Strategic Bed Capacity Requirements

Transcription

1 Appendix J: Projected The Capacity Shrewsbury and Requirements Telford Hospital NHS Trust

2 Report Strategic Bed Capacity Requirements Report version 1.8 August 2011 Based on SaTH bed model v1.9g TTC House, Hadley Park, Telford, Shropshire TF1 6QJ Tel: Fax:

3 Contents 1.0 Introduction Background Key Challenges Future Configuration of Hospital Services OBC Current (Baseline) Inpatient Bed Capacity Current Performance against National Indicators Commissioner Perspective Methodology and Assumptions Overview of Modelling Approach Modelling Stages Baseline Activity and Capacity Demographic Change Epidemiological Trends Procedures of Limited Clinical Value Avoidable non-elective admissions Increasing Day Surgery Rates Length of Stay Throughput Impact on bed requirements Scenario Planning Scenario Definition Summary of Strategic Bed Requirements Projected Activity and Bed Requirements for each Specialty Other Considerations Assessment Ambulatory Emergency Care Rehabilitation / Intermediate Care Stroke Neonatology and Critical Care Cohort and Escalation Appendix 1: Trust Bed Census 27 th June Appendix 2: FCHS OBC Changes in the Strategic Context Appendix 3: 2011/12 Commissioning Plans

4 List of Tables Table 1: Baseline... 5 Table 2: Summary of performance against Better Care, Better Value indicators... 7 Table 3: Better Care, Better Value: Reducing Length of Stay, Trust performance against benchmark, quarter / Table 4: Better Care, Better Value: classification of specialties with scope for reducing beddays... 9 Table 5: Baseline Activity Profile Table 6: Projected Population Change - Shropshire County and Telford & Wrekin Table 7: Impact of Projected Population Change on Activity and Inpatient Bed Requirement Table 8: Procedures of Limited value Table 9: Avoidable Emergency Admissions Table 10: Increasing Day Surgery Rates Table 11: Reducing Length of Stay Table 12: Impact of Each Model Stage on Demand for Inpatient (95% occupancy) Table 13: Scenario Definition Table 14: Notional Net Impact of Each Scenario (based on 95% occupancy) Table 15: Summary of Inpatient Activity and Bed Requirements Table 16: Projected Spells by Specialty for each Scenario Table 17: Projected Bed Requirement by Specialty for each Scenario Table 18: Ambulatory Emergency Care: Potential Impact by Specialty Table 19: Summary of Bed Usage by Length of Stay Group Table 20: Analysis of Long Stay (20+ days) Beddays by Specialty Table 21: Bed Use by Length of Stay and Locality Table 22: Current and Projected Stroke Activity and capacity Requirements Table 23: Stroke Rehabilitation Bed Requirement by Locality Table 24: FCHS OBC Proposed bed Capacities compared with Wider Bed Capacity Model Scenarios. 37 3

5 1.0 Introduction 1.1 Background This report presents the results of an analysis of the Trust s longer term strategic bed capacity requirements to inform the service and estate planning agenda for the next 5-10 and 10+ years. This builds on the work undertaken across the health economy during 2008 and 2009, Developing Health and Healthcare, 2020 Vision. The clinical vision and objectives from that earlier work were considered to remain valid for the current study: Prevention of disease and the promotion of healthy lifestyles and independent living; Provision of services at home or as close to home as possible; Provision of sustainable and accessible acute hospital services. The study was sponsored by the Trust Chief Operating Officer, and overseen by a working group consisting of key stakeholders including: Director of Strategy, SaTH Director of Commissioning Intelligence, NHS Telford and Wrekin (also on behalf of SCPCT) Interim Associate Director of Operational Performance, SaTH Medical Director, SaTH Value Stream Lead, Unscheduled Care, SaTH Head of Continuous Improvement, SaTH Contracts and Performance Manager, SaTH Associate Director of Estates and Facilities Management, SaTH FCHS Programme Manager, SaTH This group oversaw the development of the activity and capacity model to quantify the Trust s strategic bed capacity requirements. The group met three times during the development of the model. An initial version of the model was reported during July to support interim submissions of the FCHS OBC. The model has subsequently been revised and refined, most notably in two key respects: The inclusion of results based on both higher (95%) and lower (90%) occupancy rates for the general acute specialties; The recalibration of the target scenarios based on a progressive shift towards upper quartile length of stay performance. 1.2 Key Challenges The objective was to project future bed requirements in a flexible way in order to be able to answer a number of key questions and challenges facing the Trust such as: The need to quantify, for strategic service and estate planning purposes, the number and balance of beds required for each specialty and service for the short, medium and long term; The challenge to reduce the Trust s cost-base while continuing to provide excellent and appropriate clinical care; 4

6 The challenge to improve efficiency and performance, taking account of available national benchmarks and evidence-based models of care. 1.3 Future Configuration of Hospital Services OBC The analysis has been undertaken in the context of the development of an Outline Business Case (OBC) for the Future Configuration of Hospital Services which is a response to three important dilemmas facing local hospital services: Making sure the Trust continues to provide 24 hour acute surgery in the county; Making sure the range of inpatient children s services are maintained within the county; Planning to move out of the deteriorating maternity and children s services building at the RSH site before this building fails for clinical care. The OBC concentrates on the service changes that need to happen in the short term (0-2 years), and was originally informed by an initial capacity modelling exercise concentrating on the services and specialties concerned: Surgery / Urology / Head & Neck; Maternity / Gynaecology / Neonatology; Children s Services. The bed capacity requirements for the OBC were subsequently worked up and agreed through a series of clinical workshops which gave detailed consideration to proposed future models of care. These are summarised in Appendix 2 of this report to demonstrate how they fit into the wider picture. 1.4 Current (Baseline) Inpatient Bed Capacity The starting point for this exercise is an assessment of existing available (staffed) bed capacity. A bed census was undertaken at the end of June 2011, and the results of this are given in Appendix 1. The summary results for each specialty are given below. The table also includes the notional bed requirement calculated based on the Trust s current activity and performance levels, with percentage occupancy at 95% for all specialties except paediatrics and obstetrics (80%). Table 1: Baseline Specialty Group Specialty Name Trust Bed Census June 2011: Inpatient & Trolleys (RSH & PRH) Notional Calculated Inpatient Bed Requirement (based on current throughput) Medicine Accident & Emergency 0 Cardiology 30 Dermatology 0 Gastroenterology 36 General Medicine 382 Nephrology 8 Neurology 0 5

7 Specialty Group Specialty Name Trust Bed Census June 2011: Inpatient & Trolleys (RSH & PRH) Notional Calculated Inpatient Bed Requirement (based on current throughput) Medicine Total Surgery Anaesthetics 0 General Surgery Plastic Surgery 0 Urology Surgery Total Head & Neck ENT 8 Oral Surgery 2 Head & Neck Total 20 9 Ophthalmology Ophthalmology 0 2 Ophthalmology Total 0 2 T&O T&O T&O Total Haematology/ Oncology Clinical Haematology 12 9 Haematology/ Oncology Total Clinical Oncology Women & Children Gynaecology Women & Children Total Neonatology Obstetrics Paediatrics Sub-total Critical Care 21 Cohort 25 Discharge Ward 20 Grand Total Excludes maternity beds at Ludlow, Bridgnorth and Oswestry Excluding critical care, cohort and discharge beds (see below), at 821 the overall currently available number of inpatient beds equates precisely with the expected number of beds based on current activity and throughput levels. The allocation of beds between specialties, however, shows some 6

8 variation, with the medical specialties being relatively under-bedded relative to current requirements, whilst the other specialties for the most part have more allocated beds. The current medical bed-base is supplemented by the Cohort Ward and Discharge Ward, as well as accounting for a significant proportion of the critical care bed use; if these are added to the 387 census medical beds, the current medical bed stock is effectively nearer to 430. The fact that this is slightly lower than the calculated number can be explained by: current medical bed occupancy is typically 97% or higher; medical patients frequently occupy beds allocated to other specialties. For every other specialty group, the notional calculated bed requirement is lower than the number of allocated beds. This is also partially accounted for by medical outliers, and by the fact that surgical specialties in particular have traditionally required a buffer against bed-borrowing by medical patients. 1.5 Current Performance against National Indicators A number of the Better Care, Better Value indicators are based on factors that influence the need for inpatient beds. A high level summary of the performance of the Trust and its major commissioners for the latest available quarter is given in the table below. These are based on the Trust moving 25% towards benchmark performance for each indicator. It should be noted that this is only a snapshot of one quarter s performance. Table 2: Summary of performance against Better Care, Better Value indicators Indicator Measure Volume Opportunity Provider Indicators: SaTH Financial Opportunity Quarter 3 ( 000) Rank Reducing Length of Stay Bed days 9,006 1, Emergency Readmissions Emergency readmissions (14 days) Pre-Procedure Non- Bed Day rate 3, Elective Bed Days Pre-Procedure Elective Bed Day rate Bed Days Increasing Day Surgery Daycase rate Rates Commissioner Indicators: SCPCT and NHST&W Emergency Admissions: SCPCT Emergency Admissions: NHST&W Managing Surgical Thresholds: SCPCT Managing Surgical Thresholds: NHST&W Emergency admissions per 100k population Emergency admissions per 100k population Operations per 100k population Operations per 100k population The rank shown in the table is indicative only as the number of organisations involved varies for each indicator. In general, a lower rank indicates better performance. From this, it appears that local performance against national benchmarks varies for different indicators, though there is room for improvement in all of them. 7

9 The indicator for reducing length of stay is based on a target of reducing the number of beddays above the median for each element of casemix by 25%. The indicator for quarter /11 suggests a potential to reduce beddays by 9,006. If converted to an annual target, this equates to 36,000 beddays, or 104 beds at 95% occupancy. The performance of each specialty against this indicator for quarter /11 is shown below: Table 3: Better Care, Better Value: Reducing Length of Stay, Trust performance against benchmark, quarter /11 Bed day saving Financial Treatment Function No. of bed days Rank % Opportunity General Medicine ,500 4, Trauma & Orthopaedics ,755 1, Obstetrics , General Surgery , Paediatrics , Gastroenterology , Cardiology , Urology , Gynaecology , Ear, Nose & Throat (ENT) , Clinical Oncology (previously Radiotherapy) , Clinical Haematology , Endocrinology , Rehabilitation , Colorectal Surgery , Nephrology , Respiratory Medicine (Thoracic Medicine) , Geriatric Medicine , Ophthalmology , Pain Management , Vascular Surgery , Hepatology , Oral Surgery , Maxillo Facial Surgery Accident & Emergency (A&E) Paediatric Dermatology

10 Bed day saving Financial Treatment Function No. of bed days Rank % Opportunity Breast Surgery Diabetic Medicine Medical Ophthalmology Respiratory Physiology Paediatric Surgery Upper Gastrointestinal Surgery Audiological Medicine Neurology This appears to show that there are a number of specialties with significant scope to reduce length of stay in comparison with national median performance (bearing in mind that this a snapshot of one quarter only). Some specialties are already performing well relative to other Trusts, while others appear to be performing less well. The table below summarises this: Table 4: Better Care, Better Value: classification of specialties with scope for reducing beddays Specialties with the most scope for reducing bed days (> 100 beddays) Specialties already doing well in comparison with other Trusts (rank <50) General Surgery Paediatrics Urology Gynaecology Specialties performing in line with mid-range performance of other Trusts (rank 50 to 120) General Medicine Gastroenterology Cardiology Specialties doing less well in comparison with other Trusts (rank > 120) Trauma & Orthopaedics Obstetrics Other specialties with some scope for reducing beddays ( beddays) Clinical Oncology Clinical Haematology Rehabilitation Nephrology Respiratory Medicine ENT Endocrinology Colorectal Surgery Ophthalmology Pain Management Geriatric Medicine Where appropriate, the detailed calculations used in the wider bed capacity model use detailed definitions based on those used in the national indicators, though there are important differences in order to ensure that the model reflects local requirements. For example, the Better Care, Better Value indicator for reducing length of stay is based on a 25% move towards median length of stay. In practice, the Trust wishes to explore more challenging targets, and the bed model therefore also looks at the potential to move further towards median length of stay, and also the potential to move towards upper quartile and upper decile performance. 1.6 Commissioner Perspective In developing the bed capacity model, every effort was made to ensure that the requirements of the Trust s main commissioners were included. The Director of Commissioning Intelligence for NHS 9

11 Telford and Wrekin was a member of the working group and was fully involved in discussion and refinement of the modelling assumptions. By agreement, he also represented the interests of Shropshire County PCT. An analysis of how the capacity model responds to the commissioning plans for the two PCTs is given in Appendix 3. 10

12 2.0 Methodology and Assumptions 2.1 Overview of Modelling Approach The bed capacity model used a sequential process to project future requirements, the starting point for which was the Trust s current activity profile at a detailed level. An assessment of various factors affecting future demand was then made, followed by consideration of appropriate models of care and performance benchmarks. Finally, relevant throughput and utilisation rates were agreed in order to derive future capacity requirements. The modelling approach is summarised below: Baseline Activity and Capacity SaTH 2010/11 inpatient and daycase activity SaTH current bedstate June/ July 2011 HRGs, specialties, age groups, elective / non elective, length of stay, PCT / locality of residence Spells, beddays, excess beddays, baseline beds Demand Population change: 0, 5 and 10 year time horizons Demand management: avoidable emergency admissions Demand management: procedures of limited clinical value Other commissioning intentions Models of Care Increasing day surgery rates Reducing Length of stay Ambulatory emergency care Throughput and Utilisation Percentage occupancy Bed availability Capacity Requirements Inpatient Each of the modelling stages is discussed in more detail in the following sections. 11

13 2.2 Modelling Stages Baseline Activity and Capacity The baseline for the model was the inpatient and daycase dataset for 2010/11. This includes details of all patient spells for the year, including diagnoses and operative procedures. This level of detail allows mapping and analysis of patient activity according to a wide range of benchmarks and model of care guidance. The baseline activity profile is summarised below: Table 5: Baseline Activity Profile Specialty Group Specialty Name Daycases Elective Inpatients Non- Elective Inpatients Grand Total Medicine Accident & Emergency 7 7 Cardiology ,477 2,236 Dermatology Gastroenterology 2, ,515 4,559 General Medicine 8, ,267 27,369 Nephrology Neurology Medicine Total 12, ,687 34,843 Surgery Anaesthetics General Surgery 5,360 2,111 5,525 12,996 Plastic Surgery Urology 4,037 1, ,658 Surgery Total 10,546 3,154 6,110 19,810 Head & Neck ENT 1, ,295 Oral Surgery 1, ,566 Head & Neck Total 2, ,861 Ophthalmology Ophthalmology 7, ,670 Ophthalmology Total 7, ,670 T&O T&O 1,856 1,417 3,267 6,540 T&O Total 1,856 1,417 3,267 6,540 Haematology/ Oncology Clinical Haematology 4, ,783 Clinical Oncology 7, ,269 Haematology/ Oncology Total 11,564 1, ,052 Women & Children Gynaecology 1, ,389 3,918 Neonatology 1,699 1,699 Obstetrics 6,407 6,407 Paediatrics 1, ,456 9,371 Women & Children Total 3,000 1,444 16,951 21,395 12

14 Specialty Group Specialty Name Daycases Elective Inpatients Non- Elective Inpatients Grand Total Grand Total 49,298 8,368 49, ,171 The baseline bed capacity for the model is summarised in section 1.4 above. The bed capacity model is aimed at understanding the future requirement for inpatient beds for RSH and PRH. As such, the bed capacity calculations shown below exclude the following: Daycase beds; Cots for healthy babies; in other settings (community hospitals, nursing homes, private sector etc) Demographic Change Population Projections The latest subnational population projections from the Office for National Statistics were used as the starting point for an assessment of future demand for services. Since between them Shropshire County PCT and NHS Telford and Wrekin account for 87% of the Trust s inpatient activity, the projections for these two areas were used. The projections for Telford and Wrekin were then adjusted to take account of the local council s view that the ONS projections may not adequately reflect local housing development plans. NHS Telford and Wrekin gave advice as to the necessary adjustments to make. The resulting projections for each age group were applied to the model for all services except maternity and neonatology as summarised below: Table 6: Projected Population Change - Shropshire County and Telford & Wrekin Population Change SCPCT and NHST&W Projected population (000) % change Age Group to to 2021 (five years) (ten years) % +3% % -5% % +3% % +27% % +44% Total % +6% The population of Shropshire as a whole is projected to increase from 458,000 in 2011 to 485,000 in 2021, a rise of 6%. A very significant increase in the number of elderly people is projected. Over a ten year period, the number of people aged between 65 and 79 is projected to increase by 27%, with those aged 80 or over increasing by 44%. The significance of this is that these age groups account for much of the demand for inpatient beds, and make up a high proportion of the patients who need to stay in hospital for lengthy periods. 13

15 Birth Projections Future demand for maternity and neonatology services is directly related to the number of births. The number of births for Shropshire, Telford and Wrekin is projected to increase by 2.6% between 2011 and 2015, and by 6.7% between 2011 and These birth projections have been used instead of overall population projections for obstetrics and neonatology. Demography: Impact by Specialty The notional impact by specialty is summarised below: Table 7: Impact of Projected Population Change on Activity and Inpatient Bed Requirement Specialty Group Specialty Name Sum of 5 Year Demography Spells Sum of 10 Year Demography Spells Sum of 5 Year Demography All Sum of 10 Year Demography All Medicine Accident & Emergency Cardiology Dermatology Gastroenterology General Medicine 1,867 3, Nephrology Neurology Medicine Total 2,247 4, Surgery Anaesthetics General Surgery Urology Surgery Total 670 1, Head & Neck ENT Oral Surgery Head & Neck Total Ophthalmology Ophthalmology Ophthalmology Total T&O T&O T&O Total Haematology/ Oncology Clinical Haematology Clinical Oncology Haematology/ Oncology Total Women & Children Gynaecology Neonatology Obstetrics Paediatrics

16 Specialty Group Specialty Name Sum of 5 Year Demography Spells Sum of 10 Year Demography Spells Sum of 5 Year Demography All Sum of 10 Year Demography All Women & Children Total Grand Total 3,664 7, The net impact of the projected demographic changes suggest that, without any change to ways of working and models of care, an additional 185 inpatient beds would be required to meet the increase in demand by This is projected to have a particular impact on the general medical specialties, and on general surgery, urology and orthopaedics Epidemiological Trends The working group did consider the potential effects of epidemiological change. It was felt that trends relating to certain conditions could influence the demand for acute hospital care over and above the demographic changes outlined above, notably: Diabetes; CHD; Stroke; Specific cancers (eg prostate, colorectal); Other obesity-related diseases (eg cholecystitis, gout, osteoarthritis, sleep apnoea). However, since there is no easily-available estimate for the local changes in these conditions relative to overall population change, it was felt that this aspect could not be included in the model at this stage. Instead, it was agreed to continue to develop an understanding of the impact of epidemiological change on acute care and to sensitivity test for this at some point in the future Procedures of Limited Clinical Value There is a range of procedures considered by commissioners to be of limited clinical value. For each of these, a commissioning policy has been developed defining the clinical criteria required for eligibility for funding. Based on commissioner advice as to the impact of the various policies across both PCTs, the following target reductions have been modelled: Arthroscopic washout of knee: 0% Carpel Tunnel: -10% Circumcision: -10% Diagnostic Arthroscopy: -50% Dupuytrens Release: -15% Gallstones: - 5% Ganglion: -15% Grommets: -20% Haemorrhoidectomy: -10% Hips threshold: -10% Knees threshold: -10% 15

17 Spinal Epidural: -35% Spinal fusion -10% Others: 0% The notional impact on the requirement for inpatient beds of achieving the target reductions for these procedures is summarised below: Table 8: Procedures of Limited value Specialty Group Specialty Name Sum of PLCV Spells Sum of PLCV Medicine Accident & Emergency Cardiology Dermatology Gastroenterology General Medicine Nephrology Neurology Medicine Total Surgery Anaesthetics General Surgery Urology Surgery Total Head & Neck ENT Oral Surgery Head & Neck Total Ophthalmology Ophthalmology Ophthalmology Total T&O T&O T&O Total Haematology/ Oncology Clinical Haematology Clinical Oncology Haematology/ Oncology Total Women & Children Gynaecology Neonatology Obstetrics Paediatrics Women & Children Total Grand Total

18 Most of the procedures defined as of limited clinical value are undertaken in a daycase setting, and so their impact on the inpatient bed requirement is low Avoidable non-elective admissions Many patients present at A&E with problems which may have been avoidable if they had been managed better in the community. The Better Care, Better Value indicators define 19 conditions where this is particularly likely. After consideration by the working group, a 15% reduction target was set for most of these conditions. The exceptions were those where it was considered that significant local initiatives and infrastructure have already been in place for some time, and the opportunities for further reduction are therefore more limited, namely cellulitis, influenza and pneumonia, for which a smaller 7.5% target reduction was agreed. Table 9: Avoidable Emergency Admissions Sum of Avoidable Admissions Spells Sum of Avoidable Admissions Angina Asthma Cellulitis Congestive heart failure Convulsions & epilepsy Dehydration and gastroenteritis Dental conditions Diabetes complications Ear, nose & throat infections Gangrene Hypertension -5-0 Influenza & pneumonia Iron deficiency anaemia Nutritional deficiencies -0-0 Pelvic inflammatory disease -8-0 Perforated or bleeding ulcer Pyelonephritis Ruptured appendix Vaccine preventable -3-0 Grand Total Were these targets to be achieved, the net impact would be a requirement for 14 fewer inpatient beds. The greatest potential reductions in admissions would be for ENT infections, influenza / pneumonia, convulsions / epilepsy, and gastroenteritis / dehydration. The greatest impact on the requirement for inpatient beds would be for influenza / pneumonia and congestive heart failure Increasing Day Surgery Rates The British Association of Day Surgery (BADS) has developed guidance on a set of aspirational targets for delivery of elective and day case activity across a wide range of specialties and 17

19 procedures 1. For each procedure, the aspirational proportion of cases is specified that could be undertaken under different management options, namely: Procedure room: operation that may be performed in a suitable cleran environment outside of theatres; Daycase: traditional day surgery; 23 hour stay: patient admitted and discharged within 24 hours; 72 hour stay: patient admitted and discharged within 72 hours. The notional impact of applying these targets to the Trust s activity would result in a shift of 1,456 cases from elective overnight care to daycase care. The impact by specialty is summarised below: Table 10: Increasing Day Surgery Rates Specialty Group Specialty Name Sum of BADS Shift to DC Spells Medicine Accident & Emergency Sum of BADS Shift to DC 0 0 Cardiology Dermatology 0 0 Gastroenterology -3-0 General Medicine Nephrology 0 0 Neurology 0 0 Medicine Total Surgery Anaesthetics 0 0 General Surgery Urology Surgery Total Head & Neck ENT Oral Surgery Head & Neck Total Ophthalmology Ophthalmology Ophthalmology Total T&O T&O T&O Total Haematology/ Oncology Clinical Haematology -1 0 Clinical Oncology 0 0 Haematology/ Oncology Total British Association of Day Surgery Directory of Procedures, v3, January

20 Specialty Group Specialty Name Sum of BADS Shift to DC Spells Sum of BADS Shift to DC Women & Children Gynaecology Neonatology 0 0 Obstetrics 0 0 Paediatrics Women & Children Total Grand Total -1,456-8 This demonstrates the potential for a reduction of 8 inpatient beds across the specialties of General Surgery, Urology, Trauma & Orthopaedics and Gynaecology and children s surgery Length of Stay There are many factors that contribute to the number of days each inpatient spends in hospital, and length of stay varies considerably between different hospitals. There is thus considerable scope for length of stay reduction. The target reduction highlighted in the Better Care, Better Value indicators is based on a 25% reduction in the number of bed-days above the median for each casemix group (base on Healthcare Resource Groups), considered nationally to be a generally achievable level of improvement. The Trust wished to explore length of stay targets across a range of scenarios and so, for the bed capacity model, upper quartile and upper decile benchmarks have used in addition to median. National length of stay benchmarks for 2009/10, the latest available national data, has been used. The impact for each specialty of applying this range of length of stay benchmarks is summarised below: Table 11: Reducing Length of Stay Specialty Group Specialty Name Sum of 25% to Median LoS Medicine Accident & Emergency Sum of 20% to UQ LoS Sum of 25% to UQ LoS Sum of 25% to UD LoS Sum of 35% to UQ LoS Sum of 50% to Median LoS Sum of 50% to UQ LoS Sum of 50% to UD LoS Cardiology Dermatology Gastroenterology General Medicine Nephrology Neurology Medicine Total Surgery Anaesthetics General Surgery

21 Specialty Group Specialty Name Sum of 25% to Median LoS Sum of 20% to UQ LoS Sum of 25% to UQ LoS Sum of 25% to UD LoS Sum of 35% to UQ LoS Sum of 50% to Median LoS Sum of 50% to UQ LoS Sum of 50% to UD LoS Urology Surgery Total Head & Neck ENT Head & Neck Total Oral Surgery Ophthalmology Ophthalmology Ophthalmology Total T&O T&O T&O Total Haematology/ Oncology Haematology/ Oncology Total Women & Children Women & Children Total Clinical Haematology Clinical Oncology Gynaecology Neonatology Obstetrics Paediatrics Grand Total This analysis bears out the conclusions in section 1.5 above that those specialties with the most potential to reduce their length of stay and thus their inpatient bed requirement are: General Medicine; Cardiology; Gastroenterology; General Surgery; Urology; Trauma & Orthopaedics; Paediatrics; Obstetrics. 20

22 2.2.8 Throughput The working group discussed the percentage occupancy to be used for planning purposes with the aim of striking the balance between being challenging while allowing for day-to-day and seasonal peaks and troughs in demand. The following two rates were agreed: Higher rate, reflecting the pressure to use facilities as intensively as possible: 95% for general acute specialties, 80% for maternity and paediatrics; Lower rate, reflecting more usual planning assumption and giving more flexibility to respond to fluctuations in demand: 90% for general acute specialties, 80% for maternity and paediatrics. The indicative bed impact for each stage of modelling (shown in sections 2.2 and 2.3) is based on the higher rate. The results for each scenario detailed in section 3.0 below are based on both rates. 21

23 Babies Elective Short Stay Elective Medium Stay Elective Long Stay Non Elective Short Stay Non Elective Medium Stay Non Elective Long Stay Grand Total 2.3 Impact on bed requirements The various factors described in section 2.2 may be combined in different ways to give an estimate of projected future activity and capacity. As a starting point for this, the indicative impact of each factor on the requirement for inpatient beds is summarised below (based, for illustrative purposes, on the higher rate of percentage occupancy): Table 12: Impact of Each Model Stage on Demand for Inpatient (95% occupancy) Sum of Baseline Notional Inpatient Sum of 5 Year Demography All Sum of 10 Year Demography All Sum of Avoidable Admissions Sum of PLCV Sum of BADS Shift to DC Sum of 25% to Median LoS Sum of 20% to UQ LoS Sum of 25% to UQ LoS Sum of 35% to UQ LoS Sum of 50% to Median LoS Sum of 50% to UQ LoS The categories in the above table are defined as follows: Babies and neonates requiring clinical care (ie admission method 82 or 83, but excluding healthy babies); Elective and Non-Elective Short Stay: length of stay 0 to 5 days; Elective and Non-Elective Medium Stay: length of stay 6 to 20 days; Elective and Non-Elective Long Stay: length of stay 20+ days. 22

24 3.0 Scenario Planning In order to develop a way forward for the future, a range of scenarios was developed based on the principle that the Trust wishes to work through a progressive series of changes over a number of years. The scenarios were defined in terms of the factors with a direct bearing on the inpatient bed requirement. Scenario A was defined to reflect the position relative to the current Better Care, Better Value length of stay target. The other scenarios were defined to reflect the Trust s desire to aim for realistic but challenging length of stay targets based on moving progressively towards the national upper quartile benchmark. 3.1 Scenario Definition The agreed scenarios are summarised as follows: Table 13: Scenario Definition Indicative Net Bed Impact (95% occupancy) Scenarios A B C D Sum of 5 Year Demography All 91 Demography included in each scenario Sum of 10 Year Demography All 185 Sum of Avoidable Admissions -14 A B C D Sum of PLCV -1 A B C D Sum of BADS Shift to DC -8 A B C D Sum of 25% to Median LoS -113 A Sum of 20% to UQ LoS -124 B Sum of 25% to UQ LoS -155 Sum of 35% to UQ LoS -217 C Sum of 50% to Median LoS -227 Sum of 50% to UQ LoS -310 D The notional net impact of these scenarios on the requirement for inpatient beds is as follows: Table 14: Notional Net Impact of Each Scenario (based on 95% occupancy) Scenario A Scenario B Scenario C Scenario D i) No demography ii) 5 year demography iii) 10 year demography Bearing in mind the Trust s current bed occupancy rates of 97%, the notional bed impact shown above is based on a very challenging 95% bed occupancy target for most specialties. A more usual 23

25 planning target is 90% occupancy. Each scenario has been calculated using both of these occupancy rates for the general acute specialties (with maternity and paediatrics at 80%). The Trust will need to consider which of these occupancy targets it wishes to aim for. 3.2 Summary of Strategic Bed Requirements The Trust s objective is to be able to make immediate improvements to allow current activity levels to be managed as efficiently and effectively as possible, and then to absorb future population-driven demand increases through a continuous programme of service improvement. This strategy can be summarised as follows: Table 15: Summary of Inpatient Activity and Bed Requirements Inpatient Activity (Spells) Inpatient Required (95% occupancy) Inpatient Required (90% occupancy) Current 55, Short term (0-2 years) Scenario Ai: 25% shift towards median length of stay 55, Short term (0-2 years) Scenario Bi: 20% shift towards upper quartile length of stay 5 years Scenario Cii: 35% shift towards upper quartile length of stay 10 years Scenario Diii: 50% shift towards upper quartile length of stay 55, , , Achievement of these improvements will enable the Trust to manage more clinical activity with fewer inpatient beds. In practical terms, the Trust s aim is to reduce the requirement for inpatient beds during 2011/12 and 2012/13, following which continuous improvement will allow further demand pressures to be managed within the resulting bed base together with a flexible cohort ward. 3.3 Projected Activity and Bed Requirements for each Specialty The net result of the scenarios described above on activity for each specialty is as follows: Table 16: Projected Spells by Specialty for each Scenario Specialty Group Haematology/ Oncology Haematology/ Oncology Total Specialty Name Scenario A Spells Scenario B Spells Scenario C Spells Scenario D Spells Clinical Haematology Clinical Oncology ,076 1,124 1,485 1,485 1,619 1,699 24

26 Head & Neck ENT 1,072 1,072 1,128 1,189 Oral Surgery Head & Neck Total 1,364 1,364 1,425 1,494 Medicine Accident & Emergency Cardiology 1,530 1,530 1,702 1,864 Dermatology Gastroenterology 1,533 1,533 1,698 1,858 General Medicine 18,045 18,045 19,912 21,746 Nephrology Neurology Medicine Total 21,533 21,533 23,780 25,976 Ophthalmology Ophthalmology Ophthalmology Total Surgery Anaesthetics General Surgery 7,228 7,228 7,721 8,164 Urology 1,445 1,445 1,621 1,764 Surgery Total 8,679 8,679 9,349 9,937 T&O T&O 4,376 4,376 4,715 5,043 T&O Total 4,376 4,376 4,715 5,043 Women & Children Gynaecology 2,113 2,113 2,119 2,153 Women & Children Total Neonatology 1,699 1,699 1,743 1,813 Obstetrics 6,399 6,399 6,524 6,760 Paediatrics 7,454 7,454 7,447 7,649 17,665 17,665 17,834 18,375 Grand Total 55,495 55,495 59,160 63,000 Between 2011 and 2020, an increase in inpatient activity is projected for every specialty, with overall activity increasing by 14%. The projected bed requirement by specialty is shown in the following table, set next to the calculated baseline bed requirement (see section 1.4 above). These projections should be read in conjunction with the notes in section 3.4 below. 25

27 Notional Calculated Baseline 95% Occupancy 90% Occupancy 95% Occupancy 90% Occupancy 95% Occupancy 90% Occupancy 95% Occupancy 90% Occupancy Table 17: Projected Bed Requirement by Specialty for each Scenario Scenario A Scenario B Scenario C Scenario D Specialty Group Specialty Name Haematology/ Oncology Clinical Haematology Clinical Oncology Haematology/ Oncology Total Head & Neck ENT Oral Surgery Head & Neck Total Medicine Accident & Emergency Cardiology Dermatology Gastroenterology General Medicine Nephrology Neurology Medicine Total Ophthalmology Ophthalmology Ophthalmology Total Surgery Anaesthetics General Surgery Urology Surgery Total T&O T&O T&O Total Women & Children Gynaecology Neonatology Obstetrics Paediatrics Women & Children Total

28 Notional Calculated Baseline 95% Occupancy 90% Occupancy 95% Occupancy 90% Occupancy 95% Occupancy 90% Occupancy 95% Occupancy 90% Occupancy Scenario A Scenario B Scenario C Scenario D Specialty Group Specialty Name Grand Total Other Considerations Assessment The Royal College of Physicians suggests the following method of quantifying the required number of assessment beds: As a guide, for efficient units, the minimum number of beds will be equivalent to the number of patients admitted per 24 hours, plus 10%. 2 Applying this guideline to the Trust s non-elective activity gives the following indicative number of assessment beds Medical Assessment : 65 Surgical Assessment : 22 Gynaecology Assessment : 4 Trauma Assessment : 10 These beds are included in the overall bed projections given in Table 17 above Ambulatory Emergency Care The NHS Institute for Innovation and Improvement defines a wide range of conditions for which acute care may be often delivered without the need for overnight stay in hospital 3. These fall into four broad categories: Diagnostic exclusion: e.g. chest pain / possible MI, breathlessness / possible PE; Low-risk stratification: e.g. some community-acquired pneumonias; Specific procedures: e.g. drainage of effusion, blood transfusion, rehydration in gastroenteritis; Infrastructure-required / outpatients with appropriate risk stratification: e.g. DVT, PE, cellulitis, acute COPD exacerbation If the recommended target ambulatory proportions for each condition are applied to the Trust s casemix, they highlight the following potential for reduction in overnight stays by specialty: 2 Acute medical care: The right person, in the right setting first time, Report of the Acute Medicine Task Force, Royal College of Physicians, October Directory of Ambulatory Emergency Care for Adults, NHS Institute for Innovation & Improvement, March

29 Table 18: Ambulatory Emergency Care: Potential Impact by Specialty Specialty Group Medicine Specialty Name Accident & Emergency Ambulatory Emergency Care Definitions applied to baseline 1 day stays: Spells Ambulatory Emergency Care Definitions applied to baseline 1 day stays: Ambulatory Emergency Care Definitions applied to baseline 1 and 2 day stays: Spells Ambulatory Emergency Care Definitions applied to baseline 1 and 2 day stays: Cardiology Dermatology Gastroenterology General Medicine -1, ,066-5 Nephrology Neurology Medicine Total -1, ,459-6 Surgery Anaesthetics General Surgery Urology Surgery Total ,163-3 Head & Neck ENT Oral Surgery Head & Neck Total Ophthalmology Ophthalmology Ophthalmology Total T&O T&O T&O Total Haematology/ Oncology Haematology/ Oncology Total Clinical Haematology Clinical Oncology Women & Children Gynaecology Women & Children Total Neonatology Obstetrics Paediatrics

30 Grand Total -3, , The above table shows the target reductions in beds based on applying the recommendations as follows: Applying targets to baseline 1 day stays: 6 beds Applying targets to baseline 1 and 2 day stays: 12 beds Rehabilitation / Intermediate Care Quantification of the need for step down or rehabilitation beds is not easy, as patients requiring active rehabilitation comprise only a sub-set of the people who currently stay for a long time in acute hospitals. A comprehensive point prevalence study would be required fully to understand the spectrum of care requirements for all of these patients. In the absence of this, the overall length of stay profile helps to develop an understanding of the relative scale of the overall requirement for long stay beds. Table 19: Summary of Bed Usage by Length of Stay Group LoS Group Baseline Spells Baseline Spells % Baseline Beddays Baseline Beddays % 0 days 10,488 18% 0 0% 1 day 15,187 26% 15,187 5% 2 days 7,585 13% 15,170 5% 3 days 5,015 9% 15,045 5% 4 days 3,762 7% 15,048 5% 5 days 2,752 5% 13,760 5% 6-19 days 10,352 18% 100,674 36% days 2,251 4% 66,846 24% >50 days 481 1% 36,366 13% Grand Total 57, % 278, % This shows that the number of patients who stay in hospital for 20 days or over represents 5% of total inpatient admissions. However, these patients account for over 100,000 beddays, 37% of current bed usage, and require almost 300 beds. These long stay beddays are shown by specialty below, highlighting that the majority of them relate to the general medical specialties, with further significant numbers in general surgery and orthopaedics: Table 20: Analysis of Long Stay (20+ days) Beddays by Specialty Specialty Group Specialty Name EL NE Grand Total Medicine Cardiology 24 3,970 3,994 Gastroenterology 67 6,030 6,097 29

31 General Medicine ,592 59,851 Nephrology ,017 Medicine Total ,531 70,959 Surgery Anaesthetics General Surgery 1,721 9,105 10,826 Urology 643 1,089 1,732 Surgery Total 2,364 10,303 12,667 Head & Neck ENT Oral Surgery Head & Neck Total Ophthalmology Ophthalmology Ophthalmology Total T&O T&O ,343 13,472 T&O Total ,343 13,472 Haematology/ Oncology Clinical Haematology Clinical Oncology Haematology/ Oncology Total Women & Children Gynaecology Neonatology Obstetrics Paediatrics 96 3,198 3,294 Women & Children Total 96 4,514 4,610 Grand Total 3,627 99, ,212 The proportion of long stay bed use varies between patients admitted from different geographical localities, as shown below: Table 21: Bed Use by Length of Stay and Locality Locality Short Stay Medium Long Stay Grand Total (0-5 days) Stay (6-19 days) (20+ days) Shrewsbury town 25% 32% 43% 100% Telford & Bridgnorth area 22% 38% 40% 100% Telford town 28% 33% 39% 100% Welshpool / Newtown area 27% 38% 35% 100% Shrewsbury area 29% 37% 34% 100% Oswestry area 25% 41% 33% 100% 30

32 Whitchurch / Market Drayton area 25% 43% 32% 100% Other 36% 40% 24% 100% Ludlow & S Shropshire 31% 48% 21% 100% Grand Total 27% 36% 37% 100% While overall 37% of beddays relate to long stay patients, the percentage is higher for the towns of Shrewsbury and Telford, and for the Telford and Bridgnorth rural area. In summary, patients who currently stay a long time in an acute setting include: Some patients who require active rehabilitation in an inpatient setting, such as stroke patients (quantified further in section below), and some trauma and orthopaedic patients; Frail, elderly patients from the Shrewsbury and Telford areas for whom the acute hospitals are effectively providing their stepdown care; Delayed Transfers of Care (DTOCs) mostly chronic / frail elderly people whose requirement for acute medical and nursing care has finished, but who are waiting for suitable packages of care to be made available elsewhere; Some patients whose need is for palliative and end of life care, many of who should probably be cared for at home or in an appropriate community-based facility. The Trust currently has 32 designated rehabilitation beds 25 at PRH and 8 at RSH, though it has not been possible to separate these out within the capacity model as the baseline data does not include details of individual ward stays. As discussed above, the patients in these beds represent only a sub-set of the number of patients who may in future be better cared for in settings other than an acute hospital site Stroke As described above, active rehabilitation pathways exist for certain conditions, most notably stroke. The National Stroke Strategy provides clear guidelines to assist with the quantification of stroke bed requirements 4 as follows: Average length of stay in acute care for 80% of stroke patients should be 7 days; Acute stroke units should run at 85% occupancy; if this is achieved, 95% of all strokes will be admitted onto an acute stroke unit; Approximately 40% of patients will require specialist inpatient rehabilitation; Patients will require rehabilitation services for an average of 37.9 days; Approximately 30% of patients could benefit from early supported discharge, reducing the length of stay for those patients by 9 days to 28.9; All stroke rehab units should have sufficient capacity to run at 85% bed occupancy to ensure that all patients that neede stroke rehabilitation can be admitted. Based on this guidance, the indicative current and projected activity and capacity requirements are as follows: Table 22: Current and Projected Stroke Activity and capacity Requirements 2011 Acute Stroke Spells National Stroke Strategy Needs Assessment, Department of Health,

33 2011 Inpatient Stroke Rehab Spells Acute Stroke Inpatient Stroke Rehab Acute Stroke Spells 1, Inpatient Stroke Rehab Spells Acute Stroke Inpatient Stroke Rehab 56 The acute stroke beds should be considered as part of the overall medical bed complement given in Table 17 above. The stroke rehabilitation bed projection would include beds currently provided both in an acute hospital and community hospital setting, and overlaps with the quantification of long-stay beds described in the previous section. In planning longer-term bed requirements for the health economy, consideration could be given to providing all of these beds in a community setting. The estimated current and future requirement for stroke rehabilitation beds by locality is summarised below: Table 23: Stroke Rehabilitation Bed Requirement by Locality Locality 2011 Inpatient Stroke Rehab 2021 Inpatient Stroke Rehab Ludlow & S Shropshire 3 4 Oswestry area 4 5 Shrewsbury area 4 6 Shrewsbury town 7 10 Telford & Bridgnorth area 7 8 Telford town Welshpool / Newtown area 4 5 Whitchurch / Market Drayton area 3 4 Other 1 1 Grand Total It must be noted that these bed requirements are based on the activity that currently relates to the Shrewsbury and Telford Hospital Trust, and does not therefore represent the total requirement for the health economy as a whole, especially in relation to those outlying areas with significant flows to other acute providers: Oswestry, Whitchurch and Market Drayton areas. Nevertheless, it does serve to inform the thinking about the correct setting for the stepdown care for those people whose acute stroke episodes are treated at SaTH. Based on this, the requirement for stroke rehabilitation beds broadly reflects the relative population density and distribution across the catchment area, with 28 out of 44 beds needed to serve Shrewsbury and Telford and their immediate hinterlands Neonatology and Critical Care The bed requirement for neonatology and critical care is dependent on factors that this capacity model is not able accurately to assess. The calculated current and projected bed numbers for 32