AGENDA ITEM No. 10 MEETING : TRUST BOARD DATE : 22 APRIL 2009 REPORT OF : CLINICAL DIRECTORATE Contact : Grayham McLean, Unscheduled Care Lead Officer Tel: 01792 562900 Email: grayham.mclean@ambulance.wales.nhs.uk IMPROVING UNSCHEDULED CARE IN WALES - UPDATE INTRODUCTION 1 The Delivering Emergency Care Services (DECS) strategy was formally launched by the Minister for Health and Social Services in February 2008. This strategy has been instrumental in assisting healthcare communities to focus on unscheduled care (USC) services in Wales. It has provided an impetus to collaborate more closely and effectively with healthcare and social care partners to improve the levels of USC for patients. 2 In addition to the implementation of the DECS strategy, the Wales Audit Office (WAO) is proceeding with a USC study. The study intends to help inform implementation of the strategy, and to provide a baseline from which progress might be assessed. 3 The purpose of this paper is to provide the Welsh Ambulance Services NHS Trust (WAST) Board with: information regarding the planning process in response to the USC national targets set within the Annual Operating Framework (AOF) 2009-2010 (see Appendix 1); clarity on the interface with the USC Partnership Boards that are in place across NHS Wales; an update on the progress of the specific work relating to modernising USC services. RECOMMENDED: That the contents of this report be noted.
BACKGROUND 4 Within the DECS strategic document the term unscheduled care (USC) is used to describe any episode of care provided for the patient which is unplanned and may require prompt action in response to an acute, minor or major injury or illness. 5 Taking the above definition into account, and written correspondence (28 January 2009 and 18 March 2009) received from Mr. Paul Williams (Head, Department for Health & Social Services, Chief Executive, NHS Wales) relating to the delivery of the AOF national targets, it is clear that WAST is regarded as an USC Trust. 6 Significant emphasis has been placed upon developing action plans to meet the requirements of the AOF USC targets. 7 The Transition Directors of the seven proposed new Local Health Boards (LHBs) have been nominated to lead the process of submitting and signing off USC action plans (or local development plans LDPs). These plans focus on the critical issues of: managing demand; improving ambulance response times; patient handover at accident and emergency (A&E) departments; A&E access and service; patient flow through hospitals; and, discharge planning/ management. 8 As an USC Trust, WAST was required to develop its own LDP for two reasons: to provide a response to the requirements of the AOF (2009-2010) and, to support integrated working, by providing a series of actions relating to the AOF targets that can be shared/ agreed with the seven new LHBs. These actions are to be incorporated into the LHB s overall USC plans. PLANNING PROCESS IN RESPONSE TO USC AOF TARGETS 9 In response to the USC national targets set within the AOF (2009 2010), there was a requirement to provide a series of actions in the format of two plans: Immediate USC Plan - requirement to address the key areas of demand management, ambulance handover/response, A & E services, discharge planning. A practical/operational plan that delivered immediate improvement and secured the national AOF targets for 2008-2009. LDP 2009-2011 - requirement to identify and address the improvement of the USC system over the medium term. A clear vision of the future; analysis of data to understand frequency/type of demand;
how it is serviced (e.g. interdependencies); understanding of whole system interface; identification of an agreed future service model; the strategic solutions to achieve it, underpinned by a detailed action / resource allocation to deliver services. 10 In essence, the LDP should provide the framework for the work that is required to improve the whole USC system, and the Immediate Plan was required to accelerate actions to address a number of key issues within the USC system. 11 Due to the focus of the action plans being on meeting the USC AOF targets (ambulance response & contribution to hospital handover at A&E), there has been an agreement that Executive responsibility for WAST will be provided by Steve Pryor (Interim Director of Ambulance Services) and Tim Woodhead (Director of Finance). INTERFACE WITH USC PARTNERSHIP BOARDS 12 WAST continues to actively engage with the USC Partnership Boards of the seven LHB areas. 13 Initial contribution to these USC Partnership Boards was via the attendance of the USC Lead and USC Development Team, with the focus of the forums primarily being on service development. 14 As a result of the circulation of the USC AOF national targets, the focus of the Partnership Boards has changed to predominantly be on operational delivery. This has been re-enforced by the requirement for an AOF response that entailed the submission of both an immediate plan (tactical & operational) and medium term LDP as described in points 9, 10 and 11 of this paper. 15 To meet the integrated approach of the USC Partnership Boards, the Executive Management Group (EMG) of WAST received and approved recommendations that the Regional Directors would interface with the Partnership Boards regarding operational issues (such as response times and patient handover at A&E). 16 In support of the drive to reduce A&E handover times, the Trust has provided a handover times action plan to each transition board. 17 Communication has been circulated to the current USC leads of the seven new LHB areas to confirm WAST s approach for further integrated work. In simple terms, this involves the Regional Directors (for operational issues), USC Lead (for service modernisation), with Executive responsibility being provided by Steve Pryor (Director of Ambulance Services for operational
services) and Sara Jones (Director of Unscheduled Care / Clinical Director for service modernisation and clinical governance). SPECIFIC WORK ON MODERNISING USC SERVICES 18 The modernisation of USC aims to identify duplication and gaps in health services, improve current services and patient experience, and ensure that patients are treated in the right place by the right person at the right time. 19 The USC Development Team have been working with the USC Partnership Boards to identify any modernisation elements of the unscheduled care system that could be accelerated/developed to contribute towards improving the patient experience. The following bulleted points are a summary of the progress of the USC development work (supported by the Clinical Directorate infrastructure of clinical governance, service modernisation & education): Identification of seven key USC aims (Appendix 2 refers) that have been agreed with the USC Partnership Boards for inclusion in their LDPs; Significant contribution to both the baseline assessments and LDP formation of the seven new LHB areas - as part of the implementation process for the DECS strategy; Full cooperation with the Wales Audit Office s unscheduled care study, and specifically the review of NHS Direct Wales (NHSDW); Agreement with the USC Partnership Boards that there is a recognition of the value of the NHSDW s education / empowerment services in terms of providing health information to patients. Continued work to improve the clinical management of category C (neither life threatening nor serious) calls. A Welsh Assembly Government (WAG) task and finish for this work was held on 19 th February 2009 to engage with staff side representatives (including senior representation from the bodies of UNITE & RCN); Capitalising on the collocation with Gwent General Practitioner out of hours (GP OOHs). A model of Paramedic referral to GP OOHs has been developed and implemented in the Gwent area; A model of referral has been developed between WAST and Gwent health community, whereby Paramedics can transport appropriate
patients to Neville Hall Medical Assessment Unit (via dialogue with both Consultant Acute Physician & Nurse Practitioners) admission avoidance at Royal Gwent Accident & Emergency (A&E) department; Plan, do study act (PDSA) cycle (to test and introduce change) agreement with Gwent OOHs to address integrated working opportunities in Vantage Point House - planning work commenced January 2009; Agreement reached with Gwent and Powys USC Partnership Boards to develop/ implement Specialist Practitioner roles As a result of service changes introduced by Abertawe Bro Morgannwg University (ABMU) Trust, a model of referral to the GP led urgent care centre and specialist wards (e.g. Paediatric and Medical) has been agreed and implemented; Introduction of additional prioritisation questions to enhance the role of the Ambulance Control Call Taker, and to refine the Acute Medical Prioritisation Dispatch System s (AMPDS) categorisations of immediately life threatening calls (category A ). Initial results have illustrated a reduction in category A prioritisation from approximately 50% to approximately 32% - far more in line with English ambulance Trusts; Provision of NHSDW services for new Glangwilli Hospital A&E department, which provides a referral route to NHSDW for telephone callers who contact the A&E department; Development and implementation of a stroke care fast track pathway has been agreed with Royal Glamorgan Hospital; Development and implementation of a percutaneous coronary intervention (PCI) pathway has been agreed with Morriston Hospital. 20 The above progress in modernising USC has been incorporated and cross referenced into the Trust s LDP to ensure that it supports the AOF response (being led by Steve Pryor, Interim Director of Ambulance Services and Tim Woodhead, Director of Finance). CONCLUSION 21 The Trust has collaborated with health and social care partners throughout the implementation process of the DECS strategy, and in the response to the national targets set by the AOF (2009-2010).
22 Continued collaboration will need to continue with the seven new LHB areas to meet the requirements of the AOF (2009 2010). Trust representation will need to be led by each Regional Director, as it is clear that WAG are putting a great deal of emphasis on achieving the AOF targets (2009 2010). The USC Development Team will continue to support the engagement with health colleagues for service modernisation. Executive support for this engagement will be provided by Steve Pryor (Interim Director of Ambulance Services operational services) and Sara Jones (Director of Unscheduled Care / Clinical Director for service modernisation and clinical governance)
Appendix 1 Requirements for 2009/2010 National Target: AOF 7 AOF 8 To ensure that: (i) 95% of new patients (including paediatrics) spend no longer than 4 hours in a major A&E department from arrival* until admission, transfer or discharge; and (ii) 99%** of patients spend no longer than 8 hours for admission, transfer or discharge. * the four hour period starts from when the A&E staff are notified in person that a patient has arrived and needs to be seen within the A&E Department. Notification will be by the Ambulance Crew, for arrival by ambulance or otherwise by the patient themselves, or a person accompanying the patient (e.g relative / friend). ** 1% tolerance level permitted for clinical exceptions only. To achieve: a monthly all-wales average performance of 65% of first responses to Category A calls (immediately life threatening calls) arriving within 8 minutes; a monthly minimum performance of 60% of first responses to Category A calls (immediately life threatening calls) arriving within 8 minutes in each new Local Health Board area; * a monthly all-wales average performance of 70% of first responses to Category A calls (immediately life threatening calls) arriving within 9 minutes; and a monthly all-wales average performance of 75% of first responses to Category A calls (immediately life threatening calls) arriving within 10 minutes. * raw data to be reported by existing LHBs and will be aggregated up by Welsh Assembly Government HCS 3 3
AOF 9 To achieve a handover of patients from an emergency ambulance to major accident and emergency departments within 15 minutes. 3 APPENDIX 2 Unscheduled Care Aim 1. To refer directly to GP, community services of social care Admission avoidance. 2.To deliver patients directly to specialist units Admission avoidance. 3. To develop a single point of access Access & Disposition. 4. To develop a directory of services Access & Disposition (Patient Flow). 5. Move to 7/7 working model Access & Disposition (Patient Flow). Benefit Admission avoidance to emergency unit (EU) Patients receiving timely access to definitive care Avoidance of unnecessary ambulance journeys to hospital, and potentially unnecessary admissions. Patient receiving safe and appropriate care locally Admission avoidance to EU Patients receiving timely access to definitive care Avoid excessive delays outside EU Support National Service Frameworks (NSFs) such as Stroke and Coronary Care. Care Coordination to help navigate a complex healthcare system for both patients and staff. Delivery of comprehensive integrated care pathways/ care packages Swift access to appropriate services More patients managed locally reduction in hospital costs Delivery of comprehensive integrated care pathways/ care packages Swift access to appropriate services More patients managed locally reduction in hospital costs Maximising referral options Reduction in length of hospital stay Consistent and predictable services (e.g. access to Falls teams) Improve admission & discharge processes Improved Patient satisfaction 6. Develop care pathways for common USC conditions, including involvement with CCM developments and end of life pathways Access & Disposition (Patient Improving the management of people with chronic conditions in primary & community settings; Facilitation of self management Prevention of unnecessary hospital admissions Appropriate safe & effective care
Flow). 7. Common transaction documents and integrated data collection systems Improved communication Greater patient safety Improved quality of care