HES data for all CSUs and NHS England 2020/21

Commissioning Support Units (CSUs) are part of NHS England (NHS E), and provide comprehensive business intelligence (BI) services to a wide range of NHS organisations, this includes both standard analytics and reporting, deep-dives and diagnostic exercises to offer insight and intelligence on a commissioner’s health economy. In addition, CSUs offer business intelligence applications allowing self-service access to a range of dashboards and configurable reports. Tools are available on a subscription-basis only to NHS organisations, limited to Clinical Commissioning Groups (CCGs), internally within the CSUs through specialist support teams, by CCG member practices, and by local authorities.

The Commissioning Support Units providing the services are:

- North East London Commissioning Support Unit

- North of England Commissioning Support Unit

- South, Central and West Commissioning Support Unit

- Midlands and Lancashire Commissioning Support Unit

- Arden and Greater East Midlands Commissioning Support Unit

NHS England’s lawful basis for processing is 6(1)(e) ‘…exercise of official authority…’. For special categories (health) data the basis is 9(2)(h) ‘…health or social care…’.

NHS England (as the legal entity) is the sole data controller, and the CSUs (as part of NHS England) are data processors. Microsoft Azure provides cloud storage services for all commissioning support units and is therefore a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.

ANS Group Ltd are assisting South Central and West CSU to transition to CLOUD services and are therefore a data processor. ANS Group will be supplying support, platform build and management services for SCW CSU’s Cloud environment. As such, they could have access to pseudonymised / aggregate / anonymous data through system administration accounts. Whilst ANS Group are a data processor as they will have sight of the data, they will not process the data for any other purpose than IT support. ANS Group using the data for any other purpose would be considered a breach of this agreement.

Hospital Episode Statistics (HES)and Emergency Care Data Set (ECDS) are required to provide support to CCGs, other commissioning bodies, and local authorities working with CSUs to meet their statutory duties under the Health & Social Care Act 2012 and to support NHS health economy wide transformation projects.

The full, national set of HES and ECDS data allows complex and detailed modelling and benchmarking of activity and diagnostic interventions (numbers and rates), essential to successful commissioning of services and contract monitoring, including analysing relationships and influences between A&E, Inpatient and outpatient care and use of diagnostic services. This will especially support benchmarking work for CCGs, other commissioning clients and local authorities taking part in health economy wide transformation projects that require detailed and comprehensive hospital level data.

There will be no direct linkage between HES data records and other data already used by any CSU or in the BI tools. HES data may be presented alongside other data but not linked to it – for example a report may contain HES data alongside workforce statistics, weather reports etc.

CCGs only receive local/regional commissioning flows of data such as SUS and local flows filtered by resident/registered populations, so analysis undertaken on national data such as HES provides significant added value. These data sources will allow CCGs, other commissioning organisations and local authorities to benchmark and highlight areas of variation, so that best practice can be identified in similar health economies anywhere in England.

The data purpose relates to the need for national data for comparative analysis, benchmarking and forecasting, and this requirement for CSUs has specified support from NHS England. Having an extended time trend also provides valuable longer-term context when looking at health populations (e.g. health needs analysis, health economics) and service transformation. National data covering a number of years is required for benchmarking purposes, enabling users to compare themselves on a national footprint. CSUs therefore require HES data with a 10-year rolling history to enable them to provide accurate time-series forecasting methodologies. Forecasting, particularly with regards to winter surge management or financial planning, are key areas of interest for the NHS currently and are areas that the NHS North of England CSU (NECS) have used the HES data to support most recently.

As the NHS evolves, there is a greater emphasis on CCGs forming part of larger collaborations called Sustainability and Transformation Partnerships (STPs), and CSUs need to accelerate this way of working throughout the country, through partnerships of care providers and commissioners in an area STPs. Some areas are now ready to go further and more fully integrate their services and funding, and CSUs will back them in doing so (Integrated Care Systems). Provision of modelling support to emergent Integrated Care Systems (ICSs) thus supporting the whole health system through modelling demand and capacity primarily in secondary care.

To support the on-going budgetary pressures the NHS is faced with, the BI services and CSU BI tools offer significant support to commissioners on their Quality, Innovation, Productivity and Prevention (QIPP) programmes. Identifying service areas where the commissioner is an outlier that may then require re-procurement of a clinical service, comparisons with peer groups and best practice to understand how a change in approach might deliver a financial saving.

Working together with patients and the public, NHS commissioners and providers, as well as local authorities and other providers of health and care services, ICS’s will plan how best to provide care, while taking on new responsibilities for improving the health and wellbeing of the population they cover.

Under this agreement, the CSUs will use the data provided for 2 purposes:

i) benchmarking dashboards and reports, and

ii) bespoke analytics and reporting.

The HES data will be utilised within CSU BI tools to provide a range of benchmarking dashboards and reports as required to address specific priorities. This may include mortality, end of life, procedures of limited clinical value, new to follow-up ratios, readmissions etc. The ability to present a national and peer-group picture of locally defined indicators is the ambition. HES data will be presented independently of existing data flows within a bespoke dashboard as well as to supplement current reports/dashboards, for example using HES to calculate a national readmission rate to be presented on a locally fed readmission report.

As well as within the BI tool, HES data will be used by the BI team for bespoke analytics and reporting. This will include analysis on behalf of individual CCGs who have requested a deep dive, for a particular area and want to understand how they compare to other areas. It will also help support whole provider and health economy analysis where service re-configurations are being proposed.

Outputs are on an on-going basis (i.e., no target date) as the HES and DIDs data are used to support general commissioning and public health needs, and are not aimed at a specific report or deadline for use. Continued refinement of dashboards and reports available via the BI tools to registered users covering a range of benchmarking and comparative analysis. This will include a focus on for example:

a. Hospital mortality

b. Readmissions

c. New to Follow-up ratios for outpatients

d. Procedures of limited clinical value

e. Falls

f. Frequent flyers

g. Delayed transfers of care

This will allow commissioners to compare the impact of their programmes and work streams against peer groups and nationally and will help determine their effectiveness and inform future commissioning decisions.

Outputs will include graphs/charts showing a national and peer group figure and also tables detailing how each commissioner compares to others.

HES allows CSUs to provide intelligence for programmes whose scope demands activity benchmarking of the CSU's clients (CCGs or other commissioning bodies) against similar health economies or populations in England. SUS data does not allow this scope. National data also supports NHS health economy wide transformation projects that require detailed and comprehensive hospital level data.

All outputs informed by information retrieved from the HES data tables are governed by adherence to the HES guidance on suppression of small numbers. Users of the data abide by the HES Analysis Guide which means that all outputs released must contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Commissioners can compare with any service known to have better outcomes or new pathways, or support large scale transformation projects that may impact several commissioners across such as an STP footprint.

Outputs expected are aggregated data to support reports or decisions across examples such as the following:

• Elements of Joint Strategic Needs Assessments (JSNA) - to support CCGs/Local Authorities to consider the needs of their local populations and in how they respond with effective commissioning of services to properly meet those needs, by enabling, for example views of the use of secondary services by different patient groups by condition, ethnicity, etc.

• Quality, Innovation, Productivity and Prevention (QIPP) development - identifying and benchmarking areas across England with better practice than locally, to help evaluate high costs and poor outcomes in hospital care.

• Providing data on hospital admissions in-year to support monitoring of national ambitions, such as avoiding unnecessary admissions across CCGs, by practice, condition, hospital trust. CCGs are required to monitor and make progress on national outcome measures and ambitions by NHS England and use of national benchmarking is promoted heavily by initiatives such as Right Care ‘Commissioning for Value’ (on behalf of NHS England). Without access to national data such as HES, CCGs cannot be ultimately certain that they are making progress or making decisions on the best basis possible.

• It is anticipated that with the transition to Integrated Care systems/organisations the need for better intelligence around health outcomes of systems/populations will become increasingly important, The further demand, to look holistically at activity and cost across a whole clinical pathway necessitates linkage between datasets which is why linked datasets are important.

Diagnostic Imaging is an acknowledged area of unexplained variation between areas and so a fruitful area for CSUs to investigate and to support improvement initiatives (eg Right Care). The DIDs data with linkage to HES will help with any deep dives and provide further opportunities for gaining insight from this data. As an example, some CCGs have very high diagnostic intervention rates per head of population (eg for MRIs). Having DIDs data allows commissioners to have the detailed data to be able to investigate these type of issues in more detail and provide useful outputs.

CSUs support commissioners for analytics services (typically benchmarking analysis, or whole provider modelling).

CSUs will utilise the HES datasets to undertake various analyses both locally and in support of a range of national projects. Having the full catchment/provider data (commissioners generally only have their registered population) will facilitate accurate modelling of services and a view of complete patient pathways. Current projects where HES data would add significant value to the CSU’s services include:

a. Supporting CCG vanguard: CSUs are providing support to a number of vanguards, validating their activity/financial models and plans. Not having direct access to a standardised national dataset limits the support that can be provided.

b. Service and pathway transformation: redesigning care pathways on behalf of CCGs requires access to activity data covering the entire provider with HES the only source for this. Commissioning plans must be based on accurate and complete information.

The business intelligence teams within the CSUs will continue to use the HES data to produce deep-dive reports and analysis on specific projects whilst ensuring small number suppression is followed for all outputs and no row level data is shared outside the organisation.

c. Future commissioning architecture: Having a comprehensive dataset covering the local population will allow the CSUs to support local and national Sustainability and Transformation Plans (STPs) as they evolve and transform care at a local level.

Specifically:

i. Development of a Regional ICS frailty outcomes framework across Cumbria and the North East – using HES data to develop and monitor metrics for the framework, specifically around national benchmarks of secondary care activity for the over 65 population.

ii. QIPP planning - HES has been used to support the build of the 19/20 QIPP plan for CCGs both to proactively benchmark against locality (non-RightCare) peers and to test the potential benefit of QIPP pipeline ideas.

iii. HES benchmarking used frequently to report on progress of CCG RightCare schemes and to contrast the performance across CCGs and their local health economies.

iv. Realising Every Asset in Community Health (REACH) – The CSUs are analysing non elective admissions due to urgent care sensitive conditions for NHSE and pilot areas to identify priorities for pathway improvement. HES provides a level of detail that is unavailable in published reports and will be critical in monitoring the impact of pathway improvements.

Some of the yielded benefits of HES data to date are:

1) Assisting NHS England in London, at identifying the rates of GP referrals to hospitals across all the CCGs in London.

There is a lot of variation, both between CCGs and between GP Practices within a CCG area and NELCSU have compared these in a way that accounts for these areas very different populations (in statistical terms this is known as “standardisation”.

The NHS is experiencing significant pressure and unprecedented levels of demand. The average annual growth in GP referrals between 2009/10 and 2014/15 was 3.9%. Growth in 2015/16 compared to 2014/15 was 5.4%. For the same period, other referrals, which include consultant to consultant referrals grew by 6.7%. There is clearly a significant need for the NHS to manage the demand that flows into hospitals by ensuring that cases are prioritised appropriately referred for face to face consultation. There is also evidence to suggest that a referral to hospital is not always necessary.

NHS England have published a demand management “Good Practice Guide” covering areas such as “peer review of referrals”, “shared decision making” and “advice and guidance”. The results of this analysis help identify which geographies to target, inform the conversation around appropriate areas to change and help monitor the impact of any implemented demand management schemes.

2) Assisting a CCG in the South of England implement improvements in the area of diabetes and respiratory disease.

The improvements will involve the health system – GPs, hospitals, community services – working more effectively together (or in the jargon working in a more “integrated” way). HES data has been used to identify variation in “outcomes” to identify potential areas to target. For example HES data was used to identify the numbers of patients admitted with complications of diabetes, as these are an indicator that a patient’s condition has deteriorated, something that could possibly be counteracted with better management of a patient’s condition within primary care. Are these numbers high relative to other areas? How much do they vary by GP practice? What is the real reason behind this variation?

Integrated care schemes internationally have evidenced significant benefits in improving patient outcomes, experience of care and reducing costs to the health system. This project is the first stage of a pilot, and will be extended out to a wider geography and to other clinical areas.

3) Identifying potential influences on high A&E attendance rates.

Within London, most A&E departments are under huge pressure from rising A&E demand. However, the rate of increase does vary significantly by geography and by patient group. By using national HES data NHS North and East London Commissioning Support Unit were able to undertake statistical modelling of most of the known drivers of A&E attendance and try to understand the relative importance of each. For example, patient ethnicity appears to be one influence. Those ethnic groups with high attendance rates can be targeted through communication campaigns or through their GPs to encourage use of alternative services where possible. The better that the reasons for growing A&E demand can be understood, the more effective commissioners can be in tackling the root cause of the issue.

Commissioning Support Units (CSUs) are part of NHS England (NHS E), and provide comprehensive business intelligence (BI) services to a wide range of NHS organisations, this includes both standard analytics and reporting, deep-dives and diagnostic exercises to offer insight and intelligence on a commissioner’s health economy. In addition, CSUs offer business intelligence applications allowing self-service access to a range of dashboards and configurable reports. Tools are available on a subscription-basis only to NHS organisations, limited to Clinical Commissioning Groups (CCGs), internally within the CSUs through specialist support teams, by CCG member practices, and by local authorities.

The Commissioning Support Units providing the services are:

- North East London Commissioning Support Unit

- North of England Commissioning Support Unit

- South, Central and West Commissioning Support Unit

- Midlands and Lancashire Commissioning Support Unit

- Arden and Greater East Midlands Commissioning Support Unit

NHS England’s lawful basis for processing is 6(1)(e) ‘…exercise of official authority…’. For special categories (health) data the basis is 9(2)(h) ‘…health or social care…’.

NHS England (as the legal entity) is the sole data controller, and the CSUs (as part of NHS England) are data processors. Microsoft Azure provides cloud storage services and is a data processor. Other organisations referred to in this agreement only supply the IT infrastructure or building and do not have access to the data.

Hospital Episode Statistics (HES), Emergency Care Data Set (ECDS) and Diagnostic Imaging Data (DIDs) are required to provide support to CCGs, other commissioning bodies, and local authorities working with CSUs to meet their statutory duties under the Health & Social Care Act 2012 and to support NHS health economy wide transformation projects.

The full, national set of HES, ECDS and DIDs data allows complex and detailed modelling and benchmarking of activity and diagnostic interventions (numbers and rates), essential to successful commissioning of services and contract monitoring, including analysing relationships and influences between A&E, Inpatient and outpatient care and use of diagnostic services. This will especially support benchmarking work for CCGs, other commissioning clients and local authorities taking part in health economy wide transformation projects that require detailed and comprehensive hospital level data.

There will be no direct linkage between HES data records and other data already used by any CSU or in the BI tools. HES data may be presented alongside other data but not linked to it – for example a report may contain HES data alongside workforce statistics, weather reports etc.

CCGs only receive local/regional commissioning flows of data such as SUS and local flows filtered by resident/registered populations, so analysis undertaken on national data such as HES provides significant added value. These data sources will allow CCGs, other commissioning organisations and local authorities to benchmark and highlight areas of variation, so that best practice can be identified in similar health economies anywhere in England.

The data purpose relates to the need for national data for comparative analysis, benchmarking and forecasting, and this requirement for CSUs has specified support from NHS England. Having an extended time trend also provides valuable longer-term context when looking at health populations (e.g. health needs analysis, health economics) and service transformation. National data covering a number of years is required for benchmarking purposes, enabling users to compare themselves on a national footprint. CSUs therefore require HES data with a 10-year rolling history to enable them to provide accurate time-series forecasting methodologies. Forecasting, particularly with regards to winter surge management or financial planning, are key areas of interest for the NHS currently and are areas that the NHS North of England CSU (NECS) have used the HES data to support most recently.

As the NHS evolves, there is a greater emphasis on CCGs forming part of larger collaborations called Sustainability and Transformation Partnerships (STPs), and CSUs need to accelerate this way of working throughout the country, through partnerships of care providers and commissioners in an area STPs. Some areas are now ready to go further and more fully integrate their services and funding, and CSUs will back them in doing so (Integrated Care Systems). Provision of modelling support to emergent Integrated Care Systems (ICSs) thus supporting the whole health system through modelling demand and capacity primarily in secondary care.

To support the on-going budgetary pressures the NHS is faced with, the BI services and CSU BI tools offer significant support to commissioners on their Quality, Innovation, Productivity and Prevention (QIPP) programmes. Identifying service areas where the commissioner is an outlier that may then require re-procurement of a clinical service, comparisons with peer groups and best practice to understand how a change in approach might deliver a financial saving.

Working together with patients and the public, NHS commissioners and providers, as well as local authorities and other providers of health and care services, ICS’s will plan how best to provide care, while taking on new responsibilities for improving the health and wellbeing of the population they cover.

Under this agreement, the CSUs will use the data provided for 2 purposes:

i) benchmarking dashboards and reports, and

ii) bespoke analytics and reporting.

The HES data will be utilised within CSU BI tools to provide a range of benchmarking dashboards and reports as required to address specific priorities. This may include mortality, end of life, procedures of limited clinical value, new to follow-up ratios, readmissions etc. The ability to present a national and peer-group picture of locally defined indicators is the ambition. HES data will be presented independently of existing data flows within a bespoke dashboard as well as to supplement current reports/dashboards, for example using HES to calculate a national readmission rate to be presented on a locally fed readmission report.

As well as within the BI tool, HES data will be used by the BI team for bespoke analytics and reporting. This will include analysis on behalf of individual CCGs who have requested a deep dive, for a particular area and want to understand how they compare to other areas. It will also help support whole provider and health economy analysis where service re-configurations are being proposed.

Outputs are on an on-going basis (i.e., no target date) as the HES and DIDs data are used to support general commissioning and public health needs, and are not aimed at a specific report or deadline for use. Continued refinement of dashboards and reports available via the BI tools to registered users covering a range of benchmarking and comparative analysis. This will include a focus on for example:

a. Hospital mortality

b. Readmissions

c. New to Follow-up ratios for outpatients

d. Procedures of limited clinical value

e. Falls

f. Frequent flyers

g. Delayed transfers of care

This will allow commissioners to compare the impact of their programmes and work streams against peer groups and nationally and will help determine their effectiveness and inform future commissioning decisions.

Outputs will include graphs/charts showing a national and peer group figure and also tables detailing how each commissioner compares to others.

HES allows CSUs to provide intelligence for programmes whose scope demands activity benchmarking of the CSU's clients (CCGs or other commissioning bodies) against similar health economies or populations in England. SUS data does not allow this scope. National data also supports NHS health economy wide transformation projects that require detailed and comprehensive hospital level data.

All outputs informed by information retrieved from the HES data tables are governed by adherence to the HES guidance on suppression of small numbers. Users of the data abide by the HES Analysis Guide which means that all outputs released must contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

Commissioners can compare with any service known to have better outcomes or new pathways, or support large scale transformation projects that may impact several commissioners across such as an STP footprint.

Outputs expected are aggregated data to support reports or decisions across examples such as the following:

• Elements of Joint Strategic Needs Assessments (JSNA) - to support CCGs/Local Authorities to consider the needs of their local populations and in how they respond with effective commissioning of services to properly meet those needs, by enabling, for example views of the use of secondary services by different patient groups by condition, ethnicity, etc.

• Quality, Innovation, Productivity and Prevention (QIPP) development - identifying and benchmarking areas across England with better practice than locally, to help evaluate high costs and poor outcomes in hospital care.

• Providing data on hospital admissions in-year to support monitoring of national ambitions, such as avoiding unnecessary admissions across CCGs, by practice, condition, hospital trust. CCGs are required to monitor and make progress on national outcome measures and ambitions by NHS England and use of national benchmarking is promoted heavily by initiatives such as Right Care ‘Commissioning for Value’ (on behalf of NHS England). Without access to national data such as HES, CCGs cannot be ultimately certain that they are making progress or making decisions on the best basis possible.

• It is anticipated that with the transition to Integrated Care systems/organisations the need for better intelligence around health outcomes of systems/populations will become increasingly important, The further demand, to look holistically at activity and cost across a whole clinical pathway necessitates linkage between datasets which is why linked datasets are important.

Diagnostic Imaging is an acknowledged area of unexplained variation between areas and so a fruitful area for CSUs to investigate and to support improvement initiatives (eg Right Care). The DIDs data with linkage to HES will help with any deep dives and provide further opportunities for gaining insight from this data. As an example, some CCGs have very high diagnostic intervention rates per head of population (eg for MRIs). Having DIDs data allows commissioners to have the detailed data to be able to investigate these type of issues in more detail and provide useful outputs.

CSUs support commissioners for analytics services (typically benchmarking analysis, or whole provider modelling).

CSUs will utilise the HES datasets to undertake various analyses both locally and in support of a range of national projects. Having the full catchment/provider data (commissioners generally only have their registered population) will facilitate accurate modelling of services and a view of complete patient pathways. Current projects where HES data would add significant value to the CSU’s services include:

a. Supporting CCG vanguard: CSUs are providing support to a number of vanguards, validating their activity/financial models and plans. Not having direct access to a standardised national dataset limits the support that can be provided.

b. Service and pathway transformation: redesigning care pathways on behalf of CCGs requires access to activity data covering the entire provider with HES the only source for this. Commissioning plans must be based on accurate and complete information.

The business intelligence teams within the CSUs will continue to use the HES data to produce deep-dive reports and analysis on specific projects whilst ensuring small number suppression is followed for all outputs and no row level data is shared outside the organisation.

c. Future commissioning architecture: Having a comprehensive dataset covering the local population will allow the CSUs to support local and national Sustainability and Transformation Plans (STPs) as they evolve and transform care at a local level.

Specifically:

i. Development of a Regional ICS frailty outcomes framework across Cumbria and the North East – using HES data to develop and monitor metrics for the framework, specifically around national benchmarks of secondary care activity for the over 65 population.

ii. QIPP planning - HES has been used to support the build of the 19/20 QIPP plan for CCGs both to proactively benchmark against locality (non-RightCare) peers and to test the potential benefit of QIPP pipeline ideas.

iii. HES benchmarking used frequently to report on progress of CCG RightCare schemes and to contrast the performance across CCGs and their local health economies.

iv. Realising Every Asset in Community Health (REACH) – The CSUs are analysing non elective admissions due to urgent care sensitive conditions for NHSE and pilot areas to identify priorities for pathway improvement. HES provides a level of detail that is unavailable in published reports and will be critical in monitoring the impact of pathway improvements.

Some of the yielded benefits of HES data to date are:

1) Assisting NHS England in London, at identifying the rates of GP referrals to hospitals across all the CCGs in London.

There is a lot of variation, both between CCGs and between GP Practices within a CCG area and NELCSU have compared these in a way that accounts for these areas very different populations (in statistical terms this is known as “standardisation”.

The NHS is experiencing significant pressure and unprecedented levels of demand. The average annual growth in GP referrals between 2009/10 and 2014/15 was 3.9%. Growth in 2015/16 compared to 2014/15 was 5.4%. For the same period, other referrals, which include consultant to consultant referrals grew by 6.7%. There is clearly a significant need for the NHS to manage the demand that flows into hospitals by ensuring that cases are prioritised appropriately referred for face to face consultation. There is also evidence to suggest that a referral to hospital is not always necessary.

NHS England have published a demand management “Good Practice Guide” covering areas such as “peer review of referrals”, “shared decision making” and “advice and guidance”. The results of this analysis help identify which geographies to target, inform the conversation around appropriate areas to change and help monitor the impact of any implemented demand management schemes.

2) Assisting a CCG in the South of England implement improvements in the area of diabetes and respiratory disease.

The improvements will involve the health system – GPs, hospitals, community services – working more effectively together (or in the jargon working in a more “integrated” way). HES data has been used to identify variation in “outcomes” to identify potential areas to target. For example HES data was used to identify the numbers of patients admitted with complications of diabetes, as these are an indicator that a patient’s condition has deteriorated, something that could possibly be counteracted with better management of a patient’s condition within primary care. Are these numbers high relative to other areas? How much do they vary by GP practice? What is the real reason behind this variation?

Integrated care schemes internationally have evidenced significant benefits in improving patient outcomes, experience of care and reducing costs to the health system. This project is the first stage of a pilot, and will be extended out to a wider geography and to other clinical areas.

3) Identifying potential influences on high A&E attendance rates.

Within London, most A&E departments are under huge pressure from rising A&E demand. However, the rate of increase does vary significantly by geography and by patient group. By using national HES data NHS North and East London Commissioning Support Unit were able to undertake statistical modelling of most of the known drivers of A&E attendance and try to understand the relative importance of each. For example, patient ethnicity appears to be one influence. Those ethnic groups with high attendance rates can be targeted through communication campaigns or through their GPs to encourage use of alternative services where possible. The better that the reasons for growing A&E demand can be understood, the more effective commissioners can be in tackling the root cause of the issue.