Back in September, we asked whether this winter was going to be the worst ever. The answer: yes, it was. How do we know? The four-hour waiting time standard for A&E.
The four-hour A&E waiting time standard is one of the most high-profile indicators of how the NHS is performing. It’s certainly the best-known barometer of the health of the NHS. And this January, only 77% of patients were seen within the 4-hour window, rather than the 95% targeted. This is the worst performance since the target was introduced and reflects how dire things got.
It’s not over, either. Last Friday the NHS released a document confirming that it ‘will not this year hit the key target for treating or assessing 95% of patients in hospital Accident and Emergency departments within four hours.’ The document states that the majority of hospitals will only achieve the 95% standard by March 2019, with the NHS overall reaching that rate later in the year.
Jeremy Hunt said last year that meeting the 95% target was “critical for patient safety,” instructing hospitals to hit them again after failing to do so since 2013.
Immediate clinical or navigation advice can help
When the BBC published the performance of 133 Trusts in October, Luton and Dunstable University Hospital NHS Trust was ranked first for A&E. 98.6% of patients attending A&E at Luton and Dunstable were treated within 4 hours, compared with the then estimated average of 90.1% across England.
Luton and Dunstable University Hospital NHS Trust recognised back in 2015 that demands on A&E could be significantly reduced if primary care colleagues were given a way to communicate with their clinicians and nurse-navigators. They wanted GPs to have access to a service that was more immediate than email or waiting on a switchboard.
In partnership with Consultant Connect, the Trust set up two telephone Advice & Guidance lines; GP Liaison, and Paediatric Advice & Guidance.
The GP Liaison line is staffed by a rota of nurses. The purpose of the line is primarily to direct the patient to the right service in the hospital for them, rather than sending them to A&E and then to the right place. In some cases, the nurse is able to offer advice that keeps the patient’s care with the GP or signposts them to community provision.
The Paediatric Advice & Guidance line is there for GPs who are thinking of sending a patient to hospital but would like the reassurance of a discussion with a consultant.
Another area that recognises the value of conversation between clinical colleagues is North East Essex. North East Essex CCG and Colchester Hospital University Foundation Trust (CHUFT) implemented Telephone Advice & Guidance in 2015 to ease pressure on A&E. At the end of last year, NHS England published a QIPP Case study on this project. The study identifies £275k annual savings for elective care through avoided referrals. It also identifies annual savings of £250 – 400k for urgent care through reduced admissions.
“The service allows the GP to talk to the Consultant about patient cases. It does not take up a lot of time and it does avoid referrals. More importantly it leads to better and timely patient care, as I can often advise on initial treatment over the phone.” Dr Charles Bodmer, Endocrinology Consultant at Colchester Hospitals NHS Foundation Trust
Usage is fundamental to success
Usage is an important consideration here. Since the project started in 2015 we have worked closely with Luton CCG to help drive engagement with their service at primary care level. Because calls are connected so quickly, Luton GPs use both lines a lot. The service typically receives 400-500 calls per month, with the majority of calls (C.75%) being to the GP Liaison line.
We also work with Colchester Hospital and North East Essex’s practices to drive sustained usage and engagement. GPs made almost 4,000 calls in 2016/17.
Establish viable alternatives to admission
Early access to a senior clinical opinion isn’t the only consideration, though. If you aren’t going to send patients to A&E you need to have somewhere else to send them if hospital is required. This was the nut that Sunderland’s Ambulatory Emergency Care (AEC) project was set up to crack:
“We recognise 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.” Dr Tracey Lucas, Sunderland CCG’s Urgent and Ambulatory Care Clinical.
The project was independently audited by NHS Elect, which found that the immediate Advice & Guidance together with better ambulatory provision was avoiding unplanned admissions. The report is a fantastic reflection of the work that has been done in Sunderland.
We’re not saying telephone Advice & Guidance is the solution to congested A&E departments, but we are saying it can be part of the solution.
If GPs are helped to find and choose better alternatives for their patients, all GPs would only use A&E as a last resort. Similarly, if GPs can be helped by specialists to keep a patient’s care with them, they will try and avoid the upheaval of a hospital visit for their patient.
If you are interested in finding out how Telephone A&E can be part of your solution for addressing A&E targets, please contact us on 01865 261 467 or by email firstname.lastname@example.org.