Right Care, Right Place, Right Time

I attended a HSJ ( Health Service Journal) seminar on 26th January 2010. It was actually about using or selling a data tool called Interqual (registered trademark) and it was clearly aimed at A&E and acute illness scenarios (heart illness etc). However, applied to maternity services and birth its principles, I think, could be an eye-opener. If it was seriously and rigorously applied to maternity services and birth services I wonder if they would be structured very differently? AS Gary Lane said at the end of his presentation – short term pain for long term gain – restructuring services to give appropriate levels of care at the appropriate time will have long term benefits for patients and Trusts.

The seminar began with a quick overview of the financial situation of the NHS:

• NHS nationally has a shortfall of £20billion. This amounts to a big cash crisis.

• Trusts and PCTs have been informed that they will only receive 30% of 2002 levels ( this needs to be checked as was not on the slide) of the money they received for Acute admissions.

• Just 10% of PCTs have managed to reduce A &E admissions accordingly

• There is a continuing demand for quality assurance through QIPP (Quality, Innovation, Productivity and Prevention) and CQUINN



The Solution


Reduce acute level of care (ie in hospital, in patient care) and providing as much care as possible in patient’s locality and community.

My comment: Surely this is the nub of the issue with regard to how maternity care is structured? The complaint of many women is that their care is inappropriately centralised and clinicalised, and not there at the right time, place and level that they really need. From maternity services point of view women are going into hospital for birth inappropriately – the system is set up for care only to be in this location. So, for example, women turn up to hospital and complain that they keep being returned home in early labour – why not assess women at home and keep them there until they wish to go in or give birth? Homebirth services are provided as optional extras by maternity services rather than being structured into the care pattern for all women as, for instance above. For many women this would be appropriate localised care at an appropriate level, and would reduce acute admissions to hospital – unnecessary acute admissions to hospital.

Postnatally, regular midwifery and social care visits to establish breastfeeding and general wellbeing of Mum and baby dyad in first 2 – 4 weeks post partum could reduce acute admissions (eg for gastroenteritis of baby) and post natal depression. The question being does saving in one departments budget offset the extra spend in another? Ie If investment in low level social care (to establish breastfeeding for instance) has big payoffs in the acute budget ( readmission of babies for instance for preventable illness) will this be acknowledged and supported within the NHS structure?


A case example given was Rotherham – this was not maternity services but hospital acute care generally – however, if read applying to maternity services it is thought provoking.

The key issue to be tackled in Rotherham: Patients in acute beds who do not need to be.

The tool was the Interqual tool.

The objectives:

• Right care, right place, right time

• Admission avoidance ( patients being admitted into hospital that do not need to be)

• Developing Alternative Levels of Care

• Better care with better value (for money)

• Building locally based care


Activity
(Taken from the HSJ Rotherham Case study PDF http://mediazone.brighttalk.com/comm/Emap/12ce4a01b3-16351-3188-12894#  )

• Rotherham Partnership began implementing InterQual in February 2009 initially on three wards covering emergency admissions; trauma and orthopaedics; and healthcare for older people. It was also implemented in the community in a purpose built facility for people with chronic obstructive pulmonary disease.

• Case Managers assessed patients both on admission and throughout their hospital stay and where they identified that patients could be cared for more appropriately elsewhere, they worked to facilitate a supported discharge.

• All patients are reviewed against InterQual’s admission criteria and then against the continued stay criteria while they are on a ward using the system. In the first16 weeks (16 February 09 to 8 June 09), 3631 reviews were undertaken on 892 patients.

• .The hospital found that 49% of the admission reviews met the criteria for an acute admission; 45% did not.

• The continued stay [in hospital] reviews show that 15% met the acute criteria and 77% did not.

• This data shows that the 77% of continued stay reviews and the 45% of admission reviews which did not meet the criteria resulted in patients occupying an acute bed. This meant a total of 1574 days, when patients could have been cared for at a sub-acute level if that level of care had been available in Rotherham.



• InterQual has subsequently been rolled out in Rotherham across respiratory medicine, and plans are in place to use the criteria in a modified way on the Stroke Unit and obstetrics and gynaecology in order to undertake retrospective audits.
• Case Managers report numerous examples where experience told them that a patient needed moving to a less acute environment but InterQual provided the evidence-based assessment to confirm this.


Long term objectives (from HSJ seminar)

• Using Interqual data to identify the number and type of patients who are not meeting or requiring acute level of care to inform future commissioning.

• To commission the most appropriate service model location and resource structure to deliver this.

• Changing the culture of the organisation and clinical practices.

• Identifying bottlenecks (eg bed blocking or delivery room blocking)

• Ensuring medical intervention at appropriate times, levels, and places.

• Short term pain for long term – redesigning care system so that they are efficient in the long term so that care is provided when and where it needed says Gary Lane.



Right Care, Right Place, Right Time


For Mums that means: One mother one midwife, at home, for the birth