Ambulatory Emergency Care Standard - Statement of Need
14 October 2014, Version 0 11, SCCI2027, HSCIC Ref 5644
Idea submitter name, organisation and email
Mike Davidge, Director, NHS Select [email protected]
Sharon Wade, NHS England, [email protected]
Inclusions
Appendix
Appendix 1
Appendix 1
Description
Additional Supporting Information
Current Definitions for Patient Classification
Type of Proposal
Is person identifiable data involved?
New Standard
Yes
Plain English description of proposal, including aims and benefits
This is a proposal to develop a new standard to capture spells1 of Ambulatory Emergency Care
(AEC) in an unambiguous manner to assure:
i)
ii)
accurate reporting of the nature and method of treatment provided and
appropriate care commissioning.
Background
Continued advances in medical technology, when supported by timely access to diagnostic and test
results, have meant that emergency care can, when appropriate, be delivered within an Ambulatory
Care Unit2. It can also assess, diagnose, treat and discharge the patient at the end of that single
spell, within the same working day, without requiring a bed. Historically, these treatments would
have required full admission to a bed. The new process is known as Ambulatory Emergency Care
(AEC) and is becoming increasingly common3, as a growing number of Trusts, driven by cost and
efficiency incentives opt to deliver emergency care in this way4.
Aside from the opportunities in business delivery, by its nature, AEC provides societal and patient
level benefits.5
NB: AEC should not be confused with other forms of treatment delivered in an Emergency
Department (ED). See appendix 1 Note 2 for further clarification.
To date, the commonly held view has been that the data structures and definitions in the
Commissioning Data Set (CDS 6) cannot be used to accurately accommodate AEC spells7 and so,
1
An interval of time involved, in this case, treatment
These patients are often admitted from a GP referral or via the Emergency Department (ED) and moved to an Ambulatory Care
Unit, from which they are discharged. Before AEC they would have been admitted, with AEC they move from ED into the AEC
Unit.
3
Today, around 60 Trusts have a policy to delivery AEC when appropriate to the circumstances of the patient
4
More information on AEC can be found at http://www.ambulatoryemergencycare.org.uk/file_download.aspx?id=16183
5
These benefits are not quantified in the Statement of Need (SoN) but could be usefully investigated should this SoN be
progressed to the next stagel
6
http://www.datadictionary.nhs.uk/web_site_content/navigation/commissioning_data_sets_menu.asp
2
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for Health Episode Statistics (HES 8) and CDS purposes, it has been suggested that these spells
may be have to be recorded as in-patient day cases9 (also see Appendix 1). Recording AEC spells
in this way does not accurately reflect the reality of the service as delivered.
As a result, AEC spells could not be:


accurately reported or analysed with confidence in the results or
consistently and accurately associated to the most appropriate Health Resource Group
(HRG)10
The problems arising from not being able to accurately identify AEC spells in CDS has had the
following adverse impacts:



Methods for recording AEC treatment are inconsistent, leading to an inability to deliver
consistent, harmonised national reporting and analysis.
Inappropriate Healthcare Resource Group (HRG) allocation may cause incorrect care
commissioning11 12.
The Best Practice Tariff (BPT) for AEC conditions is set using a benchmark derived from the
admitted patient care dataset. As increasing numbers of AEC patients are not recorded in
this way, it makes the benchmark seriously flawed.
Following lengthy discussions (lasting some years) it is confirmed that the requirement is to produce
a standard, embodying the necessary guidance to ensure existing outpatient CDS data sets can be
used to accommodate AEC spells.
Aims and benefits
By correctly identifying AEC spells within CDS, the aim is to:






Eliminate inconsistency in methods of recording AEC treatment
Deliver consistent, harmonised national reporting and analysis
Assure allocation of appropriate HRG allocation resulting in appropriate care commissioning11
Ensure any BPT is accurately set in future
Reduce the administrative burden required to correctly account for AEC episodes
Information stored in national information assets reflects the reality of the business
Other considerations
7
At present, AEC is not consistently reported in in either Inpatient/Outpatient/A&E attendances recording groups – this
requires standardising
8
http://www.hscic.gov.uk/hes
9
This is a pragmatic approach and should be recognised as such. AEC patients do not typically meet the criterion for being
classified as an inpatient. So according to the rules they should not be. If this approach were adopted it should be made clear as
to why AEC is an exception. There is a strong case to identify AEC as such, to avoid potential for ambiguity that may arise
10
Healthcare Resource Groups (HRGs) are standard groupings of clinically similar treatments which use common levels of
healthcare resource. HRGs are used as a means of determining appropriate reimbursement for care services delivered by
providers
11
And corresponding financial impacts
12
HRGs require depth of coding. Trusts who do not code their AEC activity (currently there are many) will not have the correct
HRGs allocated. This causes the volume of affected HRGs to be lower than they should be.
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Properly recording AEC spells of care will reduce the burden imposed on administrative staff and
commissioning negotiators when accounting for AEC spells.13
Irrespective of which solution may be chosen to deliver AEC from a CDS perspective, consideration
should be given to capturing AEC activity and medications using SNOMED CT14. Not only would
this approach align with other initiatives to exploit SNOMED CT, but it would improve the granularity
of information recorded for an AEC spell and subsequent opportunities for its detailed analysis. The
improved data quality resulting from use of SNOMED CT also brings with it opportunities to reduce
burden when providing analyses.
If any information regarding healthcare professionals is to be included within this data set, then
reference should be made to the existing data standards, that is, the National Workforce Data Set /
NHS Occupation Codes as relevant. Similarly, any changes to Treatment Function Codes / Main
Specialty Codes should be discussed with the workforce team.
There is a large, high-profile piece of work on Crisis Care being led by NHS England Medical
Directorate; their views should be taken into consideration before any changes are made. Their view
is that this should be collected via the A&E data set.
Stakeholders
The following stakeholders are affected by development of this standard:

















Administrative staff involved with AEC
Providers of Patient Administration Systems (PAS) and Electronic Health Record Systems (EHR)
in secondary care
HSCIC - developers of CDS data sets and the NHS Data Model and Dictionary Service
Terminology Developers (SNOMED CT)
NHS England
The Urgent and Emergency Care Review
Commissioning Organisations (CCGs, NHS England Area Teams, CSUs, DSCROs etc.)
Hospital Episode Statistics (HES)
Providers of NHS Funded Care (including Trusts and Independent Sector Providers)
CDS XML/middleware suppliers.
Casemix
Clinical Coders
Healthcare Professionals (if they are expected to capture/record additional items)
Royal Colleges/Association of Medical Royal Colleges (AoMRC)
Care Quality Commission
Public Health England
Summary Care Record
13
The extent of this burden saving is not yet known and should be evaluated in the Burden Assessment process
14
This could not be the only approach as many acute systems are not currently SNOMED compliant.
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Scope or Outline of outputs
A CDS capable of accurately identifying AEC spells
Parallel Development
A proposal is being made by the College of Emergency Medicine to redesign the Accident and
Emergency (A&E) Commissioning Data Set (CDS). It is understood that this CDS revision has
support from the Secretary of State for Health. Whether or not that support persists may depend on
the costs of developing such a change, when these become known.
If the proposal by the college of Emergency Medicine progresses15, best efforts should be made to
coordinate activity to ensure outcomes are aligned. For the avoidance of doubt, this statement of
need places no direct dependency on the work of the College of Emergency Medicine referred to
here.
Direction / Policy Drivers / Obligations
Across England, emergency systems are under considerable pressure with Emergency Department
(ED) attendances and the conversion rate to hospital admission both rising. Clinical teams across
England have recognised that a new approach is needed and have successfully redesigned their
systems to reduce demand by implementing Ambulatory Emergency Care (AEC).
Using the AEC approach, appropriate patients are diagnosed and treated on the same day and sent
home with ongoing clinical support and supervision as needed. This approach has improved both
clinical outcomes and patient experience and reduced costs and pressures in the urgent care
system.
See http://www.nhselect.nhs.uk/Service-Transformation/Ambulatory-Emergency-Care
Desired timescale for national implementation
As soon as possible.
DH Sponsor
SRO name, role
and organisation
15
To be determined
To be determined
This is only relevant as far as the options for the outcome of an Accident and Emergency event includes AEC
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Solution options / approaches
Option 1:
Recommended
Use existing, unmodified CDS data set to accommodate AEC by
developing appropriate administrative guidance
Delivery body: HSCIC and Suppliers
Aim
To deliver accurate recording of and accounting for AEC spells by:
 Making use of an existing CDS type 16
 Recording AEC patients as outpatients (not typically done in CDS)
 Developing the necessary administrative guidance to support the above
Business Process
 AEC spells will be recorded to existing CDS as outpatients.
 When referred from ED or GPs, patients will be classified as a first attendance (new)
 There are then four possible outcomes of a first attendance: (a) discharge to GP; (b) referral
onto another outpatient based pathway; (c) return to the unit; (d) admission.
o Outcomes a, c and d can be dealt with by existing CDS rules.
o Outcome b generates another first attendance in the other clinic.
 Ideally, the AEC spell will be coded using ICD-10 and OPCS-4 classification to support
statistical analysis and commissioning
Approach to solution delivery
This is a pragmatic approach that relies on use of an existing CDS type to accommodate this need.
The likely candidate for use is:

CDS type 020 (Outpatient CDS)
The modifications that would be required are:

Make use of the following CDS data elements to flag AEC17:



16
Local Sub Speciality – to create a ‘nationally agreed’ new local sub-speciality
Clinic code (for AEC involving Out-patient).
 NB: This is only available from CDS v 6-218
To account for intended AEC patients that become later true non elective inpatient
attendances (in this case the outcome will be to admit). Guidance will be developed as a part
CDS TYPE is a code to identify the specific type of Commissioning Data Set data. CDS TYPE will be replaced with CDS TYPE CODE
17
A llonger term solution could consider use of new, dedicated Treatment Function Code
Uptake of CDS 6.2 is believed to be around 80% and so mitigates any concerns relating to its low uptake, and hence
jeopardising the implementation of this standard.
18
.
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of this standard to ensure that such admissions do not lead to “double counting”

AEC spells should also be coded (using ICD-10 and OPCS-4 Classifications) and make use
of existing grouping processes used in commissioning

All of the above to be the subject of a new standard providing guidance to administrators of
AEC. This guidance is the principle focus of this standard

Any change of data element usage may affect other existing statistics, including the following:

Readmission rates

First to Follow up ratios

Did Not Attend rates

Mandatory collections including Monthly Activity Return (MAR) & Quarterly Activity
Return (QAR)
The guidance required to support this standard will include instructions to properly account
for AEC in all of the above.
Risks /Issues

This involves the capture of diagnostic / procedure coding which is traditionally collected in
the admitted patient care data set. However, collection for outpatient attendance is not
thought to be a major problem provided administrators are provided with adequate guidance

Use of ICD-10 and OPCS-4 Classifications are of great value in accurately determining the
grouping and hence commissioning for a treatment spell. However, this clinical coding is not
traditionally done for out-patients, mainly because of work load pressures on clinical coders.
It should be noted that if the activity which this standard is intended to cover is not delivered
by AEC then it would be dealt with as an admitted patient. Admitted patient care is clinically
coded, therefore there is no significant increase in coding requirements. However, any
increase in administrative work load is greatly offset by the revenue opportunities accruing to
AEC providers resulting from accurate coding.
Opportunities

This option has no technical risks as it involves no technical change and is a very low cost
solution to the problem

A standardised approach to the use of Local Sub-specialty and Clinic code allows for
effective identification of AEC activity

Improved accuracy of commissioning through accurate clinical coding will result in
appropriate levels of commissioning

This approach has no effect on system suppliers or commercial arrangements with them
Ballpark costs
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Burden days:
Data Provider - Burden
required to assess this.
not yet evaluated. The Burden Assessment and Advisory Service will be
Total Costs
Other impacts:
Not yet assessed.
Available capacity:
Not yet assessed.
Funding Status:
Development Programme: Not funded.
Implementation Programme: Not funded.
Option 2:
Modify existing CDS data set to accommodate AEC
Delivery body: HSCIC and Suppliers
Aim
To deliver accurate recording of and accounting for AEC spells by modifying the existing CDS type 19
Approach
There are a number of approaches that could be used when adapting existing CDS types to
accommodate this need. If an existing CDS type is to be modified, the likely candidate for
modification is:

CDS type 130 (Admitted Patient Care - Finished General Episode)
The modifications that would be required are:
19
20

New codes added locally to Patient Administration Systems / Electronic Patient Record
(PAS/EPR) systems AND

Attributes added to HES to identify AEC spells AND

Attributes added to CDS to specifically identify AEC spells OR

Modify the use of existing CDS attributes (intended management and admission method) to
identify AEC spells20. Options for this include:

Create new Admission Method of “Intended AEC” 0 nights length of stay (LOS), OR

Define AEC spells in a similar way to elective day cases. Here a combination of two
data items “Intended Management” and “Patient Classification”21 are used to define a
day case. If the validation rules on Intended Management were relaxed then this
would set AEC apart from those cases that just happened to be discharged the same
CDS TYPE is a code to identify the specific type of Commissioning Data Set data. CDS TYPE will be replaced with CDS TYPE CODE
This is a pragmatic approach and should be recognised as such. AEC patients do not typically meet the criterion for being
classified as either an inpatient or an outpatient. So according to the rules they should not be. If this approach is adopted a
reliable means of refining the settings must be made to assure correct identification of AEC spells
21
NB: patient classification is derived from intended management and administration method
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day from an inpatient bed

To account for intended AEC patients that become later true non elective inpatient (similar to
switch from intended day case (DC) to elective inpatient)

All modification to be reflected in the NHS Data Model and Dictionary Service
Risks /Issues
Any alteration to HES / CDS constitutes a major change to central and local information systems,
with far reaching technical and commercial implications and consequently, is not the preferred
HSCIC option:

HES / CDS have been extended several times beyond its initial agreed scope and thus
involve expensive change control negotiations with the HSCIC’s IT service provider.

Significantly, any further development of CDS is currently on hold pending contract extension
/ renewal negotiations with the service provider.

Effect on Service Level Agreements

Impact on coding departments – additional episodes need to code if changing from
Outpatient based recording
Technical impacts of this type of change are not trivial and include the following:

Payment Grouper in SUS will need modification to correctly identify these spells

Healthcare Resource Group (HRG) derivation may need to be changed, as above,

Derivation of patient classification (inpatient / day case) is affected 22

Agreements with local Commissioners may have to be put in place to take account of
any variation to the derivation of patient classification (see above)

it should be noted that not all PAS hold date and time data – though it is a
requirement of CDS 6.2 (currently optional)23

Length of stay calculations may be affected

Such a change will affect other existing statistics

Readmission rates

First to Follow up ratios
22
The existing calculation for patient classification causes any attendance spanning midnight to change from ‘day
case’ to ‘inpatient’. For example, where a patient is admitted at 23:00 and leaves the following day at 02:00 this is
deemed as an Inpatient. However, an attendance for the same duration e.g. 08:00 to 11:00 would be recorded as a
‘day case’
23
This should not be a showstopper. Only the date is required to prove that the patient went home the same day as they
presented
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

Did Not Attend rates

Mandatory collections including Monthly Activity Return (MAR) & Quarterly Activity
Return (QAR)
Effect on Contracting/Finance systems.
Benefits using this method

Better monitoring both locally and nationally of treatment of patients admitted to providers for
a specified range of diagnosis (Length of Stay, procedures, specialties involved etc.)
Ballpark costs
Burden days:
4 to 5 Years to delivery (elapsed time)
Data Provider - Burden not yet evaluated. The Burden Assessment and Advisory Service will be
required to assess this.
Total Costs
4 to 5 Years (approx. £5m +)
Other impacts:
Not yet assessed.
Available capacity:
Not yet assessed.
Funding Status:
Development Programme: Not funded.
Implementation Programme: Not funded.
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Option 3:
Design a new supplementary Data Set to capture AEC spells
Delivery body: HSCIC
Design a new, supplementary data set and submit through the Information Standards development
process, in order to standardise the data flowed by all Trusts. This would then be linked to the SUS
data within the HSCIC.
In terms of delivery, this could be a more efficient solution until such time as the requirement could
be accommodated within a subsequent release of CDS.
This solution would be easier to flow and join through the HSCIC Data Linkage Service
Risks / issues

Technically not as “elegant” or as streamlined as option 1, but has no impact on existing
information flows and definitions.

This is a potentially lengthy development process, though timescales may be reduced by
modifying replicas of existing extraction definitions.
Other Considerations:
1. Even this option does not obviate the need to make changes to existing data dictionary items; In
introducing a new concept of ambulatory care means that, for example, the A&E CDS would
need a new value adding to the data item A&E ATTENDANCE DISPOSAL, as the current list of
values available to that field does not allow identification of those attendances which lead to an
‘ambulatory care’ episode. This necessitates changes be made to the CDS in its own right24.
Work-arounds might be possible until CDS can be modified to cater for this. See also appendix
1, Note 1
2. Additionally costs could be incurred for:
 server/hosting,
 ongoing linkage and analysis,
 updates to HES (if it is to be added to HES),
 development of statistics/indicators
Ballpark costs
Burden days:
estimate 18 to 24 months development time (elapsed)
Data Provider - Burden £not yet evaluated
Total Costs
estimate 18 to 24 months development time (elapsed)
Funding Status:
Development Programme: Not funded
Implementation Programme: Not funded
24
this too would need the agreement of the waiting times /CQI teams
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Option 4:
Increase administrative burden to rectify reporting discrepancies
Delivery body: Trusts delivering AEC + HSCIC
Risks / Issues
Failure to develop the AEC CDS data set will result in:
 Inability to report AEC efficiently with any confidence on the completeness, dimensional
conformity, harmonisation and cleanliness of the reported information
 Inability to analyse the performance and opportunities relating to AEC business operations
 Errors in commissioning and re-imbursement
o Increased “hands on” management of AEC
 Increased administrative burden to:
o prepare and verify AEC reports / submissions and
o rectify reporting anomalies of AEC
Ballpark costs
£68,895 per AEC providing Trust per Annum
(cost of 1 @ WTE @ band 7 to process coding inconsistencies arising from mis-reported discharge /
re-admission)
Funding Status:
None in place.
Do Nothing:
Do Nothing / Continue with Status Quo
Risks / Issues
Failure to develop the AEC CDS data set will result in:
 Inability to report AEC efficiently with any confidence on the completeness, dimensional
conformity, harmonisation and cleanliness of the reported information
 Inability to analyse the performance and opportunities relating to AEC business operations
 Errors in commissioning and re-imbursement
o Increased “hands on” management of AEC
 Reputational damage as a result of ill-informed business information
Ballpark costs
£ nil
Funding Status:
None in place
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Recommendation See option 1
Option 1 is recommended. This option, though not a typical use of CDS, is a pragmatic solution
which has the following benefits :
i)
ii)
iii)
iv)
v)
vi)
delivers a working solution at minimal cost
has minimal impact on existing data flows
has no commercial impact
improves accuracy in commissioning and returns to AEC providers
improves accuracy in business analysis
reduces the barriers in administration necessary to deliver this type of care, resulting in
a. improved cost efficiencies
b. improved (reduced) bed usage
c. societal benefits
d. is more patient centric
e. can be measure
Important note concerning modifications to CDS:
The technical complexity involved in making any change to CDS (outlined in option 2) continues to
become a recurrent theme in more that one Statement of Need. Consideration should be given, to
initiate a work item separate from this idea, to undertake a full impact assessment of making change
to CDS. That work item should involve all parties who may be affected by such a change, and could
include, but not be restricted to:






Casemix,
Payment by Results (PbR),
Secondary Use Systems (SUS) / Health Episode Statistics) HES,
NHSE waiting times,
DH policy,
other data set owners
Such an impact assessment would be a useful, re-usable resource that could be used to inform any
of:



Other Statement of Need having CDS impacts
Blue printing work for any CDS developments that may take place in the future
A business case for assessing the impact that difficulties on developing CDS has in allowing
HSCIC and its customers to effectively record and hence manage their business
See appendix 1, Note 2 for a wider discussion on this point)
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Appendix 1: Further supporting information
Note 1
ACCIDENT AND EMERGENCY ATTENDANCE DISPOSAL
This note relates specifically to the changes required to CDS if option 2 is progressed:

Where a patient attends A&E this creates an A&E Attendance (which flows in CDS type 10).

If the patient should then be moved onto an AEC spell, the A&E Attendance must finish.

Part of the data requirements for the CDS type 10 is the ACCIDENT AND EMERGENCY
ATTENDANCE DISPOSAL which describes what happened to the patient when the A&E
attendance finished – admitted, discharged to GP, etc..

Currently, there is nothing suitable in CDS for identify ‘transferred to Ambulatory Care’, apart from
the value ‘Other’.

In order to marry up an A&E attendance with its subsequent ambulatory care spell (if any) it would
be easier in data terms if to do so using a specific disposal code for AEC.

In any event, work must be done to ensure the coherence of all the data flows around a patient’s
activity, and ensure that this does not have any unintentional, adverse impacts on existing flows,
statistics, etc.
Note 2
Handing and AEC versus Emergency Department Treatment
Advances in technical and management processes led a number of Trusts to develop the concept of
Ambulatory Emergency care (AEC). An AEC spell allows for the patient to be admitted, diagnosed, treated
and discharged within the same day. This leads to significant reduction in bed usage and the associated
costs. Currently, over 60 Trusts deliver AEC.
In 2007 the NHS Institute for Innovation and Improvement outlined 49 conditions that could be handled via
AEC.
In April 2012 the Department of Health recognising the significance of AEC, introduced Best Practice Tariffs
for 12 (of the 49) conditions in order to promote AEC. The move was welcomed as, without such a move,
Trusts were effectively penalised for short length of stay, receiving only a fraction of the tariff.
Although AEC treatment can be initiated from an Emergency Department (ED) attendance it is important to
note that the care is delivered in an Ambulatory Unit.
This early attendance at ED has given rise to (incorrect) assumptions that AEC is a form of ED care and
should be recorded as such. This then places the AEC spell alongside ED care, AEC then becomes
indistinguishable from ED care and is measured according to the same performance criteria, including :
 Waiting time measurements
 The four hour wait rule
Currently, CDS and HES are not able to recognise AEC spells and hence commissioning and accurate
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business reporting is compromised. Workarounds have been suggested such as the coding of outpatients.
However, most Trusts do not do it. But even if it were done, it may not be possible to distinguish AEC
patients from normal outpatients. Use of clinic code is a possible candidate solution, but again, this is not
passed on to commissioners.
These compromises are often mitigated by relying on local commissioning agreements with Care
Commissioning Groups (CCGs).
Modification to CDS would seem to be a clear solution, and it is recognised that there are many impacts of
amending the data items suggested elsewhere in this SoN (ADMISSION METHOD, INTENDED
MANAGEMENT, PATIENT CLASSIFICATION) – not least that the latter two are aligned to elective
(planned) activity and not emergency activity; INTENDED MANAGEMENT can, on most PAS systems, not
be entered for emergency admissions.
These data items are also referenced in many other places and used for derivation of other data items in
other data sets, or directly flowed (for example cancer outcomes & services, cancer waiting times, VTE,
Diagnostic Imaging, MHLDDS, KP90, Maternity).
All these data sets would need analysis to ascertain the impact on them, and their owners would need to
agree to bring any resulting changes to their standards to SCCI.
These far reaching impacts are not a reason to not do this work, but may lead to:
 The need to develop an interim, pragmatic solution compromise until such time as a more complete
solution is available (see recommendation)
 Undertake a separate work item to thoroughly investigate the emerging requirements business
change places on CDS and the impacts of making such changes (see recommendation, “Important
note concerning modifications to CDS”)
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Appendix 2: Existing Definitions for Patient Classification
There is information about how to classify a bed in the following day case guidance published in the NHS Data Model
and Dictionary. This is included here to describe the technical barriers to defining AEC spells within the current
specifications used for CDS.
http://systems.hscic.gov.uk/data/nhsdmds/faqs/cds/admitpat/daycase
Day Case admission
Recording activity as a Day Case admission or Out-Patient Attendance
Consultant. Is there a list of procedures that should be recorded against them?
There is no list of procedures or types of procedures which should be recorded as Out-Patient
Attendances Consultant or Day Case admissions. How each individual Patient's procedure should be
recorded depends on whether the activity satisfies the following NHS Data Model and Dictionary definitions:
Day Case
The definition of a Day Case admission can be found within the description of the NHS Data Model and
Dictionary attribute Patient Classification:
'A patient admitted electively during the course of a day with the intention of receiving care who does not
require the use of a hospital bed overnight and who returns home as scheduled. If this original intention is
not fulfilled and the patient stays overnight, such a patient should be counted as an ordinary admission.'
It follows from this and other related NHS Data Model and Dictionary definitions that:

A Day Case admission must be an elective admission, for which a Decision To Admit has been
made by someone with the Right Of Admission
1. The Patient uses a Hospital Bed for recovery purposes. If a bed or trolley is used for a specific short
procedure rather than because of the Patient's condition, this does not count as a hospital bed.
2. The Patient is not intended to occupy a hospital bed overnight, and does not actually occupy a bed
overnight
Out-Patient Attendance Consultant
The NHS Data Model and Dictionary definition of an Out-Patient Attendance Consultant states that it is an
attendance at which a Patient is seen by a Consultant, a member of the consultant firm or locum for such a
member.
Within the definition of Ward Operational Plan it is stated:
'A Patient may need to use a bed, couch or trolley whilst attending for a specific short procedure taking an
hour or less, such as an endoscopy. If such devices are being used only because of the active intervention
and not because of the Patient's condition, they should not be counted as beds for statistical purposes.'
It follows from this and other related NHS Data Model and Dictionary definitions that:
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1. The Patient must be seen by a doctor for the activity to qualify as an Out-Patient Attendance
Consultant.
2. If a Patient is using a Hospital Bed because of the active intervention rather than because of the
Patient's condition this activity is not counted as an admission but as an Out-Patient Attendance
Consultant.
http://systems.hscic.gov.uk/data/nhsdmds/faqs/pbr/guidance-for-pbr
Supplementary guidance for Payment by Results
The guidance below was produced following an exercise co-ordinated by the Audit Commission, and was
agreed by the Department of Health Payment by Results team, The NHS Information Centre for Health and
Social Care and the Information Standards Board for Health and Social Care. It is intended to provide
guidance to distinguish short term admitted patient care activity from out-patient activity for the purposes of
Payment by Results.
Differentiating between day cases, outpatient attendances where a procedure is performed, and
ward attendances, for elective and emergency activity types.
Classifying routine elective short-stay activity
The classification of a patient treated in a hospital environment is driven by the level of care they receive.
The concept of setting may be helpful to the NHS in managing care, but this is not a formal data item in the
data dictionary. Deciding whether to record activity in a particular way, and whether to submit activity via
the Out-Patient Commissioning Data Set or the Admitted Patient Care Commissioning Data Set is where
this distinction is made, and this is dependent on whether a clinical decision to admit has been made.
This FAQ describes how to understand whether activity should be classified as a day case and submitted
via the Admitted Patient Care Commissioning Data Set or as an outpatient or ward attendance and
submitted via the Out-Patient Commissioning Data Set.
Day case
A day case is defined as:

a patient admitted electively during the course of a day with the intention of receiving care, who
does not require the use of a hospital bed overnight and who returns home as scheduled. If this
original intention is not fulfilled and the patient stays overnight, such a patient should be counted as
an ordinary admission.
For a patient to be a day case they must be admitted to hospital following a decision to admit, made by
someone with the right of admission. A decision to admit is defined as:

a record of the event that a clinical decision to admit a patient to a particular healthcare provider has
been made by, or on behalf of, someone who has the right of admission. This decision denotes that
the patient is intended to be admitted to a hospital bed, either immediately or subsequently in the
future.
The decision to admit is a decision on whether a patient requires admission to a hospital bed, under the
care of a consultant. A hospital bed is defined as:
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
any device that may be used to permit a patient to lie down when the need to do so is as a
consequence of the patient's condition, rather than the need for active intervention such as
examination, diagnostic investigation, manipulation/treatment, or transport.
Put simply, if a patient uses a bed (or trolley or chair) for treatment, and does not need to use the bed
because of the medical condition being treated, because of some other medical condition, or to recover
from the treatment itself, then this does not require a decision to admit. It follows that this activity would not
routinely be classified as day case activity.
Where the activity should be classified as a day case, then it will flow in the Admitted Patient Care
Commissioning Data Set.
A decision to admit does not need to be made for every individual patient. Care pathways that define how
to classify patients for routine activity can be agreed and documented with input from clinicians responsible
for that activity. These can then differentiate between day cases (using the criteria above), outpatient
attendances or ward attendance as described below. However, where a patients' condition or treatment
varies from the care pathway during their hospital visit then the decision to admit (or not admit) should be
reviewed.
Outpatient attendance where a procedure is performed
If a patient is treated by a doctor (a consultant or a member of the consultant firm) but does not require a
bed beyond the treatment itself this should be treated as outpatient attendance and submitted via the OutPatient Commissioning Data Set. The appropriate OPCS codes can be included to describe the treatment.
This definition includes treatment by doctors on wards.
Ward attendance
If the patient receives nursing care for a treatment on a ward then this should be classified as a ward
attendance. For submission purposes, ward attendances are treated as outpatient attendances and
submitted via the Out-Patient Commissioning Data Set. The appropriate OPCS codes can be included to
describe the treatment.
Where the patient is treated by a doctor on a ward, this is an outpatient attendance, not a ward attendance
(where the patient is not admitted).
Classifying short-stay emergency activity
The definition of an emergency admission is 'when the admission is unpredictable and at short notice
because of clinical need'. If the decision to admit is at short notice because of clinical need, and the
decision to admit and admission could not be separated in time, (in other words, the admission could not be
delayed to some later date), then the admission should be classed as an emergency admission.
If the NHS wishes to use outpatient clinics and ward attenders to manage urgent care more efficiently and
effectively for the patient, then a care pathway can be defined and documented with the clinicians
responsible for that activity. This care pathway should include how to classify that activity, using the
principles outlined above for elective care.
Ward attendance guidance can be found at:
http://systems.hscic.gov.uk/data/nhsdmds/faqs/cds/admitpat/wardattend
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Dated
Version
Status
Template used
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Simon Blackburn
14th October 2014
0.11
For submission to SCCI
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