NHS Digital Data Release Register - reformatted
Kingston Hospital NHS Foundation Trust
Project 1 — DARS-NIC-09949-T4N3W
Opt outs honoured: No - data flow is not identifiable (Does not include the flow of confidential data)
Sensitive: Non Sensitive
When: 2016/09 — 2019/09.
Repeats: Ongoing, System access, System Access
Legal basis: Health and Social Care Act 2012, Health and Social Care Act 2012 – s261(1) and s261(2)(b)(ii)
Categories: Anonymised - ICO code compliant
- HES Data Interrogation System
- Hospital Episode Statistics Outpatients
- Hospital Episode Statistics Admitted Patient Care
- Hospital Episode Statistics Accident and Emergency
- Hospital Episode Statistics Critical Care
Kingston Hospital Foundation Trust (KHFT) is a busy NHS hospital in South West London (SWL), serving a catchment of 350,000. The trust's clinical services include: An A&E department seeing 110,000 patients p.a., A paediatric department providing services including continuing cancer care to local children, A large maternity department, delivering almost 6,000 women p.a., Comprehensive emergency services including a stroke ward and two full-time emergency theatres, and Planned services encompassing 350,000 outpatients and 30,000 admissions p.a. across a wide range of surgical and medical specialties. The planning and strategic development team at KHFT is responsible for a wide range of activities, including: Trust level activity, capacity and income modelling, Development of strategies to ensure achievement of key goals, Development of business cases for investment, Benchmarking performance against peers to inform the productivity programme and deliver high quality care, Monitoring changes in the external environment and local health economy and supplying business intelligence to clinical teams and the Board. The NHS is in a time of significant flux, and NHS hospitals operate with a great deal of uncertainty. It is more important than ever that hospitals understand their own business, and how they sit in the local healthcare economy, to enable development of a clear strategy. Funding is falling, and significant savings need to be delivered every year, meaning decisions must be made based on evidence, ensuring affordability. KHFT needs an understanding of the healthcare needs of the local population. What services does the hospital need to provide, and what should they look like, to best serve the local catchment? Patient care is always KHFT’s first priority, and the hospital needs to continuously monitor the quality of services, and outcomes for patients. The following lists some recent and on going KHFT pieces of work that utilises the HES data accessed via the HDIS database. • Scenario modelling – understanding how patient flows will change if clinical services were reconfigured across SWL • Strategy development – analysis to support development of award winning dementia strategy • Productivity / efficiency – ongoing benchmarking of performance, and identification of opportunities to make savings • Delayed transfers of care – scoping opportunity to strengthen community care and reduce need for acute capacity • Richmond CCG – understanding how patient flows changed following reconfiguration • Maternity – understanding changes in deliveries and ante natal activity • Enabling decision-making Data will only be used for purposes relating to the provision of healthcare or the promotion of health in line with the requirements of the Health and Social Care Act 2012 as amended by the Care Act 2014.
In the previous 12 months I have used HES data in the following ways: Geographical analysis using patient LSOA I have used HES data for extensive scenario modelling, in light of likely changes in service provision at another hospital site nearby. I linked HES data containing patient LSOA with DfT travel time data to ascertain where activity would flow in the future if services were not provided on a particular site, assuming patients prefer to be treated at their nearest site. I have therefore been able to provide the Board with expected changes in activity, capacity and income at KHFT, under a range of scenarios. KHFT has been asked to consider managing a local community site. I have used HES data as described above to assess the opportunity to increase flows through that site and improve its productivity. Analysis suggests that there is little opportunity to improve productivity. We will use this information in making our decision. We have a partnership with another organisation for the provision of local cancer treatment. I used the LSOA field in HES data as described above to assess if patients were being diverted to their nearest site across the two organisations. I was able to establish that patients were not being sent to their closest site, and our cancer service have been able to broach this with our partner, backed up by evidence. Benchmarking I used HES data to benchmark our outpatient procedure recording rate. Overall, I found that we were recording a procedure at approximately the same rate as the London average. However, this was only due to very high rates in a handful of specialties, and for most specialties we were well below average. We brought these outputs together with internal data and local knowledge, and embarked upon a program of work to improve capture of outpatient procedure data and increase associated income. Maternity activity has been below expected levels at the Trust. I used HES data to assess if we had lost market share to other providers. The analysis revealed that we had not, and in fact maternity activity is down at most local providers compared to previous years. Under these circumstances we will employ a different strategy to increase maternity activity, than if our market share had shifted to other providers. We know from internal data that our growth rate for endoscopy procedures over the last few years has been very high. I used HES data to compare our growth rate with those at comparable hospitals. Rates were found to be similar. We have therefore incorporated this historical rate into our planning for the future. Regular reporting I have used HES data on a quarterly basis to produce a market share report, monitoring flows of activity to KHFT and neighbouring trusts, to ensure we are maintaining a constant share of local activity. I have found in fact that our share has slightly increased, likely due to significant access issues at a neighbouring hospital. I have used HES data regularly to benchmark our adult emergency LoS. The analyses show that we continue to be best in peer or close to for younger adults and surgery, but have some opportunity to improve LoS for frail elderly medical patients. This has enabled us to focus effort where it will have most impact, and there are several workstreams underway to manage our adult, emergency medical bed base. SLA and commissioning In response to a commissioner challenge, I used HES data to establish that we are undertaking an increased percentage of the local diabetic foot amputation activity, following a change in service offering at a nearby hospital. Commissioners were therefore reassured that the overall level of activity was not increasing. Following a query from commissioners, I used HES data to assess whether our planned ophthalmology service had the same average acuity as our peers. I was able to establish that it does, and we undertake approximately the same amount of occuloplastics and vitreo-retinal work as peers. In response to a query from commissioners, I used HES data to compare our ambulatory performance with London acute peers. I was able to show that the percentage of adult emergency that we deliver as 0LoS is approximately the same as the London average. This has reassured us that we are not outliers, and can pursue expansion of our AEC model at a manageable pace.
Productivity and efficiency benchmarking outputs will continue to help shape KHFT’s CIP programme. Meeting CIP targets is vital to the continued financial stability of the trust and the local healthcare economy. In addition, benchmarking of performance contributes to continuous improvement in patient experience and clinical outcomes. The descriptions of previous workstreams are examples of analyses KHFT has already undertaken. Over the next 12 months, it is expected that HES data will continue to be used for similar workstreams. 1) Scenario modelling – understanding how patient flows will change if clinical services were reconfigured across SWL The outputs from this modelling mean that judgement calls can be made about the likelihood of various scenarios, based on indicators such as flows out of sector, or unacceptable changes in the quality of service offering to patients. This has helped KHFT to crystallise clinical strategy, and enable decision-making on where to make investments, for example, such as maternity. This is especially valuable given how little capital is available in the current financial climate. Whilst no one can be sure what final decisions will be taken, the modelling has provided some points that can be considered as semi fixed in a time of uncertainty. 2) Strategy development – analysis to support development of award winning dementia strategy The realisation that KHFT's dementia rates were twice the average, and knowing from population projections that dementia prevalence will only increase, prompted KHFT to consider radical redesign of dementia services and develop an ambitious vision for the future. The hospital has since been recognised for the quality of the work on developing dementia services at the Patient Safety and Care Awards (2015), and has embarked on an appeal to raise £750,000 to transform dementia care in Kingston and beyond. 3) Productivity / efficiency – ongoing benchmarking of performance, and identification of opportunities to make savings An internal review of productivity demonstrated that KHFT is already a very efficient trust. The Carter review confirmed this, calculating the hospital to be the most efficient acute trust, along with one other, in England. Nevertheless, benchmarking analysis did indicate some opportunities, such as DNA rates and care setting rates. It was identified that KHFT’s outpatient hysteroscopy rate is much lower than peers, for example, and improving this is enabling the service line to free up capacity in day surgery, where KHFT is capacity limited. As a knock on, this is enabling the surgical teams to improve the daycase rate in breast and urology, which was identified as being lower than peers from the benchmarking analysis. If KHFT was to reach best in peer outpatient hysteroscopy rate, more than 235 cases will have been moved to a more appropriate care setting, with associated reduction in cost. This frees up a day surgery session per week for appropriate breast and urology cases, currently undertaken in main theatres, where there is an increased chance patients will have an unnecessary hospital stay. 4) Delayed transfers of care – scoping opportunity to strengthen community care and reduce need for acute capacity HES data was used to deep dive into South Devon's activity and length of stay (the South Devon and Torbay healthcare system is an example of best practice for integrated and community care). It was found that their length of stay for emergency medical patients was 1/2 of KHFT’s on average, when comparing cohorts of patients of similar age and with similar diagnoses. It is hypothesised that those patients are being supported elsewhere once the acute phase of their care is concluded. Applying this target LoS to KHFT’s activity enabled the planning team to calculate that as many as 60 acute beds could be freed up if there was more support available to patients in the community. This is equivalent to at least 2 wards, with a saving of £1m-£1.5m released per ward if those beds were closed. This provides a figure for what is affordable to invest in out of hospital services, to ensure value for money for a range of options. 5) Richmond CCG – understanding how patient flows changed following reconfiguration Comparison with the previous year had already revealed that RCCG activity at KHFT had gone up, but analysis of HES data revealed that this was actually a market share shift, and activity at West Middlesex and St George’s had fallen. The likely explanation is that uncertainty in the local health economy around West Middlesex’s future, and reports in the press on St George’s financial situation, had caused more patients and GPs to look towards KHFT. KHFT are continuing to monitor the situation via HES data. If it becomes apparent that market share is shifting back, there is a plan to mobilise on a program of GP engagement, or otherwise mitigate losses. Given the unexpected market share shift, KHFT overperformed on the contract with RCCG for 15/16, by more than £1m, between Apr15 and Jan16. Understandably the CCG challenged the level of activity and cost. The analysis of HES data enabled the planning team to explain the patient flows and help move us to a position of shared understanding, ensuring the trust will be paid for the activity undertaken. 6) Maternity – understanding changes in deliveries and ante natal activity The cause of the reduction in booking appointments is still being investigated. It is reassuring that KHFT has not lost market share, and the strategy is now to seek to attract work from the periphery of the catchment and increase market share to maintain deliveries at planned levels. The service line believe they can deliver an additional 150 women per annum, equivalent to total income of more than £600k. HES data is being used to identify GP practices with whom the trust might engage, to maximise the effect of limited NHS resource. 7) Enabling decision-making HES data is also used to answer questions posed by the board, executive team or service lines, providing a robust and rapid steer on which projects to work up. A recent example is scoping kidney stone work in the local catchment to ascertain if there was sufficient to recommend investment in a lithotripter, at a cost of £0.5m. It was found that local levels of kidney stone activity, and geography of existing lithotripters meant that there was not, and hence no further resources were expended on developing a loss making project. Similarly, the critical care dataset was used to test whether KHFT had similar levels of critical care capacity to peers. It was found that KHFT was underprovided in level 2 care, by 2 beds. As a consequence an investment was made in level 2 critical care capacity during 15/16. The scenario modelling, and insight it provides, means that the Chief Executive and other Directors are as knowledgeable as possible as to the consequences of strategic decisions. This enables informed decision making at trust and sector level, contributing to the long term financial stability of healthcare locally. Knowing the likely outcomes of various scenarios, and hence the likelihood they will be adopted, also allows investment proposals to be worked up and considered ahead of completion of sector level deliberations.
Use of HES data for scenario modelling, especially the implications of SWL reconfiguration hypotheses, will continue to be vital to the planning and strategy development function at the hospital. As for the last 12 months, in the coming year, outputs will either not be circulated, but used within the planning team to enable development of proposed strategy, or will be presented to Executive Directors, key clinical leads and the Planning team in the form of high level activity numbers (spells, split to point of delivery) that would be expected to flow between providers. Productivity and efficiency also continue to be a significant focus for the NHS, and KHFT plans to continue to use HES data to benchmark efficiency and performance on a regular basis. Clinical teams will be provided with KHFT’s performance against peer group average, top quartile and best in peer. Indicators will include length of stay, outpatient procedure rates, and daycase rates. In line with best practice, small numbers will suppressed in line with the HES analysis guide. Where relevant, the financial benefit of improving to top quartile will also be calculated and supplied. Target dates are not provided as workstreams that are described have already taken place. 1) Scenario modelling The NHS is facing financial challenge at an unprecedented scale, due to changing demographics, a need to invest in quality, and ageing estate. In SWL alone, there is a projected deficit of more than £500m by 2021, in a scenario where no action is taken. There is currently no solution. In response to a similar financial outlook, other hospital systems such as NWL have worked through and embarked upon reconfiguration plans, involving a reduction in the number of sites offering hot services such as A&E, emergency surgery and maternity, and rationalisation of hot work on to fewer sites. Similar reconfiguration options are being considered for SWL. Internally, KHFT has undertaken significant scenario modelling, using HES data and travel time data, to understand how patient flows would be affected if various services were 'switched off' at SWL sites. Outputs from analysis were presented to the Strategy Steering Group (Chief Exec, key Directors, Planning Team), in the form of activity numbers (high level numbers of spells, split to point of delivery) that would be expected to flow between providers under reconfiguration scenarios. Equivalent income and capacity (beds) were also calculated and presented. 2) Strategy Development A key responsibility of the planning team is the development of strategy. HES data was used to undertake a detailed assessment of patient and workload profile, comparing KHFT to London and England averages, to see how the hospital was similar and how the hospital was different. A key finding was that KHFT had twice as many patients with dementia as the London and England averages. This is related to the demographics of the hospital’s catchment. Patients with dementia are resource intensive, but research has revealed that there are changes to environment and model of care that can improve staff and patient experience. Findings were presented at several meetings, including the Whole System Transformation Board, a meeting where the hospital, local CCGs and other key stakeholders came together to discuss issues impacting across the healthcare system. Findings were presented in a simple graph, showing dementia prevalence at KHFT, London average dementia prevalence, and England average dementia prevalence, against time (mm/yy). 3) Productivity / Efficiency The current financial situation across the NHS has led to an increasing focus on productivity, culminating with the Carter review, which has described widely varying resource utilisation across the NHS. In order to help shape KHFT’s CIP programme for 16/17, the planning team undertook a systematic review of productivity at service line level during 2015. HES data was used to benchmark a range of indicators, including length of stay, emergency readmissions, outpatient DNA rates, follow-up ratios, and care setting rates (daycase and outpatient procedure rates). A peer group of London acutes was used. Given the demographics and population density of London, previous workstreams have found this to be the most useful peer group. The review demonstrated that KHFT is already a very efficient trust. The Carter review confirmed this, calculating the hospital to be the most efficient acute trust, along with one other, in England. Nevertheless, benchmarking analysis did indicate some opportunities, such as DNA rates and care setting rates. Outputs were presented to a small group of senior finance and planning staff. For each indicator, KHFT’s performance was shown against peer group average, top quartile and best in peer. Where relevant, the financial benefit of improving to top quartile was also presented. 4) Delayed Transfers of Care The issue of delayed transfers of care (DTOC), and its implications for bed blocking in NHS hospitals, has been widely reported in the press. The frail elderly cohort has grown in recent years, and they are high volume users of acute healthcare. Community capacity for the non-acute phase of their recovery has not kept pace, however, meaning expensive NHS beds are being blocked with patients who are strictly well enough to move on, but have nowhere suitable to go. The demographics of KHFT’s catchment mean this is a significant issue for the hospital. The residents of KHFT's catchment are affluent and long-lived. This means KHFT have an above average number of elderly patients, who are frail and/or have long term conditions that mean they take longer to recover. It is not straightforward to understand the scale of the issue, and how much acute resource could be freed up, if sufficient community support were in place. The definitions of a DTOC bedday, and the medically fit cohort, are complex, and reasons for delays to transfers take many forms. South Devon and Torbay CCG is an example of best practice co-ordinated care for people with long-term and complex needs, including innovative use of proactive case management and community virtual wards, and investment in integrated health and social care teams, hospital discharge co-ordinators and re-ablement beds in the community. HES data was used to deep dive into South Devon's activity and length of stay. It was found that their length of stay for emergency medical patients was 1/2 of KHFT’s on average, when comparing cohorts of patients of similar age and with similar diagnoses. It is hypothesised that those patients are being supported elsewhere once the acute phase of their care is concluded. Outputs were presented to a group including local commissioners and KHFT’s strategy lead. Findings were summarised in narrative on a single slide as part of wider presentation on the future of the KHFT Galsworthy Road site. 5) Richmond CCG A significant piece of investigative analysis was recently undertaken on Richmond CCG (RCCG). There is no acute provider in RCCG, and approximately 1/3 of RCCG activity flows to KHFT, 1/3 to West Middlesex (situated in Hounslow, in NWL), and the remainder to other providers, most significantly St George’s. The health economy in NWL has recently been reconfigured, with Ealing Hospital significantly reducing the services offered, and West Middlesex merging with Chelsea & Westminster. Much of Ealing’s hot work was expected to flow to West Middlesex. The scale of change is significant, and it was not possible to predict what would happen to RCCG patient flows. RCCG activity is almost 25% of KHFT’s planned workload (>£13m) therefore a change in flows would have a significant impact. Activity, market share and waiting times around the patch were examined to assess the impact of reconfiguration, if any, on flows. Comparison with the previous year had already revealed that RCCG activity at KHFT had gone up, but analysis of HES data revealed that this was actually a market share shift, and activity at West Middlesex and St George’s had fallen. The likely explanation is that uncertainty in the local health economy around West Middlesex’s future, and reports in the press on St George’s financial situation, had caused more patients and GPs to look towards KHFT. Findings were summarised in a paper that laid out changes in activity and market share over time, for the trust overall, and for a few key specialties. The paper was circulated to the contracts team and shared with commissioners. 6) Maternity Maternity is one of KHFT’s flagship services. It is the largest unit in SWL, delivering almost 6,000 women p.a., and the service is worth £25m of income to the trust. KHFT has the highest rated service across the whole of London, according to patients. Ensuring that the hospital continues to provide a high quality, well regarded service is a key objective of KHFT’s strategy, and a number of tools are employed to monitor quality and patient experience. In recent months KHFT has seen a reduction in the number of booking appointments. These are the attendances at which a mother has decided where she wants to give birth, and is booked in to deliver at her preferred centre. It is also the attendance which triggers the ante natal pathway payment under PbR rules. KHFT’s maternity department asked the planning team to establish whether maternity activity had fallen sectorwide, or women were simply choosing other providers. Analysis of HES data showed that in fact maternity activity had fallen sectorwide; specifically that obstetrics first outpatient appointments are reduced at several providers. Other hospitals have seen more significant reductions than KHFT. Findings were presented verbally at the maternity service line’s monthly performance meeting.
Analysis of HES data is undertaken several times a week to support all aspects of the team's responsibilities. HES data is accessed by the Lead Planning Analyst only, and never circulated, even within the organisation. Aggregated query result sets are downloaded and stored in private folders, for analysis and manipulation in MS Excel or SQL. At this point data is sometimes linked with publically available travel time data, reference cost data, or ONS/GLA population projections. All extracted data is stored with appropriate security controls including encryption. Data is kept and destroyed in accordance with good information governance practice. Outputs from analysis are shared either at an extremely high level, ie a table of length of stay by provider for London acutes, or are not shared, but instead used to inform reports generated by the planning team, and submitted to the clinical teams or Executive team for decision making, strategy development, etc. Outputs will contain only aggregate level data with small numbers suppressed in line with HES analysis guide. Queries always contain an aggregate function such as sum, count or average. Data will not be stored, processed or in any other way accessible by a third party organisation or across multiple locations within this organisation.