0 Paper Name: Urgent and Emergency Care Strategy Date: 18 Mar 2015 Release: v5 Status: APPROVED Authr: Dr Ann Sephtn, Suth Glucestershire CCG Review Date: March 2016
1 1. Intrductin 1.1 This paper sets ut Suth Glucestershire CCG s emerging visin fr Urgent and Emergency Care. The intentin is fr it t be used as a starting pint fr the CCG and partners acrss the lcal health ecnmy (thrugh the Nrth Bristl System Flw Partnership) t set ut the intended directin f travel fr urgent and emergency care services. 1.2 The CCG has develped a high level visin fr the future f health care services, and identified assciated pririties fr service change in Suth Glucestershire s lcal health care system ver the next five years. This is set ut in the CCG s five year strategy, which reflects lcal pririty themes in the Suth Glucestershire Health and Wellbeing Strategy, the challenges frm an ageing ppulatin (which are examined in detail in the 2013 Jint Strategic Needs Assessment), natinal guidance and evidence f best practice, and the views f lcal GPs, patients and members f the public. 1.3 The urgent care strategy is ne f a number f mre detailed strategies and plans that set ut hw the CCG intends t wrk twards the achievement f its visin, with financially sustainable health care services that successfully meet the needs f the lcal ppulatin. This strategy has been develped in parallel with plans fr the future develpment f primary care services in Suth Glucestershire, reflecting the interdependencies and the imprtance f primary and cmmunity care prviders fr implementing effective urgent care services in the future that are easy t access by vulnerable patients. 2. What is ur visin? 2.1 The challenges facing urgent and emergency care will nt be addressed thrugh minr change. If we are t meet the needs f a grwing and ageing ppulatin and the increasing demands being made f urgent care services then we need t see a whlesale shift f care and resurces int primary and cmmunity care settings. Only in this way will we enable ur acute accident and emergency departments t deliver the best care fr patients with the mst serius r life threatening cnditins 1 (Cwling et al., 2013). We will prvide a service fr urgent care that is sustainable, resilient and with equity f access fr all Suth Glucestershire residents. 1 Cwling TE, Cecil EV, Sljak MA, Lee JT, Millett C, Majeed A, Wachter RM, Harris MJ. Access t primary care and visits t emergency departments in England: a crss-sectinal, ppulatin-based study. PLS One 2013; 8(6):e66699. http://www.ncbi.nlm.nih.gv/pmc/articles/pmc3680424/
2 2.2 Our visin is fr an urgent and emergency care system that delivers measurably high quality care, by the persn with the right skills, in the right place, first time. This means that: a) We want t see an increasing prprtin f urgent care needs delivered in primary and cmmunity care settings, including ver the phne r nline, clse t the patients hme t maximise hspital admissin avidance where apprpriate; b) We want all urgent care services t be highly efficient services that deliver great care, are affrdable and ffer gd value fr mney; c) We want patients t be able t easily navigate the system and knw where t g t have their urgent care needs met with services that respnd urgently and effectively t avid the default psitin f avidable attendance at and pssible admissin t a hspital setting. Increasingly urgent care respnses need t be prvided by primary and cmmunity care in practice settings accessible t all Suth Glucestershire regardless f where in the cunty they live; d) We want care fr patients t be effectively c-rdinated between settings and rganisatins s that patients wh are nt in need f acute hspital care can be supprted in their hme; e) We want an urgent care system that staff are prud t wrk in; f) We want all staff wrking in delivery f urgent care services t feel valued and respected and fr their views t be used t infrm service develpment; g) We want a system that is respnsive t the needs and views f the peple f Suth Glucestershire and strives t cntinually imprve based n their feedback. 3. Hw are we ging t get there? 3.1 T enable ur visin t be delivered, we will fcus n 8 key aspects: 3.1.1 General Practice and Cmmunity Services; Primary care will play an enhanced rle in the prvisin f urgent care as part f an integrated urgent care netwrk. This is in line with patient wishes fr imprved lcal access and capacity as recrded in Suth Glucestershire CCG s Call t Actin and a recent survey f Suth Glucestershire patients attending at Accident & Emergency. We will develp a netwrk f interlinked/ clustered practices t share capacity and triage acrss practices t supprt urgent care access t primary care including a hme visiting service t ensure respnsiveness.
3 GP Practices will wrk cllabratively and with ther stakehlders t agree cmmn criteria and standards fr access t same day appintments and senir review. Primary and Cmmunity clinicians will have timely access t diagnstic imaging with immediate reprting when needed and t plastering services. This will facilitate prvisin f minr injury services clse t hme. There will be an enhanced hspital frnt dr, including an expanded ambulatry care functin and a wider range f ht clinics fcussing n specific health prblems Primary Care will increasingly lk t expand its use f IT t make better use f technlgy, fr example virtual cnsultatins in targeted grups f patients, such as thse wh are husebund, and increased use f cmmunicatins technlgy t enable GPs t prvide advice t ther healthcare prfessinals. We will wrk with Primary, Cmmunity, Scial and Vluntary sectr clleagues t develp effective, regular, multidisciplinary meetings based within practices t discuss thse mst at risk f admissin and t develp jined up fully integrated care plans, which respnd t changes in patients health status ver time. Special fcus will be given t patients wh are frequently admitted t hspital and secndary care staff will wrk with cmmunity multidisciplinary teams t ensure all nn-hspital ptins are adequately explred. We will lk t ensure that each multidisciplinary team has an apprpriate tlkit f services that they can use t supprt peple in the cmmunity including step-up beds, night sitters and persnal care. Thse patients attending mst frequently t ED and thse frequently admitted t hspital will have multidisciplinary care plans develped between ED, cmmunity services primary care and the patient t identify alternative care and supprt. We will aim t prvide fr patients health and scial care needs in their hmes wherever pssible, thus reducing the need fr lng term admissin t a care hme, except t participate in rehabilitatin and reablement. We aim t ensure that the End f Life pathway is used as effectively as pssible s that stages in the pathway are managed t reduce the likelihd f admissin t hspital r a care hme when that is nt the wish f the patient. We will recnfigure the existing Emergency Care Practitiner rle t align with the recently agreed GP clusters t utilise their skills t prvide a rapid access service that maximises admissin avidance pprtunities by mbilising a range f services t enable patient t safely remain at hme.
4 We will develp a GP Supprt Service (GPSS) with 3 well defined cmpnents: 1. Triage f referrals fr medical admissin frm Primary and Cmmunity care, with prmtin f alternative care pathways; 2. Redirectin r basic treatment f patients presenting at A&E with cnditins apprpriate fr primary care; 3. Enhanced supprt f cmplex elderly and frailty pathways at the frnt dr. We will develp enhanced cmmunity services fr patients living with frailty, t cmplement existing services including geriatrician f the day, GP Supprt Service and cmprehensive geriatric assessments. 3.1.2 Hspital Services and flw; We will wrk twards what the patient needs rather than what the system needs/wants. The rhetric is abut reducing admissins but we will use a mre sphisticated fcus that includes length f stay, why peple are admitted and what they get frm the admissins. This will be used t refcus the whle debate n what the patient needs. Frail patients will be seen by a dedicated multidisciplinary team, led by cnsultant geriatricians frm the frnt dr f the hspital. The team will see patients in a dedicated medical assessment area with cllcated geriatricians, therapists, nurses and scial wrkers. The fcus will be n multidisciplinary assessment, early senir review, avidance f duplicatin f assessments, increasing use f an ambulatry care apprach and the use f the discharge t assess plicy right frm the frnt dr. We will priritise and invest in eight key principles t supprt flw within the acute hspital: 1. Early senir review Patients will be reviewed by a specialist within 30 minutes f referral, with the aim f turning arund ptential referrals. At times f high demand the first cntact t be by a senir clinician. Cmplex frail patients will have early multidisciplinary cmprehensive geriatric assessments. 2. Daily senir review Daily Bard Runds (7 days a week) will be held n every ward led by a senir clinical decisin maker fllwing the 5 step apprach 3. A fcus n discharge A multidisciplinary team will set EDDs within 24 hurs f patient arrival. The EDD will be cmmunicated alng with the reasn fr admissin t primary & cmmunity care. This will be fllwed by practive
5 multidisciplinary evlving discharge planning at daily bard runds with clear leadership, wnership f tasks and accuntability n all wards. Discharges will be facilitated by develping an integrated discharge liaisn service by amalgamating the resurces f secndary and cmmunity. Once n lnger in need f acute hspital care, patients will be discharged hme t have an assessment with the apprpriate member f the scial and cmmunity teams t enable them t access the right level f care. 4. Cntinuity f care 2 The rapid expansin f specialist cnsultants within the acute sectr has increased the need fr care crdinatin within hspital fr patients with multiple health prblems. Every cmplex patient will have a named clinical case manager at the right level f senirity wh will crdinate, cmmunicate and take respnsibility fr the patient. These peple will be crdinating interventins t happen quickly and effectively as much as pssible in parallel rather than in series. They shuld, at an early stage, begin t identify pprtunities fr intermediate and final placements in assciatin with patients and families. Once the patient is n lnger in need f acute hspital care, managers wuld be respnsible fr wrking with the Discharge Liaisn service t achieve safe, apprpriate and timely discharges. The managers will be accuntable t the bard rund leader (supervisry ward sister) wh will crdinate practive discharge planning acrss the ward. Cntinuity f care will crss bundaries between primary & cmmunity and secndary care with care plans fllwing the patients int and ut f hspital and excellent cmmunicatin t facilitate handvers between named managers in bth settings. The care plans will be develped in either setting and added t in either setting. 5. Apprpriate standardisatin and matching capacity t demand The Alamac system will be used t help ensure that the crrect prvisin is available t fulfil patient needs. Wider capacity and demand mdels will supprt the system in planning and preparing fr times f increased pressure. 6. Internal prfessinal standards Organisatins will be expected t adhere t the Operatinal Standards agreed thrugh the System Flw Partnership. A crucial indicatr fr measuring patient flw in the system is delivery f the 4 hur standard in NBT. Underperfrmance against this standard leads t a crwded A&E 2 Crnwell J, Levensn R, Snla L, Pteliakhf E. Cntinuity f care fr lder hspital patients: A call fr actin. http://www.kingsfund.rg.uk/sites/files/kf/field/field_publicatin_file/cntinuity-f-care-fr-lder-hspitalpatients-mar-2012.pdf
6 department which, in turn, prduces a higher risk f mrtality 3. We believe that, if all rganisatins adhere t the standards they have cmmitted t, the 4 hur standard shuld be cnsistently achieved. 7. Ambulatry emergency care becming the default mdel f urgent and emergency care Upn arrival at A&E, the default assessment and treatment pathway will be ambulatry emergency care. 8. Use flw streams t chrt admissins with minimal handvers thus limiting ward transfers and duplicatin. 3.1.3 Care utside f acute hspitals; We, in partnership with Suth Glucestershire Cuncil, will ensure that all f ur prviders have the ability t prvide care that meets the needs f the Suth Glucestershire ppulatin including peple with reablement and rehabilitatin needs, withut rehabilitatin ptential and thse with challenging behaviurs, dementia, mental illness and learning difficulties. Decisins abut funding rutes shuld nt delay patients in hspital. The hspital MDT bard-runds shuld fcus n ensuring the patient is n lnger in need f acute hspital care and is discharged prmptly where their n-ging needs can be assessed. Lng term funding decisins will be taken ut f hspital. Supprt will be given t selffunding patients t ensure they d nt stay in an acute hspital fr lnger than needed. We will fcus n: Dmiciliary care; Nursing / residential hmes; Intermediate / step-up and step-dwn care; Discharge t assess mdels. 3.1.4 Patient flws and behaviurs; We recgnise that the urgent and emergency care system is ften t cmplicated fr patients t navigate easily. This is a factr in why patients ften chse t attend A&E r phne 999 when ther ptins might have been mre suitable 4. We will therefre develp ur services in line with the findings frm the natinal urgent and emergency 3 Richardsn DB. Increase in patient mrtality at 10 days assciated with emergency department vercrwding. Med J Aust2006;184:213-6. https://www.mja.cm.au/jurnal/2006/184/5/increase-patientmrtality-10-days-assciated-emergency-department-vercrwding 4 Purdy S. Aviding Hspital Admissins: What des the research evidence say? http://www.kingsfund.rg.uk/sites/files/kf/aviding-hspital-admissins-sarah-purdy-december2010.pdf
7 care review and will lk t prvide a simplified and cnsistent urgent and emergency care ffer t patients with a much greater emphasis n self-care, use f NHS111 and Primary and Cmmunity care urgent care prvisin as the default psitin. We will cntinue t wrk t cmmunicate t patients and the public key messages abut hw t access urgent and emergency care services. This will include reinfrcing the message that patients have a respnsibility t manage their wn health needs It is vital that patient experience f urgent care access is cnsistent and psitive if these messages are t result in changed patient behaviurs in the medium t lng term. 3.1.5 Leadership and Culture; In rder t deliver the significant change required t make the whlesale shift f care and resurces int primary and cmmunity care, and t make the changes we need t make in secndary care, we need t shift ur mind-set and that f ut prviders, abut hw we safely deliver change. We will adpt the five principles set ut in the NHS Imprving Quality reprt The new era f thinking and practice in change and transfrmatin 5 in rder t deliver this change: We will listen t the disruptrs, heretics, radicals and mavericks within ur health care system and embrace change; We will lead transfrmatin frm the edge - radical thinking abut future pssibilities is unlikely t cme frm the centre r tp f ur rganisatins and game changing ideas ften cme frm thse further away frm the tp f the hierarchical structures; We will change ur stry: as well as using traditinal diagnstic methds f change (identify the prblem and get peple t change hw the system wrks) we will increasingly deliver change thrugh dialgue seeking t increase the ptential f individuals at all levels f ur rganisatins t influence change. We will curate rather than create: cllecting, filtering, evaluating, cntextualising and sharing knwledge frm multiple surces. We will build bridges t cnnect the discnnected: the kind f netwrks we perate in makes a big difference t the level f change we are able t achieve. T deliver large scale transfrmatinal change, we must build bridging netwrks that cnnect up disparate individuals and grups that were previusly 5 http://www.nhsiq.nhs.uk/resurce-search/publicatins/white-paper.aspx
8 discnnected. We will spend less time pushing change thrugh discrete imprvement prgrammes and mre time pulling change by cnnecting peple, experiences and ideas that were previusly discnnected. 3.1.6 Wrkfrce; In rder t prvide an adequate wrkfrce we will need t increase the number f practitiners wrking within primary and cmmunity care prviding urgent care. By surcing lcally prvided mdular cmpetency training t ur current wrk frce and by wrking with HEE t train a primary and cmmunity urgent care wrkfrce. We will cntinue t explre ways in which the CCG can supprt enhanced wrkfrce planning in all areas f ur urgent care system.
9 3.1.7 Financial flws; Funding resurces will need t be released and reinvested t ensure that the key pririties f the strategy are financially achievable. Transfers f ur funds will enable us t deliver ur strategy. 3.1.8 Infrmatin; We will have IT enabling real time access t apprpriate parts f the patients recrds acrss the health and scial care system fr read and write. Our cmmunity prvider, Sirna will implement EMIS Web, t allw recrd sharing between primary and cmmunity care. We will wrk with the One Care Cnsrtium arund recrd sharing between practices and shared telephny We will cntinue t wrk with Cnnecting Care t allw read nly recrd sharing acrss a brader range f rganisatins including secndary care, scial services, ut f hurs primary care and mental health, and in phase 2 t include care plans t which multiple rganisatins can cntribute We will rll ut Suth Glucestershire CCGs intranet prject making it easy fr primary care clinicians t find the right infrmatin quickly which can help t avid admissins 3.2 Initially, we will fcus n 6 key care pathways: Falls Preventin. We will wrk twards delivery f the Better Care Fund target t reduce emergency admissins due t falls in the ver 65s extending ur current emphasis n primary care t implement whle system pathway redesign. End f life care. We will imprve capacity in the cmmunity fr supprting patients t die in their usual place f residence and cntinue t fcus n shared access t recrds acrss the system. Dementia. We will wrk with partners t develp cmmunity alternatives t emergency admissin t general and mental health beds, supprting peple with dementia and their families better. This initiative will als aim t enable peple with dementia t be discharged earlier than they ften are nw. Mental health and wellbeing. We will develp a mental health strategy in respnse t the mental health needs assessment that will supprt prviders t meet peple s mental health needs alngside their physical needs. This will
10 include: Parity f esteem; giving the same discharge pririty fr lder peple with functinal r rganic mental disrders; strengthening the care hmes prject and intensive supprt team appraches in cmmunity settings; and timely access t apprpriate psychiatric liaisn services fr patients attending r being admitted int secndary care with mental health prblems. We will als supprt the adptin f the shared recmmendatins in the Suth Glucestershire Mental Health Crisis Care Cncrdat. Alchl harm reductin. We will take actin as part f the alchl harm reductin strategy t reduce alchl related attendances and admissins ensuring whle system invlvement. Children and Yung Peple. We will wrk with partners t develp parent educatin prgrammes, and child-fcused sign-psting and triage systems which supprt apprpriate use f the urgent care system. We will cntinue t explre ptins fr increasing the availability f paediatric cmmunity nursing services, aviding/shrtening unplanned hspital admissin where pssible. We will implement ur revised paediatric cntinence pathway, incrprating specialist nursing advice, reducing admissins fr UTI and cnstipatin. 3.3 We will deliver imprvements t patient care and system perfrmance thrugh fur peratinal wrking grups: 1. Admissin avidance: Ensuring cmmunity alternatives t hspital admissin are easily accessible by patients and healthcare prfessinals; 2. Imprving flw thrugh NBT: Ensuring the patient jurney thrugh hspital is efficient and that thught is given t the next patients due t be admitted t minimise delays t their care pathways; 3. Enabling discharge: Ensuring that patients are discharged as sn as they are n lnger in need f acute hspital care; 4. Frail & elderly care: Ensuring there is hlistic, multi-disciplinary end-t-end care fr peple living with frailty and cmplex cnditins. These wrking grups will each be led by a senir CCG manager, with dedicated prject management supprt, and will have representatin frm all key partners. All new and existing service develpments will reprt t ne f these wrking grups which, in turn, will reprt t the System Flw Partnership n a mnthly basis.
11 Cntributrs Dr Ann Sephtn Dr Andrew Appletn Dr Charlie Recrd Dr Jn Evans Dr Peter Bagshaw Dr Stephen Illingwrth Dr Tharsha Sivaykan David Jarrett Kate Archibald Kate Lavingtn Lindsay Gee Luise Rickitt Pat Nagle Paul Frisby Sharn Kingsctt James Beyer Dr Janna Bayley Sasha Karakusevic Janet Rwse Jenny Theed Denise Prter Jn Shaw Dr Mark Pietrni Sara Blackmre Ben Bennett Ruth Charles GP, Suth Glucestershire CCG GP, Suth Glucestershire CCG GP, Suth Glucestershire CCG GP, Suth Glucestershire CCG GP, Suth Glucestershire CCG GP, Suth Glucestershire CCG GP, Suth Glucestershire CCG Suth Glucestershire CCG Suth Glucestershire CCG Suth Glucestershire CCG Suth Glucestershire CCG Suth Glucestershire CCG Suth Glucestershire CCG Suth Glucestershire CCG Suth Glucestershire CCG NHS England Nrth Bristl NHS Trust Nrth Bristl NHS Trust Sirna Care & Health Sirna Care & Health Suth Glucestershire Cuncil Suth Glucestershire Cuncil Suth Glucestershire Cuncil, Public Health Suth Glucestershire Cuncil, Public Health Suth West Cmmissining Supprt Suth West Cmmissining Supprt The authr wuld like t thank all thse wh have cntributed time and expertise t develping this strategy dcument.