1. Demand Forecasting - Approach in Buckinghamshire Buckinghamshire County Council – Public Health Intelligence Dr. Ash More – Head of Public Health Intelligence Ash.more@nhs.net Conducted in August 2015 Presented at SEPHIG meeting on Dec 12, 2015 Demand forecasting in Buckinghamshire1 DRAFT

2. SCOPE AIM: To co-relate the increase in population especially the elderly population (65+ and 80+), projected prevalence of long term conditions and secondary care activity trends in Buckinghamshire to forecast the demand on secondary health care services over 5-10 years. Demand forecasting in Buckinghamshire2 OBJECTIVES: 1.To understand population change in different age groups using population projection estimates at county level. 1.To understand the projected prevalence of long term conditions eg Diabetes, Dementia, limiting long term illness and Frailty (using evidence, models and population projections). 2.To understand the trends in in-patient and out-patient activity in Buckinghamshire over past 5 years and forecast activity growth over next five years. 3.Understand the main causes of hospital admission in the population especially older population (aged 65+ and 80+) by primary diagnosis and specialty groups. 4.Co-relate population growth to secondary care activity growth and forecast demand.

3. DRAFT NOTES 1.Buckinghamshire Public Health has conducted this analysis using available data from available data sources which includes national and local data sources on hospital activity and population projections. All projections are estimates and approximation based on scenarios included in the analysis. 2.Population projections are based on trends in births, deaths, migration while secondary activity projections are based on trends analysis and certain assumptions. Hence caution is advised while planning services as the future secondary care activity need and demand will be directly influenced by several factors such as – population health status, management of LTCs in the population especially those at greatest need, primary care, community care, adult social care and urgent care services. 3.Since growth in demand for services in the NHS is directly proportional to availability of those services, the secondary care activity over next 3-5 years needs to be continuously monitored and analysed to note increase or changes to activity trends for planning acute and community services. 4.Understanding the main causes of hospital admissions as well as repeat admissions in individuals by disease/conditions is essential to understand case mix as this can vary from one region to another and is also influenced by availability of specialised services such as for stroke or maternity or cancer in different acute trusts. Probability of admission depends on severity of illness and availability of related primary or community care services in an area 5.Lifestyle related issues such as diet, smoking, alcohol consumption, physical activity will have a great influence on prevalence of long term conditions such as diabetes, CVD, stroke and dementia over the next 5-10 years. Early intervention and prevention is beneficial in reducing the future burden of disease and corresponding demand on secondary care activity. 6.This is part of the work to support demand forecasting for health and further modelling to review impact of population change on LTCs and corresponding secondary care need is presently being scoped. Demand forecasting in Buckinghamshire3

4. DRAFT Ageing population 21% 19% 20% 81% 80% 79% POPULATION GROWTH Annual Population Growth Rate Total Population = 0.7% per year 65+ Population = 2.2% per year

5. DRAFT POPULATION PROJECTIONS Demand forecasting in Buckinghamshire5

6. DRAFT FINDINGS – POPULATION PROJECTIONS 1.By 2020, the 65+ population in Bucks is projected to increase by 11,000 to 108,000 compared to 2015 estimates of 96,800. 2.By 2020, the 80+ population in Bucks in projected to increase by 5,400 to 32,200 compared to 2015 estimates of 26,800. 3.The annual growth rate of Bucks population in all ages is 0.7%, in 65+ population is three times higher at 2.2% and in 80+ population is 3.7%. 4.By 2020, the total Bucks population is expected to rise by 4% compared to 2015, while the 65+ population is projected to grow by 11%. 5.From 2015 to 2020, the 90+ age group is expecting the highest increase of 30%, followed by an increase of 23% in population aged 70-74 and 85-59. Demand forecasting in Buckinghamshire6

7. DRAFT ESTIMATES OF FRAIL ELDERLY POPULATION - PROJECTIONS Demand forecasting in Buckinghamshire7 1.In 2015, around 10,700 Bucks residents are estimated to be frail elderly meaning those with more than one long term condition or those with a condition that needs assistance with activities of daily living (approximately 11% of the elderly population*) 2.By 2020, the estimated frail elderly population is expected to rise to 12,000 means a rise of 1300. Evidence shows that the frail elderly population is 3 times more likely to end up in a hospital compared to the non-frail older population aged 65 and over. 3.Around 42% elderly population are considered as pre-frail which equates to around 45,000 people pre-frail in Bucks by 2020 compared to 40,000 in 2015 *Reference: Collard et al (2012). Prevalence of frailty in community-dwelling older persons: A systematic review. J Am Geriatr Soc; 60: pp1487-92.

8. DRAFT Demand forecasting in Buckinghamshire8 QOF DETECTED PREVALENCE OF LTCs IN BUCKINGHAMSHIRE

9. DRAFT Demand forecasting in Buckinghamshire9 MULTI-MORBIDITY – CO-MORBIDITY

10. DRAFT PROJECTIONS OF LONG TERM CONDITIONS Demand forecasting in Buckinghamshire10 DIABETESDEMENTIA Limiting Long-term illness FALLS Source: POPPI

11. DRAFT Main tasks 1.Analyse co-morbidity and quantum of complex patients 2.Analyse top causes of hospital admissions (ICD-10 Chapter) in All ages, 65+ and 80+ 3.Top Causes of hospital admissions (ICD-10 Causes) in All ages, 65+ and 80+ Demand forecasting in Buckinghamshire11 SECONDARY CARE ACTIVITY - ANALYSIS

12. DRAFT NHS CHILTERN CCG – COMPLEX PATIENTS Demand forecasting in Buckinghamshire12 Source: NHS England CCG Information Packs

13. DRAFT NHS AYLESBURY VALE CCG – COMPLEX PATIENTS Demand forecasting in Buckinghamshire13 Source: NHS England CCG Information Packs

14. DRAFT PROJECTIONS USING PAST TRENDS UNDER DIFFERENT SCENARIOS SCENARIO 1: Linear exponential projections SCENARIO 2: Rolling average exponential projections SCENARIO 3: Projections using past 3 years trend SCENARIO 4: Projections using past 2 years trend Note: Due to confidentiality issues (and the fact that further work is underway) all the findings and outcomes of projections in secondary care activity using different scenarios are not included in these slides. The projections are only presented for one scenario in the next slide as an example. Demand forecasting in Buckinghamshire14 SECONDARY CARE ACTIVITY

15. DRAFT CORELATION OF POPULATION GROWTH AND SECONDARY CARE ACTIVITY GROWTH 15 FINDINGS 1.The population growth in all age groups shows a substantial increase till 2020 compared to the 2012 baseline 2.The secondary care activity growth in the chart above is projected using the past 2 years growth average as an example of a scenario to note the projections in comparison with 2014-15 baseline. 3.The secondary care activity growth can be co-related to population growth till 2020 based on the average increase in IP and OP activity – however this is disproportionately large and further analysis is recommended to understand case mix and complex patients especially elderly patient with frequent admissions. 4.The secondary care IP activity is projected to increase by 16.7% for all ages if trend of past two years continues over next five years. In 65+ the activity is projected to increase by 36.8% by 2020 compared to 2015. In 80+ the IP activity is projected to increase by 56.8% 5.The total OP activity for all ages is projected to increase by an average of 4.8%. The OP activity in 65+ population is projected to increase by 9.9% annually and the 80+ activity is projected to increase by an average of 13.3% annually till 2020.

16. DRAFT HEALTH CARE IN THE 80+ & 90+ POPULATION 1.Majority of patients aged over 75 years in the UK have three or more long term medical conditions (co-morbidities) such as hypertension, diabetes, stroke, arthritis, cancer, dementia, including frailty, disability which makes them vulnerable and result in increased health care use. With ageing population this need will increase depending on local models of health care and population life expectancy and disability-free life expectancy 2.1 in 3 are obese and 1 in 2 people over 80 fall each year resulting in ambulance call outs to homes and consequent hospital admission 3.1 in 6 people over 80 are at risk of having Dementia leading to frailty and need for health care 4.Dementia and Alzheimer’s poses its own complication if the patient has other long term conditions in addition to Dementia. 5.There is Increased use of primary care and prescriptions in the elderly 6.Unplanned hospital admissions account for 68% of total hospital emergency bed usage in the NHS in the elderly. (NHS England) 7.80% of older patients stay in hospital more than 14 days 8.Increase in hospital admissions during winter and excess winter deaths continue to be a risk for the elderly population. 9.Hospitalisation raises the risk of health care acquired infections especially in the immuno-compromised elderly population. 10.Increase in hospital admissions in older adults is related to long term conditions such as - exacerbation of COPD, diabetes (hyper or hypoglycaemia) or musculo-skeletal related conditions eg joint(knee/hip) replacement means more beds and more bed-days needed. 11.The median age of people using intermediate care or reablement services is 83 12.Increased hospital admissions leads to increased need for intermediate care (nursing) post discharge from acute hospital before discharge to a residential home or patient’s home during the step-down approach 13.Spend on non-elective admissions, elective admissions, community health services and Adult social care treble after the age of 65 16

17. DRAFT METHODS a.The demographic information, health service activity info and prevalence of long term conditions (LTCs) were obtained from reliable sources of information listed in the next slide. b.The secondary care information was obtained from Secondary Uses Services (SUS) courtesy Central Southern Commissioning Support Unit. Buckinghamshire general practice registered population has been used with regard to hospital activity projections. ICD 10 chapters and diagnostic codes have been used to query SUS activity by age, cause and chapter. c.The data on disease prevalence was obtained from General practice disease registers as well as NHS England and the various prevalence models developed by Public Health England that estimated the prevalence of certain chronic diseases. d.The data storage and analysis was done using SQL, Microsoft Access and Excel tools and forecast of activity was done using exponential projections based on past trends and presented as time-series charts. e.Population projections have been used from the Office for National Statistics sub-national population projections that account for births, deaths, immigration, emigration, fertility rate to project population in single year and 5 year age bands up to 2030, using census 2011 as baseline data. f.Exponential projections have been used to forecast secondary care activity and findings presented in four different scenarios g.Scenario based projections using past 2 years trends and 3 years trends average in activity growth has been applied to project secondary care activity over next five years to 2020. The projections and forecast in this report are based on assumptions, since it is not possible to predict the growth in secondary care activity directly without applying service level changes and financial inputs in addition to population growth estimates. h.Accuracy of projections is subject to error analysis related to prediction and needs to be accounted for in the projected trends in activity. i.Further analysis is being scoped to understand co-morbidity and impact of increase in LTC on secondary care activity Demand forecasting in Buckinghamshire17

18. DRAFT SOURCES 1.Health and Social Care Information Centre [Quality and Outcomes Framework (QOF)] 2.Health Service Journal (HSJ), LANCET online, British Medical Journal (BMJ) 3.Office for National Statistics (ONS) – Sub-national population projections (2012, SNPP) 4.National Institute for Health and clinical excellence (NICE) 5.NHS England - Primary Care Web Tool (PCWT) 6.Projecting Older People’s Population Information System (POPPI) [Institute of Public Care] 7.Public Health England [Association of Public Health Observatories (APHO)] 8.Secondary Uses Services (SUS) – Central Southern Commissioning Support Unit Dr. Ash More Head of Public health Intelligence Buckinghamshire County Council - Public Health Email: amore@buckscc.gov.uk or ash.more@nhs.netamore@buckscc.gov.ukash.more@nhs.net Demand forecasting in Buckinghamshire18 CONTACT