Neurology. Initial Scoping Pack. May Clare Young Programme Management Office (PMO)

Transcription

1 Neurology Initial Scoping Pack May 2016 Clare Young Programme Management Office (PMO)

2 Introduction The PMO has triangulated local data, benchmarking and national reports from the sources below to identify the potential problem areas for Neurology in Southampton and a set of recommendations. The Neurology Task & Finish Group should use this scoping pack as a starting point to further explore the problem areas and recommendations. Sources: Local Data: CCG SUS Data National Benchmarking Data: Benchmarking from HES and NHS RightCare Neurology Focus Pack (Apr 2016) Wessex Strategic Clinical Network (SCN): Neurology Intelligence Report (Apr 2016) House of Commons Committee of Public Accounts: Services to people with Neurological Conditions: Progress Review (2015/16) Pharmaceutical Industry Neurology Group (PING): Neurology: Integrating care through networks (Jan 2016) CCG GP Feedback: FYI Friday and CEG 2

3 Structure of Neurology This pack uses the programme budgeting categorisation for Neurology which is consistent with the RightCare approach. It is important to note that Neurology also includes pain; e.g. chest pain, abdominal pain, joint pain, back pain and limb pain. Neurology therefore includes two subcategories: Pain and Neurological Disorders Programme Budgeting Category: Programme Budgeting Subcategories: Pain Neurology Neurological Disorders Main Condition Groups: Chest Pain Abdominal & Pelvic Pain Headaches & Migraines Syncope & Collapse Joint Pain Back Pain Epilepsy Tendency to Fall Limb Pain Nervous System Pain Disorientation Parkinsonism & Extrapyramidal Disorders Unclassifiable Pain Neck Pain Neuromuscular Diseases Motor Neurone Disease & Spinal Muscular Atrophy Multiple Sclerosis & Inflammatory Disorder Carpal Tunnel Syndrome 3

4 Summary of findings: Key Problem Areas & Recommendations

5 Headlines from Local Data Analysis Neurology Between 2009/10 and 2013/14, Southampton has had a 41% increase in NEL admissions compared to elective admissions. Over the past two years, there has been a further 6% increase in NEL admissions and a 2% decrease in elective admissions In 2015/16, we spent nearly 10m on elective and non elective admissions (8,374 admissions), of which 75% were NEL admissions (6,321). There is an imbalance of CCG spend on Neurology with considerably more being spent on NEL admissions 80% ( 7.6m) of our spend is on NEL admissions and 20% is on elective admissions. Our top 6 primary diagnoses with the biggest spend in NEL are: abdominal pain ( 1.4m), chest pain ( 1.2m), tendency to fall ( 950k), epilepsy ( 525k), syncope & collapse ( 522k) and headache/migraine ( 355k). Only 5% of Neurology NEL admissions in 2015/16 were from frequent users NEL Short Stay Admissions (NELSS) 77% of neurology NEL admissions are short stay, costing us 3.8m a year. On average, there are 430 NELSS admissions a month for neurology. 32% of short stays are admitted within 15 minutes before the A&E 4 hour breach deadline. 65% of short stays are from working age adults 89% of short stays are discharged without having a diagnostic or surgical procedure Top 5 NELSS primary diagnoses based on biggest spend: Chest pain ( 1.1m), abdominal pain ( 873k), epilepsy ( 297k), headache/migraine ( 284k) and syncope & collapse ( 270k) Only 5% of NELSS are from frequent users 5

6 Headlines from Benchmarking Comparison Neurology In 2014/15, we spent 3.2m more on Neurology across elective and non elective compared to our 10 most similar CCGs 2.9m more on non elective 0.4m more on elective We spent 375k less on Neurology primary care prescribing We have 68% fewer epilepsy admissions being managed by a consultant neurologist compared to our similar CCGs Pain We spent 1.6m more on Pain compared to our similar CCGs 1.5m more on non elective 0.08m more on elective On NEL admissions, we spent: 591k more on abdominal pain 481k more on chest pain 117k more on back pain 114k more on joint pain Neurological Disorders We spent 1.7m more on Neurological Disorders compared to our similar CCGs 1.5m more on non elective 0.3m more on elective On NEL admissions, we spent: 709k more on tendency to fall 232k more on syncope & collapse 117k more on headache/migraine 114k more on epilepsy 6

7 Summary of Key Problems Following the triangulation of local data, benchmarking and national reports, the PMO suggests that there are two key problem areas in Southampton that need to be addressed: Problem 1: Inappropriate or avoidable A&E attendances & NEL admissions Problem 2: Inappropriate NEL Short Stay Admissions Potential Root Cause 1: Lack of integrated Neurology service provision across primary, secondary, tertiary and social care Potential Root Cause 1: A&E 4 hour breach avoidance Potential Root Cause 2: Risk adverse A&E department and GPs Potential Root Cause 2: Poor access to Consultant Neurologists Potential Root Cause 3: Patient expectation of treatment in hospital vs.self care, lack of patient knowledge and/or willingness to use their GP and NHS 111 7

8 2. Poor access to Neurologists 1. Lack of integrated Neurology service provision across health and care Problem 1: Inappropriate or avoidable A&E attendances & NEL admissions Potential Root Causes Confusion in relation to commissioning responsibilities has created fragmentation within neurology services We have a number of neurology and pain services commissioned, but how effective are they and how well do they talk to each other? Ineffective management and identification of patients with neurological disorders and chronic pain in Primary Care Health and social care not coordinated to manage neurological LTCs and a lack of active care plans An imbalance of CCG spending on Neurology we spend more on NEL than Elective GPs not accessing advice & guidance Poor access to GP appointments so patients present at A&E Lower Primary Care prescribing spend on Neurology than similar CCGs There is an acknowledged shortage of Neurologists in England, with one neurologist per 115,000 population Neurology outpatient waiting times too long so patients present at A&E for example, worried patients who do not want to wait several months to see a neurologist and have a CT scan to reassure them that they don t have a brain tumour, could be presenting at A&E in the hope that they ll get access to a scan quicker. Neurology outpatient appointments taken up by new appointments, so patients with long-term neurological conditions requiring multiple follow-ups cannot get access to a specialist, and deteriorate. Neurologists only manage a small number of admissions, so a patient may be readmitted as an emergency if they don t receive correct diagnosis and care Recommendations Produce a map of all Neurology health & care services in Southampton are we clear on what services exist and how they relate to each other? This should include outpatient services which the CCG is now responsible for commissioning. Contact our best CCG peers (Brighton & Hove, Leeds West and Canterbury & Coastal) to find out what their Neurology pathway and service landscape looks like. Review effectiveness of existing Neurology services for example, the community pain service; how effective is this at reducing NEL pain admissions? Which conditions does the service cover, could the scope be expanded? Explore implementation of a multidisciplinary team for Neurology (national recommendation): integrated primary, secondary and tertiary resources to achieve a neurology network that is easily accessible, provides local care and and involves the regional neurosciences centre (UHS). There are several approaches that could be incorporated into networks such as centres for particular neurological conditions (e.g. GPwSI clinics for headaches), and greater use of technology and triage services. Guidance suggests piloting an MDT through a vanguard site. Explore GP direct access to MRI/CT scan (headaches). This is currently being piloted by WHCCG with HHFT (see appendix). Is it more cost-effective to quickly CT scan patients to reassure them they don t have a brain tumour so they don t present at A&E? Explore rapid access GPwSI clinic for headaches & migraines patients could feel more assured if they get advice from a clinic rather than a GP. Explore a rapid access first seizure clinic for epilepsy to ensure patients get the right care early on, reducing need for follow-up support. Review outpatient waiting times and understand why access to consultant neurologists is worse for our population, even though we have a specialist neuro centre at UHS. Can we free up Neurologist capacity by making more use of specialist neurological nurses? Audit how many of our long term neurological patients have active, written care plans Run GP tutorials for Pain and Neurological Disorders a recent survey in FYI Friday showed that our GPs prefer tutorials to map of medicine. Review Advice & Guidance from consultant neurologists to GPs this is currently in place in Brighton & Hove and Portsmouth have recently run a pilot with UHS (results to be published in June) HeadMat decision support tool for GPs currently being investigated by WHCCG (but not currently compatible with MoM) Prescribing explore if there is a correlation between higher prescribing and lower NEL admissions and review new pain management prescribing guidelines released in December 8

9 2. Risk adverse A&E & GPs 1. A&E 4 Hour breach avoidance 3. Patients Problem 1: Inappropriate or avoidable A&E attendances & NEL admissions Potential Root Causes Recommendations Worried patients panicking over severity of pain and presenting at A&E - e.g. headache or brain tumour? Abdominal pain or appendicitis? Chest pain or heart attack? Cultural issues: some nationalities, e.g. Eastern European, have a culture of going straight to A&E rather than a GP Patient expectation of treatment for pain in hospital vs. selfcare pain management Lack of education for patient self-care and pain management Website for patients on self management and advice on headaches in development by WHCCG, we could use this. Improve patient education for pain management Review the language format of our comms about alternative urgent care services. It is suspected that comms handed out in A&E about other services are only printed in English. Targeted communications for highest presenting age groups and nationalities. Liaise with Brighton & Hove regarding comms campaigns. Lack of patient knowledge of NHS 111/OOHs Problem 2: Inappropriate NEL short stay admissions Potential Root Causes Recommendations UHS is fined if patients stay in A&E longer than 4 hours, so UHS could be admitting some patients unnecessarily just to avoid a fine As a result, the CCG ends up paying for a full cost NEL admission A&E and GPs may not be following referral/admission guidelines and criteria for Neurological conditions which need emergency care Engage secondary care clinicians (A&E, AMU and Neurology) at UHS. Are short stay admissions reviewed by consultant neurologists? Is there a risk stratification set of criteria for admitting neuro NEL patients in A&E? Headaches and chest pain are top priorities for UHS so this should make it easier for us to engage with them. Clinical audit at UHS on NEL short stay admissions were the admissions appropriate? Review the guidelines and algorithms for urgent referral/admission are they over-cautious? Find out where other CCGs have successfully implemented locally agreed NEL short stay tariffs 9

10 DATA FOR PROBLEM 1: Inappropriate or avoidable A&E attendances & NEL admissions

11 Imbalance of CCG spending This chart shows Southampton CCG 2015/16 spend on Neurology for elective and non elective activity. For some conditions, almost 100% of our spend is on NEL admissions. How do we shift our activity so we spend more on elective, to prevent NEL admissions? 11

12 Imbalance of CCG spending The graphs show that there has been a 2% decrease in Southampton CCG elective activity and spend in 2015/16 vs. 2014/15, and a 6% increase in non elective activity and spend. Elective Activity & Spend Non Elective Activity & Spend 2% decrease in 2015/16 vs. 2014/15 6% increase in 2015/16 vs. 2014/15 12

13 Good Bad Imbalance of CCG activity In this graph, negative values represent a reduction in non elective admissions compared to elective admissions over the time period, whereas positive values indicate an increase in the proportion of non elective admissions. Southampton CCG has had a 41% increase in non elective admissions compared with elective admissions. Increase in non elective admissions may create pressure on emergency services and secondary care. It might also represent a marker for evaluating the provision and effectiveness of community services. % Change in non elective vs. elective admissions ratio (2009/10 to 2013/14) What have other CCGs done to decrease their rate of NEL admissions? 13

14 Benchmarking our Non Elective spend vs. similar CCGs This graph shows Southampton CCG NEL spend in red, and then how much more we spend compared to similar CCGs For example, on abdo pain, we spend 1.4m on NEL admissions and the benchmarking suggests we spend 591k more than our similar CCGs How much more we spend on NEL admissions vs. similar CCGs 14

15 Southampton Benchmarking: How much more we spent on NEL Pain The graphs below show that CCG was the 5 th highest spender on NEL Pain admissions out of all CCGs in the country in 2014/15 (weighted). In our peer group, we are the highest spender out of our 10 similar CCGs All CCGs in the country Our 10 similar CCGs 15

16 Southampton Benchmarking: How much more we spent on NEL Neuro Disorders The graphs below show that CCG was the 3 rd highest spender on NEL Neurological Disorder admissions out of all CCGs in the country in 2014/15 (weighted). In our peer group, we are the 2 nd highest spender out of our 10 similar CCGs All CCGs in the country Our 10 similar CCGs 16

17 Poor access to Consultant Neurologists Recent studies into Neurology and anecdotal feedback from GPs suggest that neurology outpatient waiting times are too long, and could adversely be driving up A&E attendances and NEL admissions. It is also nationally reported that there is a shortage and a lack of access to consultant neurologists. According to one report, in areas where there are specialist centres with neurologists permanently based on site, patients could be seen by a neurologist on four or five days in a week. However, in district general hospitals where the neurologists were visiting, patients might be able to see a neurologist only on one or two days a week. UHS is classed as having specialist neuroscience centres, neurology centres and/or DGH with neurology beds which means that access to neurologists should be good. However, the benchmarking suggests the opposite; 68% fewer epilepsy admissions are managed by a consultant neurologist, and 6% fewer new outpatient neurology outpatient appointments seen by a consultant In addition, a survey on patient experience run by the Neurological Alliance indicated shortcomings in neurological services. The diagnosis of neurological conditions took too long people often had four or five GP appointments before they were referred to a neurologist. 17

18 Southampton Epilepsy admissions being managed by a consultant neurologist In the graphs below, you can see that Southampton CCG ranks the 11 th worst CCG in the country for epilepsy admissions not being managed by a consultant neurologist, and the worst CCG in our similar CCG peer group. All CCGs in the country Our 10 similar CCGs 18

19 Southampton New outpatient neurology appointments seen by a consultant Southampton CCG is the below the national average and is the 3 rd worst CCG in our similar CCG peer group All CCGs in the country Our 10 similar CCGs 19

20 Outpatient appointments New to follow up ratio New to follow-up ratios are a measure of the ability of a neurology service to deal with new cases. Low ratios imply a heavy burden of follow-up care which may limit availability of new patient appointments. Such ratios may also suggest difficulty in obtaining an appointment in individuals with long-term conditions who experience deterioration, or who require more urgent review. High ratios however may disadvantage access for those with long-term neurological conditions unless there are alternative options such as clinical nurse specialists or community teams with specific neurological expertise. Southampton has a high ratio of new appointments vs. follow ups This could be positive that lots of new neurology patients are being seen, however this could also disadvantage our population of patients with long term neuro conditions who need frequent follow up care. 20

21 Primary Care & Community Primary Care In Primary Care, there are currently no neurological conditions that are part of QOF. Epilepsy used to be a QOF measure but was decommissioned in April We therefore don t have any visibility of how well our Southampton GP practices are at identifying and managing patients with neurological disorders, including chronic pain. In Primary Care prescribing, we spent 375k less on primary care prescribing for Neurology compared to our 10 similar CCGs. Although this could suggest that we are doing well at managing our spend, alternatively it could be doing more harm than good. For example, Brighton & Hove spend more than us on primary care prescribing for Neurology but have fewer NEL admissions could there be a correlation? Community Integrated Care A survey run by the Neurological Alliance in January 2015 found the following: Nationally, just 12% of people with a neurological condition have a written care plan and only 20% of people had been offered one. Care plans are important in coordinating people s treatment and helping them manage their conditions in the community. In the community, health and social care services are often poorly coordinated; 42% of people surveyed nationally said that the different people treating them worked well together only some of the time, or never. A lack of coordinated care could result in individuals being readmitted to hospital rather than being cared for in the community, which results in the NHS incurring additional costs. 21

22 Weighted A&E attendances by GP practice The GP practices below had higher weighted A&E attendances for Neurology compared to the CCG average. Looking across other specialities, some of the same GP practices are also higher than the CCG average. Practices with higher than average A&E attendances for Neurology (weighted) Neurology Gastroenterology Respiratory Urology ENT TOTAL J Nichols Town Surgery Central J Weston Lane Surgery East J Portswood Solent Surgery Central J Raymond Road Surgery West Y Adelaide Health Centre West J University Health Service Central J Walnut Tree Surgery Central J St.Mary's Surgery Central J Cheviot Road Surgery West J Alma Road Surgery Central J Grove Medical Practice West J Burgess Road Surgery Central J Regents Park Surgery West J Lordshill Health Centre West CCG Practice Weighted Average Could there be an access issue? Could there be a correlation with different population groups? West Locality Central Locality East Locality 22

23 GP Patient survey: ability to get an appointment with a GP Taken from GP Patient Survey - Jan 2016 (January - March 2015 and July - September 2015) Practice Able to get an appointment? code Practice name Locality YES NO J82622 LADIES WALK PRACTICE East 69% 30% J82024 NICHOLS TOWN SURGERY Central 66% 25% J82187 WESTON LANE SURGERY East 79% 21% Y02838 ADELAIDE GP SURGERY West 74% 21% J82092 ALDERMOOR SURGERY West 76% 19% J82171 BITTERNE PARK SURGERY East 79% 18% J82081 ST.MARY'S SURGERY Central 78% 17% J82605 WALNUT TREE SURGERY Central 81% 15% J82080 UNIVERSITY HEALTH SERVICE Central 79% 15% J82115 ATHERLEY HOUSE SURGERY West 81% 14% J82076 WOOLSTON LODGE SURGERY East 82% 14% J82180 TOWNHILL SURGERY East 78% 13% J82208 ST.PETERS SURGERY East 80% 12% J82022 VICTOR STREET SURGERY West 83% 12% J82122 ALMA ROAD SURGERY Central 86% 12% J82663 HIGHFIELD HEALTH Central 82% 11% J82101 CHESSEL PRACTICE East 89% 11% J82619 PORTSWOOD SOLENT SURGERY Central 83% 9% J82126 RAYMOND ROAD SURGERY West 90% 8% J82207 HILL LANE SURGERY West 90% 7% J82203 REGENTS PARK SURGERY West 88% 7% J82088 GROVE MEDICAL PRACTICE West 87% 7% J82001 BURGESS ROAD SURGERY Central 87% 7% J82062 CHEVIOT ROAD SURGERY West 82% 6% J82128 OLD FIRE STATION SURGERY East 93% 6% J82002 LORDSHILL HEALTH CENTRE West 93% 6% J82087 STONEHAM LANE SURGERY Central 93% 5% J82141 BATH LODGE PRACTICE East 88% 5% J82213 BROOK HOUSE SURGERY West 90% 4% J82040 WEST END ROAD SURGERY East 95% 2% J82183 MULBERRY HOUSE SURGERY Central 88% 1% GP Practices in black are the practices from the previous page which had higher than average A&E attendances for Neurology As you can see from the table to the left, some of these GP practices also scored poorly on patients perceived ability to get access to a GP appointment Nichols Town had the highest number of A&E attendances for Neurology and also has one of the worst scores for ability to get a GP appointment. CCG Average 84% 12% 23

24 DATA FOR PROBLEM 2: Inappropriate NEL Short Stay Admissions

25 A&E conversion rate: what % of A&E attendances were then admitted as a NEL admission Benchmarking has looked at neurology A&E conversion rates at UHS versus similar teaching hospitals across the country. The data shows that Brighton (our best CCG comparator) has the lowest A&E conversion rates for Neurology. A&E Conversion Rates for Neurology compared to similar teaching hospitals What does Brighton Hospital do differently to UHS to admit fewer neurology patients from A&E? 25

26 NEL Admissions: % short stay This graph looks at each condition group and splits out what proportion of our total NEL admissions were on short stay (0/1day LoS) vs. non short stay (>1 day LoS). The graph shows that pain NEL admissions generally have a much higher proportion of short stays compared to longer lengths of stay. Long term neurological conditions, such as MS, have a higher proportion of longer lengths of stay than short stay. 26

27 NEL Short Stay Admissions Neurology Overall 77% of NEL Neurology admissions are short stay 65% are working age adults (18-64yrs) Only 5% are frequent users 32% are admitted within 15min before the ED 4 hour breach 89% are discharged without having a diagnostic/surgical procedure Top 3 NEL Short Stay Conditions Chest Pain (32%) Abdominal & Pelvic Pain (18%) Headaches & Migraine (7%) 84% are admitted via A&E 10% are admitted following a request by a GP 58% are admitted during Out of Hours 27

28 NEL Short Stay Admissions Pain Subcategory 84% of NEL Pain admissions are short stay 70% are working age adults (18-64yrs) Only 7% are frequent users 33% are admitted within 15min before the ED 4 hour breach 93% are discharged without having a diagnostic/surgical procedure Top 3 NEL Short Stay Conditions Chest Pain (49%) Abdominal Pain (28%) Joint Pain (6%) 84% are admitted via A&E 11% are admitted following a request by a GP 56% are admitted during Out of Hours 28

29 NEL Short Stay Admissions Neurological Disorder Subcategory 66% of NEL Neurological Disorder admissions are short stay 55% are working age adults (18-64yrs) Only 3% are frequent users 30% are admitted within 15min before the ED 4 hour breach 81% are discharged without having a diagnostic/surgical procedure Top 3 NEL Short Stay Conditions Headaches & Migraines (23%) Syncope & Collapse (20%) Epilepsy (16%) 83% are admitted via A&E 8% are admitted following a request by a GP 60% are admitted during Out of Hours 29

30 NEL Short Stay Admissions The table below shows analysis of short stay admissions by condition groups. The cost of these short stay admissions in 2015/16 added up to 3.25m. Why are UHS admitting these patients as short stay? Condition Group Neurological Disorders Headaches & Migraines Syncope & Collapse % NEL Admissions that are short stay Cost Average no. short stay admissions per month % Discharged without having a procedure % Admitted within 15min before 4hr ED breach % Admitted during OOHs % Admitted via A&E % Age Bands % Frequent users 84% 284, % 30% 57% 75% 82% working age 3% 79% 269, % 37% 60% 97% 50% over 65yrs 45% working age Epilepsy 71% 297, % 30% 64% 89% 52% working age 5% 4% Tendency to fall 34% 113, % 32% 64% 95% 92% over 65yrs 0% Pain Chest Pain 94% 1,089, % 28% 60% 94% 73% working age 7% Abdominal & Pelvic Pain 73% 873, % 35% 53% 68% 74% working age 9% Joint Pain 86% 138, % 45% 60% 89% 47% over 65yrs 42% working age 2% Back Pain 74% 105, % 40% 56% 89% 69% working age 6% Limb Pain 95% 77, % 38% 46% 73% 61% working age 1% 30