1. Acute Demand ……an overview January 2011

2. Better, sooner, more convenient 2 Davis,P. (2010) Quality or Quantity? Markets or Management? University of Auckland NZ Public Hospital Performance2 Hospital beds & discharges (1988 – 2001) Day-stay Inpatient Day stay Inpatient

3. Better, sooner, more convenient 3 Total Hospital Discharges per 1,000 Population (2007) * 2006 Source: OECD Health Data 2009 (June 2009).

4. Better, sooner, more convenient 4 Increase in Life Expectancy at Birth (1986–2006) * 1985–2005 Source: OECD Health Data 2008, “June 2008.”

5. Better, sooner, more convenient 5 Philosophy of Kaiser Permanente: “Unplanned hospital admissions are a sign of system failure” Ham, C. (2006), Developing Integrated Care in the NHS: adapting lessons from Kaiser, Health Services Management Centre, Birmingham University

6. Better, sooner, more convenient 6 Acute demand – what does it look like? ED Some increase: but national ED data prior to 2009/10 not as robust as inpatient data Acute inpatient (excludes short stay admissions <24 hours, electives, and mental health admissions) 2000-2009: increase from 323,000 to 371,000 pa - 2/3 in Auckland. A 15% increase, but only 2.4% greater than the increase in population.

7. Better, sooner, more convenient 7 What is driving it…... conditions? 21% increase in acute medical discharges (2000 – 2009) The top 8 conditions accounted for 24% of acute inpatient discharges in 2009 Diagnosis Related GroupingsDischarges % of Total Chest Pain 13,2363.6% Oesophagitis Gastroent & Misc Digestive System 12,9803.5% Respiratory Infections/Inflammations 12,8383.5% Cellulitis 10,9953.0% Neonate Admission 10,3382.8% Circulatory Disorders 9,3852.5% Chronic Obstructive Airways Disease 9,3622.5% Abdominal Pain or Mesenteric Adenitis 9,1552.5%

8. Better, sooner, more convenient 8 OECD Health Care Quality Indicators Database 2009

9. Better, sooner, more convenient 9 The people perspective NZ Health Survey 1996/97, 2002/03, 2006/07

10. Better, sooner, more convenient 10 Frequent attenders 600k unique individuals with an average of 1.5 visits to ED per year About 75% of patients visited only once 1.5 % visited >6 times One person visited 145 times

11. Better, sooner, more convenient 11 The main demographic drivers Age (total population) Ethnicity.. 25% growth for Maori 2000-2009 56% growth for Pacific 2000-2009 30% growth for people 65+ 2000 - 2009

12. Better, sooner, more convenient 12 Conditions also vary by ethnicity

13. Better, sooner, more convenient 13 and by DHB……….

14. Better, sooner, more convenient 14

15. Better, sooner, more convenient 15 Change in inpatient discharge rates ( 2000 – 2009)

16. Better, sooner, more convenient 16 ED admissions & discharges ED attenders & admission: strong association with age – the elderly weaker association with ethnicity and deprivation ED attenders not admitted: people from deprivation quintile 4&5 = 40% of the population yet 55% of non- admitted patients DHB factors are significant smaller DHBs have a higher proportion of ED attenders not admitted

17. Better, sooner, more convenient 17 Relationships Statistically significant inverse relationships between: size of the DHB population and ED not admitted numbers GP/nurse consults and ED not admitted numbers – if West Coast and Wairarapa excluded No apparent relationship with VLCA

18. Better, sooner, more convenient 18 Relationship between GPs & Acute Hospital Discharge Rates

19. Better, sooner, more convenient 19 Relationship between GPs & Acute Hospital Discharge Rates High acute discharge rates Low GP FTE per 100,000High GP FTE per 100,000 DHB Acute ASR GP FTE Wairarapa 1184 74 Tairawhiti 1201 84 Counties Manukau 1102 59 Lakes 1153 83 Waitemata 1049 58 Hawkes Bay 1061 80 Bay of Plenty 1012 79 Auckland 1052 103 Hutt Valley 1009 67 Whanganui 958 88 South Canterbury 971 85 Low acute discharge rates Waikato 882 67Southland 939 83 Taranaki 823 56Northland 866 81 MidCentral 803 71Canterbury 860 84 West Coast 724 75Capital & Coast 778 84 Nelson Marlborough 722 75Otago 752 94 Acute inpatient discharge rate, age standardised. (2009) Medical Council Workforce Survey (2009)

20. Better, sooner, more convenient 20 The system

21. Better, sooner, more convenient 21 Community services EDInpatientCommunity Primary Care (distribution & availability – inc after hours) Changing GP practice Poor access to diagnostics and specialist opinions Changing referral patterns (variability++) variable attachment with general practice Financial barriers Changing use of ambulances Fragmentation of services Improved ED services & facilities Changing (& variable) admission thresholds Inpatient bed availability Repeat attenders Local behaviours Bed availability Advances in medical technology Discharge planning Family & community support Relationship with primary care Primary care capability & capacity Aged residential care capability & capacity Patients – changing: demographics – two broad segments – young adult & elderly morbidity – more chronic illness expectations – more “consumerism” + a “medicalised” population more self-referral, but people confused about where to go

22. Better, sooner, more convenient 22 Through a consumer’s eyes……..

23. Better, sooner, more convenient 23

24. Better, sooner, more convenient 24 And it depends on the problem definition Growth reducing our overall growth rate requires a focus on metropolitan Auckland Variation between DHBs presents a significant improvement opportunity. Addressing this will require good comparative data clinical engagement an understanding of local initiatives/patterns of behaviour/admission thresholds a whole of system approach - ? the DHB funder role Its complex - there’s no “silver bullet”

25. Better, sooner, more convenient 25 What works Kings Fund Seminar Proactive management of people with long term conditions, especially people with multiple conditions Integrated working between health and social care Multiple coordinated strategies, underpinned by an integrated information system Use of advance directives and a range of alternatives to hospital eg hospice Preventing re-admissions – active management of transitions The use of “virtual” wards in the community The use of practice based commissioning enabling integration between general practices and other services A single assessment and coordinated care approach for older people at risk of hospital admission Ham C, Imison C, Jennings M (2010) Avoiding hospital admissions, lessons from evidence and experience. Kings Fund

26. Better, sooner, more convenient 26 Next steps Expert Roundtable – second meeting Sector engagement o BSMC business cases – DHBs & primary care o DHBs – through their regular meetings o ED Advisory Group – Feb 2011 o Professional groups eg Colleges

27. Better, sooner, more convenient 27 Useful resources Basu A, Brinson D (2008) The Effectiveness of Interventions for Reducing Ambulatory Sensitive Hospitalisations: A Systematic Review. HSAC Report Blunt I, Bardsley M, Dixon J (2010) Trends in Emergency Admissions in England 2004 – 2009. Nuffield Trust Blunt I, Bardsley M, Dixon J (2010) Trends in Emergency Admissions in England 2004 – 2009: is greater efficiency breeding inefficiency?. Nuffield Trust Booz, Allen, Hamilton (2007) Key Drivers of Demand in the Emergency Department. NSW Department of Health Curry N, Ham C (2010) Clinical and Service Integration, the route to improved outcomes. Kings Fund Ham C, Imison C, Jennings M (2010) Avoiding hospital admissions, lessons from evidence and experience. Kings Fund NZHTA Report 8 (1998) Emergency Department Attendance a critical appraisal of the key literature. New Zealand Health Technology Assessment, University of Otago Purdy S (2010) Avoiding Hospital Admissions, what does the research evidence say? Kings Fund

28. Better, sooner, more convenient 28 Appendix

29. Better, sooner, more convenient 29 Age Standardised Rates* DHB of Domicile Acute In Patient Discharges 2009 ED 2009/10 Rate:ED presentation: Acute In Patient Discharges Northland 866 2,4542.8 Waitemata 1,049 2,2412.1 Auckland 1,052 2,0271.9 Counties Manukau 1,102 2,0561.9 Waikato 882 2,5272.9 Lakes 1,153 4,4933.9 Bay of Plenty 1,012 3,4413.4 Tairawhiti 1,201 3,9713.3 Taranaki 823 4,3655.3 Hawkes Bay 1,061 2,4942.4 Whanganui 958 3,2643.4

30. Better, sooner, more convenient 30 Age Standardised Rates* DHB of Domicile Acute In Patient Discharges 2009 ED 2009/10 Rate:ED presentation: Acute In Patient Discharges MidCentral 803 2,3022.9 Hutt Valley 1,009 3,2213.2 Capital and Coast 778 1,7382.2 Wairarapa 1,184 5,4834.6 Nelson Marlborough 722 2,6113.6 West Coast 724 4,6756.5 Canterbury 803 2,0802.6 South Canterbury 971 2,9303.0 Otago 752 2,1872.9 Southland 939 4,3164.6 National 945 3,0893.3