Results

 

The new specialist hospital provides most emergency hospital care for the population of Northumberland CCG

Figure 3 shows trends in hospital use for the population of Northumberland CCG, without risk-adjustment. As expected, there was a sharp reduction in the number of A&E visits at Northumbria Healthcare’s three general hospitals after June 2015. From then, the new specialist emergency care hospital delivered around 49% of A&E visits for the population of Northumberland CCG and 62% of emergency admissions. It provided only a small percentage of elective admissions (2%), as would be expected.

The analysis also revealed changes over time to the characteristics of patients seeking health care. For example, the average age of the population of Northumberland CCG experiencing emergency admission increased from 55.0 years before the redesign to 56.1 years afterwards (see Table 1). Patients also tended to have more comorbidities following the changes (they had on average 2.0 conditions after the changes, compared with 1.8 before). Interestingly, these overall averages disguised substantial changes within particular hospitals. For example, the average age of patients being admitted as an emergency in Hexham increased from 69.4 years before the changes to 78.9 years afterwards. These patterns are not directly relevant to the evaluation, since it is concerned with the impact of the changes across the entire population of Northumberland CCG – however, they are suggestive of the complexity involved in redesigning health care.

Table 1: Characteristics of the population of Northumberland CCG experiencing emergency admission, April 2011–June 2015 and July 2015–June 2016

 

Average age in years

Average number of comorbidities

Number of emergency admissions per quarter

 

Before

After

Before

After

Before

After

The Northumbria specialist emergency care hospital at Cramlington

-

54.3

-

1.8

-

5,275

Hexham general hospital

69.4

78.9

1.7

2.3

862

260

Wansbeck general hospital

59.3

74.8

1.8

2.9

4,650

929

North Tyneside general hospital

34.5

67.3

1.7

2.9

993

176

Other hospitals

49.9

52.7

1.7

1.9

2,377

2,498

Average across Northumberland CCG

55.0

56.1

1.8

2.0

-

-

Note: ‘Before’ is April 2011–June 2015. ‘After’ is July 2015–June 2016.

Figure 3: Trends in hospital use for the population of Northumberland CCG

Note: Years are financial years. The vertical line is drawn at 1 July 2015 but the changes to urgent and emergency care were made slightly earlier, on 16 June 2015. These figures will not match Figure 4, since they are not risk-adjusted and are expressed as total numbers of visits rather than numbers per 10,000 people.

Results from applying the synthetic control method

While Figure 3 shows the trends in hospital use over time for the population of Northumberland CCG, it provides limited insight into the impact of the redesign of emergency care on hospital use. This is because, although the total volume of A&E visits for Northumberland CCG patients seems to have increased in Figure 3, it is necessary to consider what would have happened in a control area. Therefore, Figure 4 shows the results of applying the synthetic control method. The red lines show the risk-adjusted hospital use of patients in Northumberland CCG, while the blue lines show the equivalent data for patients in the synthetic control area. The two lines tend to be similar over the 4 years preceding the changes to urgent and emergency care (ie to the left of the first vertical line). The impact of the changes can be assessed by comparing the lines for Northumberland CCG and the synthetic control area over the post-intervention period (ie to the right of the second vertical line).

The results are summarised here (see Table 2 for the data).

  • The rate of A&E visits – the rate for Northumberland CCG increased to approximately 340 visits per 10,000 people per month following the changes to urgent and emergency care. However, it remained broadly constant in the synthetic control area at around 300 A&E visits per 10,000 people per month for the local population. There were around 40 more A&E visits per 10,000 people per month for the population of Northumberland CCG than for the synthetic control area (13.6% more). Since the significance score was 0%, the Improvement Analytics Unit has a high degree of confidence that these findings represent a systematic difference.
  • The rate of inpatient admissions (including ambulatory care) – following the changes to urgent and emergency care, the overall admission rate in Northumberland CCG was 274.6 admissions per 10,000 people per month, compared with 272.3 for the relevant synthetic control area. While this is an increase of 2.3 admissions per 10,000 people, the significance score was very high at 95%, meaning that such differences might easily be the result of chance.
  • The rate of emergency admissions (including ambulatory care) – following the changes, there were 74.2 emergency admissions per 10,000 people per month for the population of Northumberland CCG, compared with 75.4 in the relevant synthetic control area. This suggests a slight reduction in the emergency admission rate, but with a significance score of 70% it is not possible to be confident that these differences were not the result of chance.
  • The percentage of patients attending A&E who were admitted, transferred or discharged within 4 hours of arrival – this remained steady for the population of Northumberland CCG following the redesign of urgent and emergency care, yet declined in the relevant synthetic control area. Indeed, 91.8% of A&E visits in Northumberland CCG lasted less than 4 hours, compared with 85.2% in the synthetic area. The percentage of A&E patients seen within 4 hours was around 7% higher in Northumberland CCG – with a significance score of 0% this was unlikely to be the result of chance.
  • The average length of a visit to A&E in minutes – the duration of A&E visits remained steady for the Northumberland CCG population at around 144 minutes, but increased in the synthetic control area. A&E visits were on average 14.3 minutes shorter for those in Northumberland CCG, compared with those in the synthetic control area. This difference was unlikely to be the result of chance, with a significance score of 0%.
  • The average length of inpatient admissions in days – the average length of stay in hospital had been falling in both areas for some time. Following the changes to urgent and emergency care, the average length of stay continued to fall for the population of Northumberland CCG, but it was hard to determine whether Northumberland CCG achieved shorter lengths of stay than the relevant synthetic control area. The Improvement Analytics Unit’s best estimate is that, compared with patients treated in the synthetic control area, patients admitted in Northumberland CCG remained in hospital on average 0.4 days longer following the changes to urgent and emergency care. However, the significance score was 10% and the synthetic control area did not track Northumberland CCG as closely over the pre-intervention period for this metric as for others. Therefore, it is not possible to be conclusive about whether there was an impact on length of stay.

The findings were unchanged when the unit amended its method in the ways described in the technical appendix.

Table 2: Comparison of hospital use between the population of Northumberland CCG and the relevant synthetic control areas, August 2015–July 2016

 

Northumberland CCG (mean, SD)

Relevant synthetic control area (mean, SD)

Difference

Relative difference (%)

Significance score

Rates of hospital use: expressed as activity per month per 10,000 people

A&E visits

339.6

(12.7)

299.1

(12.1)

40.5

13.6

0%

Admissions

274.6

(9.1)

272.3

(7.1)

2.2

0.8

95%

Emergency admissions

74.2

(1.8)

75.4

(1.4)

-1.2

-1.6

70%

A&E visit length in minutes

143.8

(5.0)

158.1

(6.8)

-14.3

-10.5

0%

Length of admissions in days

2.7

(0.2)

2.3

(0.8)

0.4

12.1

10%

Expressed as a proportion of patients

A&E visits lasting less than 4 hours

91.8

85.2

6.7

6.9

0%

Note: SD=standard deviation. A lower significance score indicates greater confidence that the effect is not due to chance.

Figure 4: Comparison of the impact metrics for the population of Northumberland CCG and the relevant synthetic control areas, April 2011–June 2017


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