Dr David Griffiths is a GP and the Medical Director at Consultant Connect. In this article he reflects on the inspirational nature of Sunderland’s Ambulatory Emergency Care (AEC) project, which has seen patient care improve markedly due to a collaborative and data-focused approach. The best practices he identifies can be applied to any project seeking to improve patient care and reduce unplanned admissions.
“AEC [Ambulatory Emergency Care] is not a location but a philosophy of care.”
If you are a regular reader of this blog, you will be aware of the recent, independent report from NHS Elect about the AEC project in Sunderland.
We have already highlighted the remarkable data within the report and I don’t propose to focus on that. Nor do I want to rehash the report itself – it is thorough and well-written, so it stands alone.
However, I do think it is worth spending a bit of time looking at the learning for those of us who don’t have such a system in place. I am coming at this as a ‘jobbing GP’ in a pretty typical UK healthcare system, admittedly one who has a longstanding interest in system redesign.
“It starts with a willingness to see that this is not just a hospital-based problem but a problem that we all face and that we all have a part to play in changing things.”
The first thing I read with real admiration was the clear description of a whole system approach to AEC. As someone who frequently despairs at the difficulty GPs and consultants face in communicating about patient care, this recognition is absolutely critical. Forget tribal considerations: it’s all about providing the care the patient needs at the right time in the right place. Avoiding admissions and reducing referrals is a fantastic corollary benefit of doing the right thing, rather than the focus of the project.
A key factor in the successes in Sunderland seems to be early access to a senior clinical opinion, for which Consultant Connect is a key enabler. This provides high level clinical and signposting advice which in turn provide a streamlined experience for both patient and GP. Secondary care clinicians gain a sense of autonomy, controlling their workload, as well as connecting with their primary care colleagues.
What is more, by filtering GP referrals, ambulatory care staff are able to ‘pull’ two thirds of patients in to their service when it is the most appropriate place for them to be cared for. This is unusual in UK healthcare where services usually receive ‘push’ workload (which they often try to deflect) and I think this mentality will be making a big difference to the entire urgent care system.
“Collaboration is key for us here in Sunderland”
As I have worked for many years on system improvement, I was particularly impressed by some of the methodology that shines through the article. In particular, the recognition of the importance of stakeholders, particularly senior staff to act as sponsors, and the need for mutual benefit. This chimes with what we see from the most successful of our projects around the UK – just buying a product will never deliver all the potential outcomes because behaviour change will be needed and that requires significant engagement.
A strong focus on communication strategies across stakeholders and, particularly, for patients was another important factor cited by the CCG.
“It quickly becomes apparent…if a new pathway is needed”
The use of the data generated by the project was also a highlight of the report. By analysing calls retrospectively two key things become apparent: where the advice provided is lacking and where the system is not set up for patient needs. It then becomes possible to redesign clinical pathways consistent with the most common real-life situations.
As Dr Tracey Lucas, the CCG’s Urgent and Ambulatory Care Clinical Lead put it: “We recognise, however, that we can only avoid admitting patients if viable alternatives to admission actually exist…we needed to ensure that robust systems were in place to support the provision of effective emergency ambulatory care.” For example, new pathways for the management of possible DVTs (including point of care testing) and cellulitis improve the GP’s ability to manage these issues in the community. Allowing paramedics direct access to ambulatory care is another simple yet impactful change in response to feedback. By dealing with the most common problems in this way, the effort required to change is most likely to provide impact.
“[We] are very much about changing the hearts and minds of everyone involved”
Consultant Connect is an enabler of communication. What is so wonderful about the work being done in Sunderland is that improved communication between primary and secondary care is occurring at a strategic level as well. That is not to say that our system is responsible – although the data it generates has clearly been helpful – but this learning is something which we will emphasise to new and existing clients.
Well done to NHS Sunderland CCG and City Hospital Sunderland. You’ve certainly inspired this slightly cynical clinician!