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Turning the Tide: Luton 2019
In March 2019, Luton and Dunstable University Hospital NHS Foundation Trust was selected as one of the 16 sites (14 trusts) to ‘field test’ the new NHS Clinical Access Standards for Urgent and Emergency Care.
Alongside this, Luton has become one of the first areas in England to successfully directly book into GP Practices and other services from 111, before the changes to the national contract. We interviewed Caroline Capell, Associate Director of Unplanned Care at NHS Luton CCG, to find out more.
When Caroline Capell discusses how Luton and Dunstable University Hospital NHS Foundation Trust (LDH) has managed to perform so consistently well over the years, she returns to one word time and again: filters.
“We’ve got many filters in place to stop you [inappropriately] going to A&E in the first place, and then once you’re at the hospital there are other filters,” explains Ms Capell.
LDH started testing proposed ‘target standards reporting’ along with 15 other sites across England. This field testing focused on five key targets:
- Time to initial clinical assessment. This will identify life-threatening conditions faster. It allows patients to be directed to the service and practitioner, best able to meet their needs, at an early stage.
- Time within one hour for emergency treatment for critically ill and injured patients. Highest priority patients get high-quality care with specific time-to-treatment, with proven clinical benefits. A ‘package’ of treatment is completed in the first hour after arrival.
- Time in A&E. Measure the mean waiting time for all patients. Strengthen rules on reporting prolonged trolley waits for admission. Measures the time all patients are in A&E.
- Increased utilisation of same day emergency care. Incentivise avoidance of overnight admissions and improve hospital flow.
- Call response standards for 111 and 999. Assure a rapid response, and match patients to the service that best meets their needs.
Caroline feels that the new targets may help address patient perception across the country. “If you ring 111, 999, or your GP practice you won’t necessarily be seen immediately which is different in the Emergency Department (ED). This inconsistency and the obvious impact on patient expectation is what has got to change.”
In Luton, when a patient turns up at the Emergency Department, there is a streaming pathway by which around a quarter of the activity is immediately streamed to an Urgent GP Clinic, (patients are assessed as ‘urgent’ rather than ‘emergency’). If the patient does need to attend ED there are interventions within ED; a team whose members focus on quickly identifying patients where the necessary course of action is immediately clear – and so speeding up an admission, an assessment or a discharge.
Better support for GPs to avoid the need for a hospital referral is also one of the key planks in the Long Term Plan ambition. “It very much starts from outside of A&E.” Caroline explains the LDH system has had a GP Liaison Team for many years, staffed by nurses who offer advice and guidance on the most appropriate support for a patient with their GP over the phone as well as facilitating alternatives when appropriate. “If a GP wants to send a patient in to the hospital, they will go through that team first. That allows the acute trust to know what’s coming and why, but also makes sure it is the best place for the patient to be. It’s a high impact quick-win.”
The GP Liaison service has been running for a number of years in Luton. Over the last 12 months, NHS Luton CCG has worked with the service and GP practices to strengthen the referral pathway and the ‘use criteria’ for the GP Liaison service, with access via a phone line, which is delivered by Consultant Connect. The results below show how the service is continually improving. “It’s because we don’t sit back – we continually remind practices of the service and how it works. We also target GP practices if they’re not using it as much as what we would expect them to” comments Caroline.
GP Liaison Line results at a glance:
There’s no contractual obligation for practices to use the GP Liaison service which makes Luton’s results even more impressive. “We take more of a partnership approach rather than enforcing a process on GPs. If we deliver a high answer rate, they will continue to use it.”
As the service is not mandatory GPs could send patients directly and avoid using the GP Liaison Line, and this does happen. “We audit the datasets (from Consultant Connect) regularly so we can pinpoint this. It is sometimes locums who may not yet be aware of the pathway and we can then target those practices and remind them that the GP Liaison Line is quicker and easier.“
A similar but separate setup is in place for paediatric patients, with GPs able to connect to urgent paediatric consultants for advice, guidance and direct referrals into the Paediatric Assessment Unit.
Urgent Paediatric Advice & Guidance results at a glance:
Once again this service is provided by GPs and the Acute Trust at no additional cost as all sides see the benefits of the pathway bringing primary and secondary care closer together.
Whole system approach
Time in A&E is another focus of the NHS Clinical Access Standards that LDH has been addressing successfully for several years. The trust has discharge coordinators on every ward. “You almost need to look at your discharges before your A&E. Because your discharges free up the beds that A&E patients may need to go into. We have an excellent Integrated Discharge Team that actively supports this. You can’t do it in isolation, and you need to draw on all your partners.” says Caroline.
It is an opinion shared by Siva Anandaciva, Chief Analyst at The King’s Fund. “There are three things high performers have in common. One is that they don’t look at A&E as an A&E department issue – they look to the rest of the hospital. Next is that they look to the rest of the system. And the final one, probably an underplayed factor, is relationships between commissioners and providers.”
“In LDH we took a different approach to the national guidance on Urgent Treatment Centres (UTCs)” explains Caroline. “LDH’s Urgent Treatment Centre is not on the site of the Acute Trust – it is in the town centre because that’s where we get a lot of demand. The service is delivered by an external provider, Herts Urgent Care, alongside a 24/7 Urgent Care hub incorporating the Out of Hours service.” “Since launching direct bookings into the UTC in 2019 we’ve seen a stepped reduction in walk-in activity and an increase in directly bookables, so we’ve been able to demonstrate that we can change patient behaviour.”
The 111 opportunity
Caroline has also spotted an excellent opportunity to further reduce A&E visits by utilising the 111 service. “Eighteen months ago, we weren’t directly booking any patients into appointment slots across Luton, so a patient would ring 111 and would then be told to go to ED or to contact their GP practice – having to navigate the health system alone and often patients would go to A&E because they couldn’t get a GP appointment or because it was the easier option.”
Caroline knew this situation needed to change and carried out her own ‘field testing’ with enhanced direct bookings into two GP practices releasing over 20 same day appointments slots per day to 111. “We have had such amazing results with these practices seeing a direct positive impact on their own demand. All other practices in Luton offer approximately 120 appointment slots to 111 per day. The enhanced direct booking approach is being replicated across all practices by October 2019 and the intention to share learning across our ICS. Patients are encouraged to ring 111 with the consistent message that if they have an urgent care need, they could be directly booked into an appropriate service 24/7 (which includes our ‘in- hours’ GP practices, Out of Hours GP and the Children’s Rapid Response clinics for children 0-4 years old) via 111 offering 160 appointments per month. Over the last twelve months what we’ve been able to demonstrate is a reduction in GP demand and a direct impact on patient behaviour by shifting patterns from the traditional evening demand to “in hours” where there is increased accessibility across Luton health services.”
“We are letting practices own the 111 calls so different practices will take a different pathway. The part we play is to pull all these different pathways together. By changing our pathways, we have been shifting patient behaviour. We have found that we can now spread demand across the day and across the week” enthuses Caroline.
“We now want to incorporate Elective Care, Mental Health, and Ambulance Services into our whole system approach. I am very keen that we should have one number for GPs to access all types of phone advice – like other areas that Consultant Connect work in.”
“We are talking to Consultant Connect about the successful projects they are running for Elective Care, Mental Health, and Ambulance Services across the country.”
Caroline has always been really keen about communicating with stakeholders and, with the Long Term Plan to achieve, this is more important than ever.
“Both myself and the Chief Operating Officer, Nicky Poulain, have been in Luton nearly five years, so we’ve been able to build stability across the Luton system. I was here at the very beginning when practice managers would not even speak to us and when we first approached the subject of 111 and direct bookings the reactions were real! We’ve been able to show that we do stick to what we say we are going to do, and we will try and support practices with changes” comments Caroline.
“Also giving things a real focus has been part of our success. For example, GPs never liked our 111 idea until we really focused on it and showed them the benefits. But it can still be a long process and our initial proposal (to move towards directly bookable appointments) was met with an absolute no. So, we found practices that were willing to try it, and fortunately one of our advocate GPs is on our Local Medical Committee. It worked so well that the GP actually quoted a 75% reduction in demand to colleagues! It’s been a lot of comms and engagement, and working with practices, and actually letting them lead.”
“I think the Long Term Plan and Clinical Access Standards are encouraging quite a cultural shift for how CCGs need to work. It’s about not forcing initiatives but demonstrating how things fit into the wider strategy. CCGs need to work directly with practices like we do. You can’t put primary care over in one corner, and urgent care in another. We have found that you can’t do one without the other. That is what the Long Term Plan is trying to do – to bring everything together.” states Caroline.
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