Cracks? - I think its already broken NHS England’s Review of Urgent and Emergency Care

Professor Keith Willett

Director of Acute Care

NHS England

97-98 99-00 01-02 03-04 05-06 07-08 09-10 11-120

1000000

2000000

3000000

4000000

5000000

6000000

Since 1990s, EMERGENCY ADMISSIONS have grown while attendances at major A&Es have stayed broadly constant

Source: King’s Fund

Attendances at type 1 A&E units have remained broadly constant

Type 1 A&Es account for 98% of emergency admissions from A&E

Emergency admissions trends vary significantly over three periods in the last 15 years

7.8% annual growth

-1.2% annual growth

-0.1% annual growth2+ day

2.2% annual growth

2.0% annual growth

4.0% annual growth

1.0% annual growth

Total

Type 1 A&E units are consultant-led 24-hour servicesType 2 A&E units are single specialtyType 3 A&E units include minor injuries units and walk-in centres

1.4% annual growth

0.5% annual growth

0-1 day

Current provision of urgent and emergency care services

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>100 million calls or visits to urgent and emergency services annually:

• 438 million health-related visits to pharmacies (2008/09)Self-care and self

management

• 24 million calls to NHS • urgent and emergency care telephone services

Telephone care

• 300 million consultations in general practice (20010/11)Face to face care

• 7 million emergency ambulance journeys999 services

• 14.9 million attendances at major / specialty A&E departments (2012/13)

• 6.9 million attendances at Minor Injury Units, Walk in Centres etc (2013/13)

A&E departments

• 5.3 million emergency admissions to England’s hospitals (2012/13) Emergency admissions

BACKGROUND

• In Jan 2013 NHS England announced the Urgent and Emergency Care Review.

• A steering group was established to develop an evidence base and principles for a new system. An engagement exercise took place from June to August 2013

• Using the information gained from this exercise we developed proposals to transform the delivery of urgent and emergency care, and published a report in November 2013.

• The Review is now moving into delivery phase

Evidence Base for Change

]5

• 90+ pages• 300+ references

supporting the Clinical Evidence Base

• End to End review of the clinical pathways

• Test and improve through engagement

THE REVIEW’S VISION …..

For those people with urgent but non-life threatening needs:

• We must provide highly responsive, effective and personalised services outside of hospital, and

• Deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families

For those people with more serious or life threatening emergency needs:

• We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery

Solution: shift care closer to home

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Helping people help themselves

Self care:

• Much better and easily accessible information about self-treatment options needs to be made available – patient and specialist groups, NHS Choices, pharmacies

• Accelerated development of advance care planning

• Right advice or treatment first time - enhanced NHS 111 - the “smart call” to make:• Improve patient information available to call handlers• Directory of Services• Improve levels of clinical input (mental health, dental heath, pharmacy) • Booking systems for GP call back, booking into UCC or A&E, dentist, pharmacy

8

Highly responsive urgent care service close to home, outside of hospital

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• Faster, convenient, enhanced service:

• Same day, every day access to general practitioners, primary care and community services

• Harness the skills and accessibility of community pharmacy

• Develop 999 ambulances so they become mobile urgent community treatment services, not just urgent transport services

• Support the co-location of community-based urgent care services in coordinated Urgent Care Centres.

Serious and life threatening conditions – expertise and facilities

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• Two levels of hospital based emergency centres

• Emergency Centres* - capable of assessing and initiating treatment for all patients

• Major Emergency Centres* - larger units, capable of assessing and initiating treatment for all patients and providing a range of specialist services.

• Emergency Care Networks

* names are illustrative

The new system

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THE DELIVERY GROUP

NHS Engla

nd

Tools & Levers

Professionals and Workforce

System Partners

Users

Commissioners and Providers

Challenge

Approach to Phase 2• Continue to “build in public”

• 8 Work Programmes:

– WHOLE SYSTEM PLANNING AND PAYMENT, COMMISSIONING AND ACCOUNTABILITY

– PRIMARY CARE ACCESS

– 111 (CONTACT FIRST)

– DATA, INFORMATION AND CARE PLANNING

– COMMUNITY PHARMACIES

– EMERGENCY DEPARTMENTS and EMERGENCY CARE NETWORKS

– AMBULANCE TREATMENT SERVICE

– WORKFORCE

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ITERATIVE

Questions

DELIVERY PLAN – big ticket itemsBetter support for self care

Promote effective self-care 1. Develop self-care resources2. Guidance produced on marketing campaigns (so that messages are same across the country so far as is practicable) 3. Signposting/linkage to LTC third sector partners, etc, for advice and support

Introduction and roll-out of advanced care planning

1. Development of national care plan template and tools to support delivery of 15m care plans by 2015

Right advice right place first time

Integrate pharmacy into the UEC system

2. Changes to national pharmacy contract to introduce minor ailments service etc.

Improve clinical input to NHS 111 and ambulance services - more ‘hear and treat’

1. Development of new national specification for NHS 111 to include recommended clinical input, and extended range of services for booking, including guidance on reprocurement2. Development of guidance on ambulance models to include support required in control room

Integrate system by improving referral rights through UEC system NHS 111 and NHS ambulance services, pharmacy, etc

1. Ensure national 111 specification and procurement strategy enable local referral rights2. Development of guidance on improving referral rights across UEC system

Enhance the DOS to be real time and accurate commissioning tool

1. DOS development work: Health and Social Care content

DELIVERY PLAN – big ticket items3. Highly responsive out of hospital services

Develop the ambulance service model to offer more treatment on the scene

1. Development of Guidance on models for treatment on scene by ambulance service2. HEE work on paramedic Development and training3. Enable GPs to offer support to ambulance and A&E (in enhanced service to go live from April 14)

Develop community pharmacy facilities to wider range of services

1. Principles for extended pharmacy offer, backed up by contractual changes

Successful models of care for improved primary care access - in and out of hours

1. Principles for improved primary care access 24/7, accompanied by necessary national contractual incentives2. Headline specification for local urgent care facilities

Successful models of care for improved community services - in and out of hours

1. Principles for improved community services (in and out of hours) accompanied by necessary national contractual incentives2. Headline specification for local urgent care facilities

7/7 access to hospital specialist advice to PC and key OOH services

1. Hospital specialists: who should be available, appropriate response times – academy/colleges/specialist (NHSE)

4. Specialist centres to maximise recovery

Designation of major emergency centre and emergency centres

1. Develop national specifications in conjunction with clinical stakeholders2. Determine process for accreditation and designation of facilities

Matching hospital resources to patient acuity and complexity

1. Develop appropriate tools and guidance on flow

DELIVERY PLAN – big ticket items

Connecting services so the system is more than the sum of its parts

New improved system of commissioning, finance, and payment

1. Guidance on recommended footprint of the commissioning unit2. Guidance on what is meant by joint (?)/ collaborative commissioning arrangements – Inc. health and Local Authorities)3. Development of new tariff and incentives structure to drive dissolution of barriers across organisations

Timely access to relevant patient clinical data across the system

1. Full implementation of the SCR2. Enhancements to improve SCR

Establishment of effective emergency networks

1. Development of guidance on constitution of emergency care network in conjunction with national clinical and operational stakeholders.

4. Unified quality measurement system

1. Development of metrics to measure whole system performance.

5. Identifying what good looks like in terms of dissolving boundary between heath and community care

1. Identify sites for exemplars and best practice

Questions