UEC system outcomes and measures Ciaran Sundstrem Senior Programme Lead: Urgent and Emergency Care Review NHS England
NHS Confederation: UEC Review update Ciaran Sundstrem 25 March 2015
Urgent and Emergency Care Review Three phases to the programme: Looked at the challenges the UEC system faces, and what principles a new system should be based on Translation of what needs to happen into how these ideas can be operationalised and delivered The final phase is focused on implementing the new models of care and ways of working developed by the Review
The Future System
Big Tickets Plan on a Page
UECR Update December NHS England Board discussion on Urgent and Emergency Care January Practical Guide to Healthy Ageing aimed at older people, particularly those over 70, to help improve general health and fitness. Handbooks on caring for patients with long term conditions to support commissioners and practitioners in planning services for people with LTCs, to achieve more effective, personalised care Outcomes Measures Workshop February Medical Leaders Conference role of medical leader in UEC network Dispatch on Disposition pilots begin Coming up Transforming UEC services in England Suite of documents to be published Spring 2015 (including networks & ambulance guidance)
Phase 3 implementation Transforming UEC services in England Suite of documents to be published Spring 2015, including: Urgent and Emergency Care Networks advice will outline formation and operation of UEC networks Clinical Models for Ambulance Services will demonstrate how ambulance services could deliver enhanced rates of hear and treat and see and treat, avoiding unnecessary admissions and ensuring that patients are treated closer to home Improving Referral Pathways guidance to improve the flow of patients and information within the UEC system by supporting an enhanced and consistent approach to the referral of patients between healthcare professionals and providers. Safer, Faster, Better: Good Practice in Delivering Urgent and Emergency Care a practical summary of the design principles for local health communities to adopt.
Looking further ahead Additional products will be developed over the next year: Workforce Work stream led by Health Education England, including: Increasing the use of pharmacists in the UEC system; Development of the paramedic workforce through a single degree level curriculum; pilots in relation to Advanced Clinical Practitioners (ACP) and Physician Associates; educational framework for district and general practice. Self care resources Knowledge portal to help commissioners and practitioners in identifying community centred approaches and evidence; alongside a range of other initiatives. Timely access to relevant patient data Working on delivering Summary Care Record (SCR) access for Ambulance Trusts, A&E, 111; work is underway on a number of initiatives including community pharmacy use of SCR; working on the development of SCR national levers.
Looking further ahead Outcome Metrics developing standards and specifications to help describe the networked system and enable commissioners to have the information and support to commission for system wide outcomes New payment models key aims are to provide a financial platform for coordination and planning of care delivery, commissioning for quality and outcomes, and sharing in outcomes across UEC networks over multiple years NHS 111 Commissioning Standards The next publication refresh is due in winter 2015 to align with the NHS England business planning cycle. Patient flows interactive tool We are continuing to develop and test the tool to show local patient flows around the whole of the UEC system. Directory of Services development search tool to be made available providing clinicians in urgent care settings with access to service information held within the NHS Pathways Directory of Services.
UECR Outcomes Ciaran Sundstrem and Nalyni Shanmugathasan 25 rd March 2015
Introduction Aims, objectives, scope and approach Trialling indicators Other possible indicators Issues for discussions
Aims and Objectives of the indicators Indicators developed should be used to measure the performance of a UEC System over time or highlight achievement that was significantly different from accepted variables. They should not be used to compare networks or services against one another. As well as demonstrating the effectiveness of individual networks, the Review is looking for a set of indicators that will encourage (alongside other pieces of work in the UECR): The development of networks and network behaviour, particularly the smooth flow of patients and patient information across the different components that comprise the total urgent and emergency care service that an individual and their family receive; and Innovative thinking about how best to commission and deliver a seamless local urgent and emergency care network.
Scope and Approach Patients with urgent and emergency care conditions (not prevention) Whole system approach: consider the way that system components work together as a whole (includes patient pathways and data sharing) Measures most useful when considered over time (rather than league tables ) Start with those measures that can be trialled now, but expand scope over time We have been working with a range of stakeholders in developing the project so far through workshops, seeking written feedback and a webinar.
Indicators: Background The indicators would be an alert system, to make individual networks aware of potential issues about effectiveness. They will focus on outcomes and therefore not necessarily provide an indication of where any problems lay, nor where remedial action should be focused. The indicators might be supported by a local toolkit, which would help networks understand what the indicators were and weren t demonstrating; and what other data networks could use to investigate changes in the achievement against the indicators, however the development of this toolkit should be for local determination and is not part of the national piece of work.
Trialling indicators in the UEC system We propose an approach to phased trialling and evaluation of a range of indicators. Starting with indicators which have been identified as good outcomes measures for the UEC system and for which data are available. Some research undertaken by John Nicholl et al at SCHARR identified a list of indicators which are suitable to understanding the UEC system using a Delphi exercise. Based on this work and in consultation with stakeholders 4 indicators have been identified for the first phase of trialling.
Trialling indicators in the UEC system Four of those developed by Jon Nicholl and colleagues have been identified for possible inclusion in a first tranche. They are: 1. Mortality rates for serious, emergency, conditions for which a well performing EUCS could improve chances of survival. 2. Case fatality ratios for serious, emergency conditions for which a well performing EUCS could improve chances of survival. 3. Hospital emergency admission rates for urgent conditions, the exacerbation of which could be managed out of hospital or in emergency departments without admission to a hospital bed. 4. Arrivals at EDs referred by emergency ambulance and discharged without treatment or investigations(s) that needed hospital facilities.
Trialling indicators approach By trialling indicators we mean that a set of indictors should be calculated and made available to local areas/commissioners to be used to see if the objectives for their use are met. We need to consider: how many trial sites we should have; and how long should the trial run for. We also need to consider and agree an approach to evaluating the trial of indicators We already have some volunteers to take part in the trial but are seeking more.
Areas for further indicator development Capturing the totality of what an urgent and emergency care system achieves Patient outcomes. Other aspects of patient experience. Equity. Cost effectiveness. Staff experience.
Patient Experience A Must do. Suggested indicators: Time from first contact with a EUCS service to clinical assessment. For patients with indicator conditions who are admitted to a hospital bed, time from first contact with a EUCS service to time of admission. Time from first contact with EUCS service to definitive care for indicator conditions. Multiple transfers between EUCS services. Communication patients and relatives being well informed, no conflicting information as they move through the system. Perceived response time? Quickly enough?
Equity Variations in time from first contact with urgent and emergency care system to first clinical assessment, comparing: in and out of hours; weekdays and weekends; patient s postcodes (could be home or GP). Variations in times from first call to admission, comparing: in and out of hours; weekdays and weekends. For patients with specified conditions, variations in times from first call to definitive care, comparing: in and out of hours; weekdays and weekends; patient s postcodes (could be home or GP). Q How and how far might any of the indicators lead to goal displacement? Q Is there any other reason not to proceed with assessing the feasibility of any of the indicators? Q Are these indicators sufficient to make a high-level assessment of whether an urgent and emergency care system is delivering well on equity?
Cost effectiveness [Hospital emergency admission rates for urgent conditions, the exacerbation of which could be managed out of hospital or in emergency departments without admission to a hospital bed.] Arrivals at EDs referred by any EUCS services and discharged without treatment or investigations(s) that needed hospital facilities. [Arrivals at EDs referred by emergency ambulance and discharged without treatment or investigations(s) that needed hospital facilities.] Adherence to evidence based, good practice guidelines for serious, emergency and urgent conditions. Q How and how far might the second or fourth indicators lead to goal displacement? Q Is there any other reason not to proceed with assessing the feasibility of any of these two indicators? Q Are the four indicators together sufficient to make a high-level assessment of whether an urgent and emergency care system is delivering well on cost-effectiveness?
Staff Feedback A Must do Workforce; Staffing vacancies; Numbers of EM consultant posts unfilled; Numbers of locums filling vacancies Training, education, staffing levels, ability to access advice and data /care plans, effectiveness of communications across different providers. Consider also effectiveness of command and control/ monitoring across UEC providers
The offer Right care Right place First time Q How might we measure this and demonstrate, from the patient s point of view, what the urgent and emergency care system is delivering?
Right Care, Right Place, First Time Access. Which service did they first access and why? Connected services. Did the whole pathway have access to contemporaneous notes/ care plans, avoiding the need for repeat questioning. Quality measure (time from arrival to treatment for all patients). Number of people receiving ambulatory care outside hospital settings. Number of contacts patient has to secure outcome. Percentage of ambulatory care patients registered with a GP.