With only a handful of major providers currently meeting the four hour A&E standard – and a thorough upheaval of standards planned – the picture on unplanned care performance is complicated to say the least. Factor in the creation of primary care networks, not to mention the planned evolutions of all sustainability and transformation partnerships into integrated care systems, and it becomes more complicated still. All that before we consider the looming winter, which may be particularly challenging in light of the bad flu season which afflicted Australia this year.
So how can we best prepare for the challenges of winter 2019 in the NHS? That was the main question on the agenda for this expert panel recently:
- Siva Anandaciva, Chief Analyst, The King’s Fund (webinar chair)
- Caroline Capell, Associate Director of Unplanned Care, Luton CCG
- David Reith (née Smith), Associate Director for Performance – Planned Care, South East London Commissioning Alliance
During an hour-long webinar (which is available to view on demand), the experts discussed the likely impact of the target changes. They also explored how urgent and emergency care might be made more resilient as winter approaches, drawing on examples from their own organisations.
In late May, a small number of trusts began field testing four of the new access standards proposed in a review by NHS England medical director Professor Stephen Powis. Among them were Luton and Dunstable University Hospital NHS Foundation Trust.
“We no longer report and monitor the four hour target at Luton and Dunstable Hospital,” explained Caroline Capell, Associate Director of Unplanned Care at Luton CCG, “and for us that’s quite a big cultural shift.”
Instead the focus has shifted to time to initial clinical assessment, emergency treatment within one hour for critically ill and injured patients and time in A&E – not to mention call response time for 111 and 999.
Ms Capell described it as “a significant change.” Full implementation of the new standards is not due until Spring 2020, but it may be that earlier preparation is needed for their arrival: an additional complication as we head into winter, she told our webinar audience.
The need for front door and back door approaches
The standards against which they are now measuring themselves may be different, but for NHS staff in Luton the approach to A&E performance – the local trust has consistently been meeting the four hour standard – remains constant.
“One of the areas that we have very much focused on is actually how we prevent patients having to attend hospital unnecessarily,” Ms Capell reported.
That includes ‘front door’ support, such as a liaison service by which GPs can get advice on whether a referral to secondary care is needed. There is also a clinical navigation team within the hospital, focused on identifying unplanned care patients whose treatment path is immediately clear and getting them onto it speedily. An integrated discharge team handles the ‘back door’ side of things, with every patient assigned a discharge coordinator.
Direct booking into other services
Ms Capell explained that around 80% of emergency department attendances are by patients that are self-present. Of those who attend A&E in such instances, half wind up being redirected to an urgent GP clinic.
“That’s very much driving forward what we call our direct bookings,” she explained during the webinar. “We use 111 as our gateway for urgent care, and we’ve been directly booking into our out of hours services and into our GP practices.”
In other words, 111 operators can now book a GP appointment for a caller who might otherwise have wound up in A&E. “We have 400 appointment slots made available from our GP practices per month for 111 to directly book them in, and the utilisation is over 60% of those slots being filled.
“At the moment we have had no DNAs [did not attends] and all the GPs have stated that the referrals have been appropriate. We’re quite strict with the DX [diagnosis] codes from the directory of service that we use to directly book those in; we want to be able to manage and control that at the moment.”
Extended access hubs, meanwhile, offer 56 directly bookable appointments per month. “88% of those are utilised, and we’re seeing that increasing month-on-month.”
David Reith, Associate Director for Performance – Planned Care, South East London Commissioning Alliance (which includes the six clinical commissioning groups in south east London) reported a similar approach, but with the direct booking option going to staff within A&E departments.
“A lot of the work that we’ve done has been about how can we make sure patients are going to the right place first time, so one of the things that we set up was streaming.”
A Band 7 nurse – ‘streamer’ – based in A&E now helps decide whether someone who has attended could be more appropriately seen elsewhere.
“Those streamers can book patients into our GP hubs – these are the extended access 8 till 8 hubs that have been set up across the borough. So [if they recognise] the patient is coming in with a minor illness and does not need to be seen in A&E, and actually would be better seen by a GP, they can redirect. The way that we did that was that we put in an EMIS portal into the A&E department [ie. a connection to the electronic patient record used in the GP practices] so that the patients could be booked directly into those slots, and the A&E team had got absolute visibility on kind of what slots were available at those GP hubs.”
While both speakers said direct booking setups had made a huge difference in making unplanned care more robust, they acknowledged challenges along the way. Ms Capell said she instituted a “very full comms and engagement programme of work, working with each individual practice” to convince them that 111 would be able to make appropriate bookings.”
Rollout has been gradual, starting with just one or two practices. “Luckily once one of the main practices that we had working with us on the enhanced model of direct bookings, [has a GP who] sits on our LMC [local medical committee] so that’s made a significant impact, because she has seen for herself the direct impact.”
In South East London, there were also some clinician concerns to overcome. “One of the things that we got fed back a lot from staff within the ED department is that where a patient has arrived at ED that is where they want to be seen, and so they’re not necessarily keen on the idea of actually leaving, perhaps getting on a bus to go to another location,” explained Mr Reith.
“So we had incidents where staff were being or felt threatened. [We recognised] that for some patients it’s fine, they will accept to be redirected elsewhere, but [with others] that brought challenges, and we couldn’t be wholly surprised when staff were going to be semi-reluctant to advise patients to go somewhere else.”
The solution was to think about geography. “We worked with the local practices, the ones which actually were within a five minute walking distance of the A&E department, and we looked at appointment slots at those practices, so that patients could be redirected. We agreed with those practices about set times of day that those appointments would be, and that the hospital had control over kind of booking patients into those slots.”
An examination of data allowed for some degree of precision here. “We were able to look at what times of day patients who would be best placed to be redirected were coming into A&E. So our evidence showed that actually it was either quite early in the morning, around lunchtime or then getting into the early evening. So we could match the GP slot times with when patients were likely to need them.”
It is even possible to book into an appointment the following day. “If someone is coming in at 8 or 9 in the evening, and we’re saying, look, it’s going to be a five hour wait to be seen, and actually you probably don’t need to be here, patients are quite accepting knowing that they’ve got an appointment at nine o’clock the following morning.”
From these examples, it is clear that partnerships are crucial to creating stronger approaches to emergency and unplanned care. Those relationships should, our panellists suggested, extend beyond the walls of hospitals. Mr Reith referred, for instance, to collaborations with the police and ambulance service.
“Between London Ambulance Service and Guy’s & St Thomas’, there is a protocol whereby the ambulance crew can call the ‘at home’ service which guarantees to respond within two hours and to care for the patient [in their home],” he explained. “That team is made up of consultants, of GPs, of pharmacists, so it’s a real multidisciplinary team that can really attend to the different needs of those patients to prevent A&E attendance.”
He said it’s used 60 to 80 times a month by the ambulance service – “so it’s one of their most used alternative care pathways.” It’s now been mirrored in mental health.“ South London and Maudsley operate an acute referral centre. If London Ambulance Service have been called out to see a patient, or indeed if the police have been, they can call the acute referral centre and that team will be able to provide clinical advice.”
Working across six CCGs also necessitates careful building of links, Mr Reith said. “I think it’s really important that we make sure we’ve got good links with both the hospitals, but also the urgent care or the planned care commissioners at each of those CCGs. I think you can absolutely design some of these things once and probably should design them once, but then it’s making sure that you’ve got people on the ground who know the local community and know the local GPs in order to really kind of help with that implementation.”
It was a theme echoed by Ms Capell. “In the hospital, in particular with the urgent GP clinic, we used our A&E delivery board and our transformation board very much around our comms messaging, and I think that’s quite key that we have the whole system sharing this.
“We have a very embedded and strong A&E delivery board and it’s very much working across the system. We have been fortunate because of the performance being so high [the trust has regularly met the four hour standard] that we’ve been able to work on transformational work rather than focusing on performance, and that means then we have had that wider buy-in.”
From the out of hospital side of things, existing forums made a difference, she said. “We have a members forum, and we have a practice manager forum, and then it was focusing on our clinical directors and very much finding champions. I know that’s a cliche, but actually it did work.”
A sense of agency and a sense of openness
As Chief Analyst at The King’s Fund, Siva Anandaciva has analysed many emergency and unplanned care setups. He said the common factor in better performing ones was a sense of agency and openness. He gave the example of one hospital that “invited GP practices, key partners into their A&E department, into the medical assessment unit, to see the pressures that are on the services. You may think that’s a small thing, but it was one of the things that really helped to re-set that relationship”.
As winter looms, it may well be the right time for more systems to look at resetting that relationship and having deeper conversations about urgent and emergency care. For, as our webinar revealed, there are techniques which can help create more robust services –but they require significant cultural change and partnership working to be implemented.
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