A&E
4
6
8
10
low rate, high distance
Provided by NHS Kirklees
12
Children’s services – Long term conditions
Asthma – A&E attendances, a practice audit (2)
33
Asthma admissions per 100,000
population fluctuate over time
across the majority of PCTs in the
region. Peaks in activity in
alternate years may be caused by
factors including increased air
pollution during bad winters and
high pollen counts during summer.
Whilst admissions for the majority
of PCTs traces the regional trend,
many have experienced reduced
admissions in 2008/09 relative to
2003/04.
Asthma emergency admissions per 100,000 population: 2003/04 –
2008/09
300
280
260
240
220
200
180
160
140
120
100
2003-4
2004-5
2005-06
2006-07
2007-08
2008-09
Source: ChiMat
Change in asthma emergency admissions per 100,000 population:
2003/04 – 2008/09
60%
40%
20%
0%
-20%
-40%
-60%
Source: ChiMat
Children’s services – Long term conditions
Asthma – Inpatient care: emergency admission rates
34
400
350
300
120
250
100
200
80
150
60
100
40
50
20
0
0
The average cost of a asthma admission
is £625. Improving asthma admission
rates in line with PCTs performing in
Potential annual cost savings through reduced
the top 5% nationally would generate
admissions
£180,000
savings of £1.12m for the region.
£160,000
North East Lincolnshire have relatively
low admissions rates, they operate a
highly integrated health and social care
model that puts a great deal of
emphasis on prevention and early
intervention which is a major factor in
prevention of escalation of asthma
symptoms.
140
£140,000
£120,000
£100,000
£80,000
£60,000
£40,000
£20,000
£0
National ranking
In 2008/09 emergency admissions
per 100,000 vary three fold. This results
from a combination of patient factors,
assessable services and, adherence to
clinical protocols, underpinned by
variation of knowledge, skills and
experience.
Admissions per 100,000 population
Asthma emergency admissions per 100,000 population: & national
ranking position (1-152) 2008/09
rates
Source: ChiMat
emergency asthma
compared to England
compared to top 25%
compared to top 5%
Source: ChiMat
Children’s services – Long term conditions
Asthma – Inpatient care: emergency admission rates
35
At SHA level, average length of stay has
declined by 1.4% over the 5 year period
between 2003/04 and 2008/09,
however there is wide variation across
the region.
Hull has experienced the largest
reduction from 3.2 days however is still
amongst the highest levels in the
region. No PCT has had a consistently
declining trend over the period.
160
140
120
100
80
60
40
National ranking position
For the majority of our PCTs there is
little correlation between rankings for
asthma admissions and average length
of stay.
Average length of stay (days)
National average length of stay for
asthma patients is 1.21 days in
2008/09.
Asthma patients average length of stay (days) 2008/09
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
20
0
Source: ChiMat
% change in average length of stay between 2003/04 and 2008/09
6.0%
4.0%
2.0%
0.0%
-2.0%
-4.0%
-6.0%
-8.0%
-10.0%
-12.0%
-14.0%
Source: ChiMat
Children’s services – Long term conditions
Asthma – Inpatient care: average length of stay
36
There is a strong relationship between
PCT rankings for asthma admissions
and emergency bed days; this
relationship implies that, as expected,
the majority of asthma admissions are
for urgent care services.
Over the period Sheffield has the
highest rate of growth (from a low
starting point) and Hull has the
highest rate of decline (from a very
high starting point).
Asthma emergency bed days per 100,000 population 2003/04 - 2008/09
600
400
Bradford and
Airedale
300
Calderdale
200
0
2003-4 2004-5 2005-06 2006-07 2007-08 2008-09
1200
400
North Lincolnshire 1000
200
100
0
Doncaster
100
500
300
Barnsley
500
Hull
800
North Yorkshire and
York
600
Rotherham
400
Sheffield
Wakefield District
East Riding Of
Yorkshire
Kirklees
Leeds
North East
Lincolnshire
200
0
2003-4 2004-5 2005-06 2006-07 2007-08 2008-09
Produced by ChiMat
Children’s services – Long term conditions
Asthma – Inpatient care: emergency bed days
37
HbA1c is a quantitative measure of
outcome in diabetes. A higher value is
associated with a substantially increased
risk of developing severe, life
threatening complications, acutely or in
the future.
The National Diabetes Audit published in
2010 has once again revealed that both
nationally and in Y&H SHA, 85% of
children with diabetes are not achieving
acceptable levels of HbA1c less than
7.5%.
Paediatric Epidemiology Group, University of Leeds
The most common long term complications seen as a result of diabetes are premature
heart disease, blindness, peripheral vascular disease leading to amputations and renal
failure often requiring dialysis and renal transplantation.
A recent study conducted by the Department of Paediatric Epidemiology, University of
Leeds, using data from the Yorkshire Register of Diabetes in Children and Young People ,
demonstrated that deaths due to diabetes in children and young people were 3.9 times
higher than in a comparable age group without diabetes.
Children’s services – Long term conditions
Long term conditions - Diabetes
38
The Paediatric Diabetes Network links 21 centres in the 14 PCT’s in Y&H SHA and shares
methods of prevention, diagnosis and treatment alongside trying to address the demand
for services and resources.
There is a plan to develop a Standard Service Specification to help Commissioners and
Providers deliver safe, high quality children and young peoples diabetes care as
efficiently as possible and to link this to a Quality Assurance Programme conducted
through Peer Review. The Network is the national exemplar and as such is assisting at DH
level with obtaining a ‘best practice ‘tariff for Paediatric Diabetes Care.
We know from the analysis undertaken by Leeds University as part of the Diabetes
Register for Children and Young People that our services do vary in clinical outcomes.
Calderdale and Huddersfield Foundation Trust have some of the best outcomes in the
region and their service model has been shared widely with others.
A programme of clinical Peer Review, using the methodology developed by the National
Cancer Team, is being piloted in Y&H in 2010/11 and will be rolled out to all centres in
2011/12. The aim is to identify what is working well in terms of compliance with national
protocols, resource allocations, skills and experience and other markers and to identify
those areas where improvement may be made.
Children’s services – Long term conditions
Long term conditions - Diabetes
39
Mean HbA1c by Unit 2007/08 and 2008/09
9.4
9.2
HbA1c %
Research by the Paediatric
Epidemiology Group at Leeds
University found wide variation in
average levels of diabetic control, as
measured by HbA1c, across
treatment centres. The proportion
of patients with good control
declined overall between 2007/08
and 2008/09.
9.6
9
8.8
8.6
8.4
8.2
2008/09
2007/08
Paediatric Epidemiology
Group, University of Leeds
Adjusted HbA1c vs Resource
Deprivation, duration of disease and
age affect the relationship between
resource and glycaemic control.
Lower resource
Higher HbA1c
Higher resource
Higher HbA1c
Harrogate
Dewsbury Hull
Barnsley
Pinderfields Bradford
York
Northallerton
Scunthorpe
Pontefract
Adjusted mean HbA1c
Doncaster
HbA1c
Services with poorer HbA1c results
despite reasonable levels of resource
tend to be those caring for children
who are older, poorer and been
diagnosed for longer.
Grimsby
Huddersfield
Rotherham
Airedale
Leeds SJUH
Bassetlaw
Leeds LGI
Sheffield
Scarborough
Lower resource
Lower HbA1c
Calderdale
Resource
Higher resource
Paediatric Epidemiology
Lower HbA1c
Group, University of Leeds
Children’s services – Long term conditions
Diabetes – Resources and outcomes
40
In 2006/07 there were an estimated
2,338 children in Yorkshire & the
Humber with all types of diabetes.
Research in North, East and West
Yorkshire examined HbA1c levels by
age at diagnosis, duration of
diabetes, sex, deprivation, size of
centre (between 60 and 229
patients). There was found to be
significantly poorer control of
diabetic conditions in deprived
areas.
Living in the most deprived areas
compared to the most affluent
translates into an increase in mean
HbA1c of 0.5%.
Healthy Ambitions: Report of Childrens
Clinical Pathway Group May 2008
Children’s services – Long term conditions
Diabetes – Disease management
41
The average cost of a diabetes
admission is £971. There is the
potential for PCTs across the region
to save over half a million pounds
through reducing diabetes
admissions in line with trusts
performing in the top 5% nationally.
Given the wide variation in
admission rates (more than 3-fold
variation between Doncaster and
North East Lincs) some areas have
greater opportunity to realise
savings.
140
160
140
120
100
80
60
40
20
0
120
100
80
60
40
20
0
National rank
Admissions per 100,000 population
The majority of hospital admissions
for diabetes reflect complications
with the condition. Better
management of conditions can
reduce complications.
Diabetes emergency admissions per 100,000 population: &
national ranking position 2008/09
Produced by ChiMat
Potential annual cost savings through reduced emergency diabetes
admissions
£100,000
£90,000
£80,000
£70,000
£60,000
£50,000
£40,000
£30,000
£20,000
£10,000
£0
compared to
England
compared to top
25%
Children’s services – Long term conditions
Diabetes – Inpatient care: admission rates
42
North East Lincolnshire, Bradford
& Airedale and Leeds have some
of the lowest admission rates in
the region, however they have
the highest average lengths of
stay in the region and nationally.
The majority of PCTs have seen a
reduction in average length of
stay for diabetes over the 5 year
period 2003/04 to 2008/09.
Diabetes patients average length of stay (days) & national
ranking position, 2008/09
4
3.5
3
2.5
2
1.5
1
0.5
0
140
120
100
80
60
40
20
0
Source: ChiMat
Diabetes: change in average length of stay (days) 2003/04 to 2008/09
8.00%
6.00%
Doncaster had the highest
average length of stay in 2003/04
and has experienced the largest
reduction, some of this is likely to
reflect improvements in data
quality.
4.00%
2.00%
0.00%
-2.00%
-4.00%
-6.00%
-8.00%
Source: ChiMat
Children’s services – Long term conditions
Diabetes – Inpatient care: average length of stay
43
For the majority of PCTs there is a
strong correlation between
diabetes admissions and
emergency bed days. Outliers
include Sheffield with relatively
high admissions but low
emergency bed days, likely
reflecting short lengths of stay.
Diabetes emergency bed days per 100,000 population 2003/04 - 2008/09
500
400
Barnsley
300
Bradford and
Airedale
Calderdale
200
Doncaster
100
East Riding Of
Yorkshire
0
250
300
250
200
150
North Lincolnshire
200
Hull
North Yorkshire and 150
York
Kirklees
Rotherham
Leeds
100
100
50
0
Children’s services – Long term conditions
Diabetes – Inpatient care: emergency bed days
Sheffield
Wakefield District
50
North East
Lincolnshire
0
Produced by ChiMat
44
Contents
Overview
Long Term
Conditions
Children
with
long term conditions
Children
Children with
with complex
complex needs
needs
Annexes
Children’s services- Contents
Variation in current patterns of care
45
A continuing care package is required when a child or young person has needs
arising from disability, accident or illness that cannot be met by existing
universal or specialist services alone.
Continuing care requires bespoke case by case commissioning to establish
individual care packages. If these individual packages of care are not put in
place, most children with this level of need will remain in hospital.
The Family Resources Survey 2002-3 estimated that there are approximately
700,000 disabled children under 16 in Great Britain. However, the
prevalence of severe disability and complex needs requiring continuing care is
steadily increasing. This is due to a number of factors, including increased
survival of pre-term babies and increased survival of children after severe
trauma or illness.
The children’s NSF published in 2004, estimated that there were up to 6,000
children living at home with complex needs who are dependent on assistive
technology.
Children’s services – Children with complex needs
Children with complex needs - Overview
46
National guidance gives the NHS responsibility
for leading the commissioning of children’s
continuing care, involving the local authority
and other partners as appropriate. Across our
region, half of PCTs have a dedicated function
for assessing and identifying children’s
continuing care needs.
The range of services included in a continuing
care package are likely to require
commissioning by PCTs, local authority
children’s services and sometimes others.
Information from two-thirds of PCTs across
the region highlights wide variation in
commissioning time dedicated to children’s
continuing care needs, from 1 whole time
equivalent to just 0.02.
Responsibility for assessment and identification
of continuing care needs
No response
Adult
Continuing
Care Team
Provider
Nursing
Team
Local
Authority
Children's
Continuing
Care
Assessor
Children’s services – Children with complex needs
Commissioning for children with complex needs
47
In 2009/10 continuing care packages were commissioned for over 100 children in
the region. There is wide variation in the costs incurred by PCTs in the provision
of continuing care packages. Based on information received from a small
number of PCTs, the average amount spent on a care package is £43,000.
Where PCTs were able to provide an hourly rate for the cost of services
commissioned this ranges from £12 to £66.
PCTs are responsible for establishing and managing governance arrangements for
the children and young people’s continuing care process and ensuring a flexible
response to meet the needs of the child and the family, including consideration
of personal budgets.
Three commissioners stated that rurality was a real issue in securing providers
of care packages and particular pockets of the region were challenged with lack
of available staff to satisfy packages.
Children’s services – Children with complex needs
Children with complex needs – cost of services
48
There are currently over 100 children in
the region with care packages
commissioned in 2009/10. Such packages
require bespoke case by case
commissioning, failure to put these
packages in place often results in
children remaining in hospital.
Currently, 9 children in hospital across
the region are medically fit for
discharge. On average, medical
stabilisation is achieved in week 16,
however on average thirty six weeks are
being spent in hospital when not
medically required.
The reasons for delay are varied but
thematic: funding for the package being
agreed, suitable provider being identified
staff recruitment and training,
equipment funding and procurement and
housing adaptations.
Number of care packages commissioned in 2009/10
40
35
30
25
20
15
10
5
0
Number of children awaiting a care package in 2009/10
PCT
EAST RIDING
BARNSLEY
WAKEFIELD DISTRICT
DONCASTER
NORTH LINCOLNSHIRE
NORTH EAST LINCS
LEEDS
NORTH YORKSHIRE & YORK
Number of
children
waiting
1
1
1
1
1
1
1
2
Children’s services – Children with complex needs
Children with complex needs - volume of care packages
49
A retrospective audit of children with long term ventilation needs in the region identified
significant overstays in hospital after children were medically fit for discharge.
The average length of stay in intensive care units was 55 weeks however patients were, on
average, medically stable for discharge at 12 weeks. The excess time spent in hospital
reflects delays in the provision of appropriate community support for each child.
There are significant potential savings to be realised through facilitating the timely
discharge of patients:
-The average cost of a community package is £600 per 24 hours
-The tariff price for an intensive care bed in £1,000 per 24 hours.
The audit revealed costs of £2.06m due to overstays in hospital, the cost of community
services for the same time period equates to just £1.23m. Being able to facilitate timely
discharge for the 6 patients included in the audit would save £824,000, over £137,000 per
patient.
There are currently 9 children in the region medically fit for discharge awaiting an
appropriate care package.
NB: These costs do not include the opportunity costs associated with blocked PICU / HDU beds and
consequential out of area transfers.
Children’s services – Children with complex needs
Children with complex needs – Long term ventilation
50
60
Number of weeks
There is wide variation across the
region in the length of time
between assessment and delivery
of care packages reflecting the
bespoke requirements and
individual needs.
Number of weeks between assessment and delivery of care packages
(2009/10)
50
40
30
20
10
0
The length of time between
assessment and package delivery
ranges from less than 1 week to 14
months. The shortest time to
delivery of a care package is
associated with PCTs using a
children’s continuing care assessor,
across the region they assess
almost 90% of cases.
Where PCTs have established a culture of
early discharge, close working with the
acute trust and between the commissioner
and community provider, forward planning
and timely services were reported to be
effectively delivered.
Children’s services – Children with complex needs
Children with complex needs – Assessment and delivery
51
Contents
Overview
Long Term
Conditions
Children
with
long term conditions
Children with complex needs
Annexes
Children’s services- Contents
Variation in current patterns of care
52
Acknowledgements
Craig Baxter - Senior Health Intelligence Specialist – ChiMat
Susan Bottomley – Programme Lead, Children & Families Programme, YHIP
Sonja Buckle (formerly Fretwell) – Assistant Regional Development Worker – YHIP
Dr Fiona Campbell – General medicine and diabetes, Leeds Teaching Hospitals NHS Trust
Dr Ian Lewis – Paediatric Oncologist, Leeds Teaching Hospitals NHS Trust
Jen Love – Children, Young People & Maternity services, NHS Kirklees
Roger Paslow – Senior Lecturer, Paediatric Epidemiology Group, University of Leeds
Geraldine Sands – Strategic lead, safeguarding and partnerships, NHS Y&H
53
Key contacts
Children and Maternal Health Observatory (ChiMat) local specialists
http://www.chimat.org.uk/resource/view.aspx?RID=84356
Jean Hawkins – Children’s and Families Services Manager, NHS Y&H
[email protected]
Ian Holmes – Associate Director, Economics and System Management, NHS Y&H
[email protected]
Helen Mercer – Economist, NHS Y&H
[email protected]
54
3) QIPP metrics
55
QIPP metrics (1)
56
QIPP metrics (2)
57
QIPP metrics (3)
58
QIPP metrics (4)
59
QIPP metrics (5)
60
QIPP metrics (6)
61
PH1: CO validated quit rate at Stop Smoking Service
%
IC Omnibus Q1 2009/10
PH2: 15-24 yr olds screened or tested for Chlamydia
YTD
HPA Sep 2009
PH3: All age all cause mortality males
rate per 100,000
ONS Q1 2008/09
PH4: All age all cause mortality females
rate per 100,000
ONS Q1 2008/09
PH5: Infants being breastfed at 6-8 week
%
VSMR - Unify Q2 2009/10
PH6: Alcohol related admissions
per 100,000
admissions
2008/9 provisional EASR
QIPP metrics – definitions and sources
Indicator
Units
Indicator
Source
Units
Source
Activity - Acute trusts
Activity - PCTs
A1: Emergency Readmission rates - nonelective; within 14 days of discharge %
Dr Foster data Q1 2009/10
A1: Emerg Readmission rates - nonelective within 14 days of discharge
%
Dr Foster data Q1 2009/10
A2: Elective LOS
Days
Dr Foster data Q1 2009/10
A3: Elective LOS compared to expected LOS
Days
Dr Foster data Q1 2009/11
A4: Nonelective LOS
Days
Dr Foster data Q1 2009/12
A5: Nonelective LOS compared to expected LOS
Days
Dr Foster data Q1 2009/10
A6: Hospital Standardised Mortality Ratio
Ratio
Dr Foster data Q1 2009/10
A7: Crude hospital-based mortality rates
%
Dr Foster data Q1 2009/10
A8: Daycase rates - Dr Foster indicator based on CQC groups
%
Dr Foster data Q1 2009/10
A9: First to Follow up OP
Ratio
BCBV data for Q1 2009/10
A10: Pre-operative bed day rates
%
BCBV data for Q4 2008/09
A11: Acute delayed discharges for adults
%
Unify Jul 2009
A2: Elective LOS (days)
Days
Dr Foster data Q1 2009/10
A3: Elective LOS compared to expected LOS (days)
Days
Dr Foster data Q1 2009/10
A4: Nonelective LOS (days)
Days
Dr Foster data Q1 2009/10
A5: Nonelective LOS compared to expected LOS (days)
Days
Dr Foster data Q1 2009/10
A6: Hospital Standardised Mortality Ratio (days)
Days
Dr Foster data Q1 2009/10
A7: Crude hospital-based mortality rates (rate per 100,000)
Rate per 100,000
Dr Foster data Q1 2009/10
A8: GP referrals (G&A) - YTD against VS Plans (%)
%
Unify & Vital Signs Oct 2009
A9: Other referrals (G&A) - YTD against VS Plans (%)
%
Unify & Vital Signs Oct 2009
Quality & Safety and Prescribing - PCTs
P1: Low cost prescribing for ACEI (%)
%
BCBV data Q1 2009/10
P2: Low cost PPI's vs all PPI's prescriptions (%)
%
BCBV data Q1 2009/10
P3: Low cost prescribing for statins - all prescriptions (%)
%
SHA Q1 2009/10
QS1: Hospital acquired Infection rates - Cumulative Rates of C.Diff
per 100,000 pop
SHA Nov 2009
QS2: Hospital acquired Infection rates - Cumualtive Rates of MRSA
per 100,000 pop
SHA Nov 2009
QS3: 62 day Cancer RTT Waits (%)
%
Unify Oct 2009
QS4: Patients treated within 18 weeks Admitted (%)
%
Unify Sep 2009
QS5: Patients treated within 18 weeks Non-admitted (%)
%
Unify Sep 2009
Quality & Safety - Acute Trusts
QS1: Hospital acquired Infection rates - Cumulative Rates of C.Diff
per 1000 ord adms
SHA Sep 2009
age 2+
QS2: Hospital acquired Infection rates - Cumualtive Rates of MRSA
per 1000 bed-days
SHA Sep 2009
QS3: 62 day Cancer RTT Waits
%
SHA Sep 2009
QS4: Patients treated within 18 weeks Admitted
%
SHA Sep 2009
QS5: Patients treated within 18 weeks Non-admitted
%
SHA Sep 2009
QS6: A&E 4 hour target
%
SHA 29/11/2009
QS7: Cancelled ops not treated within 28 days of last min cancellation
%
SHA Q2 2009/10
WF1: PCT total paybill
millions £
ESR Jul-Sep 2009
WF2: PCT total Staff in Post by organisation
number
iView Sep 2009
WF3: PCT annualised Av Basic Pay per FTE
thousands £
iView Q2 2009
WF4: PCT sickness Absence rates
%
iView Q2 2009
WF5: PCT turnover using FTE
%
ESR Jul-Sep 2009
WF6: PCT ratio of Clincal to Non-clinical staff
Ratio
Med & Non-Med Census '08
WF7: Acute trust total paybill
millions £
ESR Jul-Sep 2009
WF8: Acute trust total Staff in Post by organisation
number
iView Sep 2009
WF9: Acute trust annualised Av Basic Pay per FTE
thousands £
iView Q2 2009
WF10: Acute trust sickness Absence rates
%
iView Q2 2009
Workforce - PCTs & Acute Trusts
Prevention and Public Health - PCTs
PH1: CO validated quit rate at Stop Smoking Service
%
IC Omnibus Q1 2009/10
PH2: 15-24 yr olds screened or tested for Chlamydia
YTD
HPA Sep 2009
PH3: All age all cause mortality males
rate per 100,000
ONS Q1 2008/09
PH4: All age all cause mortality females
rate per 100,000
ONS Q1 2008/09
PH5: Infants being breastfed at 6-8 week
%
VSMR - Unify Q2 2009/10
PH6: Alcohol related admissions
per 100,000
admissions
2008/9 provisional EASR
Indicator
Units
Source
Activity - Acute trusts
A1: Emerg Readmission rates - nonelective within 14 days of discharge
%
Dr Foster data Q1 2009/10
WF11: Acute trust turnover using FTE
%
ESR Jul-Sep 2009
A2: Elective LOS
Days
Dr Foster data Q1 2009/10
WF12: Acute trust ratio of Clincal to Non-clinical staff
Ratio
Med & Non-Med Census '08
A3: Elective LOS compared to expected LOS
Days
Dr Foster data Q1 2009/11
A4: Nonelective LOS
Days
Dr Foster data Q1 2009/12
A5: Nonelective LOS compared to expected LOS
Days
Dr Foster data Q1 2009/10
A6: Hospital Standardised Mortality Ratio
Ratio
Dr Foster data Q1 2009/10
A7: Crude hospital-based mortality rates
%
Dr Foster data Q1 2009/10
A8: Daycase rates - Dr Foster indicator based on CQC groups
%
Dr Foster data Q1 2009/10
A9: First to Follow up OP
Ratio
BCBV data for Q1 2009/10
62