London Ambulance Service – calls Number of Category A calls to London Ambulance Service from City and Hackney residents has increased: from 1340 in 2011/12.

London Ambulance Service – calls

• Number of Category A calls to London Ambulance Service from City and Hackney residents has increased: from 1340 in 2011/12 to 1500 in 2012/13 to 1600 in 2013/14 (7-9% increase per year; this increase is comparable to the increase across London of 5-13% each year.

• Number of calls stable across 2013/14: compared to increase over the year in previous 2 years• Majority of these calls are Category A (R2) and Category C2: together making up nearly 70% of all calls• Proportion of Category A calls responded to in 8 minutes and 19 minutes has remained stable over last 3 years:

75% of calls responded to in 8 minutes across all 3 years and slight decrease in number responded to in 19 minutes (from 99% to 95%). Both of these proportions are comparable to response rates across London

Source: LAS CCG monthly report

London Ambulance Service – action

• Following call to LAS vast majority of patients conveyed to A&E: of 37,620 calls in 2012/13 65% conveyed to an A&E (of patients conveyed to an A&E 66% of these were conveyed to Homerton A&E and 20% to Royal London)

• Stable % conveyed to A&E over time – and similar 5 referred but not conveyed, alongside increase in proportion of patients not conveyed (from 16% in 2011/12 to 26% in 2012/13) and more patients conveyed elsewhere (Maternity/HASU/Trauma Unit)

• Proportion conveyed to A&E higher in the winter – 71% in Jan-Mar as opposed to 68% in rest of year

Source: LAS Referral Pathways report

111 – calls

• Average number of calls to 111: 1440 per month over 2013/14• Majority of calls are in daytime (9am-3pm) or evening (7pm-midnight) – together accounting for 60% of

calls. Only 20% between midnight and 9am. • Majority of calls are recommended to attend primary care: 61%. 17% are recommended to attend other

service.• Nearly 20% of calls are recommended to attend A&E or an ambulance is dispatched. Proportions of

recommendation/action in response to calls stay reasonably constant across year. Source: NEL CSU; 2013/14

Out of Hours Primary Care – calls

• Average number of calls increased with change of provider to CHUHSE by at least 5%: an average of ~1700 calls per month over last 2 years, but this has increased to 2140 since December 2013 and the appointment of CHUHSE (however this is a period so calls higher in winter – but average over Dec 2012-March 2013 = 2035 (5% lower than winter 2013/14)

• Number of calls 30% in winter: average number of calls 2090 in winter months (Dec-Mar) compared to 1500 in rest of year

• Cost of CHUHSE contract: The provider is contracted to see 21,000 patients per year for an agreed price of £1,460,460 or £121,705/month. 21,000 calls is 30% higher than Harmoni saw from Dec 2012 to Nov 2013.

OOH – CHUHSE – action

• Majority of calls only telephone advice: 57%, but significant proportion (37%; ~768 per month) require attendance and 6% (~128 per month) require patient visit (data from Dec 2013 to March 2014)

• 98% of calls are routine/less urgent– 1.6% urgent– 0.7% emergency

• Small proportion of cases directed to A&E: 1.8% or ~ 50 cases per month/ 1.3% of calls directed to call 999/LAS (~36 cases per month)

A&E attendances

• Attendances increasing over time: there were 123,000 A&E attendances for City and Hackney patients in 2013/14, the same number as in 2012/13 but an increase from 2011/12 when there were 105,000 A&E attendances. This equates to an increase in the monthly average attendances from 9,600 in 2011/12 to 10,300 in 2013/14

• Vast majority of attendances at Homerton: 70% of these A&E attendances for City and Hackney patients were at the Homerton (2013/14; 9% in same period at Barts Health) Source: SUS

A&E attendances

• Rate of A&E attendances 10% greater in City and Hackney than London average: converting the A&E attendances to a rate to be expressed per 1000 GP registered population shows that for the last 2 years the A&E attendance rate is 10% higher in City and Hackney than across London (average of 32 attendances per month per 1000 population in City and Hakcney compared to 29 per 1000 London population)

Source: HES

A&E attendances

• Attendance at which department – PUCC, Paeds, Majors, Injuries– Total year numbers for 13/14 (Pie chart)– Trend over last 3 years

Source: Homerton Informatics Department

A&E attendances – tariff/cost

• The vast majority of A&E attendances at Homerton A&E are non-complex: cat 1/2 investigations with cat 1/2 treatment: 40% of attendances are cat 1 investigation with cat 1/2 treatment and 25% are cat 2 investigation with cat 1 treatment (these proportions are matched when looking at the total of the top 5 providers).

• A&E attendances at Barts Health are more complex: with higher proportions of more complex investigations and treatments (nearly 30% are cat 3/4 investigation or treatment)

• Total spend on A&E attendances at the Homerton is £7.4million (2013/14) Spend for same period at Barts is £1.3million (higher cost than the proportion of activity suggests due to higher proportion of more expensive tariff attendances)

• Cost of attendances – by attendance department i.e. tariff costs for Paeds, Majors etc, block for PUCC

Source: SUS; 2013/14

A&E attendances – referral source

• 54% of people who attend A&E refer themselves: this proportion of all A&E attendances has been stable over the last 3 years (7% increase in absolute numbers over 3 years)

• 14% of attendees are referred by their GP: this proportion of all A&E attendances has been stable over the last 3 years (but 14% increase in absolute numbers over 3 years)

• There have been some large % increases in referral sources (generally sources with fewer absolute numbers of referrals) from 2011/12 to 2013/14: – 50% increase in referrals from other healthcare providers– 31% increase in referrals from emergency services– 70% increase in referrals from social services

Source: SUS

A&E attendances – time and day

• 25% of A&E attendances are at the weekend: this is a constant for both 2012/13 and 2013/14 (for City and Hackney patients at all trusts)

• Variation in numbers of attendances on different days between 2012/13 and 2013/14 – some very large e.g. a decrease from 30,00 attendances on Thursdays in 2012/13 to less than 10,000 in 2013/14

• Attendances at different times of the day is constant between weekends and weekdays and over the last 2 years. Nearly 75% of attendances are between 8am and 8pm (divided equally between the 3 4hr periods within this). The fewest people attend A&E in the early morning – 4-8am (only 5% of all attendances)

• 95% of people spent 4 hours or less in A&E in 2013/14 (over 50% spent 2 hours or less)• Waiting time target achievement – 12/13 and 13/14

2012/13 2013/14

Source: SUS

Time of attendance; 2013/14

A&E attendances – by practice

• Large variation in A&E attendance rates (per 1000 population) from 214 (Neaman) to 607 (Sorsby) • Sandringham, Sorsby, Beechwood, Wick and Greenhouse all have attendance rate greater than 2 SDs from

City and Hackney mean• Attendance rates mapped against:

– patient satisfaction with access– by distance of practice (or centre point of patient address) to HUH/other trust

Source: SUS; 2013/14

Frequent attenders – visits and patients

• 103,000 A&E attendances in 2013/14 were made up by 60,000 patients • 40,000 patients attended A&E only once; 20,000 patients attended A&E 2-5 times; 1000 patients attended

6-10 times, 200 patients attended 11-19 times and 90 patients attended more than 20 times (during 2013/14)

• Majority of visits to A&E are by those who have been more than once in a year – largest proportion of visits is from those who visited 2-5 times (19,400 patients)

Source: SUS; 2013/14

A&E admissions

• Admissions decreased slightly in 2013/14: total admissions increased from 16,500 in 2011/12 to 17,000 in 2012/13 and then decreased to 15,800 in 2013/14. at the same time as A&E attendances are increasing slightly. The drop of over 2000 admissions in 2013/14 came at a time when A&E attendances had remained at 123,000 from previous year levels.

• Vast majority of attendances at Homerton: 76% in 2013/14. 10% at Barts Health (similar to proportions of A&E attendances at different providers)

Source: SUS

A&E admissions

• Rate of non-elective admissions at similar level to London average (excl dental, maternity, sickle): an average of 6.2 admissions per 1000 population per month. This is despite having a higher attendance rate than London.

• The conversion rate of A&E attendances to admissions in City and Hackney is lower than London and other WELC CCGs (fewer admissions per unit attendance)

• The conversion rate of attendances to admissions increased from 2009/10 (0.16) to 2011/12 (peaking at 0.23) but then decreased during 2012/13. Average admission rate is 0.2 (meaning 1 admission for every 5 attendances).

• Recent analysis by the CSU suggest there is a strong correlation between A&E attendances and admissions, but other factors are more important in dictating admission rates than attendance numbers

Source: HES

A&E admissions – LOS and time of admission

• Nearly 50% of emergency admissions via A&E have a length of stay of more than 2 days . However, the proportion of admissions which are >2 days has decreased slightly since 2011/12

• Barts and UCLH have slightly higher proportions of admissions that have a LOS of more than 2 days . The Whittington have a higher proportion of admissions with a LOS of less than 1 day

• Emergency admissions via A&E cost City and Hackney CCG £34.1million in 2012/13 and £29.1million in 2013/14. Excess bed days charges make up 7% of that cost for both years.

• Benchmark as % of all admissions, to London average• 50% of admissions admitted within 5 hours of arriving at A&E. Of these admissions 35% are admitted in the

half an hour between 3hr 31mins and 4 hrs (the A&E target time) Source: SUS

A&E admissions – discharge

• Vast majority of patients discharged to home (91% in 2013/14)• Admissions to OMU – cost, cost by other A&E department

19,700 calls to OOH GP 3% referred to A&E

(or 999) 6% visited

17,200 calls to 111 10% (1,700)

referred to A&E 9% (1,600) referred

to 999

91% discharged home; 9%

other

123,000 A&E attendances (70% at

Homerton)

Attendance to admission ratio

= 0.2 (20% of attendances

admitted)

38,000 calls to 999 (42% of these Cat A) 65% (24,556)

conveyed to A&E 4.3% of

conveyances to HUH ‘blue lights’ 54% self referral

14% GP referral2% other healthcare

provider

60,000 patients

71% within 8am-8pm (25% at the weekend)

Summary of patient flows for 2013/14

% each A&E dept

15,800 A&E admissions (76% at

Homerton)

50% of admissions have LOS >2 days

22% admitted at 3h50m

Cost

Conveyance to A&E data for 2012/13 but no major change from 2011/12

Cost

Quality and Current interventions

• Quality measures?• Current projects• Cost