The NHS is experimenting on increasingly large scales with new ways of delivering health care. With so much in motion, including sustainability and transformation partnerships and now accountable care systems, it is more important than ever to have ways of assessing the impact that these changes are having on quality and cost.     

The impact of redesigning urgent and emergency care in Northumberland is based on an analysis by the Improvement Analytics Unit – a partnership between the Health Foundation and NHS England. It examines the early impact of changes to A&E and urgent care services in Northumberland following the opening of the country’s first bespoke emergency hospital in Cramlington in 2015. The work was conducted in collaboration with the Northumbria Primary and Acute Care System (PACS) vanguard, which includes Northumberland Clinical Commissioning Group and Northumbria Healthcare NHS Foundation Trust.

Our study found that people in Northumberland attended A&E departments 13.6% more frequently in the year following the opening of the new hospital than would have been expected. They also spent on average 14 minutes less time waiting in A&E and urgent care centres than would have been expected. We did not find evidence of a reduction in emergency admissions overall, but here we were limited by the data. Northumbria has introduced ambulatory care units to provide lower-intensity care for some patients attending A&E. These are indistinguishable from other emergency admissions in the administrative data, yet have lower cost.

In part, the results we found may be because the three other hospitals run by Northumbria Healthcare NHS Foundation Trust at North Tyneside, Wansbeck and Hexham were not fully converted to walk-in centres as originally planned, and continued to accept A&E patients throughout the period that we studied (August 2015 to July 2016).

What might explain these findings? With an increased number of A&E departments to access, local people may have chosen to use A&E over other alternatives if they felt it was more convenient or likely to provide better quality care. In other words, quality may have increased, but along with it, demand for this type of health care.

Interestingly, evaluations of successful changes to health care often show that the anticipated impacts materialised only after a long period of time had elapsed, while in the short term there were unexpected outcomes. Ten years from now, we may look back on this stage of the Northumberland story and see it as one valuable step taken along the way towards achieving the ultimate aim of higher quality and sustainable health care.

The journey towards better, more efficient care may require some careful consideration of these findings and course correction. Indeed, the building of the Northumbria Specialist Emergency Care Hospital was only the first stage of an extensive change programme planned by the PACS. Further system changes are already planned in Northumberland, including investment in primary and community care. Now, two and a half years after the new hospital opened, it would be useful to look again at the impact of the PACS and whether the way local people are using hospitals has evolved further.

As the new care models programme comes to an end and Sustainability and Transformation Partnerships and Accountable Care Organisations evolve, understanding the unintended consequences of change and how to learn from them and correct them is essential for the development of a strong and sustainable health service.

Adam Steventon is Director of Data Analytics at the Health Foundation.
This blog was originally published in the Health Services Journal.

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James Ward

Thank you - very interesting! Do you think that these unintended consequences - and those for similar systems, such as STPs - might have been reliably predicted, and if so how might this best be done?

Linda Jane McLean

Practice is essential to cope efficiently with such demands., devised by a Pittsburg Orthopaedic Surgeon, is being used with some success in Scotland.It drives improvement through seeing the situation from the patient viewpoint. I recently heard an A&E doctor who was passionate about it, because of the way it had opened her eyes and changed her practice.

Julia Howarth

Have the unintended consequences for Northumbria’s neighbouring NHS Trust been included in the evaluation? Ambulances turned away from or too far from Cramlington use Newcastle.

Adam Steventon

Thanks for your question, Julia. The evaluation assessed the impact of the changes for people who were registered with a GP in Northumberland, and included all of their hospital activity, regardless of whether that happened at Northumbria Healthcare Foundation Trust or elsewhere in England. So, if the changes to urgent and emergency care affected how often Northumberland patients went to Newcastle for their care, then that impact is captured in the evaluation findings. For more detail on our approach and rationale, see page 6 of the report.

Adam Steventon

Hi James, that’s a good question. It’s hard to say. There are various models for predicting the relationship between health care supply and demand. However, health care is complex and sometimes the unexpected happens. Shows the importance of monitoring the impact of these changes closely and making adjustments if and when they are needed.

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