unscheduled care: developing a whole systems approach

Unscheduled care: developing a whole

systems approach

15 December 2009

www.wao.gov.uk

UnscheduledCare726A2009_PV11:Layout 1 08/12/2009 10:19

Unscheduled care: developing a whole systems approach

I have prepared this report for presentation to the National Assembly under the

Government of Wales Act 1998 and 2006.

The Wales Audit Office study team that assisted me in preparing this report comprised

Tracey Davies, Lucy Evans, Martin Gibson, Delyth Lewis, Gill Lewis, Stephen Lisle,

Ann Mansell, Elaine Matthews, Carol Moseley, Rob Powell, Joy Rees,

Gabrielle Smith, Chris Thompson and Mandy Townsend.

Jeremy Colman

Auditor General for Wales

Wales Audit Office

24 Cathedral Road

Cardiff

CF11 9LJ

The Auditor General is totally independent of the National Assembly and Assembly Government. He

examines and certifies the accounts of the Assembly Government and its sponsored and related public

bodies, including NHS bodies in Wales. He also has the statutory power to report to the National

Assembly on the economy, efficiency and effectiveness with which those organisations have used, and

may improve the use of, their resources in discharging their functions.

The Auditor General also appoints auditors to local government bodies in Wales, conducts and

promotes value for money studies in the local government sector and inspects for compliance with best

value requirements under the Wales Programme for Improvement. However, in order to protect the

constitutional position of local government, he does not report to the National Assembly specifically on

such local government work, except where required to do so by statute.

The Auditor General and his staff together comprise the Wales Audit Office. For further information

about the Wales Audit Office please write to the Auditor General at the address above, telephone

029 20320 500, email: [email protected], or see web site http://www.wao.gov.uk

© Auditor General for Wales 2009

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Report presented by the Auditor General to the

National Assembly on 15 December 2009


Summary 5

Recommendations 12

1 Despite a number of strengths, the system of unscheduled

care often does not operate coherently 18

The unscheduled care system meets a vast range of needs and demands and

provides some form of help at all times of the day and night 18

The disjointed pattern of services within the unscheduled care system can result

in inefficiency as well as uncertainty and delays for service users 20

2 There is growing momentum for change but partners still

face a number of short and longer-term challenges

across the unscheduled care system 50

The higher priority that partners now give to improving unscheduled care has

supported progress towards addressing the less complicated problems in

the system 50

Partners still face a number of short and longer-term challenges across the

unscheduled care system, particularly in developing sustainable solutions to

these challenges 57

Appendices 69

Appendix 1 - Methodology 69

Appendix 2 - Key findings from other relevant Wales Audit Office studies 72

Appendix 3 - Detailed findings regarding out-of-hours unscheduled care services 77

Appendix 4 - Detailed analysis of ambulance trust performance 91

Appendix 5 - Detailed analysis of access to emergency departments and staffing 95

4 Unscheduled care: developing a whole systems approach

Contents


5Unscheduled care: developing a whole systems approach

Summary

1 Unscheduled care is a term used to describe

any unplanned health or social care but it is a

term that is not consistently used or

understood across public services.

Unscheduled care can be in the form of help,

treatment or advice that is provided urgently

or in an emergency situation. Figure 1 shows

the main ways in which unscheduled care is

provided.

2 Scheduled care is a term used to describe

any planned, non-urgent health and social

care. The way in which unscheduled care is

delivered impacts directly on scheduled care

and vice versa, not least because most of the

services shown in Figure 1 provide elements

of both scheduled care and unscheduled

care. Therefore, effective planning of

unscheduled care is impossible without full

consideration of scheduled care.

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Mental Health phone line

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Figure 1 - Unscheduled care is a broad term and includes the work of many services

and organisations

Source: Wales Audit Office


6

3 In 2006 and 2008, the Wales Audit Office

carried out two reviews of the ambulance

service in Wales, and in March 2009 we

provided the National Assembly’s Audit

Committee with a further update1 2 3.

Whilst we identified numerous weaknesses

within the ambulance service, we also found

that the service faced some issues that

were not wholly within its control and

resulted from problems in the wider

system of unscheduled care.

4 In February 2008, the Welsh Assembly

Government (Assembly Government)

published its strategy for improving the

system, entitled Delivering Emergency Care

Services (the DECS strategy). The DECS

strategy acknowledges problems in the

existing system of unscheduled care including

frustration and confusion among people using

the system, problems at the interfaces

between different services and increasing

demand on individual services such as

hospital emergency departments, NHS Direct

Wales and the ambulance service.

5 A national vision is now emerging through the

Primary and Community Services Strategic

Delivery Programme which covers both

scheduled and unscheduled care. The vision

seeks to achieve a fundamental shift of

emphasis from the current system of health

and social care which pushes people into

hospital and then pushes them out again, to a

‘pull’ system achieving steady flow through

the system by pulling people towards the

most appropriate care setting, usually in the

community. Plans for the delivery of the

model proposed in the primary and

community services strategy are in their

infancy, but the diagnosis set out in the

strategy is consistent with the conclusions of

our work on unscheduled care.

6 We decided to carry out an examination of the

whole system of unscheduled care from the

citizen’s perspective. Our approach has

involved looking at specific aspects of the

unscheduled care system in discrete but

inter-related modules. Together, these

modules provided comprehensive evidence

about the operation of the whole system.

Further detail regarding these modules can be

found in Appendix 1 and 2. This report is the

last in our suite of reports and covers our

work on the module regarding the whole

system of unscheduled care and our module

on out-of-hours services. Appendix 3 contains

detailed findings from the module on

out-of-hours services.

7 We considered whether there has been

sufficient progress in the planning and

delivery of unscheduled care from the

citizen’s perspective. We concluded that

unscheduled care services succeed in helping

a large number of people with very different

needs but despite growing momentum,

partners still face a number of short and

longer-term challenges to address the lack of

coherence in the operation of the

unscheduled care system. Against the

backdrop of the severe pressures on public

funding, public sector bodies now need to

think in radically new ways about how they

build on the strengths of the system to deliver

improved unscheduled care in ways that

make better use of their collective resources.


1 Auditor General for Wales, Ambulance services in Wales, December 2006.

2 Auditor General for Wales, Follow up review – Ambulance services in Wales, June 2008.

3 Auditor General for Wales, Ambulance services in Wales – further update to the National Assembly for Wales’ Audit Committee, March 2009.



Despite a number of strengths,

the system of unscheduled

care often does not

operate coherently

The unscheduled care system meets a vast

range of needs and demands and provides

some form of help at all times of the day

and night

8 The system of unscheduled care in Wales has

some considerable strengths. We estimate

that there were nearly 2.2 million contacts

with unscheduled care services in Wales

during 2008-094. The majority of people

receive the care they need, when they need

it, often at a time when they are extremely

vulnerable or in the midst of a crisis or

emergency. Another strength of the system is

the wide range of services that are able to

provide unscheduled care, although we have

also found that this variety can be confusing

for people. Collectively, the staff who work

within the various services have extensive

skills, which means the system is able to

support people with hugely varying needs and

demands. A further strength of the system

is that some form of help, be it assurance,

assessment or treatment, is available at

any time of the day or night.

9 It is an important finding of our work that

people think highly of certain unscheduled

care services and generally value the

professionals working within the system.

User surveys show high satisfaction levels for

hospital emergency departments, GP

surgeries and ambulance services5. Academic

research in Wales shows that many people

greatly respect the professionals providing

unscheduled care6.

The disjointed pattern of services within the

unscheduled care system can result in

inefficiency as well as uncertainty and delays

for service users

10 Despite the strengths of the unscheduled care

system, there are numerous problems in the

way that services work together. These

problems and the associated fragmentation

can have detrimental effects on the people

using unscheduled care services and can

also result in inefficient use of resources.

We found problems at the interfaces between

services, within organisations, across sectors

such as health and social care, and between

professional groups. There are also problems

because the distinction between scheduled

and unscheduled care is somewhat artificial

from the citizen’s perspective.

11 As a consequence of the complexity of the

system, people can be uncertain about how

and where to seek help, often resulting in

people calling 999 or attending a hospital

emergency department as a default. Part of

this uncertainty stems from the wide range of

different access points within the system. For

example, a person suffering a minor injury

may have a choice of attending an

emergency department or minor injury unit,

going to see their GP, phoning NHS Direct

Wales or caring for themselves. People face

further uncertainty because of the variation in

services that are available at different times of

the day and night, and at weekends, in

different areas of Wales. The range of

services can also be confusing for

professionals working within the system.

4 This estimate includes people given urgent or unplanned treatment, care or advice by the following services; the ambulance service, hospital emergency departments, minor injury

units, NHS Direct Wales and GP out-of-hours services. Due to a lack of robust data, this estimate does not include the significant number of people who access an urgent GP

appointment in normal working hours, or people accessing unscheduled care from local authority services. Research by the All Wales Alliance for Research and Development in

Health and Social Care, referenced in footnote 6, provides an estimate that there were around 2.65 million unscheduled care visits to GPs in 2007.

5 Welsh Assembly Government, Findings from the 2007 Living in Wales Survey into Citizens’ Views of Public Services, Part 6 – Accident and Emergency Services and Part 7 – Ambulance Services

6 All Wales Alliance for Research and Development in Health and Social Care, Understanding How the Public Chooses to Use Unscheduled Care Services, June 2008


8

12 People can experience delays at various

times during their episode of unscheduled

care. These delays can be caused by a

particular service being slow to respond or by

problems at the interface between services.

The emergency department is commonly a

bottleneck where people can face delays but

only some of the delays are due to the

management of the department itself. Very

often, the delays in emergency departments

are because of problems elsewhere in the

hospital or at the interface between the

hospital and community-based health and

social care services. Understanding the

nature of the delays, and establishing

measures that deal with their causes, is key

to improving flow through the system.

13 The current model of unscheduled care in

Wales has some significant gaps that are

preventing the system from functioning

coherently. Firstly, there is considerable scope

to improve the development and use of

pathways. Pathways are pre-designed routes

that are intended to help patients with

particular symptoms or conditions to flow

more efficiently through the health and social

care system. Pathways can help reduce the

number of handovers and accelerate access

to the care people need. However, we

identified weaknesses in many of the existing

pathways in Wales. There is scope for more

effective communication to address the

limited awareness and understanding of

certain pathways amongst health and local

government professionals, which sometimes

prevents pathways being used. The

development and use of pathways is further

inhibited by the lack of robust understanding

of demand, poor sharing of information

between services and the lack of a common

triage and assessment process in Wales.

14 Another significant gap in the current model of

unscheduled care is that there are not

currently enough appropriate and effective

community-based services to meet demand

and act as genuine alternatives to acute care.

These community-based services are vital in

providing care close to people’s homes,

managing low-level unscheduled care needs

before they escalate. Such community-based

services can prevent unnecessary use of

more acute services. There has been little

progress in understanding demand and then

developing appropriate services to meet that

demand in the community rather than in acute

care. This means that in certain areas, at

certain times of the day and night, there can

be few genuine options for people with

physical health, mental health or social care

needs, other than to seek help from acute

services like emergency departments and

ambulance services.

15 The third significant gap in the model is the

lack of progress in developing staff with

extended, specialist roles. If the decision to

develop such expertise is taken from a

position of true understanding of demand,

these roles can have considerable benefits for

patients and the system. Such staff can play

an important role in working autonomously

and taking definitive decisions to address

people’s care needs without them having to

use any other unscheduled care service.

These roles can also be effective in reducing

the demand on other unscheduled care

services, often by seeing and treating patients

closer to their homes.

16 Although the term ‘unscheduled care’ may

imply unpredictability and therefore problems

in forecasting demand, total demand for

unscheduled care is largely predictable.

A fundamental weakness in the current

system of unscheduled care is that there is

no coherent understanding of demand.




Work to understand demand has focused on

individual services rather than at a population

or system level and the work has focused on

basic activity levels rather than trying to

understand more about the totality of demand.

17 Allied to the poor understanding of demand,

there is very little understanding of costs

across the unscheduled care system.

We estimate that the absolute minimum

annual cost of providing unscheduled care in

Wales is £256 million7. Despite these

significant costs, there has been little

progress in modelling the cost and flow

implications of potential changes in service

models across the whole system. This is

especially serious in the current and projected

fiscal climate. The Assembly Government is

developing a long-term service and

improvement framework for the NHS

which will focus heavily on releasing such

potential efficiencies.

18 Some unscheduled care services are put

under pressure, partly due to people using the

service who might have had their needs more

appropriately met by an alternative service,

resulting in high pressure on certain services

as well as considerable opportunity costs.

More effective prevention work, particularly

through community pharmacists, telecare and

chronic conditions management, could reduce

some of the preventable demand that

unscheduled care services currently face.

There is also considerable scope to better

manage the demand on emergency

departments and the ambulance trust by

preventing unnecessary ambulance

transportations and helping people to access

alternative services to emergency

departments when their needs could be more

appropriately met elsewhere.

19 Whilst it is a strength of the current system

that some form of help is available at any time

of the day or night, we also found that the

disjointed nature of the system is at its worst

during the out-of-hours period which is far

longer than the in-hours period. Many

services stop after normal working hours.

The majority of services that are available

outside normal working hours have more

limited capacity when compared with normal

working hours, whilst some services restrict

their care to existing customers. The

restricted nature of out-of-hours services,

problems with information flows between

different unscheduled care services out of

hours and their often more limited capacity

means that whilst out-of-hours services try

to ensure people are safe by addressing

their most urgent needs, the consideration

of their wider needs is often left until the

next working day.

There is growing momentum for

change but partners still face a

number of short and longer-term

challenges across the

unscheduled care system

The higher priority that partners now give to

improving unscheduled care has supported

progress towards addressing the less

complicated problems in the system

20 During 2008, the Assembly Government

required each health and social care

community, at the level of the new health

boards, to submit a local delivery plan (LDP)

setting out proposals to improve unscheduled

care over the next two years. Each

community was also required to submit an

action plan setting out the immediate steps to

deliver improvements by April 2009.

7 This is an estimate of the absolute minimum costs because we have not been able to use cost information from significant parts of the system because of poor quality data or a

complete lack of collection. The full calculation is explained in paragraph 1.67.


10

21 That increased focus on unscheduled care

has begun to produce improvements, albeit

regarding the less complicated problems

within the system. There has been a

reduction in the extent of delays that people

face at emergency departments during

handovers between ambulance crews and

hospital staff. There has also been some

mixed progress in co-locating unscheduled

care services so that they now work on the

same site or share telephone contact centres.

Whilst the co-location that has happened has

not involved true integration of service

delivery, the co-location has potential to

simplify people’s access points to

unscheduled care, provide people with

smoother transfers between services and

offer efficiencies in the way that services

are delivered.

22 Our report on NHS Direct Wales concluded

that the organisation is starting to have a

greater impact in supporting people to

self-care but could add further value if there

was greater clarity about its strategic fit within

the wider unscheduled care system8.

We reached this conclusion because NHS

Direct Wales provides valuable services to the

public at a comparatively reasonable cost,

supported by sound processes; and NHS

Direct Wales has potential to add further

value to the unscheduled care system but

needs a clearer strategic direction.

Partners still face a number of short and

longer-term challenges across the


23 There is widespread support for the general

principles set out in the DECS strategy but

many stakeholders have criticised the

strategy for not being prescriptive or specific

enough. The Assembly Government is having

to strike a delicate balance between

excessive central prescription, which risks

over-specifying the system and reducing the

ability of local partners to find local solutions

to specific needs, and the need to develop

national approaches to key issues which

might include workforce planning, public

education, single points of access, developing

community-based unscheduled care services,

pathway development and joined-up

information systems.

24 There is scope for the new health boards and

their partners to study unscheduled care

provision and demand, and to design a local

model of services around their analysis.

Recent planning has focused predominantly

on hospital services without fully considering

the role of local government services,

particularly social care, as well as community

and primary healthcare.

25 Throughout our fieldwork we were frequently

told that the time has come for immediate and

decisive action to improve unscheduled care.

Achieving change across the whole system of

unscheduled care will require complex, multi-

agency actions where no organisation alone

can deliver the scale of change required.

Whilst there are now multi-agency

unscheduled care forums in place across

Wales, in some areas there has been

insufficient engagement and involvement in

designing the unscheduled care system from

social services, primary care and the

ambulance service.

26 An important finding of our work is that there

is a general lack of understanding of the role

that local government can play in providing

unscheduled care. Health and local

government are inter-dependent in the

provision of unscheduled care and local

government’s involvement in unscheduled

care is much broader than just through social


8 Auditor General for Wales, NHS Direct Wales, September 2009.



services. Emergency housing, local

government call centres and preventative

services such as fitting home aids and

adaptations can all have an impact on the

system of unscheduled care.

27 Effective collaborative leadership and

governance will be vital in delivering change.

We found that change is currently being

affected by a lack of clarity about who is

accountable for change and by the complex

legal, clinical governance, political, financial

and managerial issues associated with

collaborative working. The formation of the

new health boards presents a considerable

opportunity to improve partnership working.

Reducing the number of organisations

involved in the planning and delivery of health

services presents opportunities to improve

integration, collaboration and coherence of

service provision. The major risks associated

with the reorganisation are that the new,

larger organisations may lose touch with the

local issues facing their communities, while

some of the existing, positive relationships

that exist between partners, may be lost.

There is also an opportunity for local service

boards to provide the necessary leadership,

commitment and momentum to support

radical changes in unscheduled care service

delivery across the public service partners.

Recognising its cross-cutting implications

for citizens, we have provided a specific

briefing note for local service boards

interested in unscheduled care.

28 Delivering change will also require support

from the clinicians, managers and other

professionals working within unscheduled

care services. These staff will be required to

work in different ways and engendering

support will require more consistently effective

clinical and managerial leadership than we

have found during our fieldwork.

29 Given the pressures on the system, changing

the unscheduled care system will require the

active participation of the people using it.

Building on a robust assessment of demand

and led nationally by the Assembly

Government, public sector bodies need to

help the public make better choices about

accessing unscheduled care services.

There is considerable scope to improve the way

that the system learns and improves

30 The way in which the performance of the

unscheduled care system is measured

currently focuses on the performance of

individual services rather than focusing on the

whole care pathway across the system.

While the current focus on speed of access to

specific parts of the system reflects issues of

concern to the public, the performance

measures are not balanced in the absence of

indicators of the quality or outcomes of

unscheduled care.

31 Poor linkages between the information

systems of different services make it

extremely difficult to track a person’s journey

through the system and to assess whether

their eventual outcome was positive. The

Assembly Government is leading work to

introduce new performance measures for

unscheduled care and has developed a

preliminary set of indicators that focus much

more on systems and interface issues rather

than the performance of individual services.

32 Sharing and adapting good practice can both

reduce duplication and cost while improving

service effectiveness. We have presented

numerous case studies of good or interesting

practice but we found that there is

considerable scope to improve the sharing

and evaluation of good practice relevant to

unscheduled care.


12

Recommendations

These recommendations should be considered

alongside the recommendations we made in our

previous reports on the ambulance service, patient

handovers and NHS Direct Wales. Appendix 2

provides details of these previous reports.

We have framed our recommendations around

the three areas of unscheduled care planning and

delivery that require the most immediate and

decisive action:

a public engagement and access to

unscheduled care;

b local and national strategic planning; and

c delivering unscheduled care services on

the ground.

Public engagement and access to

unscheduled care

1 The system of unscheduled care is

complicated and people can be uncertain

about how and where to seek help. There are

numerous ways of accessing help and the

access points to the system change at

different times of day and in different

geographical areas. These issues also make

it difficult for health and social care

professionals to be aware of what services

are available and at what times of day,

thereby causing problems when making

onward referrals. Designing services against

demand and effective public engagement can

help the public make better choices about

how to access unscheduled care. A pilot

communications campaign is currently taking

place in North Wales based on an example of

good practice from England. To improve

public engagement and simplify access to

unscheduled care, we recommend that:

a The Assembly Government should

develop a national communication

strategy to improve public

understanding about how to most

appropriately access unscheduled care.

This strategy should focus on high-level

messages that are equally applicable

across Wales regardless of the local

models of unscheduled care services

and the circumstances in which these

services should be used.

b Based on their analysis of demand for

unscheduled care and the current

service configuration, the new health

boards should seek to provide points of

access to unscheduled care that better

reflect the nature of demand. In any

future rationalisation of points of

access to the system, health boards

should consider whether:

i a single point of access should be

contactable by phone at all times of

the day and night;

ii they could establish a hub for all

referrals to unscheduled care and

transfers between parts of the

unscheduled care service, using

appropriate technology to transfer

calls and patient-level data directly

to other unscheduled care services;

iii the different services should use an

agreed, common triage or

assessment system and agreed

clinical governance arrangements;

and

iv to maintain a regularly updated

directory of services to give service

users details of how to contact other

services.




2 The urgent care provided by GPs and other

primary care professionals is a vital part of the

unscheduled care system in Wales, whether

in or out of hours. However, our review has

found a mixed picture regarding access to

urgent primary care appointments and home

visits. Whilst there appears to be general

satisfaction with access to GP services, there

is evidence that some people, in some areas,

can struggle to get the urgent support they

require from primary care. The new health

boards should exploit the opportunities

across their primary and secondary care

remit to improve the integration of

unscheduled care, for example by:

a carrying out local analysis to highlight

areas where people are not able to

access urgent primary care

appointments consistently;

b working with GP practices to ensure

that their working hours are in line with

those set out in the General Medical

Services (GMS) contract;

c using the results of their local analysis,

work with GP practices to consider

revising their access arrangements and

opening times so they better match the

needs of their registered patients; and

d carrying out a review of the provision

of out-of-hours primary care services

across the health board area, including

consideration of responsiveness of the

current mechanisms through which

people access urgent home visits.

3 There is considerable scope to improve the

development and use of pathways because

the right care is not always provided at the

right time and in the right place. Pathways

vary considerably between different areas and

different times of the day. An important barrier

to the development of new pathways and the

more effective use of existing pathways in

Wales is that there is a lack of shared clinical

governance across the unscheduled care

system. This means that staff working in the

various unscheduled care services have

separate risk and governance procedures to

adhere to. To improve pathways, we

recommend that:

a Through the unscheduled care forums,

the new health boards should carry out

audits of their existing pathways to

better understand the strengths and

weaknesses of their current

arrangements. The audits should focus

on the most common conditions

experienced by local people and should

consider not only the outcomes of

people’s care but awareness of the

pathways among the public and,

critically, professionals within the

unscheduled care system.

b The Assembly Government should

make arrangements to share the

lessons from these audits at a national

level to support the sharing of good

practice.

c Using the benefits of their broader

remit, the new health boards should

work together to develop a strategic

approach across Wales to piloting new

pathways. These pathways should

target common presentations for

unscheduled care and the approach

should involve national evaluation,

shared learning and rapid roll-out of

new pathways.


14

4 There is poor sharing of patient-level

information between unscheduled care

services. This means that when a person

sees more than one service during their

episode of care, they often have repeated

assessments and have to answer the same

questions more than once. Due to the poor

patient-level information sharing between

services, it is extremely difficult, and in many

cases impossible, to analyse a person’s

journey through the unscheduled care

system. Therefore, there is very little analysis

of people’s pathways through the system and

how these pathways affect their eventual

outcome. We recommend that:

a The Assembly Government should

facilitate health and local government

organisations in developing joined-up

information systems across health and

social care providers. Discussions

about joining up information systems

should involve GPs and their

representatives as the primary holders

of patient-level information.

b In the short term, local organisations

should develop and use clinical

transaction documents that provide

details of a person’s journey through

the unscheduled care system. Where

clinical transaction documents are

already in use, unscheduled care

forums should carry out local audit

work to analyse the strengths and

weaknesses of the current

arrangements. The forums should work

together at a national level to share the

messages from these audits.

c Subject to favourable evaluation, the

Individual Health Record (IHR) should

be rolled out across Wales and into a

full range of unscheduled care settings.

Studying the unscheduled care system locally

and nationally

5 Radically new models are needed to deliver

improved unscheduled care against a

backdrop of significant resource constraints.

These models should be developed from a

comprehensive analysis of the way the

system operates and demand for services

within each health and social care community.

The elements of the local visions that have

been developed are too focused on hospital

services without fully considering the role of

local authorities as well as community and

primary health services which can reduce

demand on the more acute unscheduled care

services. Strategic planning is hampered by

poor information about the variable nature of

demand for services and costs across the

whole system. The new health boards

should take the lead in studying and

redesigning unscheduled care services.

Building on shorter-term local delivery

plans already in place and considering

wider system changes, the health boards

should:

a Consider whether and how to engage

local service boards in the cross-cutting

issue of developing a coherent

unscheduled care system, for example

by providing the local service boards

with regular progress reports on the

development of the unscheduled care

system.

b Identify clearly the current gaps in

integration between the various

services and how they plan to achieve

greater integration and seamless care

from the citizen’s perspective.

c Work with their partners to agree a set

of desired outcomes that unscheduled

care systems should deliver for the

population they serve.




d Without focusing on mandatory national

targets, consider what measures would

indicate the successful delivery of these

desired outcomes. These measures

should drive change to the system, be

agreed with professional leads, and be

used to enable the system to learn as

new models of unscheduled care are

piloted and rolled out.

e As a priority, inform their plans by

studying demand and the performance

of the unscheduled care system. As a

minimum, the data should consider:

i the volume and nature of activity

within existing services;

ii the volume and nature of demand for

unscheduled care across all health

and local government unscheduled

care services, taking account of

presenting conditions and underlying

causes of demand;

iii indicators of the quality of

unscheduled care including the

outcomes for people who access

services;

iv access to services, flow through the

system and the nature of any delays,

unnecessary handovers or use of

particular services; and

v the costs of unscheduled care

services across the whole system

regardless of organisational

boundaries.

f Work effectively with local authority and

voluntary sector services to provide a

wider range of timely support for people

to ensure that access gaps in

community-based services and a lack of

alternatives other than hospital

admission, do not result in unnecessary

admissions to hospital.

6 There is widespread agreement with the

principles within the DECS strategy but there

is also criticism that the strategy is not

prescriptive or specific enough on particular

issues that are most appropriately determined

at a national level. While it is right to avoid

over-specifying the system of

unscheduled care, the Assembly

Government should assist the new health

boards improve their strategic approach to

unscheduled care by:

a Following the evaluation of the pilot of

the Primary and Community Services

Strategy and development of an

implementation plan, consider any

changes that might be required in the

local delivery plan template to help

health boards and their partners in

developing their own medium to long-

term unscheduled care strategies. For

the next round of local delivery plans in

2011, the central driver should be the

need for the new health boards and

their partners (particularly primary care,

mental health, social care, ambulance

services and the public) to develop a

much more robust understanding of

demand, against which to develop their

plans and local performance measures.

b Where appropriate, joining up local

developments in unscheduled care

provision at a national level,

considering for example:

i Workforce issues to ensure people

receive the right care from the right

professional. In particular, the

Assembly Government should

facilitate discussions between the

health boards, ambulance trust, and


16

representative bodies representing

unscheduled care professionals, to

develop a clear framework through

which to extend the scope of practice

of unscheduled care professionals.

This framework should support the

national development of the

paramedic profession but provide

significant local flexibility to support

tailored solutions to meet local

demand.

ii The need to develop a framework to

support local bodies in working

towards twenty-four seven working

where appropriate to meet demand,

with greater continuity, consistency

and coherence between in-hours and

out-of-hours care.

iii The Assembly Government should

establish mechanisms to increase

the flexibility of, and alignment

between, the health and local

government workforces supported by

a set of national standards and

supported by appropriate training

and development.

iv In responding to the

recommendations of our separate

report, clarify the potential future

role, at an all-Wales level, for NHS

Direct Wales within the wider system

of unscheduled care and encourage

its better integration into local

service planning to improve the flow

of patients through the system.

Delivering unscheduled care services on

the ground

7 Staffing issues in unscheduled care services

are contributing to problems within the

system. There is a lack of capacity in some

areas of the system, including shortages of

emergency department medical staff which

can lead to senior clinical decision-making not

happening soon enough in some

departments. Another factor in delaying senior

decision making is the lack of progress in

developing extended scope, specialist staff

roles. Working with local authority

partners, the new health boards should

conduct a fundamental review of their

unscheduled care workforce to ensure

there is a reasonable balance between

supply and demand across the various

services and sectors. In particular they

should:

a Review activity and staffing levels

within their major acute specialties

and emergency departments using

the soon-to-be revised College of

Emergency Medicine staffing

guidelines.

b Consider the size and utilisation of the

primary care workforce across the

system to support unscheduled care,

for example the placement of GPs in or

nearby emergency departments.

c Ensure that the availability and working

patterns of emergency nurse

practitioners are sufficiently matched

to demand.

d Consider increasing nurse staffing

levels where emergency department

pressures frequently result in nurse

practitioners resorting to core nursing

roles.




e Introduce professional leads for

unscheduled care to act as a figurehead

and contact point for engaging

professionals in their field. This is

necessary because change will not be

delivered without the support of the

professionals working within the

system. Professional leads must cover

the whole system across the range of

professions required to deliver

unscheduled care in new ways.

8 The way in which performance of the

unscheduled care system is measured

focuses primarily on access to individual

services rather than the whole experience of

the person accessing unscheduled care.

Current performance targets measure

important parts of the journey but do not

reflect the whole journey, nor do they reflect in

any way the overall outcome. Using a target-

driven approach to performance management

that focuses on access to services can act as

a disincentive to system change, important

though access to unscheduled care is.

We recommend that the Assembly

Government should:

a Ensure that the measures it is currently

developing incorporate a wider system

perspective and ensure that they:

i are based on a comprehensive

examination of demand for

unscheduled care services;

ii balance access, quality and

outcomes recognising in particular

the need to avoid managing clinical

services with reference to the time an

episode of care takes without

reference to its quality or outcome

for the citizen; and

iii include measures of health service

performance and measures relevant

to other public sector services,

especially those delivered or

commissioned by local authorities.

b Ensure that its performance

management framework is sufficiently

flexible to consider, alongside national

indicators, local organisations’ own key

measures of longer-term system

improvements.


18

Part 1 - Despite a number of strengths, the system of

unscheduled care often does not operate coherently

1.1 This section of the report sets out the current

strengths of the unscheduled care system in

Wales before discussing some of the

problems that are preventing the system from

operating coherently.

The unscheduled care system

meets a vast range of needs and

demands and provides some

form of help at all times of the

day and night

1.2 The system of unscheduled care in Wales has

some considerable strengths but these

strengths may sometimes be taken for

granted. Regardless of the weaknesses in the

system that this report sets out, we recognise

that in the vast majority of emergency

situations, unscheduled care services

succeed in providing the care that people

need, when they need it.

1.3 Figure 1 shows the large number of services

that are involved in providing unscheduled

care. The fact that so many services are

capable of delivering unscheduled care

means that many people have a choice about

how they would like their needs to be met,

although we have found that this wide range

of services can be confusing for people. As

the staff working in the various unscheduled

care services have diverse specialisms and

skills, the system is flexible enough to be able

to care for people with a huge range of

different needs, demands and expectations.

1.4 Another of the system’s strengths is that it is

able to support the needs of a huge number

of people. Whilst we do not have data

regarding the total number of people given

unscheduled care in Wales, we have

estimated that during 2008-09, people made

nearly 2.2 million contacts with the following

services: the ambulance service, hospital

emergency departments, minor injury units,

NHS Direct Wales and GP out-of-hours

services9. These data do not include other

significant parts of the system such as the

unscheduled care provided by local

government and urgent primary care

appointments during normal working hours.

The DECS strategy says that between

2.3 million and 2.4 million people contact their

GP practice every year and whilst many of

these contacts will have been of an urgent

nature, there is no robust recording of this

information.

1.5 A key strength of the unscheduled care

system is that some form of help, be it

assurance, assessment or treatment, is

available at any time of the day or night.

Hospital emergency departments and the

ambulance service are some examples of

unscheduled care services that operate 24

hours a day, seven days a week. This

continuous availability of support can be a

source of reassurance to people and function

as a safety net for people who might be

unable to get help from elsewhere.


9 In 2008-09 there were 977,555 attendances at hospital emergency departments and minor injury units. The data from our survey of LHB chief executives suggests that there

were approximately 514,000 calls from callers who spoke to the various GP out-of-hours services in Wales in 2008-09. In 2008-09, NHS Direct Wales answered 314,687 calls.

In 2008-09, the ambulance trust responded to 315,057 emergency calls and 52,128 urgent calls from GPs.



1.6 In general, hospital emergency departments

and the ambulance service are highly valued

by the public. In 2007, the Assembly

Government’s Living in Wales Survey showed

that overall satisfaction with accident and

emergency departments was 83 per cent and

overall satisfaction with the ambulance

service was 93 per cent10. An overview report

on the joint reviews of social services carried

out by the Wales Audit Office and the Care

and Social Services Inspectorate Wales

concluded that whilst out-of-hours contact

services had improved to some degree

between 1998 and 2008, far fewer adults

(57 per cent) were satisfied with the

out-of-hours response from social services

than the response during normal working

hours (85 per cent)11. The Welsh GP Patient

Survey showed that 88 per cent of patients

were satisfied with the care they received at

their GP surgery12.

1.7 A study commissioned by the Assembly

Government in 2008 to examine how the

public chooses to use unscheduled care

services found that ‘one of the most striking

aspects of interview respondents’ descriptions

of unscheduled healthcare was how positive

the majority of them were about the

experience’13. Many of the positive comments

were regarding the professionals working

within the unscheduled care system.

Box A shows a selection of positive views

that people have expressed about

unscheduled care in Wales.

10 Welsh Assembly Government, Findings from the 2007 Living in Wales Survey into Citizens’ Views of Public Services, Part 6 – Accident and Emergency Services and

Part 7 – Ambulance Services.

11 Care and Social Services Inspectorate for Wales and the Wales Audit Office, Reviewing Social Services in Wales 1998-2008, Learning from the Journey, June 2009.

12 Welsh Assembly Government, Welsh GP Patient Survey, SDR 100/2009, 30 June 2009.

13 All Wales Alliance for Research and Development in Health and Social Care, Understanding How the Public Chooses to Use Unscheduled Care Services, June 2008.

14 All Wales Alliance for Research and Development in Health and Social Care, Understanding How the Public Chooses to Use Unscheduled Care Services, June 2008.

Box A - Examples of some positive views

about unscheduled care in Wales

a I think it is brilliant to have someone on call to phone up

(NHS Direct Wales) and say that something’s not right

and to get their point of view on what you should be

doing because your instinct might be that they need to

go to hospital but it’s nice just to have a backup.

b Good advice, prompt ambulance service, good care in

A&E and on the wards.

c I have nothing but praise for the A&E department.

d You’ve got a satisfied customer here. I thought I

received an excellent service and have nothing but

praise for the staff. I am extremely fortunate to live

within 10 minutes of A&E and have used it a couple of

times before, always receiving an impressive, timely and

efficient service.

e Generally I feel we have a fantastic health service

support with all the subsidiary supports in place,

perhaps more people need informing about the rest,

ie, that A&E or GP is not the only option.

f The best thing about my care was the speed I was dealt

with, both with the return of my call from NHS Direct and

the speed I was able to get through to the out of hours

service and ability to get an appointment.

g The ambulance service was absolutely outstanding -

careful and considerate. I could not praise them enough.

h I was treated with such speed and efficiency was the

best part and I felt really proud of our health service.

i Well my doctor (GP) is my friend as well and I’ve been

with him for so many years. He doesn’t have to look at

my notes or anything because he knows me so well.

Source: Responses to an appeal for views on the Wales Audit Officewebsite and views collected as part of the AWARD academic research14



The disjointed pattern of

services within the unscheduled

care system can result in

inefficiency as well as

uncertainty and delays for

service users

1.8 Despite high satisfaction levels with certain

unscheduled care services, we found a wide

range of issues related to a general lack of

coherence in the way that different services

currently work together. This lack of

coherence contributes to uncertainty and

delays for people who need care and results

in inefficient use of resources.

The public and the professionals working in

health and local government can be uncertain

about how to use the system

1.9 The wide range of unscheduled care services

shown in Figure 1 (see page 5) offers people

choice about where to access help. For many

of these services, users have the added

option of contacting them by telephone,

in person or electronically via the internet or

e-mail. But the range of options can be

confusing for some people, as shown by the

views in Box B.

1.10 Academic research carried out in Wales

entitled Understanding How the PublicChooses to Use Unscheduled Care Servicesconcluded that many respondents ‘did not

have a complete picture of the range of

unscheduled care services available’.

Awareness of services was varied and was

consistently highest for accident and

emergency services, whilst awareness of

pharmacy out-of-hours services and minor

injury units was lower16. The report also said

that ‘the boundaries of unscheduled care are

blurred – both in terms of the range of

services included and in terms of how the

line is drawn between unscheduled and

scheduled’.

1.11 In response to our survey, NHS trust chief

executives agreed that public uncertainty

about where to access help during the

in-hours period can be a barrier to people

receiving swift and effective unscheduled

care. However chief executives of local health

boards (LHBs), directors of social services

and GPs did not agree. The respondents

generally felt that there was more public

uncertainty about access to services during

the out-of-hours period than during the

in-hours period.

1.12 To add to the complexity of the system, many

of the ways in which people can access help

vary by time of day or geographical area.

For example many services stop during the

out-of-hours period and are therefore no

20

Box B - Some service users find the

unscheduled care system confusing

a It is utterly confusing and some services seem to be

replicating others wasting time and public money.

b No one gives an answer via phone. You are always

referred back to your GP. It’s easier to go and sit in A&E.

c They don’t really advertise the places you can phone up

first, there seems to be an imbalance in the media.

d If I had a 'one point of contact' who could filter my query

to the relevant department rather than me trying to make

that decision knowing that the system doesn't work as it

should do in theory. If there is such a person then they

will know what isn't working and put it right.

Source: Responses to an appeal for views on the Wales Audit Officewebsite and views collected as part of the AWARD academic research15





longer contactable, whilst some other services

restrict their services to existing clients during

the out-of-hours period. The range of services

available and therefore the access points to

the system may vary between geographical

locations, even within local authority areas.

1.13 The range of services within the system can

be confusing for professionals working within

health and local government. This uncertainty

can result in these professionals referring a

person to a particular service when referring

them to a different service might have been

more appropriate. Directories of services have

the potential to improve understanding of

what services are available, particularly

voluntary sector services. These are

documents that give details of what services

are available, the working hours of the

services and the criteria services use to

decide whether people can use their services.

The review carried out by the National

Leadership and Innovation Agency for

Healthcare (NLIAH) of the DECS baseline

assessments showed that the development of

directories of service was an area that was

not consistently developed in Wales. Our

fieldwork also suggests that the directories

that do exist soon get out of date because

they are rarely updated to reflect changes to

the locally available services. However, our

report on NHS Direct Wales gives details of a

pilot project in Carmarthenshire where NHS

Direct Wales is promoting the use of a single

directory and signposting service for health,

local government and voluntary services17.

People can face delays in receiving care and

these delays often have consequences for

unscheduled care services

Although there is general satisfaction and improving

access to primary care, delays in accessing primary

care can lead to some patients defaulting to more

acute services

1.14 The disjointed nature of the unscheduled care

system can contribute to people facing delays

at various times during their episode of care.

Such delays might be experienced when a

person initially requests assistance, there may

be delays in providing care or there may be

delays when a person is transferred into the

care of another service.

1.15 Primary care plays a vital role regarding

access to unscheduled care, dealing with

the majority of initial contacts. When primary

care is slow to respond to requests for

unscheduled care, this can result in people

defaulting to more acute services.

Ninety-seven per cent of Welsh GP practices

receive additional payments for ensuring

access to an appropriate member of the

primary care team within 24 hours of a

request for an appointment, which is a more

stringent standard than the 48 hours that

applies in England and Scotland. Overall,

people are satisfied with their access to

urgent primary care appointments. The Welsh

GP Patient Survey found that 83 per cent of

the respondents who had tried to see a doctor

fairly quickly were able to access a GP or

other healthcare professional on the same

day or the next day18. However, during our

fieldwork we did identify some concerns from

the public and from health and local

government professionals regarding access to

primary care appointments. A particular

concern was that it can sometimes require

persistence on the part of the service user to

17 Auditor General for Wales, NHS Direct Wales, September 2009, page 42

18 Welsh Assembly Government, Welsh GP Patient Survey, SDR 100/2009, 30 June 2009.


22

secure an urgent GP appointment. Box C

shows some examples of positive and

negative views from the public regarding

access to primary care.

1.16 A mystery shopping exercise carried out by

Gwent Community Health Council in 2008

suggested that some people struggle to

access primary care appointments because of

extended closures at practices during

lunchtimes and some afternoons. The local

results of the Welsh GP Patient Survey also

suggested some issues in Gwent. In all but

six unitary authority areas, more than 80 per

cent of respondents to the survey were able

to see a GP or healthcare professional on the

same day or the next day20. Four of these six

unitary authority areas are in Gwent21.

1.17 Findings from Understanding How the PublicChooses to Use Unscheduled Care Servicesalso suggested that there are some problems

with access to primary care. The report said

availability of same-day consultations varies

greatly between practices and some patients

may feel excluded by appointment

arrangements.

1.18 The Assembly Government’s quarterly

monitoring of the Annual Operating

Framework shows that there have been

problems in certain unitary authority areas

with GP practices not meeting contractual

requirements22 for opening times23.

The monitoring report for the quarter

ending June 2009 shows that five unitary

authority areas had GP practices that were

not meeting these requirements, and three of

these areas were within Gwent24. Data were

unavailable in another three areas.


Box C - Examples of positive and negative

views about primary care access

Positive views

a (I chose to access my GP) because it’s easy to get an

appointment.

b (I chose to go to my GP surgery) because it’s local and

convenient.

c (My GP surgery) is local. They have my records and

know me. Can always see a nurse if I don't need to see

a GP. Excellent.

Negative views

a When I rang my doctor's surgery to ask for an

emergency appointment I was told there were none

available. I then asked if I could speak to a doctor. I was

advised to ring back later. Having rung nine times in one

day, at the times I was told to I finally asked if perhaps

the doctor could ring me. I was told he did not telephone

patients.

b The worst (thing about my care) is the bureaucratic

system my GP surgery operates when trying to make an

appointment with a doctor of my choice.

c (My GP surgery has an) interminable system for getting

an appointment that day.

d You have to queue up even before the doors open to be

able to see a doctor that day.

e The current wait for a GP appointment in a lot of

surgeries in Wales is unacceptable. Our large surgery

has in excess of a two-week wait for both doctor and

nurse appointments.

Source: Responses to an appeal for views on the Wales Audit Officewebsite and views collected as part of the AWARD academicresearch19


20 Welsh Assembly Government, Welsh GP Patient Survey, SDR 100/2009, 30 June 2009

21 Caerphilly, Rhondda Cynon Taf, Blaenau Gwent, Newport, Flintshire and Torfaen.

22 The Assembly Government’s guidance on the GMS Contract says that practices are resourced under the GMS Contract for the provision of General Medical Services during

the core hours of 8am to 6.30pm. ‘Delivering Investment in General Practice’ (January 2004) states that normal surgery hours must be ‘to the extent necessary to meet

reasonable need’

23 Welsh Assembly Government, NHS Wales Annual Operating Framework Monitoring Report 2009-2010, August 2009

24 Abertawe Bro Morgannwg community, Cardiff, Monmouthshire, Newport and Torfaen



1.19 Our fieldwork interviews and responses from

the public on our website raised some

concerns about difficulties and delays in

receiving an urgent home visit from GPs or

other healthcare professionals. The views

provided in Box D suggest that there is some

demand for better access to home visits,

however, primary care has to strike a difficult

balance between meeting such demand whilst

prioritising home visits based on clinical need.

Case Study A gives details of an initiative in

St Helens, Merseyside, that has succeeded in

improving access to GP home visits and

resulted in improved patient care as well as

financial savings. Case Study B gives details

of the Penarth Integrated Care Team which

has succeeded in reducing hospital

admissions through providing prompt and

early primary care intervention for patients in

nursing and care homes.

There are signs of ambulance response time

improvement at an all-Wales level but the variation

between local authority areas shows that too many

people continue to experience delays

1.20 When people call 999 to request an

ambulance, this normally means there is a

genuine emergency. The timeliness of the

ambulance response is therefore vital in

saving lives and giving patients the greatest

chance of making a full recovery.

1.21 Full analysis of ambulance response times is

shown in full in Appendix 4. Our previous

work on the ambulance trust showed that

performance had dipped significantly across a

range of measures since June 2008.

The most recent data shows that all-Wales

response time performance regarding

life-threatening calls has improved since

December 2008 and the national target for

responding to 65 per cent of these calls within

eight minutes was achieved every month

between March 2008 and June 2009.

Nevertheless, too many people continue to

experience delayed ambulance responses,

as highlighted by the considerable variation in

performance within and between different

unitary authority areas.

Delayed handovers at emergency departments

are detrimental to patients and are costly to the

ambulance service

1.22 Delayed handovers have detrimental impacts

on patients who often await medical attention

on ambulance trolleys in hospital corridors.

This has implications for privacy and dignity

as well as exacerbating the anxiety that these

patients and their families or carers might be

feeling. Our April 2009 report on patient

handovers showed that patients are

frequently delayed too long and the data on

handovers is not yet providing an accurate

view of the extent of the problem26.

Box D - Examples of negative views about

access to home visits from GPs or other

healthcare professionals

a Very occasionally it feels like a doctor ought to come to

the house to help with something. However, it feels like

those days are completely gone and there's no chance

of getting a doctor's visit nowadays.

b The GP refused to see me despite being in pain, told me

to take paracetamol and call back after 9am the next

day or wait until Monday to see my GP.

c More GPs should be available for home visits. GPs

should be available for appointments and walk in

surgery should not be so full, or more GPs should be

available to meet demand.

Source: Responses to an appeal for views on the Wales Audit Officewebsite25


26 Wales Audit Office, Unscheduled care - Patient handovers at hospital emergency departments, April 2009



Case Study A - Acute Visiting Scheme in Merseyside

The Acute Visiting Scheme involves a local GP specifically employed to carry out home visits during normal working hours.

Data showed that St Helens GPs were admitting relatively high numbers of people to hospital. One possible cause was that

GPs in the area, many of whom were running single-handed practices, were unable to respond rapidly to requests for home

visits. The delays in responding often meant that people’s conditions would deteriorate and this would frequently result in

people deciding to access unscheduled care in an alternative way, commonly calling an ambulance to take them to the

emergency department.

The scheme was set up by United League Commissioning, a practice-based commissioning consortium which now covers 23

GP practices and around 100,000 patients. The consortium decided to pump-prime the scheme using its management

allowance and within eight weeks the scheme was operational.

The scheme employs a roving doctor on a sessional basis. This doctor is a local professional locum and therefore has in-depth

knowledge of local services and care pathways.

Patients call their own practice if they want a home visit. This is important because their surgery has access to the patient’s

notes and is therefore best placed to carry out an assessment of the patient’s needs over the telephone. The scheme describes

this as ‘intelligent first contact’; ensuring that each practice remains accountable for their decisions. The consortium took the

decision that developing and agreeing a clinical decision tool for practices to use would have been too complicated and would

have been a significant barrier to the scheme getting off the ground.

If the practice deems a home visit necessary, the practice sends a request to the daytime staff of the GP out-of-hours

cooperative which acts as a conduit for co-ordinating the calls to the roving GP.

The roving GP spends, on average, 20 minutes with each patient, compared with eight minutes when the home visit is carried

out by the patient’s own GP. The roving GP also carries out 76 per cent of visits within an hour compared with less than 10 per

cent if the visit is carried out by the patient’s own GP. Therefore the service is avoiding delays where patient’s conditions can

exacerbate, and the time that the service can dedicate to each patient provides reassurance and prevents anxiety.

If the GP does not have a call to go to, they visit a list of residential homes to carry out proactive prevention work.

At the end of each session the roving GP completes a standard form and sends it to each patient’s practice to keep them

updated on the treatments received and action taken.

The Primary Care Trust’s (PCT) perception that daytime visits constitute core GMS work that GPs were already being paid for,

posed a significant problem for the scheme. The consortium argued that local GPs were not refusing to carry out home visits

but the delays in providing home visits in the traditional model were more likely to result in hospital admissions.

The PCT now runs two parallel schemes; one in St Helens and one in Wigan. Each scheme costs around £1,500 per week,

covering doctors’ sessions, transport and administration.

An internal evaluation of the six-month pilot phase suggested that one per cent of the scheme’s visits resulted in admissions

compared with five per cent when visits were carried out by the patient’s own GP. The consortium estimates the annual savings

through avoided admissions from both schemes to be around £1 million.

With local GPs no longer required to carry out so many home visits, a spin-off benefit from the scheme is that each visit from

the roving GP releases about 30 minutes of local GP time. Local GPs have, as a result, been able to increase the number of

appointments they are able to provide.

The consortium believes it should be a GP that carries out the home visits rather than a community matron or nurse. This is

because GPs have faster consultation rates, are generally more confident and experienced in working with only basic patient

information and because patients feel more reassured when being seen by a doctor.

The scheme currently operates from 9am to 6.30pm on weekdays and employs two roving GPs so that the service has the

capacity to meet needs at times of peak demand.

There have been no clinically significant events or formal complaints regarding the scheme which now covers a population of

around 100,000 people within 23 GP practices.

Source: Wales Audit Office fieldwork



Case Study B - Penarth Integrated Care Team

Penarth, in the Vale of Glamorgan, has an ageing population where 1 in 10 of the patients registered with the four GP practices

are aged 75 years or older. Penarth also has a high number of beds in nursing and residential homes. Analysis in 2007 found

that GPs were making an average of 28 home visits a week, with more than half of these visits to nursing and residential

homes. In addition, there was an average of 35 Penarth residents admitted to hospital as an emergency each week for chronic

conditions and falls.

The Vale of Glamorgan Local Health Board and the four GP practices in Penarth developed a proposal to introduce a shared

clinical team comprising a community physician and two registered nurses. The team is now also supported by an elderly care

physician, a specialist registrar and a part-time consultant. The team was set up to work with the GP practices, nursing homes,

residential homes, hospitals and the local authority to identify patients who would benefit from detailed assessment and support

from services linked to primary care. The team, known initially as the Winter Pressure Team, is now known as the Penarth

Integrated Care Team (PICT). The team’s staff are currently subcontracted from Nester Primecare and direct costs totalled

£131,000 in 2008-09, with on costs borne by the GP practices.

PICT operates five days a week, except bank holidays. The community physician works three days a week, Monday,

Wednesday and Friday, while the two registered nurses work three days each, overlapping on Wednesdays. PICT is based in

one of the GP practices in Penarth with a single GP lead taking management responsibility for the work of the team. The way in

which the team operates, including its clinical responsibilities, clinical decision making, record keeping and how it links across

practices, was developed and agreed by the GP practices. The team holds regular clinics in nursing and residential homes and

accepts referrals from GP surgeries, social services and hospitals if the patients meet any the following criteria:

a housebound with complex care needs requiring a Level 1 and 2 assessment to assist in the management of chronic

conditions management;

b live in a residential home and have complex needs requiring a Level 1 and 2 assessment;

c housebound or residential home patients with less complex conditions, such as chest infections or minor illnesses; and

d nursing home patients with medical needs.

PICT aims to:

a improve the health and well being of frail older people;

b improve chronic conditions management in frail older people;

c co-ordinate and deliver multidisciplinary services in a primary care setting;

d support staff in nursing and residential homes to manage health needs of residents more effectively;

e reduce unplanned contacts with healthcare services, for example GP out-of-hours services and ambulance services; and

f reduce unplanned hospital admissions.

A baseline was established in 2007 against which to assess quantitative and qualitative improvements for patients and

practices, including reductions in unplanned admissions and contacts with out-of-hours services, as well as improved

co-ordination of community services. Since the baseline analysis in 2007, the number of unplanned admissions and contacts

with healthcare services have reduced, in particular:

a there has been a reduction in the number of emergency admissions for people living in nursing and residential homes;

b there has been a 35 per cent reduction in GP home visits; and

c the number of contacts with GP out-of-hours services reduced by 62 per cent.



26

We further discuss the extent of patient

handovers in paragraphs 2.7 to 2.14.

1.23 With ambulance crews being delayed at

emergency departments, there are fewer

crews available to respond to other

emergency calls. And the delays that crews

face at hospital have a direct cost. During the

year ending 31 July 2009, ambulance crews

spent 38,536 hours waiting at hospital

emergency departments beyond the

20-minute target to complete the handover

and make the ambulance ready for the next

emergency call. These delays have an

estimated direct cost of more than

£2.9 million27.

There has been variable progress in reducing

waiting times in emergency departments

1.24 A delayed patient handover is just one

example of the delays that a patient might

experience within the acute hospital. Full

analysis regarding the delays that people can

face in hospital emergency departments can

be found at Appendix 5. Our main findings

are that:

a performance against the national target for

emergency department waiting times

dipped significantly during 2008 but there

have been improvements during 2009;

b the average waiting time has reduced in

seven major emergency departments

between 2003-04 and 2007-08; and

c issues with emergency department staffing

levels may be contributing to delays for

patients.

1.25 Some of the problems that NHS trusts face in

reducing waiting times are due to the fact that

the emergency department performance is

heavily dependent on the performance of the

rest of the hospital. During the fieldwork for

our patient handover report, in some hospitals

we were told that a lack of support for

emergency departments from inpatient ward

teams was delaying the movement of patients

from emergency departments to the wards.

1.26 A review by the Assembly Government’s

Delivery and Support Unit in 2006 said that if

short-stay assessment and observation areas

are managed by the emergency department

and if they are separate from the hospital bed

pool, they can improve efficiency and patient

flow through the hospital28. However, the

report said that these types of short-stay units

were not always operating efficiently, resulting

in patients being admitted for assessment

rather than a robust clinical assessment being

carried out before taking the decision to admit

the patient.

1.27 Our review also highlighted some

weaknesses in the way that these short-stay

units are being used in Wales. Further details

of these weaknesses can be found in

Appendix 5. The appendix also contains case

studies giving details of two different models

for clinical decisions units that have had

benefits for the trusts involved.

Although the trend is improving, delayed transfers

of care continue to have serious implications for

people’s independence as well as direct and

indirect costs for the health service

1.28 Access is a key element of unscheduled

healthcare services yet delays elsewhere

within the system, for example in discharging

patients at the ‘back door’ affect access to

unscheduled care. Our work on delayed

transfers of care concluded in 2007 that the

independence of vulnerable people and

treatment of others was being compromised


27 This calculation uses the total time that crews from the Welsh Ambulance Services NHS Trust spent at hospital emergency departments in Wales and England beyond the 20

minutes target to complete the handover and make the ambulance ready for the next emergency call. The calculation also uses the trust’s own estimate that the direct cost of a

double crewed ambulance per hour is £76

28 Welsh Assembly Government, Emergency Care – A report from the Delivery and Support Unit, WHC (2006) 59, 11 August 2006



by unnecessary delays in hospital due to the

whole system problem of delayed transfers of

care not being tackled effectively in a whole

systems way. Delayed transfers impact on the

individual but they also have a significant

financial cost. Appendix 2 gives the main

findings from our follow through report on

delayed transfers of care29. Figure 2 shows

that there has been progress at an all-Wales

level in reducing the number of people who

experience delayed transfers of care and in

the total number of bed days that are lost due

to delayed transfers of care. The number of

people who experienced a delayed transfer of

care in 2008-09 was 4,586, a 10 per cent

reduction from the previous year. The total

number of lost bed days was 211,849 in

2008-09 which represents an 18 per cent

decrease from the figure in 2007-08.

1.29 Despite the progress made, each instance of

a delayed transfer of care threatens the

independence of the individual involved.

There are also cost implications of delayed

transfers of care. During 2008-09 there were

211,849 lost bed days due to delayed

transfers of care. The direct cost of these lost

bed days was approximately £54.7 million.

1.30 More than 41 per cent of the delayed

transfers of care during 2008-09 were due to

patient/carer/family reasons such as choice of

care home, disputes and legal and financial

issues. Uncertainty about the costs of social

care can contribute to such problems. A

measure proposed to the National Assembly

by the Deputy Minister for Health and Social

Care in June 2009 aims to improve the clarity

around the funding of non-residential social

care. The measure outlines changes for

greater consistency and fairness in local

authority charging for non-residential social

care. The measure would put an obligation on

local authorities to provide free information

about charging and where the authority

decides to levy a charge, they will have to

produce a clear statement giving details of

exactly what the person is to be charged for

and how the person may seek to have these

charges reviewed.

Figure 2 - The number of patients who experienced a delayed transfer of care and the number of

lost bed days reduced between 2006-07and 2008-09

Total number of patients experiencing a delayed discharge across Wales Total number of delayed days across Wales

6000

5000

4000

3000

2000

1000

0

300,000

250,000

200,000

150,000

100,000

50,000

0

Num

ber o

f del

ayed

day

sin

yea

r

Num

ber o

f pat

ient

s in

yea

r

2005-06 2006-07 2007-08

2008-09

2005-062006-07 2007-08

2008-09

Source: Wales Audit Office analysis of Health Solutions Wales delayed transfers of care data

29 Auditor General for Wales, Delayed transfers of care follow-through, May 2009.


28

1.31 The promotion of independence requires

health and social care organisations to work

together strategically but also operationally,

at both the front door and the back door of

the hospital. By working together in this way,

these organisations can prevent unnecessary

hospital admissions and facilitate appropriate

discharges. Our Good Practice Exchange

website (http://www.wao.gov.uk/2302.asp)

gives numerous examples of positive

developments regarding delayed transfers of

care and regarding effective joint working

between health and social care services.

1.32 Case Study C gives details of a service that

runs in Carmarthen and Llanelli to manage

demand at the front door of the hospital and

prevent admissions to the emergency

department for largely social reasons.

This can reduce the risk of vulnerable older

people becoming a delayed transfer of care

if they are admitted to hospital.

Local authorities are generally quick to respond

when people are in immediate danger but they are

more commonly delayed in responding in less

urgent situations

1.33 Local authorities play a vital role in delivering

unscheduled care. Social services are heavily

involved in providing urgent support for

vulnerable people including personal care at

home, advice and information, night-sitting

and residential care. But local authorities’

involvement in unscheduled care is much

broader than just through social services. For

example, housing services, through the timely

fitting of home aids and adaptations, impact

on the system of unscheduled care. By

providing such services rapidly and effectively,

local authorities can meet people’s needs

quickly and without the need to access other,

more acute services.


Case Study C - Twilight Service in Carmarthen and Llanelli

Analysis of the admissions at two West Wales hospitals showed that elderly patients were sometimes unnecessarily admitted

through the emergency department during the evening because of a lack of services to support these people at home.

This lack of support was also preventing discharges during the evening and night-time. Therefore, vulnerable older people were

spending time in hospital despite them having no medical or clinical need to be there.

A joint initiative was started at West Wales General Hospital in Carmarthen and Prince Philip Hospital in Llanelli. The Twilight

Service is delivered by a voluntary sector organisation called Menter Cwm Gwendraeth, is commissioned by Carmarthenshire

LHB and Carmarthenshire Council, and is supported by Hywel Dda Health Board.

The project employs one co-ordinator, six support workers and two volunteers. Trained support workers are based in the

emergency departments and clinical decisions units of each of the hospitals. The support worker greets elderly patients, offers

friendship, support, counselling, advice and signposting to other services. The worker can also support the discharge of elderly

patients from the department during the evening and night-time through organising transport and follow-up packages once the

patient has returned home. These packages are provided by Home From Hospital support workers from the British Red Cross.

The 10-month cost of the scheme is around £83,000 and an internal evaluation of the scheme suggests that during the first five

months of operation, 110 admissions which equates to cost savings of more than £400,000 per annum for Hywel Dda Health

Board. The scheme runs from Thursday to Monday between 2pm to 10pm although the partnership is now considering

extending the scheme’s working hours.




1.34 During the out-of-hours period, local

authorities use emergency duty teams to

coordinate requests for help and support. The

remit of these teams varies across Wales with

some teams being responsible for all out-of-

hours social services issues whilst other

teams being responsible for a broader range

of the local authority’s services and not just

social services. But the core functions of

these teams tend to involve providing

information and advice, providing a visit from

a social worker to carry out emergency

assessments, and arranging or deploying

other services. The team’s ability to deploy

another service depends very much on the

range of local authority services available out

of hours. Home care services tend not to be

available 24 hours a day but many are now

extending their hours of working and rapid

response home care services are beginning

to emerge in some areas of Wales. These

services can provide support such as

personal care like washing, dressing and

undressing, preparation of food and drinks,

and monitoring or prompting for taking

medication. Examples of other services that

the emergency duty team may be able to

deploy during the out-of-hours period include

emergency foster placements, emergency

residential home placements and night-sitting

services. However, the availability of these

services outside normal working hours is

variable.

1.35 A common theme that emerged from our

fieldwork was that emergency duty teams,

and some of the services they deploy, are

generally quick to respond when an individual

is in immediate danger, for example when a

child or vulnerable adult is in immediate risk

of abuse, but delays are more common in

less urgent cases. In responding to our

survey, chief executives of NHS trusts and the

former LHBs gave mixed views regarding the

unscheduled care provided by social services.

These views ranged from satisfaction with the

availability of urgent social care services to

concerns about responsiveness, the hours

that these services are available, capacity

constraints and the limited ability for social

services to put packages of care in place out

of normal working hours.

People with urgent mental health needs can face

delays in receiving assessments and treatment

1.36 Whilst the chief executives of the NHS trusts

and former LHBs gave a range of views

regarding the unscheduled care provided by

mental health services, there were general

concerns about their responsiveness,

particularly out of normal working hours. A

separate Wales Audit Office study into adult

mental health services is ongoing. The

fieldwork for that study has already found that

people suffering a mental health crisis and

those with other urgent mental health needs

can face delays in receiving care, support or

advice. The individual can face delays in

receiving an assessment of their needs, often

due to the limited availability of professionals

qualified to carry out specialist mental health

assessments. Even when the individual

receives a timely assessment, the individual

might be admitted unnecessarily to hospital

because many community mental health

services are unavailable outside normal

working hours.

1.37 The Assembly Government’s Annual

Operating Framework for 2009-10 makes it a

requirement for health communities to

develop crisis resolution and home treatment

services that meet a set of minimum

requirements30. These services should be

available to respond to psychiatric

emergencies 24 hours a day, every day of the

year. A survey carried out in September 2008

30 Welsh Assembly Government, NHS Wales: Annual Operating Framework 2009-10


30

provided a snapshot of the ways in which

crisis resolution and home teams were

developing in Wales31. The research found

that there were 18 such teams in existence

and that these did not cover all parts of

Wales. The research also found that whilst

the majority of teams provided a service

between 9am and 9pm, seven days per week,

only three of the teams offered a 24-hour

service. The research also found that there

were significant differences in the

arrangements for referring to these services.

A key finding was that in circumstances where

these teams are unable to support people in

their own homes, the teams have limited

options other than admitting these people

to hospital. Only two teams had access to

a dedicated crisis house and one team

had access to a crisis bed in a local

authority-funded residential unit. The research

also highlighted some issues about these

teams’ capacity to respond rapidly. These

concerns are due to some teams covering

large geographical areas, up to 987 square

miles, and three teams not meeting minimum

recommended staffing levels.

1.38 In addition to the services provided by crisis

resolution and home treatment teams, people

can be assessed out of hours in the

community for compulsory admission to a

mental health ward, or can be assessed in

secondary care by someone on the psychiatry

rota, who will often be a junior doctor.

Respondents to surveys raised a number

of concerns about delayed responses

provided from psychiatry rotas out of

normal working hours.

The disjointed nature of the system is

exacerbated by gaps including a lack of

well-developed pathways, community-based

services and extended staff roles

There is considerable scope to improve the

development and use of pathways because the

right care is not always being provided at the right

time and in the right place

1.39 Pathways are pre-designed routes that

patients with particular symptoms or

conditions can take through the health and

social care system. Figure 3 shows a diagram

of the falls pathway used by ambulance crews

in Cardiff and the Vale of Glamorgan and

Figure 4 shows the guidelines used in the

Vale of Glamorgan and Powys to determine

the most appropriate pathway for elderly

people who have fallen. Such pathways

should be designed so that people receive the

most appropriate care as soon as possible,

without unnecessary delays or transfers

between services. The baseline review

carried out by the NLIAH as part of the DECS

framework found that referral systems and

patient pathways were not well developed32.

Similarly, a June 2009 report to the National

Advisory Board regarding the Primary and

Community Services Strategy said that the

creation of care pathways had been

fragmented with little focus on the whole

patient journey33.

1.40 Our review looked at three tracer conditions

to examine the extent to which pathways are

in place. These conditions were falls, chest

pain and acute breathlessness. We found

variable progress in developing formal

pathways for these conditions. Whilst falls

pathways were more developed than those

for the other two tracer conditions, a common


31 Jones and Robinson, A National Survey of Crisis Resolution Home Treatment Teams in Wales, September 2008

32 National Leadership and Innovation Agency for Healthcare, DECS Baseline Self Assessment, October 2008

33 Paper to the National Advisory Board, Primary and Community Services Strategic Delivery Programme, 29 June 2009



Figure 3 - The falls pathway in Cardiff and the Vale of Glamorgan

Elderly faller(65 years and over)

Ambulance crew

assessment

Integrated carepathways form

initiated / completed

Clinical on-call officerPatients own GP or

GP out of hours provider(if OOH)

Follow clinical advice*

Transport to A&Eif patient consents

If patient refuses:1 complete RTT/012 Inform GP/GPOOH(with consent)

Make referral to community falls

assessment teamvia duty manager

Crew stood down

Documents leftwith patient

Complete final sectionof ICP checklist /

patient to sign form

Consider clinicaladvice / offer

transportation to A&E

Complete RTT/01

Document clinicalfindings on PCR

*Clinical advice could include1 A &E referral2 Intermediate care referral3 GP to attend

Advice required?Criteria met for

intermediate care referralto falls team?

Consent to referral?

Refusal oftransportation?

Yes

Yes

Yes

Yes

No

No

No

A&E – accident and emergency

ICP – integrated care pathway

OOH – out of hours

PCR – patient care record

RTT – refusal of treatment/transport form

Source: Welsh Ambulance Services NHS Trust



Figure 4 - Elderly fallers’ guidelines for ambulance services in the Vale of Glamorgan

and Powys

Guidelines were developed to help ambulance crews in the Vale of Glamorgan and Powys give the most appropriate level of

care when responding to 999 calls about elderly people who had fallen but not sustained a physical injury requiring emergency

department treatment or for those who did not want to go to hospital.

As well as following the usual procedures for assessing patients and completing the Patient Clinical Record (PCR), the

ambulance crew also completes an Elderly Fallers Check. The check is a series of questions to determine if it is safe to use an

appropriate pathway of referral for the patient. The questions are:

1 Has the patient fallen more than one metre or five steps?

2 Does the patient have a positive face arm speech test (FAST)?

3 Has there been any altered level of consciousness since the fall?

4 Has the patient suffered any amnesia before or after the fall?

5 Has the patient vomited since the fall?

6 Does the patient have any injuries that require treatment?

7 Is there any loss or reduction of function in any limb related to this episode (TIA/CVA)?

8 Is there any evidence of limb deformity?

9 Is there any loss of limb function, as a result of the fall?

If the answer is ‘yes’ to any of the above, the patient must be advised to attend hospital.10 Is there any history of falls and/or a fracture caused by a fall during the last year?

11 Is the patient taking more than four medications?

12 Does the patient have any serious conditions such as Parkinson’s disease, Dementia or Arthritis?

13 Is the patient able to get out of their chair, walk three metres, and return unaided to the chair within 20 seconds?

14 Are there differences in systolic blood pressure when standing or lying greater than 20mmHg?

15 Are there differences between diastolic blood pressure when standing or lying is greater than 10mmHg with

associated dizziness?

16 Does the patient have any self reported problems with their balance?

17 Are there any abnormalities on the electrocardiogram (ECG)?

18 Are there any signs of adverse social factors?

If the answer is ‘yes’ to questions 10 to 18, seek clinical advice from the patient’s GP or primary care out-of-hoursservices.

If the ambulance crew requires additional clinical advice they can contact ambulance clinical on-call officers, the patient’s GP or

the primary care out-of-hours provider, depending upon the time of day.

If the answers to all of the above questions are ‘no’, the patient has met the criteria for referral to the community falls

assessment team. If the patient meets these criteria and it is appropriate for them to remain at home, the ambulance crew will

ask the patient if they agree to being referred to the programme. The crew then notifies the ambulance control centre of the

outcome and requests that a referral form is faxed to the LHB’s Referral Management Centre. A copy of the completed PCR

and the Elderly Fallers Check is left with the patient.

If an elderly faller does not meet the referral criteria but refuses to attend hospital then the ambulance crew follows the

guidelines laid out in their ‘Refusal of Treatment / Transport Policy’. These guidelines allow the ambulance crews (with patient

consent) to directly notify the patient’s GP during the day, or at night via the relevant primary care out of hours services at night.




weakness was the lack of standardisation in

pathways between neighbouring areas,

causing confusion for professionals and

inequalities for service users. Other common

problems were that many of the pathways

only detail the route a person takes once they

enter the acute hospital and other pathways

are only in place during normal working

hours. We also found that poor

communication to health and local

government professionals about existing

pathways was resulting in some pathways not

being used.

1.41 One of the ambulance service’s main

unscheduled care objectives is to ensure that

people with certain conditions can be directly

admitted to specialist services rather than

automatically going through the emergency

department. This has benefits of reducing

patient handovers, improving efficiencies and

ensuring people receive the right care as

soon as possible. Whilst there has been some

progress in developing such direct routes of

referral for the ambulance service, there is

considerable scope for improvement, such as

in the development of pathways to support

direct admission of patients with coronary

occlusion to the catheterization laboratory.

1.42 An important barrier to the development of

new pathways and the effective use of

existing pathways in Wales is that there is a

lack of shared information and poor

communications between unscheduled care

services. For example, we found some

communication weaknesses between the in-

hours and out-of-hours social service teams,

particularly where the out-of-hours service is a

joint service between more than one local

authority. There are poor information links

between the emergency departments and

other services. In some hospitals, the

emergency department patient information

system is not linked to the system used on

the wards, and in primary care, the patient’s

notes held by their GP practice are generally

not available to the primary care out-of-hours

service.

1.43 In Scotland, since 2006, clinicians working in

emergency departments, primary care out-of-

hours services and NHS 24 have had 24-hour

access to key information about patients

through the Emergency Care Summary34 35.

This secure, electronic system allows

clinicians providing unscheduled care to see

basic information such as medication

prescribed for the patient and any allergies

they may have. The Individual Health Record

(IHR) is a similar example of a positive

development in Wales. The IHR system is

part of the Informing Healthcare project and

has been introduced in Gwent where the

primary care out-of-hours service and the

hospital medical assessment unit can access

important information about patients held on

their GP’s computer systems. The information

made available includes prescribed

medicines, major diagnoses, blood pressure,

test results and allergies. Access to this

information is designed to inform clinical

decisions and improve patient safety.

Planning is ongoing to roll out the scheme

across Wales and our forthcoming work on

Informing Healthcare (Appendix 2) will carry

out a full evaluation of the scheme in Gwent.

1.44 Where electronic links have not been

developed between services, referrals

between unscheduled care services can be

improved by the use of paper forms or clinical

transaction documents. These documents

should contain important information about

the person including personal and

demographic data as well as information

regarding assessments, tests and diagnoses.

The NLIAH’s baseline review found that there

34 NHS 24 is Scotland’s equivalent of NHS Direct Wales.

35 Scottish Executive, Your Emergency Care Summary: What does it mean for you? 2006


34

had been little progress in developing and

using clinical transaction documents. We

found that there are problems with the

documentation passed between unscheduled

care services36. For example, when a patient

attends a hospital emergency department,

the hospital should send a letter or email to

notify the patient’s GP. However, these letters

are often automatically generated and

sometimes provide very little information

about the patient’s presenting condition and

the care they received.

1.45 Ambulance crews have a wide range of

documents to complete when they treat,

convey or refer patients. Academic research

regarding ambulance services’ use of

documentation when a person has fallen at

home and is not conveyed to hospital found

that the appropriate documents are in place

for less than 20 per cent of these cases37.

For each patient encounter, the ambulance

crew is required to complete a patient clinical

record (PCR) form. An internal audit in 2008

showed that Welsh Ambulance Services NHS

Trust crews were completing the PCR forms

for 78.3 per cent of patients.

1.46 Another important barrier to the development

of new pathways and the effective use of

existing pathways in Wales is the lack of a

shared clinical governance38 framework

across Wales. This means that staff working

in separate services have different risk and

governance procedures to adhere to. These

differences can slow down or even prevent

services accepting referrals from other

services, for example we identified issues

where some services would not accept

referrals directly from ambulance crews.

1.47 There are at least nine different triage

systems in place across the current

unscheduled care system but the poor

electronic links between systems means

that people often have to answer the same

questions repeatedly, including personal

information39.

1.48 One barrier to the implementation of shared,

electronic triage and assessment systems is

the perception that these systems are

risk-averse. However, Case Study D gives

details of the NHS Pathways system that is

being used in the North East of England to

improve the initial assessment of patients and

to ensure that patients are sent along the

correct pathway so they are provided with the

most appropriate response matched to their

individual needs. The Welsh Ambulance

Services NHS Trust is considering the

potential for NHS Pathways in Wales.

The lack of community-based unscheduled care

services can add to the burden on other parts of

the system

1.49 It is a key finding of our report that in many

areas of Wales, a better understanding of

demand is needed to help develop

appropriate pathways for patients to avoid

unnecessary access to acute services.

This unnecessary use of acute services can

lead to avoidable hospital admissions and

therefore the associated risks of healthcare

associated infections and loss of

independence. If the system of unscheduled

care involved an adequate range of

appropriate and effective community-based

services, this would provide care closer to

people’s homes and assist in managing

low-level unscheduled care needs and


36 National Leadership and Innovation Agency for Healthcare, DECS Baseline Self Assessment, October 2008.

37 Centre for Health Improvement Research and Evaluation (CHIRAL), University of Swansea, Snooks H, Close J, Gaze S, Halter M, Lyons R, Lervy B, et al. Older fallers attended

by ambulance service and left at home: risks and opportunities, 2003.

38 Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services and

safeguarding high standards of care and services. NHS Quality Improvement Scotland (2005).

39 This was stated at a meeting of the Assembly Government’s Intelligent Targets Group in January 2009.



Case Study D - NHS Pathways has potential benefits in increasing the understanding

of demand

The North East Ambulance Service covers the counties of Northumberland, Tyne and Wear, Durham and Teesside, an area of

approximately 3,230 square miles. The trust employs 1,750 people and serves a population of 2.6 million.

In 2006, the North East Ambulance Service experienced problems with people making 999 calls who did not necessarily need

an emergency ambulance. There were also doubts about the effectiveness of the service’s existing triage and ambulance

dispatch system.

In conjunction with the local primary care out-of-hours service, the ambulance service decided to pilot NHS Pathways, an

electronic tool for assisting clinical decisions and ensuring people receive the right care, at the right time in the right place.

The tool was developed by a team of NHS professionals including doctors and nurses as part of a Department of Health

funded project. Whilst other similar systems have been developed, these tend to have been designed for the health system in

the United States of America and are therefore often not wholly relevant to the UK health system.

NHS Pathways is more than a triage system. It also has an integrated database of all relevant health and social care services

available in the local area. This database is populated directly by local organisations via the internet. After triaging the caller’s

needs, the system automatically matches these needs to the most appropriate service that is open and locally available.

The system is therefore designed to ensure people are provided with the most appropriate response.

An added benefit of the database is that it can be used to show gaps in service provision and inform commissioning.

Commissioners can use data from the system to study demand before deciding whether to commission particular services or

whether existing arrangements need to change to more accurately reflect local needs.

Whilst NHS Pathways is less risk-averse than the service’s previous triage system, there is evidence that the system is

providing a safe service. The ambulance service has used the system for more than 1.2 million calls and there have not been

any serious adverse incidents due to the system. The system has reduced the proportion of ambulance calls that are

categorised as Category ‘A’. An academic evaluation of NHS Pathways has shown that around 32 per cent of all 999 calls

are assigned to Category ‘A’. Most other English ambulance services categorise more than 40 per cent of these calls as

Category ‘A’. The improved assessment process means that the North East Ambulance Service can more effectively identify

non-emergency calls. Data from the ambulance service suggests this is enabling the avoidance of around 2,000

inappropriate ambulance journeys per month.

Calls take slightly longer to triage using NHS Pathways than using the previous triage system and whilst a small proportion of

patients have been resistant to being told they do not require an emergency ambulance response, call takers are given specific

training to manage these situations. The ambulance service is now considering a patient education campaign but the system

has already achieved a 93 per cent satisfaction rate from callers.

In February 2009 the Department of Health approved the use of NHS Pathways across England, allowing ambulance services

to choose to use the system. The Emergency Call Prioritisation Advisory Group has assessed and approved the system.

The system is also due to be extended to allow paramedics to continue the NHS Pathways assessment once on scene. This

means that even if an ambulance has been dispatched, a transfer to hospital might still be avoided safely and appropriately.

NHS Pathways is also designed to be used in non-emergency telephone assessments and the North East Ambulance Service

is now commissioned to provide telephone assessment of all calls to 24-hour urgent care services, including all primary care

out-of-hours calls, from the County Durham and Darlington area. Electronic links between the ambulance service, urgent care

centres and the primary care out-of-hours providers enable automatic referral of the patient to the relevant provider, and

transfer of patient details including the summary of the assessment to date to inform the receiving clinician and reduce the

degree of repetition by patients.



36

demands before they escalate. This would

also have the benefit of reducing unnecessary

demand on more acute services.

1.50 Our work on delayed transfers of care has

also shown that partner organisations are not

consistently moving resources around the

system to reduce pressures on the acute

services. Consequently, resources are locked

into certain parts of the system when they

might be better invested elsewhere to

promote and maintain independence rather

than institutional care. The work showed that

there has not been enough progress in

developing intermediate care services that

can be used as an alternative to more acute

care. These services can help break the

vicious circle which can draw patients towards

more expensive, institutional forms of care but

we found that the provision of intermediate

care remains fragmented with considerable

variation between different areas in the

availability of such services.

1.51 In our unscheduled care fieldwork we found

that there are not currently enough

appropriate and effective community-based

unscheduled services to meet demand and

act as genuine alternatives to acute care.

These findings are in line with the work of the

Primary and Community Services Strategic

Delivery Programme. A paper presented to

the National Advisory Board stated that ‘there

is little evidence of community-wide

sustainable changes that are delivering

significant shifts in the overall model of care

which continues to be dominated by acute

hospital beds and care homes within social

care40. The paper to the advisory board also

said that ‘whilst it appears that all partners

aspire to a more primary and community

services led NHS, movement in that direction

has been largely through pilot projects or new

stand-alone services.’ We found that

unscheduled care planning remains

hospital-centric and that health and local

government organisations have not

adequately considered the range of

community unscheduled care services that

their model requires. Our report on chronic

conditions management found that existing

community services were fragmented and

poorly co-ordinated. Our unscheduled

care fieldwork found that the map of

community-based services varies widely

between different geographical areas which

can be confusing for health and social care

professionals. Many of the existing community

services are not available outside normal

working hours and many have not been

evaluated for their effectiveness.

1.52 Paragraphs 1.32 to 1.34 highlight the fact that

the availability of community-based local

authority services varies widely by

geographical area and by the time of day.

Assessment and care management

arrangements tend only to be available during

office hours whilst other services, like home

care services, are more generally available

during extended hours.

1.53 The range of community mental health

services is often insufficient to prevent people

accessing more acute care. Paragraphs 1.35

to 1.37 describe how crisis resolution and

home treatment teams are not available in all

parts of Wales and that few of these teams

operate 24 hours a day. These teams can

also have limited options when treating

people other than to admitting people to

hospital. An inquiry carried out by the National

Assembly’s Health, Wellbeing and Local

Government Committee in September 2009

found that there was a need to prioritise and

strengthen the development of community-

based mental health services to reduce the

incidents of hospital admission and delayed


40 Paper to the National Advisory Board, Primary and Community Services Strategic Delivery Programme, 29 June 2009



transfers of care41. The committee’s report

also raised concerns about the use of police

cells for detaining people experiencing a

mental health crisis. The committee said it

was unacceptable that people in a state of

mental distress are taken to police cells

because alternative health facilities are not

available. The report recommends that the

Assembly Government works with the UK

government to develop mental health

assessment centres across Wales with the

aim of reducing the use of police cells.

1.54 Despite the general scarcity of community

unscheduled care services, we did find some

examples of community-based support that

appear to be having beneficial impacts.

Case Study E gives details of the Crisis

Intervention Team in Flintshire and our

previous work on delayed transfers of care

has highlighted the work of Torfaen’s

Advanced Clinical Assessment Team as

shown in Case Study F.

Case Study E - Flintshire Crisis Intervention Team

In 2001, rapid response teams were introduced to Wrexham and Flintshire in order to relieve workload pressures during the

winter months in secondary care. Their initial remit was to provide short periods of intervention in a crisis situation to either

prevent a hospital admission or provide additional nursing therapy or social support to enable a more timely discharge.

However, the remit of these teams then changed to include an element of rehabilitation. Whilst the rehabilitation provided

was effective, the teams’ capacity to respond rapidly was significantly decreased.

In 2006, North East Wales NHS Trust reviewed the teams’ functions and took the decision to disband the Wrexham team.

In Flintshire, the team was found to be covering too large a geographical area and was suffering capacity issues due to the

demands of the rehabilitation element.

The trust therefore reconfigured the team, removing its remit for rehabilitation and the team was re-named Crisis Intervention

Team to more accurately reflect the new remit of the team in providing shorter, sharper periods of support to people in crisis

or to provide this support to reduce the length of a secondary care stay.

The team now consists of health, social care and therapy staff, who aim to prevent unnecessary hospital admissions,

facilitate hospital discharge and enable people to remain safely within their own homes.

The team also now focuses its work in the Deeside area where there is a relatively large range of community-based schemes

and services working to prevent unnecessary hospital admissions and facilitate discharge from hospital. The team takes

referrals from all areas of the Countess of Chester Hospital, GPs, district nurses, community psychiatric nurse, GP out-of-hours

services, minor injuries units, community hospitals, social workers in the community or hospitals, long term conditions case

managers and the ambulance service. The scheme is particularly popular with GPs because the scheme meets a local need for

GPs to be able to directly refer people to receive support for social care needs.

Another important function of the team is in taking referrals directly from the ambulance service for people who have fallen.

As part of an ‘assess and refer’ pathway, the team carries out a mobility and social care assessment, provides equipment,

attends to nursing needs and carries out medication reviews.

We have not evaluated this service but an evaluation of the scheme carried out by Flintshire LHB suggests that the team

contributed to a 5.6 per cent reduction in emergency hospital admissions at the Countess of Chester Hospital between

2006-07 and 2007-08. The team also estimated that over this period, the team has made financial savings in the range of

£90,000 to £268,000 through the avoidance of unnecessary admissions to hospital and a reduction in spot purchasing of

care home placements42.

During our fieldwork we heard many positive views about the effectiveness of the Crisis Intervention Team. However, we were

also told that there is considerable unmet demand for the team’s services outside of its normal working hours, which are

9am to 5pm, Monday to Friday).


41 National Assembly for Wales, Health, Wellbeing and Local Government Committee, The Inquiry into Community Mental Health Services, September 2009

42 Flintshire Local Health Board, Evaluation of Crisis Intervention Team Secondment to Flintshire Local Health Board, July 2007 to June 2008


38

There has been slow progress in developing

extended roles within the unscheduled

care workforce

1.55 One of the key principles of the DECS

strategy is that staff will work in innovative

ways across traditional boundaries, fully

utilising their skills in order to maximise their

contribution to the more seamless delivery of

unscheduled care services. But we have

found that there has been slow progress in

developing such expertise as a result of a

thorough understanding of demand.

1.56 There is considerable scope to improve

unscheduled care through the development

and effective use of extended nursing roles.

Our survey of NHS trust chief executives

showed that emergency nurse practitioners

are generally present in hospital emergency

departments. But the wide variation in the

number of these practitioners per emergency

department suggests that there are very

different definitions used across Wales. Our

fieldwork has shown that emergency nurse

practitioners often do not have enough time to

carry out their extended roles, particularly

during times of high pressure. Emergency

nurse practitioners in some departments do

not work during peak times of pressure and

we found that many trusts have problems

retaining staff once they are trained.

A scoping exercise carried out by the Welsh

Emergency Departments Federation on behalf

of the Chief Nursing Officer found that there

is inconsistency in practice and in training

for nurse practitioners in different emergency

departments43. The scoping exercise also

found that there is scope to introduce

more nurses who have extended

prescribing roles44.

1.57 There is a lack of standardisation around

Wales in the presence of different

professional groups within emergency

departments and minor injury units. Our

survey of NHS trust chief executives showed

that there is a wide range of different

professionals, functioning within these areas

of the hospital but there is little evidence of

these roles being mainstreamed. Such roles

include occupational therapists, physiotherapy

practitioners, social workers, GPs, emergency

care practitioners (ECPs), play specialists,

registered mental health nurses and mental

health liaison workers.

1.58 There is considerable scope to develop and

introduce extended paramedic roles in Wales

to improve the operation of the whole system

of unscheduled care. The development of a

more clinically-focused paramedic profession


Case Study F - The Advanced Clinical

Assessment Team in Torfaen

This award-winning team was established in Torfaen to

prevent hospital admissions from patients in the community

or in care homes.

The team provides an alternative to acute hospital

admission for elderly patients by bringing early expert

nursing and medical assessment, diagnostics and treatment

directly into patients` own home. This is carried out on the

day of referral by GPs creating a virtual ward in the

community.

The locality’s Intermediate Care Steering Board has played

a key role in ensuring there is a multi-organisational

framework to commitment and a shared framework of

services to ensure that the Advanced Clinical Assessment

Team (ACAT) can function within a supportive and effective

service model.

An internal evaluation of the service in June 2008 reported

that between January 2007 and April 2008, 1,208 patients

were referred to ACAT. The number of hospital admissions

avoided during this period was 975 (81 per cent). The

evaluation concluded that the team’s admission avoidance

has resulted in savings of more than £2,000,000 between

January 2007 and April 2008.


43 Welsh Emergency Departments Federation Nurses Group Scoping Exercise of Emergency Nurses Prescribing Practices in Wales 44 Welsh Emergency Departments Federation Nurses Group Scoping Exercise of Emergency Nurses Prescribing Practices in Wales



is relatively young but is progressing rapidly

internationally. Paramedics’ expertise allows

them to work autonomously by making earlier

clinical decisions and treating people at the

first point of contact. ECPs are new roles that

require special training so that they can

assess and treat minor injuries and illnesses

in people’s homes or in care settings, without

necessarily referring the patient to other

services. A detailed evaluation of these roles

reported in March 2009 that ECP care is

associated with high patient satisfaction,

score highly in terms of quality of care and

that there is strong evidence that ECPs can

reduce costs when operating as mobile

resources45.

1.59 In Wales there has been slow progress in

establishing a clear vision to develop the

paramedic profession so that a greater

emphasis is placed on paramedics’ clinical

roles rather than simply providing

transportation. The ambulance trust’s

high-level action plan for unscheduled care

states an intention to introduce policies and

procedures that increase paramedics’ scope

of practice. This would allow paramedics to

access alternative referral pathways and not

routinely transport people who do not have a

clinical need to go to hospital. Whilst we

have found evidence of some so-called ‘see

and treat’ initiatives, where ambulance crews

are trained to treat particular conditions at the

scene and therefore do not need to convey or

refer patients elsewhere, these developments

have not been mainstreamed. A definitive

evidence base in this area is currently lacking

although trials have shown encouraging early

results46. The plan also states an intention to

develop a new role called specialist

practitioners who would have extended

involvement in autonomously assessing and

treating patients with primary care needs,

have minor illnesses or injuries, social care

needs or non-immediately life-threatening

conditions. This role is the trust’s equivalent to

the ECP role developed in other parts of the

UK. The trust has started training specialist

paramedics and plans to develop 30 new

specialist paramedics each year. However,

due to the educational requirements of such

a role these staff will not be operational

until 2010.

The lack of coherent understanding and

management of demand and cost is causing

high pressures on certain services and

considerable inefficiencies

Demand is poorly understood across the

whole system

1.60 Although the term ‘unscheduled care’ may

imply unpredictability and problems in

forecasting demand, demand for unscheduled

care is largely predictable. However, our work

has identified a fundamental weakness in the

understanding of demand. Work to assess

demand has primarily focused at a service

level rather than a population level, and has

tended to focus on activity levels rather than a

wider understanding of the level, nature and

acuity of people’s unscheduled care needs.

Consequently, understanding of demand

reflects patterns of access to existing services

rather than a sophisticated understanding of

the total demand for unscheduled care.

1.61 There has been little progress mapping

demand and flows across the system, an area

of weakness highlighted in the NLIAH review

of baseline assessments. Another problem is

the lack of data on preventable demand

where patients access the system multiple

times for the same care need, or receive care

45 Report for the National Institute for Health Research Service Delivery and Organisation programme, A Multi-Centre Community Intervention Trial to Evaluate the Clinical and Cost Effectiveness of Emergency Care Practitioners, March 2009

46 Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, Snooks H, Perrin J, Nicholl J. Paramedic Practitioner Older People´s Support Trial (PPOPS): A Cluster Randomised Controlled Trial. British Medial Journal, In Press, 2007


40

in a more acute setting than they really need.

Understanding demand and improving flow

through the system requires robust analysis

and understanding of the causes of delays

and unnecessary transfers between services.

1.62 The Assembly Government has recognised

this lack of data on demand and has taken

some initial improvement actions. The LDP

template requires organisations to set out

their baseline demand position regarding a

range of different unscheduled care services.

This guidance is a useful step forward but is

characterised by health-centric metrics with

no mention of social care demand. None of

the LDPs has provided all of the data required

by the template, with some significant gaps

regarding the number of urgent GP

appointments and the number of community

pharmacy unscheduled care consultations.

Therefore, the LDPs are based on an

incomplete understanding of demand within

the whole system.

1.63 Tools are available to map flows across the

system and predict flows by altering certain

parts of the system, for example Department

of Health commissioning toolkits and

techniques47. It will be important for the new

health boards to develop a more

sophisticated understanding of the volume

and nature of demand for health and social

care across the whole system. This is

particularly important in the context of current

financial pressures and likely increases in

demand; the population aged over 85 is

expected to double between 2007 and 2031

and the population aged between 75 and 84

expected to increase even more quickly over

the same period. These demographic

changes are likely to result in citizens

having a wider and more complex range of

inter-linked needs. Following from this,

unscheduled care service providers are

likely to need to provide more bespoke and

holistic services rather than the current,

largely episodic approach to unscheduled

care provision.

1.64 Existing information on demand has not been

shared effectively to improve planning across

the system. For example, there is little sharing

between the ambulance service and social

services of information about those who have

experienced falls. NHS Direct Wales has a

significant amount of data on demand from its

telephone and web-based information and

advice services. The former LHBs could have

used data about access to NHS Direct Wales

services to better understand demand for

local unscheduled care services, as well as

the types of support callers are seeking.

There is very little data sharing between NHS

Direct Wales and other NHS organisations in

relation to activity and costs. Data on call

volumes and types of calls could help predict

demand and support service planning across

the unscheduled care system both locally and

nationally.

1.65 Sharing information about local and national

use of NHS Direct Wales services would help

encourage more positive perceptions about

the service and provoke dialogue about how

to achieve a better strategic fit with the rest of

the unscheduled care system. Better

integration of NHS Direct Wales within the

whole system of unscheduled care would

provide opportunities for sharing information

more effectively with other services. Many

people who access NHS Direct Wales advice

may do so to protect their anonymity.

However, in many cases it would be very

helpful if patients’ GPs or other healthcare

professionals had a record of the contact with

NHS Direct Wales. The ability to track


47 These toolkits include Tackling Demand Together which is a toolkit for improving urgent and emergency care pathways by understanding increases in 999

demandhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_106924.pdf.



patients through the unscheduled care system

could help improve outcomes and create a

clearer picture of demand and how effectively

the system was operating. In our separate

report, we recommended that NHS Direct

Wales should share cost and performance

information including call outcomes, nationally

and locally to inform better understanding of

demand for unscheduled care and support

the planning and funding of services across

the unscheduled care system.

There is variable information on costs but poor

understanding of the end-to-end cost of

unscheduled care across the whole system

1.66 Allied to the poor understanding of demand,

there is very little understanding of costs

across the unscheduled care system. There is

a lack of overall understanding of the total

end-to-end cost of unscheduled care services

within communities or how the total resources

might be better used to deliver effective and

economical care. Without a holistic

consideration of costs across the whole

system, there is little scope to model the

cost implications of potential changes in

service models.

1.67 Figure 5 gives details of our basic estimate of

the total annual cost of unscheduled care in

Wales. This calculation is limited because of

the poor information that exists regarding

costs and because it does not include the

costs of all parts of the unscheduled care

system. Nevertheless, the calculation is

helpful in providing an absolute minimum cost

of unscheduled care in Wales of

approximately £256 million.

1.68 Some costing information is available for

particular activities or parts of the system,

although this is less useful than end-to-end

costing which takes account of flow through

the system. For example, a single patient

could access NHS Direct services, a GP and

the emergency department of a hospital

during a single episode, yet the costs would

be collected individually without reference to

the nature of that citizen’s needs and whether

the number of handovers they experienced

between different services was appropriate.

Figure 5 - The minimum annual cost of

unscheduled care in Wales is around

£256 million

Unscheduled care service Annual cost

Major emergency departments £97,762,000

Minor injury units £18,770,000

Social services emergency duty teams £4,256,000

GP out-of-hours £31,453,000

Emergency ambulance services £94,472,000

NHS Direct Wales £8,951,000

TOTAL £255,664,000

Note: This calculation does not include the costs of local government unscheduled care

other than the basic cost of providing an emergency duty team. The cost of the social

services emergency duty team is in relation to 2007-08 and includes an estimate for

local authorities who did not respond to our survey. The figure for ambulance services

includes only the costs for the emergency medical service. The emergency department

and minor injury unit costs are from the Welsh health costing returns for 2007-08.

The figure for GP out-of-hours services is from Wales Audit Office analysis of data from

LHB consolidated accounts. The figure for NHS Direct Wales is from NHS Direct Wales.


42

1.69 We found that there is large variation in the

cost of emergency department services per

attendance. Figure 6 shows that in 2007-08,

the cost per attendance varied from £133 in

Ceredigion and Mid Wales NHS Trust to £71

in North Glamorgan NHS Trust.

1.70 Information held by the former LHBs

regarding primary care out-of-hours services

was much more comprehensive. The cost of

primary care out-of-hours per head of

population ranges from just under £20 in

Pembrokeshire to just over £7 in Swansea

(Appendix 3). Variations in costs per head of

population are difficult to interpret because of

rurality. The variation in costs is similar to that

seen in Scotland, with higher costs in more

remote or rural areas48. Apart from rurality

and geographical spread, some variation in

costs arises from local differences in the

scope of the contracts. For example, in

Powys, the contract includes medical cover

for community hospitals and in Swansea the

contract includes medical cover at Singleton

Minor Injury Unit and Swansea Prison.


Figure 6 - There is large variation in the cost of emergency department services per attendance

0

20

40

60

80

100

120

140

Cos

t per

atte

ndan

ce (£

) Average for Wales £101

£133

£110£105 £103

£95 £93 £91£84 £82

£77£71

£92

NHS Trusts

Source: Wales Audit Office, Welsh health costing returns, 2007-08

48 Audit Scotland, Primary care out-of-hours services, August 2007



1.71 There have been significant changes to the

global economic climate over the last two

years. Public sector organisations are facing

financial pressures that are unprecedented in

recent history and these organisations now

face difficult decisions as their revenue

declines, demand continues to rise and public

expectations grow. It is highly likely that these

organisations will have reduced resources

with which to deliver improvements in

services. This will require some radical

changes in the way that services are

delivered. In this context, there will be a need

for improved knowledge and understanding of

demand, flow and outcomes within the whole

system of unscheduled care. Another

significant risk is the potential further

tightening of eligibility criteria for social

services. This could be a rational response of

local authorities to growing pressures on their

resources, but could significantly increase the

overall costs to the system, particularly if

demand shifts to more expensive, acute and

institutional services rather than services that

maintain people’s independence in the

community.

Some of the demand on unscheduled care services

could be avoided by more effective prevention work

1.72 The current system of unscheduled care is

characterised by peaks in workload pressure

that individual services sometimes struggle to

cope with. These pressures are exacerbated

by misplaced demand – by which we mean

services providing care to certain people

when it would be more appropriate and often

more cost effective for other services to be

delivering this care.

1.73 Demand within the system would be reduced

if there was greater success in identifying

frequent users of unscheduled care services,

the nature of their demands on the system

and ensuring adequate arrangements to meet

the demand. For example, people with

chronic conditions are significantly greater

users of unscheduled care than the general

population49 but our 2008 report entitled The

management of chronic conditions by NHS

Wales concluded that too many people with

chronic conditions are treated in an

unplanned way in acute settings50. A number

of chronic conditions ‘demonstrator sites’ are

piloting new ways of supporting patients with

chronic conditions.

1.74 There is scope to carry out more prevention

work through community pharmacies.

Community pharmacy services are generally

provided close to people’s homes and as

stated in the DECS strategy, have a role in

providing advice and helping people manage

their medication. The strategy also says that

pharmacies have a developing role in

near-patient testing and in managing people’s

chronic conditions. However, we were told

throughout our fieldwork that pharmacies are

not yet being used to their full potential within

the unscheduled care system. For example,

subject to thorough understanding of demand,

there is scope for community pharmacists to

prevent people’s needs exacerbating through

better management of people’s minor

ailments. The management of minor ailments,

such as coughs, diarrhoea, and headaches

places considerable demands on GPs during

normal working hours. One academic study

estimated that GPs spend 39 per cent of their

time dealing with minor ailments51. The

pharmacy contract allows community

pharmacists to provide a minor ailments


50 Auditor General for Wales, The management of chronic conditions by NHS Wales, December 2008

51 Bradley C (1998) Self-medication and the GP, in Proprietary Association of Great Britain OTC Directory 1997/1998 London: PAGB


44

service. These services take referrals from

NHS Direct Wales, provide advice and supply

medicines for specific conditions without the

need for prescriptions. This therefore reduces

the demands on GP practices in dealing with

minor ailments. However, local health board

commissioning of community pharmacists to

provide minor ailments services was limited

in Wales.

1.75 There is also scope to use community

pharmacists to meet the needs of people who

require urgent, repeat prescriptions. Whilst

pharmacists are able to provide people

directly with an emergency supply of repeat

medication, the patient must pay for this

service because it is not funded through the

NHS. The pharmacy contract allows

commissioning of community pharmacists to

provide a repeat dispensing service. Under

this service, pharmacists can directly supply

repeat medication to specific patients for a

period of up to a year. The scheme should

therefore free up GP capacity and provide

greater convenience for patients. Again,

there are few such services in Wales, partly

because of limited electronic information links

between pharmacies and GP practices.

1.76 Technology in people’s homes or in care

settings can be used to monitor people’s well

being and existing conditions and act as an

early warning system so that problems can be

addressed before they become more serious.

The Assembly Government’s consultation

document on the future of rural health in


Case Study G - The use of telecare in West Lothian

Health and social care partners in West Lothian took their close collaborative working to the next level when in 2005 NHS

Lothian and West Lothian Council entered into a formal partnership agreement.

Partner organisations carried out a joint assessment of the current and projected needs of the population and a major finding

from the needs assessment was that demand was predicted to rise among people who have fallen or who were at risk of

falling. The vision therefore set out the potential to use smart technology and different telecare initiatives were trialled. The

partnership has now developed a proactive and preventative approach by creating an integrated home safety service.

Staff have been brought into joint teams and budgets have been aligned rather than pooled. An integrated team of health and

social care professionals runs the 24 hour Home Safety Service. Every user of the Home Safety Service has a lifeline machine

that acts as the hub for two-way communications between the person’s home and the service’s call centre.

The lifeline machine uses various technologies to monitor factors such as the person’s movements and blood pressure as well

as technology to raise an alarm if the house becomes flooded or if it has high carbon monoxide levels.

The partnership is now the biggest user of telecare services in Europe and there is evidence that the Home Safety Service is

making a real difference. There has been very positive feedback from service users, there has been a considerable reduction

in the number of people experiencing delayed discharges and there has been a reduction in the average length of stay in care

homes. There are also cost benefits of the Home Safety Service because the annual cost of supporting a person within the

service is £8,681 compared to the £21,122 annual cost of a care home placement and the £46,696 annual cost of a long term

hospital bed place.

Key success factors in West Lothian have been the emphasis placed on empowering staff and strong financial management

with knowledge of unit costs allowing for convincing business cases. Change has been driven by a high level of senior

executive commitment at all stages and by investing time in raising the awareness of staff, users and carers so that there is

shared understanding.

Telecare is now firmly embedded as a key service in the community but there is scope for further development. The partners

now aim to formalise their governance arrangements, develop pooled budgets, implement joint performance management and

expand the use of the technology to manage long-term conditions.

Source: Auditor General for Wales, Delayed transfers of care follow-through, May 2009



Wales concludes that telecare technology has

not yet been fully integrated with other health

and social care services and is yet to achieve

its potential52. Respondents to our survey of

social services raised concerns about low

uptake of telecare and reluctance from

service users to contribute to the cost of

telecare packages. We found that the further

development of telecare in Wales would have

considerable potential to prevent people from

needing unscheduled care. Case Study G

gives details of the preventative use of

telecare in West Lothian. The Scottish

Government commissioned an academic

evaluation of telecare use in Scotland53.

The research concluded that telecare use in

Scotland achieved a fivefold return on

investment, with an estimated saving of

£43 million in care costs between 2007 and

2010. The evaluation also found that telecare

helped prevent hospital admissions, hastened

discharge from hospital and reduced the

numbers of people entering residential care,

while users and carers reported

improvements in their quality of life.

Recognising the benefits of telecare, the

Assembly Government made £9 million

available over two years to March 2009 to

support increased telecare provision in Wales.

However, a number of authorities told us that

they did not have clear plans for funding the

maintenance and mainstreaming of telecare

going forwards.

1.77 A more general finding is that we were told

during our fieldwork that the workload

pressures on certain unscheduled care

services can act as a barrier to services

focusing sufficiently on prevention work.

Some frontline unscheduled care staff told us

that the high pressures within their services

often mean that staff only have time to

address the patient or service user’s

immediate presenting conditions and they do

not have time to fully consider their other

existing needs or needs that they are likely to

develop. These findings are again in line with

the findings of the Primary and Community

Services Strategic Delivery Programme that

identified that the new model of care in Wales

will need to be designed around the holistic

needs of the individual not just the eradication

of disease.

Individual services are put under pressure because

of preventable demand and demand in the wrong

place within the system

1.78 Some unscheduled care services are put

under pressure, partly due to people using the

service who might have had their needs more

appropriately met by an alternative service.

And the Understanding How the PublicChooses to Use Unscheduled Care Servicesresearch showed that many people access

multiple services for one problem54. This

misplaced and duplicative demand is partly

due to uncertainty from the public about what

services they should access (see paragraphs

1.9 to 1.13) and is compounded by some

uncertainty amongst the public and health and

social care professionals about how best to

access services.

1.79 During our fieldwork we were told many times

about so called ‘inappropriate’ attendances at

unscheduled care services. Whilst a small

minority of people may deliberately misuse

unscheduled care services, the term

‘inappropriate’ is unhelpful because many

other people might use a service because

they feel they have no other option or

because they do not understand what other

services are available. Figure 7 was taken

from the Understanding How the PublicChooses to Use Unscheduled Care Services

52 Welsh Assembly Government, Rural Health Planning – improving service delivery in Wales, April 2009

53 Joint Improvement Team, Evaluation of the Telecare Development Programme, York Health Economics Consortium, January 2009



46

research that found that the most important

factor that people use when deciding how

best to access services was whether or not

the service was the ‘most appropriate to

use’55. The study also concluded that people

are generally anxious to make correct and

appropriate use of NHS services, especially

emergency departments.

1.80 During the fieldwork for our patient handovers

report, ambulance crews frequently told us

about the large number of patients that the

ambulance service transports to hospital

unnecessarily. Academic studies from various

countries have estimated the proportion of

ambulance transportations that could have

been avoided. Whilst the methodologies of

these studies varied widely, most of them

have estimated that between 30 and 52 per

cent of ambulance transportations were either

unnecessary or inappropriate56. None of these

studies were carried out in Wales although

clinical staff at Morriston Hospital’s

emergency department have carried out an


Figure 7 - ‘Appropriateness’ is the most important factor for people deciding how to use the


0 20 40 60 80 100

Not considered/not important

Quite important

Very important

Most appropriate

First to come to mind

Used before

Know and trust service

Nearest to me

Shortest waiting time

Knew would be open

Didn't know where else to go

Recommended

Percentage of responses

Source: All Wales Alliance for Research and Development in Health and Social Care, Understanding How the Public Chooses to Use UnscheduledCare Services, June 2008


56 Snooks H, Williams S, Crouch R, Foster T, Hartley-Sharpe C, Dale J. NHS emergency response to 999 calls: alternatives for cases that are neither life-threatening nor serious. BMJ. 2002; 325:330-333



audit to estimate the proportion of ambulance

patients that could have been seen

appropriately by primary care services.

The audit carried out during one week in

February 2008 suggested 10 per cent of

ambulance patients could have been seen in

primary care57. Another indication of the

extent of unnecessary ambulance

transportations is an estimate from the

ambulance trust that 40 per cent of the

patients it transports to hospital are

discharged the same day from emergency

departments with minimal intervention.

1.81 Preventing unnecessary ambulance

transportations would improve the patient

experience because these people would not

be transported in an ambulance and await

treatment in an emergency department

needlessly. Preventing needless journeys and

ensuring people are seen in primary care

means that those with a genuine need for

emergency services get a better patient

experience while others would be seen by the

right people at the right time with the right

skills. Preventing such cases would also

result in financial savings. The ambulance

trust transported 30,239 Category ‘C’ patients

to hospital during 2008-09. These are low

acuity patients where the patient’s condition is

neither serious nor life-threatening. If 10 per

cent of these patients were not transported to

hospital by ambulance but instead saw a GP

during normal working hours, the annual

financial saving would be approximately

£626,00058. In Swansea, providing

paramedics with rapid access to a GP to

discuss Category ‘C’ cases has enabled

better clinical discussions and a reduction in

the number of ambulance dispatches and

emergency department attendances.

1.82 Our reviews of the ambulance trust in Wales

have shown that there is more that the trust

can do, unilaterally, to reduce the proportion

of patients that it transports to hospital.

Benchmarking in 2006-07 showed that the

ambulance trust in Wales categorised a

significantly higher proportion of calls –

around 50 per cent – as Category ‘A’

compared with 11 other UK ambulance

services, all of which categorised between 24

and 39 per cent of calls as Category ‘A’. This

high proportion of Category ‘A’ calls makes it

more difficult for the ambulance trust to reach

its performance targets. The trust could target

its resources more effectively, reduce clinical

risks and risks to staff and the public from

driving unnecessarily on blue lights seeking to

respond within eight minutes and improve its

ability to respond to genuinely life-threatening

Category ‘A’ incidents within eight minutes if

its call categorisation was more sophisticated

and specific.

1.83 The Assembly Government told us that the

trust has been advised that there is no

absolute requirement to send an ambulance

to every 999 call where the presenting

conditions do not require their attendance.

The trust is discussing with the Assembly

Government the response time standards that

should be applied to Category ‘C’ calls and

the trust’s clinical desk pilot (Case Study H,

see page 55) has shown that by using nurse

advisers in control centres, two fifths of these

low acuity 999 calls can be resolved with

advice to self care or to contact their GP or

other healthcare professional.

57 Swansea Local Health Board, A&E Pilot, 18 Feb 2008 to 25 Feb 2008

58 This is a simplistic calculation and provides only an indicative estimate of potential cost savings. For this estimate we have used data from the ambulance trust that estimates the

direct cost of an ambulance response per patient to be around £142. We have also used data from the Welsh health costing returns from LHBs that suggest the average cost of

an attendance at Welsh emergency departments is £101. The estimated the cost of an in-hours GP appointment is around £36 (Personal Social Services Research Unit, Health

and Social Care Unit Costs, University of Kent, 2008).


48

1.84 During our fieldwork we were commonly told

about excessive demand placed on

emergency departments due to people who

might have been more appropriately treated

elsewhere. The data suggests that this is an

issue but not to such a large extent as some

people may think. Data collected by the

Assembly Government during April 2008

suggested that five per cent of patients

attending Welsh emergency departments did

not meet the criteria for typical emergency

department patients as set out by the College

of Emergency Medicine (formerly the British

Association of Emergency Medicine). Some

units have more of a problem with patients

attending who might have been more

appropriately seen elsewhere because at the

emergency departments in Ysbyty Glan Clwyd

and Prince Charles Hospital the percentage of

patients that did not meet the criteria was 17

and 11 per cent respectively. Further audit

work at Prince Charles Hospital found that

most primary care-related emergency

department attendances took place during

normal GP practice opening times

(8am to 6.30pm).

1.85 Using the same cost estimates as in

paragraph 1.81, we have calculated that if five

per cent of the approximated 734,000 people

who attended major emergency departments

in Wales during 2008-09 could instead be

given an in-hours GP appointment, this would

potentially have saved around £2.4 million59.

1.86 Trusts have taken differing approaches to the

problem of people attending the emergency

department when another service might better

meet their needs. A small number of trusts

have developed protocols to divert these

patients elsewhere, such as to their GP or to

the GP out-of-hours service. We found that

one unit had succeeded in diverting large

numbers of patients to other services but

there had been no evaluation to see whether

this had resulted in excessive pressure on the

other services or in detrimental impacts on

the patient.

1.87 The demands within hospital emergency

departments could be further reduced by

minimising other sources of preventable

demand. The results of our survey of NHS

trust chief executives showed that the rate of

unplanned follow-ups at emergency

departments, as a percentage of all

unplanned attendances in 2007-08 ranged

from 2.5 per cent at the University Hospital of

Wales to 6.6 per cent at Wrexham Maelor

Hospital. Whilst we were only provided with

data for 7 of the 13 major emergency

departments, these data suggest that in some

instances, patients are not having their

unscheduled care needs met effectively and

are therefore ‘bouncing back’ to the hospital

emergency department for an unplanned

follow up. Further evidence of preventable

demand is that in some trusts, a

comparatively high proportion of emergency

department patients are admitted to an

inpatient bed. Guidance from the College of

Emergency Medicine states that in

departments with a normal case mix, this

admission rate should be between 15 and 20

per cent60. Our survey of NHS trust chief

executives showed that in 2007-08, all but

two of the major emergency departments in

Wales had admission rates higher than 20 per

cent and five departments had rates of 25 per

cent or higher61.


59 Welsh Assembly Government, Stats Wales

60 The College of Emergency Medicine, The Way Ahead 2008-2012: Strategy and guidance for Emergency Medicine in the United Kingdom and the Republic of Ireland,December 2008

61 Only Bronglais General Hospital and Wrexham Maelor Hospital had conversion rates lower than 20 per cent



The system of unscheduled care is particularly

disjointed during the out-of-hours period

1.88 Whilst it is a strength of the current system

that some form of help is available at any time

of the day or night, we also found that the

disjointed nature of the system is at its worst

during the out-of-hours period.

1.89 Some unscheduled care services are not

available outside normal working hours which

means that people have fewer options about

where to seek help. The more limited

availability of services also restricts the

options for health and social care

professionals making an onward referral.

The services that are available outside

normal working hours, such as primary care

out-of-hours services, hospital emergency

departments and local authorities’ duty teams,

can therefore experience demand from

people who would have gone elsewhere for

help during the in-hours period. We asked

chief executives of the former LHBs what

factors they believed reduced or increased

demand for primary care out-of-hours

services in their area. The main factor cited

was a lack of alternative services at

weekends, bank holidays and evenings, in

particular community nursing services

provided by trusts. The former LHBs also

mentioned limited access to out-of-hours

pharmacy services and dental services, both

of which are commissioned by LHBs. We also

found that there is variability across Wales in

the availability of local authority, community

health and mental health unscheduled care

services outside normal working hours.

1.90 Many of the unscheduled care services that

do operate during the out-of-hours period

have more limited capacity when compared to

normal working hours. Whilst this might be

expected due to reduced demand during the

out-of-hours period, we found that the

reduction in the capacity was often not based

on robust analysis of demand. In general

terms we found that there is little evidence

that local authorities undertake an analysis of

need or demand for social care out of hours.

1.91 Another issue with out-of-hours unscheduled

care is that whilst some services do continue

beyond the normal working day, sometimes

they restrict their services to existing

customers. This is true of some district

nursing teams, rapid response schemes and

certain social services. The restricted nature

of out-of-hours services and their often more

limited capacity in comparison to in-hours

services means that whilst out-of-hours

services try to ensure people are safe by

addressing their most urgent needs, the

consideration of their wider needs is left until

the next working day.

1.92 Some of the problems at the interfaces

between different services providing

unscheduled care are at their worst during the

out-of-hours period. For example, a common

problem with many of the pathways in Wales

is that they do not take place outside normal

working hours. Similarly, information flows

between different unscheduled care services

can be more problematic out-of-hours. More

details regarding unscheduled care provided

in the out-of-hours period can be found in

Appendix 3.


50

Part 2 - There is growing momentum for change but partners

still face a number of short and longer-term challenges

across the unscheduled care system

2.1 This section of the report sets out how the

momentum for public service partners to

change the system of unscheduled care is

growing as well as identifying a number of

challenges, both short-term and long-term,

to delivering a more citizen-focused system.

The higher priority that partners

now give to improving

unscheduled care has supported

progress towards addressing

the less complicated problems

in the system

The Assembly Government has taken a range of

actions to show that improving unscheduled

care is one of its major priorities

2.2 The DECS strategy provided a clear

indication from the Assembly Government that

whole systems improvement is a priority.

The strategy sets out broad principles (Box E)

of what the unscheduled care system should

deliver and the Welsh Health Circular that

accompanied the launch of the strategy set

out a list of local and national actions required

to implement the strategy.

2.3 Through the DECS delivery framework, local

health bodies carried out baseline

assessments of their local unscheduled care

system and national work streams were

established to support and advise the overall

DECS Project Board. There is a clinical

reference group and four early adopter sites

undertook projects which tested various

elements of the DECS model (Conwy and

Denbighshire, Pembrokeshire and Derwen,

Bro Morgannwg and Cwm Taf). The national

DECS work streams include:

a engagement and communications;

b managing and sharing information from the

initial assessment;

c ambulance modernisation;

d social services interface;

e workforce planning; and

f performance management review.

2.4 During our fieldwork we were frequently told

that the Assembly Government had taken too

long to produce the DECS strategy and the

extent of progress within some of the DECS

work streams is unclear. Stakeholders also

perceived insufficient coordination of the


Box E - The main principles of the

DECS strategy

a increasing understanding of unscheduled care and

people taking responsibility for their own care;

b dignity and respect;

c management of demand through right care in right

place, by right people at the right time;

d easy access to information;

e collaborative planning and delivery;

f innovative working across organisational boundaries;

g clear measurable standards; and

h care as close to home as is safe.

Source: Welsh Assembly Government, Delivering Emergency CareServices, February 2008



Assembly Government’s strategies that

impinge on unscheduled care, for example

chronic conditions management, ambulance

service modernisation, primary care

development and the community nursing

strategy.

2.5 Nevertheless, our fieldwork also revealed a

clear sense that the Assembly Government

has focused more strongly on the

performance of the unscheduled care system

in recent months. During 2008, the primary

driver of changes to the unscheduled care

system shifted from DECS towards the LDP

process. Through this process local health

organisations are required to develop LDPs to

show how they intend to deliver against the

targets set out in the NHS Wales Annual

Operating Framework. The LDP that each

organisation was required to develop for

unscheduled care is a two-year action plan

and aims to strike a balance between

medium-term planning and immediate actions

to support improvement. The Assembly

Government also required local bodies to

produce a short-term action plan setting out

immediate improvements in unscheduled care

to be delivered before April 2009.

2.6 There has been some criticism from local

health bodies that the timescales for the LDP

process were so tight that they devalued the

process. The Assembly Government does not

accept this criticism because it argues that

the LDP process is not necessarily intended

to generate new plans but it instead requires

local bodies to clearly set out their existing

plans and how they hope the intended actions

will improve unscheduled care. The Assembly

Government returned seven out of the eight

communities’ LDPs because they judged the

plans insufficiently specific, particularly a

requirement for tighter timescales. While this

clearly frustrated the local bodies, the extent

of the focus on the rapid achievement of key

deliverables was a clear signal that the

Assembly Government expected more rapid

progress in delivering tangible improvements

to the unscheduled care system.

There has been progress in addressing some of

the more immediate problems within the


The level of excessive patient handover delays

is reducing

2.7 The increased focus on unscheduled care

has begun to produce improvements. There

has been a reduction in the extent to which

patient handovers are delayed at emergency

departments. In April 2009 we reported on the

problems that had been experienced with

excessive times to hand patients over from

ambulance crews to accident and emergency

departments. Appendix 2 and paragraphs

1.22 to 1.25 provide further discussion of

these findings.

2.8 Recognising the seriousness of the problems

of excessive handovers, both for individual

patients being handed over and, across the

wider system, for other patients and the

quality of service they received, the Assembly

Government established new systems to

measure handover times using touch screen

technology. These systems went live from

September 2008 to measure the target that

patients should be handed over to emergency

departments within 15 minutes of arrival.

Measuring handovers focuses on a

symptomatic problem within the system.

2.9 Our spot check of the new systems, which

took place between October and December

2008, found that while there have been some

positive steps in improving the handover

process, patients are frequently delayed too

long and the data on handovers is not yet

providing an accurate view of the extent of

the problem. Further progress depends on

NHS organisations taking a firmer grip of the

handover issue in the context of improving the



wider system of unscheduled care. The

problems we identified were a vivid example

of the whole system of unscheduled care

failing to work coherently, a problem

characterised by problems at the interface

between services, poor flow within the system

and the absence of a citizen focus in

recognising the impact of delays at

emergency departments on other people

urgently requiring an ambulance.

2.10 Since the publication of our report, the

Assembly Government has led a task and

finish group to improve both compliance with

recording handover data and improve

performance against the 15-minute target.

The National Assembly’s Audit Committee has

also conducted its own inquiry into ambulance

services which included patient handovers

and reported in July 200962.

2.11 There have been considerable improvements

in the consistency and comprehensiveness of

patient handover information although there is

still marked variation in compliance,

particularly at weekends. In March 2009, only

22 per cent of handovers across Wales had

the required timing information recorded.

Between 8 June and 10 September 2009, this

rate had increased to 63 per cent. This rate

was greater than 70 per cent at four hospitals,

Royal Glamorgan, Morriston, Glan Clwyd and

Withybush but the rate at the University

Hospital of Wales was just 39 per cent63.

2.12 Whilst acknowledging the ongoing issues in

some hospitals regarding the

comprehensiveness of the data regarding

patient handovers, there is evidence that the

extent of delayed handovers is reducing.

Figure 8 shows that between April 2009 and

July 2009 there has been an incremental

improvement in performance64.

2.13 Figure 9 shows that the number of ambulance

turnarounds that took longer than an hour

peaked in January 2009 and has since

reduced considerably. The data has now

stabilised at around 600 turnarounds per

month taking longer than one hour.

2.14 Whilst there have been incremental

improvements in handover performance at a

national level, considerable variation in

performance remains between individual

hospitals. In July 2009, the percentage of

handovers completed within 15 minutes was

more than 90 per cent at five hospitals;

Princess of Wales, Withybush General,

Royal Glamorgan, Wrexham Maelor and

Morriston. However, at three hospitals,

less than 70 per cent of handovers were

completed within 15 minutes. These three

hospitals were Prince Charles, Ysbyty

Gwynedd and the Royal Gwent.

52

62 National Assembly for Wales Audit Committee, Ambulance Services in Wales Inquiry, July 2009 http://www.assemblywales.org/cr-ld7660-e.pdf

63 Since September 2009 the rate of compliance with recording the required handover information has improved at the University Hospital of Wales. For the period between

9 September and 11 November the compliance rate was 59 per cent.

64 Welsh Assembly Government, NHS Wales Annual Operating Framework Monitoring Report 2009-2010, August 2009

Figure 8 - In Welsh emergency departments the

proportion of patient handovers completed

within 15 minutes improved between April 2009

and July 2009

Month Percentage of handovers

completed within 15 minutes

April 2009 79.9

May 2009 80.3

June 2009 83.7

July 2009 84.3

Source: Welsh Assembly Government



There has been some progress in co-locating

unscheduled care services but these need to be

more effectively integrated

2.15 One opportunity to provide more seamless

and coherent unscheduled care services is to

achieve greater co-location of services, for

example social service teams and primary

care out-of-hours services being located

within or alongside the hospital emergency

department. While co-location is not

guaranteed to improve the coherence of

service provision, it can help simplify the

access points to the system, create smooth

pathways for citizens to follow and produce

efficiencies in the way that services are

delivered. There has been some progress

in co-locating unscheduled care services,

for example:

a Since April 2009 in the eastern division of

the North Wales NHS Trust, there has

been a phased implementation of the

North East Wales Emergency Response

Area (NEWERA) centre at Wrexham

Maelor Hospital. This development will

eventually see the co-location of the

emergency department, clinical decision

unit, primary care out-of-hours service,

out-of-hours social services team and the

social services night visiting team.

The centre has opened but not all of the

services will be co-located there until

March 2010. The social services

out-of-hours team was due to move in by

October 2009 and the clinical decision unit

is not yet operational. The new service

model aims to provide a physical single

point of access, rapid access to

diagnostics and early clinical

decision-making, all of which is in line with

good practice. The model involves the

Figure 9 - The number of turnarounds taking longer than an hour has decreased considerably

since January 2009

18001600140012001000

800600400200

0

Mar

08

Apr

08

May

08

June

08

July

08

Aug

08

Sep

08

Oct

08

Nov

08

Dec

08

Jan

09

Feb

09

Mar

09

Apr

09

May

09

June

09

July

09

Minimum Maximum Total for Wales

Num

ber o

f am

bula

nce

turn

arou

nds

taki

ng lo

nger

than

one

hou

r

Source: Wales Audit Office analysis of data from the Welsh Ambulance Services NHS Trust


54

various partners using the benefits of

co-location to develop more coherent,

shared procedures, care co-ordination and

communication to support citizen-focused

care that overcomes service boundaries.

b Call handling for primary and social care

services out-of-hours have been co-located

in the Pembrokeshire locality of the Hywel

Dda Health Board. There is ongoing

planning within Hywel Dda to further

co-locate unscheduled care services.

This work involves the ambulance service,

health board, local authorities, and

voluntary sector.

c GP out-of-hours services are located within

walking distance of the emergency unit of

Ysbyty Glan Clywd which is part of the

Betsi Cadwaladr University Health Board;

staff involved in unscheduled care at this

site reported that co-location helped

support some improvements in

collaboration and communication between

the GP out-of-hours and emergency

department services.

d In South East Wales, ambulance control

staff, NHS Direct Wales staff and call

handlers for the primary care out-of-hours

service are co-located in the new

ambulance control room at Vantage Point

House; while this has provided the

opportunity for all three services to work

more closely together, these services are

not yet fully integrated; it may provide

valuable capacity to improve clinical

decision-making in the ambulance control

room and provide lessons for the further

integration of the unscheduled care system

(Case Study H).

2.16 Case Study I gives details of the

Gloucestershire Hub for Health which acts

as a single point of access for out-of-hours

health and social care services in

Gloucestershire.

NHS Direct Wales has improved its impact in

supporting people to self-care but could add further

value if there was greater clarity about its strategic

fit within the wider unscheduled care system

2.17 One of the modules of this study was an

examination of whether NHS Direct Wales is

a valuable part of the wider system of

unscheduled care. NHS Direct Wales was

established in 2000 to provide a 24-hour

confidential telephone help-line. It provides

information and advice about health, illness

and health services to help callers make

better decisions about their health and that of

their families. In recent years, it has expanded

to provide a range of local services including:

out-of-hours call handling and telephone

triage for three former LHBs; telephone triage

for calls redirected from six hospital

emergency departments; a dedicated dental

helpline for 13 LHBs and the ad hoc provision

of public health information. In addition to

telephone services, NHS Direct Wales

provides a range of web-based information

services where the public and healthcare

professionals can access information and

request advice. The management of NHS

Direct Wales was transferred from Swansea

NHS Trust to the Welsh Ambulance Services

NHS Trust on 1 April 2007.

2.18 Appendix 2 provides further details regarding

our NHS Direct Wales report. However,

overall we concluded that NHS Direct Wales

provides a valuable service but there is scope

to add further value if there was greater clarity

about its strategic and operational fit with the

wider unscheduled care system. We reached

this conclusion because:




Case Study H - Vantage Point House and the Clinical Desk pilot: a step towards a

healthcare hub

Vantage Point House

In South East Wales, with £1.7 million capital support from the Assembly Government, the ambulance trust has established a

new control room at its regional headquarters at Vantage Point House. As well as consolidating staff from the previous

ambulance control centres at Mamhilad and Church Village into a single control room, the new control room houses other

unscheduled care call handling services. These include call handlers and nurse advisors from NHS Direct and call handlers

from Gwent primary care out-of-hours service.

Staff from the various unscheduled care services are co-located within Vantage Point House but are not yet operating in a fully

integrated manner. Co-location is beneficial and aids communications, with the ambulance control staff, NHS Direct nurses and

GP out-of-hours call handlers able to communicate and work together more effectively as a result of being in the same room.

However, their IT systems do not talk to each other, which leads to ongoing duplication and unnecessary handovers between

the different types and levels of service as a result of numerous points of access and boundaries between services. For

example, the Clinical Desk is not able to link electronically with other co-located services within the Vantage Point House

control room. If a patient speaks to an NHS Direct nurse on the Clinical Desk but is referred to the GP out-of-hours service, the

caller has to end their call with the NHS Direct nurse, and ring a different number to speak to an out-of-hours call handler who

can physically see the NHS Direct nurse who took the previous call; the lack of inter-operability between the IT systems means

that the caller will have to provide the same information to the out-of-hours service which they already provided to the NHS

Direct nurse. There are plans to move to a common platform which will support integrated working. This integration would help

embed stronger clinical governance across the points of access to unscheduled care. It could also help address the need for

stronger clinical governance arrangements and clinical support in the control room, for example through GPs providing advice,

support and coaching to those handling calls in the control room. Since June 2009, there has been an ongoing trial in the

control room whereby a GP is present in Vantage Point House to support nurse advisors triaging Category ‘B’ calls during

periods of escalation because of high levels of demand.

Vantage Point House represents a prototype for a health care communications hub, which forms a key part of the model within

the Community and Primary Care Strategy. Subject to robust evaluation, there are significant opportunities to further develop

the Vantage Point House model in Gwent, and if this is successful extend it to other parts of Wales, for example through:

a creating a flexible workforce to deliver joint call handling, cross-training across NHS Direct Wales, 999 and primary care

out-of-hours services so that all staff could use all three systems using common software systems to direct people to the

most appropriate part of the unscheduled care system;

b addressing current problems with the lack of inter-operability between the primary care out-of-hours service, NHS Direct

Wales and ambulance control software, to enable the creation of a single Electronic Patient Record (EPR) to reduce the

current duplication and improve information sharing with the patient’s consent;

c as whole systems working in Vantage Point House becomes more mature, exploring the opportunities to bring other

neighbouring out-of-hours GP call handling services into the Vantage Point House initiative; and

d using spare capacity in Vantage Point House out-of-hours when the ambulance trust’s Patient Care Services staff go

home at 5pm.

The Clinical Desk pilot

A clinical model of triage, the ‘Clinical Desk’, was first introduced as a three-month pilot to two of the three ambulance control

centres in November 2007. The aim of the Clinical Desk pilot was to manage the high number of inappropriate emergency

ambulance responses to 999 calls from people with neither life-threatening nor serious conditions. For low acuity calls, the aim

is to ensure callers get the appropriate advice or were effectively signposted to healthcare services. The Clinical Desk uses the

skills of NHS Direct Wales nurses to assess or triage low acuity 999 calls, and in some instances where calls are serious but a

full emergency ambulance response is not necessary. Nurse advisers assess callers using the same computer decision

software (CAS) utilised by NHS Direct Wales so that callers receive the most appropriate advice and support for their needs.



Case Study H - Vantage Point House and the Clinical Desk pilot: a step towards a

healthcare hub (continued)

The Trust’s evaluation of the first phase of the pilot concluded that there was frequently the potential to stand down the

ambulance that had been dispatched at the start of the call. The Clinical Desk was given insufficient time to triage patients

before dispatching an emergency ambulance. The second phase of the Clinical Desk pilot considered whether an emergency

ambulance response could be stopped once low acuity 999 calls were transferred to the Clinical Desk. Over a two-month

period between August and October 2008, Nurse Advisers working on the Clinical Desk triaged more than 500 low acuity 999

calls (one-fifth of eligible calls for transfer). Two-fifths (39 per cent) of these calls were resolved with advice to self care or to

contact their GP or other healthcare professional. This meant that 211 emergency ambulance responses were stopped, freeing

up the equivalent of 3.5 ambulances each day. Sixteen per cent of calls were transferred back for a 999 emergency ambulance

response, which the Trust believes illustrates the safety of the clinical desk model, as these calls would have been designated

a low priority response by the Advanced Medical Priority Dispatch System. Of the remaining calls, 30 per cent were

downgraded to an urgent ambulance response, 14 per cent were categorised as ‘other’ because the caller refused nurse triage

and one per cent were returned to ambulance control because they should have been excluded from the Clinical Desk.

At the time the evaluation was carried out the Clinical Desk was not operational at peak times (8am to midnight) seven days a

week. The Trust estimates that if the Clinical Desk had been fully operational then an additional 1,420 calls could have been

resolved without the need for an emergency ambulance response. Avoiding an unnecessary emergency response, when safe

and appropriate to do so, can be positive for the patient, the wider public and the whole system of unscheduled care. It reduces

unnecessary journeys to hospital for patients, and releases emergency ambulances to respond to other life threatening calls.

Source: Auditor General for Wales, NHS Direct Wales, September 2009

Case Study I - Gloucestershire Hub for Health

Gloucestershire Hub for Health is an integrated out-of-hours health and social care hub covering Gloucestershire. The hub

involves close working by various teams from Gloucestershire County Council, the Great Western Ambulance Service and

Gloucestershire PCT.

Change to the primary care out-of-hours contract in 2005 was the catalyst for developing new ways of working in the county.

The new out-of-hours primary care service began by integrating with the out-of-hours district nursing service but since then

more and more services have become involved in the hub.

The out-of-hours primary care service is at the centre of the hub and is managed by the ambulance trust. Workers involved in

the hub believe the ambulance trust is well placed to provide this service because of its expertise in call taking and vehicle

dispatch. As well as dispatching calls to mobile GPs, the hub's call takers also have access to a wide range of urgent care

services including the social services emergency duty team, the domiciliary care team, district nurses and mobile emergency

care practitioners.

The hub also works closely with the 999 ambulance call takers located directly next to the hub call takers. This close working

facilitates appropriate non-conveyance of patients by preventing the unnecessary use of emergency ambulances when the out-

of-hours GP or other hub services are better placed to respond.

The hub involves only a minimal, formal framework for partnership working. For example, whilst there is a memorandum of

understanding between the ambulance service and the district nursing service, there are no other formal shared clinical

governance arrangements or shared procedures and there are only limited IT information links between services. It is the

informal links rather than formal links between teams involved in the hub that have benefits for the citizen. The co-location of

services means that there is enhanced understanding about what partner services are able to provide and there is greater

willingness to help other services. Close communication between the teams ensures the most if made of the hub’s collective

knowledge about individual patients.

There is scope to extend the role of the hub including a need to integrate further with mental health services, chronic conditions

management teams and home oxygen teams.




a NHS Direct Wales provides valuable

services to the public at a comparatively

reasonable cost, supported by sound

processes; and

b NHS Direct Wales has potential to add

further value to the unscheduled care

system but needs a clearer strategic

direction.

Partners still face a number of

short and longer-term challenges

across the unscheduled care

system, particularly in

developing sustainable

solutions to these challenges

The national and local strategic plans for

unscheduled care are inadequate in their

current form

2.19 The high-level principles set out in DECS

strategy are widely accepted but a number of

stakeholders criticised the vision as being

insufficiently specific or prescriptive,

particularly in terms of providing a blueprint

for the model of unscheduled care that local

communities should develop. The Assembly

Government deliberately avoided providing a

highly specific blueprint because it felt the

different health and social care communities

in Wales require different solutions to the

problems within the local unscheduled care

systems. For example, there are particular

challenges associated with delivering

unscheduled care services in largely rural

areas such as Powys (Box F). Consequently,

the DECS framework places the onus on local

organisations to develop solutions to meet

local problems. The divergent views on DECS

reflect an inherent tension between central

prescription, which can lead to

over-specification of the system and

insufficient flexibility to develop services truly

reflective of local need, with the need for

certain issues to be developed at a regional

or national level.

Box F - Key issues facing rural areas, such

as Powys, in delivering unscheduled care in

a rural environment

The Rural Health Planning consultation demonstrates the

priority the Assembly Government is giving to solving some

of the intractable challenges of providing unscheduled care

services in rural areas. It offers a platform from which to

develop innovative and more flexible service models. The

consultation document highlighted some of the issues

facing sparsely populated, rural communities, such as:

a poor transport links which affect travel times to

unscheduled care facilities, make it difficult for the

ambulance service to provide timely emergency

responses and make it more difficult for services to visit

people at home;

b the need for new workforce models to deliver primary

care in rural settings;

c the scope for pharmacists to play a more leading role in

delivering unscheduled care through minor ailments

services and the provision of diagnostic tests; and

d the need to modernise the role played by community

hospitals in delivering health and social care.

Whilst the exercise says that Powys is uniquely placed to

act as a focus point for innovation in rural healthcare, local

audit work by the Wales Audit Office has found that Powys

is not well placed to deliver more effective unscheduled

care services. Some of the main issues facing

organisations in Powys were:

a a lack of progress from previous initiatives to improve

patient experience and avoid unnecessary hospital

admissions;

b the rate of progress on improvements to the

unscheduled care system has been relatively slow and

is hindered by the need for more complete analysis of

demand and further strengthening of partnership

arrangements; and

c plans for developing unscheduled care need to be

strategically set within the wider context of modernising

health and social care, particularly given the significant

future challenges facing the LHB.



58

2.20 The local visions for developing unscheduled

care in individual communities are not

generally pulled together in a single document

but are provided by a range of plans and

strategies. Some of the plans and strategies

in place in different communities include the

DECS baseline assessment, unscheduled

care strategies, two-year LDPs, immediate

action plans to meet the national unscheduled

care targets, and broader strategies for

changing the system of scheduled and

unscheduled health and social care. We

found that many of the local plans are too

hospital-centric and do not sufficiently cover

what needs to happen in the community to

divert demand from more acute services.

2.21 Our fieldwork suggested that whilst local

health and local government organisations

need to work much more effectively to

improve the system of unscheduled care,

there is a strong consensus that to assist

local strategic thinking, the high-level

principles of DECS need to be supported by

national guidance on certain elements of a

modernised unscheduled care system. Where

appropriate, the Assembly Government

should join up local developments in

unscheduled care provision at a national

level, considering for example:

a workforce issues to support new service

models to meet demand, particularly :

i how the paramedic and nursing

professions are to develop, expand and

increasingly align their activity to deliver

more seamless unscheduled care closer

to citizens’ homes where this is

appropriate; and

ii how the health and social care

workforce can become more closely

aligned to provide seamless care.

b the need to achieve greater continuity

between in-hours and out-of-hours care, to

move towards twenty-four seven working

with a less acute distinction between

scheduled and unscheduled care and

greater flexibility in scheduling contact with

various forms of care;

c in responding to the recommendations of

our separate report, clarify the potential

future role of NHS Direct Wales within the

wider system of unscheduled care and

encourage its better integration into local

service planning to improve the flow of

patients through the system; and

d developing an effective national approach

to planning and development activity,

taking advantage of the smaller number of

health and social communities to pilot

different approaches, for example in

pathway development, to enable the more

rapid sharing of learning and good

practice.

2.22 A wider national vision is now emerging

through the Primary and Community Services

Strategic Delivery Programme which seeks to

achieve a fundamental shift of emphasis in

scheduled and unscheduled care. It proposes

moving from the current system which pushes

people into hospital and then pushes them

out again to a ‘pull’ system achieving steady

flow through the system by pulling people

towards the most appropriate care setting,

usually in the community. The document also

talks about a more holistic approach that

looks beyond addressing people’s presenting

conditions to consider their longer-term

needs. Plans for the delivery of the model

proposed in the strategy are in their infancy

following recent consideration by the National

Advisory Board, but the diagnosis set out in

the strategy is consistent with the conclusions

of our work on unscheduled care.




Partner organisations have not yet achieved a

sufficiently strong joint commitment to improve

the coherence of the unscheduled care system

Multi-agency unscheduled care partnerships are in

place but they have not had adequate engagement

from certain partners and stakeholders

2.23 There is considerable scope for more

effective joint working and collaboration

across the various elements of the

unscheduled care system to provide more

holistic and co-ordinated services. All health

and social care communities have put in

place multi-agency groups to plan and take

forward the changes required to improve the

system of unscheduled care but we found that

many of these groups have not yet had

sufficient engagement from social services,

primary care and the ambulance trust.

2.24 Our fieldwork suggests that there is a

common perception within local government

that health professionals do not fully

understand the role that local government can

play in providing unscheduled care. Some

social services staff told us that there was a

perception that local authorities are included

in the unscheduled care planning agenda

simply to help solve the problems of the

health service rather than to develop a

genuinely citizen-centred, integrated approach

to meeting unscheduled care needs. In some

areas we found that social services are

members of the local unscheduled care group

but do not attend regularly. We concluded

that, in general, there is an under-emphasis

on local government services, both those

provided directly and commissioned from the

voluntary or private sectors, within the current

and planned unscheduled care system.

Similarly, we found that that the role of the

voluntary sector in providing services is not

yet fully considered during unscheduled care

planning and delivery.

2.25 Our work on delayed transfers of care also

showed that there is scope to develop a more

coherent approach to partnership working

between health and local government. There

is scope to develop integrated service models

that promote health and well-being, help

people avoid admission to hospital and help

pull people out of hospital as quickly as

possible.

2.26 One mechanism to develop more integrated

services across health and social care is to

use Health Act flexibilities to pool, share or

align resources. While sharing resources is

not a panacea, it is a very effective tool when

supporting a clear and shared vision.

Although we have not identified any examples

of pooled budgets for providing unscheduled

care, local authorities and NHS bodies are

working together to jointly provide a number

of intermediate care and rapid response

services to support people with urgent

care needs.

2.27 Primary care practitioners have an absolutely

central role in the delivery of unscheduled

care. In response to our survey, most chief

executives of former LHBs were positive

about their engagement with primary care on

unscheduled care but the majority of the small

number of GP practices responding to our

survey said that they were not involved in

planning unscheduled care services.

Consequently, the new health boards should

prioritise achieving more effective

engagement to tap the expertise of primary

care practitioners in demand for services and

citizens’ experience of various unscheduled

care services.

2.28 The ambulance trust is engaged in

unscheduled care planning in all communities.

However there have been problems with its

strategic capacity to engage in a consistently

effective way in unscheduled care groups

across the 22 former LHB areas. The NLIAH


60

review of the DECS baseline assessments

highlighted engagement with the ambulance

trust as an area of weakness, while our work

on NHS Direct Wales highlighted concerns

from stakeholders that NHS Direct Wales was

not sufficiently engaged in national strategic

planning for unscheduled care.

2.29 The ambulance trust is implementing a

management review which will create a

strategic planning directorate to augment its

strategic planning capacity. Although this

should foster stronger engagement with the

new health boards, the trust may still face

capacity pressures in interacting more

effectively with the 22 local authorities

providing social care. The trust currently has

little interaction with local authorities in terms

of out-of-hours social care. They are not

involved in jointly developed pathways

involving social care which might help share

intelligence on social care issues, needs and

risks which paramedics will often identify

when they see people in their homes. Such

sharing of intelligence by paramedics could

support early social care interventions to

prevent further problems. The biggest barrier

is continuing silo working and a tendency

towards parochialism despite different

communities facing very similar issues.

This can lead to significant reinvention

of the wheel.

There needs to be clear accountability and

ownership for individual organisations,

based around the outcomes partners wish

to deliver for citizens

2.30 Throughout our fieldwork we were frequently

told that the time has come for immediate and

decisive action to improve unscheduled care.

Achieving change across the whole system of

unscheduled care will require complex,

multi-agency actions where no one

organisation alone can deliver the scale of

change required. In this context, effective

collaborative leadership and governance

across the system are vital. Our work

suggested that progress in modernising

unscheduled care is often affected by the

number of partners involved and the lack of

clarity about accountability for change. The

scale of the plans that have been produced,

and the mixed pace of implementation,

probably reflect the challenges of delivering

change given the complex legal, clinical

governance, political, financial and

managerial issues involved.

2.31 Our work on delayed transfers of care in

Gwent highlighted a project that aims to

achieve large-scale system change through

multi-agency commitment and action. Case

Study J gives details of the Pan-Gwent Fraity

Project which is based on a genuinely shared

approach to the cross-cutting issue of frailty.

The formation of new health boards presents a

considerable opportunity to develop a more

coherent system of unscheduled care as long as

strong partnerships remain

2.32 The formation of seven health boards in place

of the previous seven trusts and 22 LHBs

potentially complicates some of the existing

partnerships involved in planning and

delivering unscheduled care, at least in the

short-term, but presents numerous

opportunities to improve integration,

collaboration and coherence of service

provision. As a national service, the

reorganisation presents the ambulance trust

with a significant opportunity to deliver more

effective senior engagement in local service

planning and delivery. There are particular

opportunities to use the reduction in the

number of organisations involved in the

planning and delivery of services to develop

much more effective systems to pilot, test,

evaluate and diffuse innovative new ideas in




unscheduled care. In a country of Wales’ size,

achieving such improvements should be

straightforward and offers significant scope for

rapid improvement.

2.33 The major risks of the reorganisation relate to

the disruption of positive, cross-organisational

relationships that are already in place in some

areas. When the new boards came into being

on 1 October 2009, partnerships and

channels of communication will undoubtedly

have changed. It will be important for the new

Case Study J - The Pan-Gwent Frailty Project is an encouraging example of service models

beginning to change and stronger multi-agency commitment

In October 2007, chief executives from across the local health and social care community in Gwent established a joint working

group to focus on what they could do to improve the outcomes for frail older people on a pan-Gwent basis. A task group of

senior managers decided that the best approach to take would be to develop an improved and standardised care pathway for

frail older people, ranging from GPs managing fall prevention through avoidance of emergency admissions to alternatives to

institutional forms of care. The next stage was to hold a series of workshops of front line practitioners, managers and clinicians

from organisations across Gwent.

A pan-Gwent programme board was formed made up of representatives from each of the five LHBs and local authorities,

Gwent Healthcare NHS Trust, Gwent Age Concern and the Welsh Ambulance Service NHS Trust. This board is chaired by a

local authority chief executive and aims to achieve transformational change by moving the focus for frail older people from

acute and institutional care to independent living.

A further meeting was held of the 11 chief executives who agreed that the project should aim for a common service model

across Gwent with shared outcomes and standards but with the flexibility for local variations. At the same meeting the chief

executives signed off a pan-Gwent continuing care bid that included funds for the appointment of a programme manager

seconded to the Chair of the programme board.

The model that is currently developing covers the provision of care for all frail people in Gwent regardless of whether they are

in hospital, at home or in the community. It focuses on providing a single point of referral for all services targeting prevention of

admission, early supported discharge, management of long term conditions and independent living within the community.

There are now seven work streams and each is led by a task group reporting to the programme board:

a workforce development;

b communication and stakeholder engagement;

c information sharing and single point of access;

d governance and structure;

e locality planning;

f outcome indicators, performance and continuous improvement; and

g financial modelling.

While the pathway is still in development, initial roll out across Gwent is planned for 1 April 2010. Support for the model

appears to be strong and growing in Gwent. Bringing in front line managers to develop the model has fostered empowerment

and ownership of the work streams.

One of the most important lessons learned from the work so far has been that by focusing the work so clearly on improving the

lives of older people, this has helped win over hearts and minds, secure political support and prevent technical objections that

might otherwise have stalled the project. It is this strong moral imperative that has broken down some of the previous cross

organisational barriers to improvement.



62

boards to maintain a balance between a focus

on local issues and the benefits of the more

strategic approach which their wider reach

should support. Most health boards will now

be dealing with more than one local authority,

which will require them to lead effective joint

planning. The joint planning will need to

involve shared priorities across the overall

footprint of the health board but will also have

to consider the specific priorities and

circumstances of each local authority.

2.34 Local service boards have the potential to

lead the multi-agency development of

unscheduled care. The service boards have a

real opportunity to provide the necessary

leadership, commitment and momentum to

support the required radical changes in

unscheduled care service delivery across the

public service partners. Recognising its

cross-cutting implications for citizens, we

have provided a specific briefing note for local

service boards on unscheduled care.

Clinical and managerial leadership is central to the

effective redesign of the unscheduled care system

2.35 Once organisations have shown their

ambition and joint commitment to improve the

unscheduled care system, it is vital that they

work effectively with their staff to ensure that

the changes are implemented. Improvements

to the whole system will require some difficult

decisions and high quality political, clinical

and managerial leadership will be essential to

progress.

2.36 Workforce planning and development is likely

to lead to professional groups working in new

ways, which may involve some of their

traditional work taking place in different

settings; the nature of their roles and

interactions with other professions is also

likely to evolve. There will also be changes in

clinical culture, as services move closer to the

community with a stronger emphasis on

prevention and primary care. This will enable

more specialist services to deal with the most

complex cases. Effective clinical leadership in

primary care and in community and hospital

settings will be crucial.

2.37 Within health boards, clinical leadership will

also be vital in supporting effective

engagement between primary and secondary

care, and between hospital unscheduled care

services (for example, the emergency unit,

clinical decision unit, medical admissions unit

and minor injuries units) and inpatient

specialties. Crucially, there needs to be

widespread support for the plans from the

various professionals who provide

unscheduled care.

Public services need to engage more effectively

with the public to help them find the most

appropriate help within the system

2.38 Part 1 of this report sets out some of the

challenges people face in deciding how and

where to access unscheduled care services.

Paragraphs 1.78 to 1.87 highlight that

problems around access to services can

result in preventable demand, where people

access one service when their needs might

have been better met by a different service.

Often, this misplaced demand results in

people using services at a higher level of

acuity than they really need. This reflects the

generally poor understanding of demand

across the system and represents a

less-than-optimal use of resources.

2.39 Most health and social care communities

have carried out some work aimed at

improving understanding amongst the public

about what unscheduled care services are

available and how best services should be

accessed. Nearly all of the former LHBs tried

to engage members of the public in relation to




unscheduled care. Most sought to involve the

public on specific aspects of unscheduled

care rather than across the whole system.

Community health councils have been

involved in many cases and at least six LHBs

have involved patients in planning primary

care out-of-hours services. Some

engagement has been in the form of

information provision rather than consultation.

In Pembrokeshire, there have been specific

public focus groups on unscheduled care,

whose main conclusion was that people do

not understand the best routes of access into

the system. The ambulance trust has

improved its systems for public and patient

involvement, and many local authorities

have produced leaflets and online

information regarding the out-of-hours

services they provide.

2.40 However, we found that most of this work is

limited because it has been small-scale, has

focused only on holiday times when workload

pressures are higher, or has focused on

individual services rather than the whole

system. The DECS work stream on

communications includes plans to carry out a

national marketing scheme but progress with

this has not been taken forward yet. Building

on a successful communications campaign in

Knowsley to help citizens to choose the right

services to meet their needs (Case Study K),

a pilot campaign is developing in North Wales

which will inform decisions on whether to run

a national campaign to help citizens choose

the most appropriate unscheduled care

services for their needs. Partner organisations

in Pembrokeshire are also planning to

implement a campaign similar in concept to

the Choose Well campaign in Knowsley.

Case Study L is another example of a social

marketing campaign from England that is

showing promise changing the way that

people use unscheduled care.

2.41 One problem in developing a national

approach to communications is that the local

service delivery models and points of access

for unscheduled care are likely to change.

Decisions about the timing of any

communications schemes will therefore be

very important, as will addressing the lack of

a common language to describe similar

services which contributes to public

confusion. It is also important that

communications campaigns support changes

in service delivery flowing from a robust

analysis of demand.

There is considerable scope to improve the way

that the system learns and improves

The Assembly Government is leading work to

develop more holistic performance measures than

the current targets which have tended to focus on

access to individual services rather than outcomes

and quality

2.42 Current performance measures for

unscheduled care tend to measure the

performance of specific parts of the system

rather than focusing on the whole of a

patient’s pathway through the system.

Current targets tend to focus on timely access

to the system with little or no reflection of the

eventual outcome of an unscheduled care

episode. Some former NHS trusts told us

that they voluntarily participate in the

measurement of clinical outcomes through

various professional associations. For

example, two trusts analyse incidents through

College of Emergency Medicine (formerly

British Association of Emergency Medicine)

and Trauma Audit and Research Network

analyses. However, most trusts recognised

the considerable scope for improvement in

measuring and reporting on the clinical

outcomes and quality of unscheduled care.



Case Study K - The ‘Choose Well’ campaign in Knowsley

http://connections.wao.gov.uk/gpx/search_case_studies_library_detail.aspx?Snippet_ID=591

Developing the ‘Choose Well’ brand

NHS Knowsley ‘Choose Well’ initiative has used communication and branding techniques, based on a thermometer brand, to

help the public make more informed choices of service to meet their urgent care need.

NHS Knowsley faced pressures because whilst the number of choices of services was increasing, people and professionals

were not making the most appropriate choices of urgent care service and were tending to default to the emergency department

or making 999 calls.

Recognising that they needed a simple, consistent and readily identifiable brand, NHS Knowsley developed the concept of a

thermometer which used colours to denote six tiers of urgent care services:

a self-care;

b NHS Direct;

c NHS care at the chemist (pharmacist);

d GP practice;

e walk-in centre; and

f hospital emergency departments.

The brand was used on Knowsley’s annual ‘Your Guide to Local NHS Services’, a directory of services which the Department

of Health prescribed nationally. A campaign took place in the winter of 2006 to coincide with the opening of the Knowsley

walk-in centre. Royal Mail worked in partnership with the PCT to pilot approaches to personalised delivery methods.

The door-drop of leaflets that showed the thermometer, levels of service and what people should do in particular

circumstances, evaluated very well, with 98 per cent public satisfaction with the brand.

The following year, NHS Knowsley led a consortium of NHS organisations from across Merseyside who all shared the same

challenges in urgent care to deliver an updated and further developed campaign across the area, which has a population of

1.5 million. An agency was commissioned to further develop the thermometer brand, refining the original thermometer concept

supported by a range of promotional material, including leaflets, posters, and radio and newspaper advertisements that

included urgent care scenarios.

One of the main risks that the partners perceived was the potential for the campaign to cause members of the public to make

clinically inappropriate choices. Consequently, the NHS Knowsley’s medical director had ultimate sign-off on the campaign and

materials, which were strongly based on simplified versions of NHS Direct information. There was a need for strong clinical

leadership for the campaign so that there was a clear understanding of risk and innovation, but also a strong underpinning

drive to maintain and improve patient safety. The campaign was careful to avoid a potentially confusing ‘anti-A&E’ message,

focusing on positively promoting when and how to use the different services across the spectrum of ‘urgent care’ and taking

trouble to ask patients to choose the right service for them, the NHSJ and others, whilst still using A&E /999 if in doubt whilst

reinforcing the alternatives.

There has been some evaluation of the campaign, with qualitative research showing good brand recognition and retention.

The PCT believes that the main qualitative impacts have been:

a the brand has been well remembered;

b the campaign is generally seen as appropriate for the NHS and a good investment of NHS resources;

c there is some evidence that the public have changed their choices about which services to use;

d generally, members of the public were clearer about the role of different NHS services;

e there is evidence that more people would generally downgrade the service they would use and were more willing to use

self-care after the campaign than before which may reduce pressure on accident and emergency services; and

f Choose Well was expressly not portrayed as a campaign to stop people using A&E, and the PCT is confident that people

still knew when they should use A&E services.



Case Study K - The ‘Choose Well’ campaign in Knowsley (continued)

The main indicators of success have been:

a reasonably good advertising awareness;

b 45 per cent of respondents believed that they would use a wider range of services than they would have before the

campaign;

c generally, people ‘downscaled’ the type of service they would use, in particular a greatly increased use of self-care;

d the campaign was well received and was endorsed by most respondents for the useful information provided and the

relevance of the thermometer symbol; and

e those exposed to multi-media (posters, local press and/or radio) were more than twice as aware as the general public.

The effectiveness of the NHS Knowsley approach was externally recognised in 2008 by the recent Healthcare Commission’s

review of urgent care. NHS Knowsley received the highest possible score from the Healthcare Commission on the range of

information provided by the PCT and PCT initiatives to improve awareness of services.

More recently, the Choose Well campaign materials have been shared across the North West, as well as with many NHS

organisations across England, Scotland and Wales. For winter 2009-10, the materials have been further developed and

rolled-out nationally in England.

In 2009, the Choose Well designs also won a prestigious marketing industry award - the Marketing Design Awards - for best

use of design in the Pharmaceutical and Healthcare category.

Lessons learned

Although Choose Well has been very successful and is being adopted, adapted or considered by other partners in England,

Wales and Scotland, the PCT has learned a number of lessons. These are:

1 Robust quantitative evaluation has been challenging. It has proved extremely difficult to obtain consistent, comparable

urgent care data over time from secondary care providers to demonstrate the impact of Choose Well. More generally,

this raises some questions about how the commissioners pay for, specify and monitor activity levels. Nevertheless, the

multi-factorial nature of service users’ access to urgent care services means that it would have been difficult to prove a

causal link between Choose Well and individual decisions about accessing a service. Some of the main indicators of

success are likely to be qualitative – interviews of key clinicians about their perceptions of the appropriateness of access to

services.

2 There is a need to close the gap between awareness of services and understanding of them. While awareness of services

increased, the level of understanding of services lags. In particular, awareness of NHS Direct is low relative to other

services, and despite high awareness of pharmacy services, few people will now consider using the pharmacist for specific

ailments, suggesting a lack of understanding of the role of the Care at the Chemist service.

3 There is scope to engage more fully with healthcare professionals throughout the campaign to offer a beneficial platform to

drive understanding of services and broaden the impact of the campaign.

4 A robust social marketing approach should be further developed to understand different groups of patients according to their

urgent care behaviours and what motivates them. Customer insight and segmentation could enable not just to further

improve the communication approach of Choose Well, but could also influence service design and influence more strongly

individual and group behaviours in accessing urgent care.

5 There is potential for Choose Well to drive commissioning by supporting a clearer understanding of what clinical service is

needed where, when and how, as well as how and why people use services. Changes in public awareness of and access

to services could actually drive changes in service configuration, financial flows and costs across the whole system of

urgent care. Choose Well could help the PCT and its partners to put the citizen at the centre of service specification,

development and promotion.

Source: Visit to NHS Knowsley



Case Study L - The Take Care initiative

Plans for major changes to the model of unscheduled care services in East Lancashire drew significant public resistance in

2006. The plans involved centralising emergency department services at the Royal Blackburn Hospital, with Burnley General

Hospital’s accident and emergency department being converted to a 24-hour urgent care centre for more minor injuries and

illnesses.

The plans were developed through the Meeting Patients’ Needs programme. This programme is run by an independent

programme office funded jointly by two PCTs, (East Lancashire as well as Blackburn with Darwen) and the provider trust

(East Lancashire Hospitals NHS Trust). Two local authorities (Blackburn with Darwen Borough Council and Lancashire County

Council) are also partner organisations within the programme.

Despite broad public consultation and an initial patient information campaign, there remained strong opposition to the proposed

changes, including a public candle-lit vigil outside Burnley accident and emergency department.

Confident that the model was the right one to meet local needs, in 2008 the programme office launched a second information

campaign to dispel myths about the changes and to ensure greater public support and understanding.

The Take Care campaign was of a significantly larger scale campaign than the first, and used clear, eye-catching branding.

The marketing material used simple, every day language and did not use more technical terms like ‘primary care’ and

‘secondary care’. The CARE acronym was used as follows:

C – contact your GP;

A – attend an urgent care centre;

R – ring NHS Direct; and

E – emergency call 999.

The marketing material also focused on photographs of clinicians in uniform because research had shown that the public might

be more likely to support the changes if clinicians backed the model.

The campaign relied heavily on local radio but it also used other methods such as mail drops, distribution of fridge magnets, as

well as advertising in newspapers and football programmes.

Evaluation of the campaign focused on people’s views rather than their actual use of services and showed that the campaign

had succeeded in securing widespread brand recognition and suggested that people would now change the way they use

unscheduled care services in the area. More people were willing to use the urgent care centre and there was greater

recognition that in many cases, people with minor problems would not need the services of the emergency department at

Blackburn.

The campaign cost around £250,000.




2.43 The degree of focus on national targets

measuring access to particular parts of the

system risks a lack of focus on longer-term

and more sustainable change to the system

as a whole. Performance management is

based around fixed monthly targets rather

than local partners deciding how to measure

whether they are improving the system as

well as measuring performance against

national priorities. For example, while the

ambulance trust’s performance against its

response time targets for Category ‘A’ calls is

clearly an important measure of performance,

there are other important measures of the

performance and improvement of the service

which receive little attention. Some of these

other measures are vital to improving the

system, for example reducing the proportion

of calls categorised as Category ‘A’, improving

the speed with which fully equipped

ambulances back-up initial responses and

reaching patients experiencing cardiac arrest

and chest pain calls within four minutes as

their likelihood of a positive outcome

increases within this timescale. It is to the

great credit of the ambulance trust that it has

started to measure, and improve performance

against, the four-minute target to respond to

cardiac arrest and chest pain calls

(Appendix 4). And while the emergency

department four-hour access targets have

helped focus attention on providing rapid care

to patients, NHS trust chief executives told us

that the target does not measure whole

system performance, does not consider

patient outcomes and does not consider the

clinical priorities of different patients.

2.44 The Assembly Government has recognised

weaknesses in the performance measures

and targets within the NHS and has set up an

Intelligent Targets Group. This multi-agency

forum aims to develop a set of measures and

targets more focused on quality of care and

outcomes for patients, supported by a clinical

reference group. Within the Intelligent Targets

work stream, there is an unscheduled care

sub-group which has a large and diverse

membership representing various professional

groups including social services. Whilst later

than anticipated, the group has now produced

a proposed list of indicators which are

potentially a significant improvement on the

status quo. They consider many more whole

system and interface issues and measure

many of the typical delays in the system such

as diagnostics and awaiting a specialty

consultant. They also include some but not

many measures of clinical outcome such as

mortality and near misses. The proposed

indicators, perhaps inevitably, do not measure

the extent to which citizens access the right

part of the system and any additional

preventable demand arising from duplication

or poor flow through the system.

2.45 In framing future measures of the

unscheduled care system, partners should

focus on the outcomes the system as a whole

intends to provide for the population it serves,

rather than individual targets for isolated parts

of the system. This can help develop a

framework for measuring performance across

the whole system which is aligned to those

outcomes. In turn, this can help identify the

key barriers to achieving those outcomes,

inform resource allocation across the system

and support effective performance

management and measurement in the

individual organisations involved delivering

the desired outcomes for the population as

a whole.


68

There is little effective sharing or evaluation of good

practice within Wales or from outside Wales

2.46 There is considerable scope for improvement

in the sharing and evaluation of good practice

relevant to unscheduled care. We have

developed a number of case studies from

within and outside Wales which are relevant

to unscheduled care, drawing on our earlier

work on delayed transfers of care. Our work

on patient handovers at hospital emergency

departments suggested that there is

considerable potential to improve the

sharing of good practice across the

unscheduled care system.

2.47 Sharing and adapting good practice can both

reduce duplication and cost while improving

service effectiveness. During our fieldwork we

were told that there may be examples of

good practice in the way that social services

deal with unscheduled care but these are not

built up into any kind of infrastructure or

standardisation with insufficient evidence of

people learning. The key is to ensure that

there is learning across the whole system,

rather than in particular silos such as health

and social care. The improvement agencies

have carried out work regarding good

practice; for example, NLIAH has produced a

Guide to Good Practice in unscheduled care

and has run seminars. There has also been

joint guidance from NLIAH, the Delivery and

Support Unit and the Assembly Government

regarding operational improvements in

emergency departments and minor injuries

units. The work of these agencies, together

with the work of the Social Services

Improvement Agency, would now benefit

from consideration of how to support the

rapid application of systemic learning

across sectors.




Appendix 1 - Methodology

1 Due to the complexity of the system of

unscheduled care, we decided to take a

modular approach to our study. We arranged

our work in discrete but interlinked modules.

These modules were:

a ambulance services;

b patient handovers at hospital emergency

departments;

c NHS Direct Wales;

d out-of-hours health and social care

services; and

e a whole systems overview.

2 Modules a to c resulted in separate published

reports. This report is the culmination of our

work on modules d and e. The range of

methods we used to deliver modules d and e

is set out in this appendix:

Document review

3 We carried out an extensive review of

documents related to unscheduled care,

within each community and at a national level.

Surveys

4 We sent surveys to all NHS trusts, former

LHBs and local authorities in Wales. We also

sent brief surveys to all GP practices in Wales

as well as to the chief officers of community

health councils. These surveys asked for

qualitative information, such as views

regarding the effectiveness of particular

services, and quantitative information, such as

specific staffing levels, costs and activity data

for individual unscheduled care services.

Data analysis

5 We carried out a detailed analysis of the

Assembly Government’s data regarding

unscheduled care, including delayed transfers

of care census data, as well as relevant

performance indicators from the Local

Government Data Unit.

Semi-structured interviews

6 We conducted detailed interviews with key

stakeholders in four health and social care

communities. We decided on these

communities after considering a number of

factors, such as rurality, regional issues and

involvement in the DECS framework as early

adopter sites. The communities we visited

were Cardiff and the Vale of Glamorgan, the

Cwm Taf area, North East Wales and

Pembrokeshire.

7 Our interviews were carried out with a wide

range of stakeholders, at all levels of the

organisations.

8 Specific fieldwork was carried out within the

Assembly Government to identify the main

ways in which the Assembly Government has

responded to our initial work and was

planning to improve the system of

unscheduled care.



Shared learning and good practice

9 To learn from successful examples of

innovative practice related to the promotion of

independence in vulnerable people we carried

out several good practice visits to Newcastle,

St Helens in Merseyside, Knowsley, Leeds

and Gloucestershire. We have also used case

studies within our report that were published

in previous Wales Audit Office reports.

10 Throughout our work we sought to identify

examples of innovative practice. Case studies

giving details of our findings are included on

our Good Practice Exchange website

(http://www.wao.gov.uk/delayedtransfersof

care.asp).

Expert panel

11 To assist us in developing our approach and

providing assurance regarding our findings,

we convened an expert panel consisting of a

wide range of expertise and experience within

unscheduled care. The panel was used as an

advisory, and not an executive, capacity.

The panel members were, see below.

12 We are extremely grateful to Professor

John Seddon, Visiting Professor at Cardiff

University’s Lean Enterprise Research

Centre, for taking the time to provide

comments on an early draft of the summary

and recommendations of this report.

Name Title Organisation

Margaret Foster OBE Chief Executive Cwm Taf Health Board

Carol Lamyman-Jones Director Board of Community Health Councils in

Wales

Dr Rupert Evans Accident and Emergency Consultant Cardiff and Vale University Health Board

Kevin Barker Inspector Care and Social Services Inspectorate Wales

Richard Bowen Director of Operations, Department of

Health and Social Services

Welsh Assembly Government

Cathy O’Sullivan Chief Officer Gwent Federation of Community Health

Councils

Mandy Collins Deputy Chief Executive Healthcare Inspectorate Wales

Michael Carpenter Reviews and Studies Manager Care Quality Commission (England)

Dr John Watkins Honorary Consultant in Public Health

Medicines

National Public Health Service for Wales

Rob Hemmings Management Consultant – Modernisation

Assessment

National Leadership and Innovation Agency

for Healthcare

Fiona Hallaran Consultant National Leadership and Innovation Agency

for Healthcare

Dr Iain Robertson-Steel Associate Medical Director

Unscheduled Care Lead

Pembrokeshire Local Health Board



Name Title Organisation

Professor Helen Snooks Emergency Care Research Specialist Swansea University

Simon Dean Director of Strategic Direction and Planning Welsh Assembly Government

Carl James Head of NHS Performance Policy, Waiting

times and Unscheduled Care

Welsh Assembly Government

Sara Jones Director of Unscheduled Care/Clinical

Director

Welsh Ambulance Services NHS Trust

Mike Ponton Director Welsh NHS Confederation

Professor Marcus Longley Acting Director Welsh Institute for Health and Social Care

Beverlea Frowen Director of Social Services and Health

Improvement

Welsh Local Government Association

Geoff Lang Executive Director of Primary Care,

Community and Mental Health Services

Betsi Cadwaladr University Health Board

Professor Malcolm Woollard Director – Pre-hospital, Emergency and

Cardiovascular Care Applied Research

Group

Chair

Coventry University

College of Paramedics

Dr Charlotte Jones General Practitioner, Director of Swansea

Out-of-Hours Service

General Practitioners Committee Wales


72

Appendix 2 - Key findings from other relevant Wales Audit

Office studies

This appendix sets out our key findings from previous studies related to unscheduled care. We also

provide details of our ongoing work that is relevant to unscheduled care.

All Wales Audit Office publications can be found at www.wao.gov.uk

Unscheduled care – NHS Direct Wales: September 2009

Delayed transfers of care – follow-through: May 2009


We examined whether NHS Direct Wales is a valuable part of the unscheduled care system in Wales.

We concluded that NHS Direct Wales provides a valuable service but there is scope to add further value, if there is greater

clarity with NHS and social care partners about its strategic and operational fit within the wider unscheduled care system.

We reached this conclusion because:

a NHS Direct Wales provides valuable services to the public at a comparatively reasonable cost and is supported by

sound processes; and

b NHS Direct Wales has the potential to add further value to the unscheduled care system but needs a clearer

strategic direction.

We made a total of nine recommendations focusing on the following issues:

a the strategic role of NHS Direct Wales and its engagement with stakeholders;

b the efficiency and performance of NHS Direct Wales; and

c the potential future role of NHS Direct Wales within the unscheduled care system.

Our follow-through work considered whether early momentum in tackling the causes of delayed transfers of care was likely to

be sustained.

We concluded that there has been positive progress which will only lead to sustainable improvement if partners seize longer-

term opportunities to design the whole system in a way that more effectively promotes independence.

We came to this conclusion because:

a there is evidence of improvement in the extent and impact of delayed transfers of care and some positive local

developments in Cardiff, the Vale of Glamorgan and Gwent;

b health and social care organisations are generally taking seriously the issue of delayed transfers of care;

c the extent and impact of delayed transfers of care is reducing despite some periodic challenges to the sustainability of the

improvement;

d partner organisations have not yet delivered consistently effective action to address the long-term barriers to independence

across the whole system;

e there are strategic visions for promoting independence but at a local and national level, there is little evidence of robust long

to medium-term planning to turn these visions into reality;

f partners have not yet, in general, developed effective approaches to sharing financial and human resources;



Unscheduled care – Patient handovers at hospital emergency departments: April 2009

g clinical, executive and political leaders will need to plan for the longer-term to deliver a more integrated approach to

promoting the independence of vulnerable older people;

h partners have still not developed an effective way of measuring the performance of the whole system in promoting the

independence of vulnerable people;

i problems with processes remain a barrier to a more citizen-focused approach; and

j to deliver better outcomes for vulnerable older people, partners will need to address new challenges and seize new

opportunities that will emerge from the restructuring of the Welsh NHS.

We made a total of five recommendations focusing on the following issues:

a aligning the performance management frameworks of health and social care in relation to delayed transfers of care;

b using existing good practice to address delayed transfers of care;

c developing a more integrated approach to strategy, delivery, resourcing and performance management across health and

social care;

d central guidance on Continuing Healthcare; and

e exploiting the opportunities presented through the formation of the new health boards.

This project considered whether the handover of patients by ambulance crews to hospital emergency departments was being

managed efficiently whilst safeguarding patient care.

We found that while there have been some positive steps towards improving the handover process, patients are frequently

delayed too long and the data on handovers is not yet providing an accurate view of the extent of the problem. Further

progress depends on NHS organisations taking a firmer grip of the handover issue in the context of improving the wider system

of unscheduled care.

We came to this conclusion because:

a the handover process frequently takes too long and results in detrimental impacts for citizens and the wider NHS in Wales;

b the true extent to which patients are delayed during the handover process is unclear;

c NHS organisations have not yet collaborated effectively to ensure there is the required leadership and vision to eliminate

excessive handover times;

d staff appear fully committed to improving handovers but NHS bodies must inspire greater commitment to data recording and

prevent handover delays becoming an accepted part of the working culture;

e poor matching of hospital resourcing to peaks in demand is a major factor in excessive handover times; and

f the processes that set out how patient handovers should happen vary widely across Wales and there is little sharing of

lessons or innovative practice.

We made a total of 10 recommendations focusing on the following issues:

a improving the completeness and accuracy of handover time data;

b improving the way that NHS staff use the data terminals;

c improving the use and analysis of handover time data;

d ensuring lessons about the handover process are learned and shared; and

e ensuring patients are transported to hospital by the most appropriate service.



Ambulance services in Wales – further update to the National Assembly for Wales’ Audit

Committee: March 2009

The management of chronic conditions by NHS Wales: December 2008

74

This report set out a number of areas for consideration of the National Assembly’s Audit Committee when taking evidence from

witnesses about the latest position of ambulance services in Wales at its meeting on 11 March 2009. These issues included:

a performance has dipped significantly across a range of measures since June 2008 as a result of a number of factors, of

which growing problems arising from unacceptably long patient handovers at some accident and emergency departments

are crucial;

b it has taken longer than planned to achieve progress with three business cases, with others still unresolved, and further

work is required to agree a strategic plan to inform investment in the trust;

c financial pressures remain a concern for the immediate and longer-term future;

d progress has been made on the human resources and cultural agenda, although some aspects have been compromised as

operational pressures have grown, and the slow pace of progress on these issues needs to be reversed through clearer

prioritisation and focus on issues of culture, morale, staff management and development; and

e our ongoing work on unscheduled care suggests that the trust stands to benefit significantly if it engages effectively with

partners to successfully improve the wider system.

Our update did not include any new recommendations.

We concluded that the way in which the NHS currently provides services does not fully support the effective management of

adults with a chronic condition.


a too many patients with chronic conditions are treated, in an unplanned way, in acute hospitals;

b the large number of community services, which are intended to reduce the reliance on the acute sector, are fragmented and

poorly co-ordinated; and

c planning and development of services for patients with chronic conditions have been insufficiently integrated.

We made a total of seven recommendations focusing on the following issues:

a understanding the healthcare needs of the population and the likely future demand for services;

b mapping the current services and improving the ongoing monitoring of service performance;

c improving the co-ordination of chronic condition services;

d improving awareness of the services that are available and developing wider approaches to self-care;

e improving the adequacy of financial, performance and clinical information;

f finding sustainable funding solutions to support the reconfiguration of services; and

g managing chronic conditions services in a more holistic and sustainable way.



Services for children and young people with emotional and mental health needs: November 2009

Ongoing work relevant to unscheduled care

Adult mental health follow-up

The Wales Audit Office published a report in October 2005 that concluded that although there were

encouraging examples of good practice, the overall way in which adult mental health services were

planned, organised and funded did not support delivery of the National Service Framework. In particular

the review found:

a significant gaps in key elements of service delivery were preventing the full implementation of

the NSF;

b scope for greater integration and co-ordination of adult mental health services across different agencies

and care sectors;

c the approach to empowering and engaging service users and carers varied considerably; and

d planning and commissioning arrangements did not fully support the development of whole system

models of care.

We carried out this review of child and adolescent mental health services (CAMHS) jointly with Healthcare Inspectorate Wales.

The review was also supported by Estyn and the Care and Social Services Inspectorate Wales. Our main conclusion was that

despite some improvements in recent years, services are still failing many children and young people, reflecting a number of

key barriers to improvement.


a comprehensive services are still not in place despite some important developments in services that focus on prevention,

early intervention and supporting those with less severe problems;

b some specialist services in the community are not provided within Wales and there are unacceptable variations in the

availability and quality of those services that are provided;

c there are important weaknesses with specialist inpatient and residential services;

d it is unclear how policy should be implemented;

e there are fundamental weaknesses with the approach to service development;

f there are important challenges in developing an appropriate workforce for delivering CAMHS; and

g although there is emerging evidence that performance management arrangements within the NHS are becoming more

robust, further development is needed.

We made a total of five recommendations focusing on the following issues:

a reviewing the way services are organised and delivered to ensure the outcomes envisaged in the national CAMHS strategy

are achieved;

b developing a national plan and local implementation plans to address issues regarding quality and availability of services;

c addressing the weaknesses in local and national performance monitoring;

d developing an appropriately skilled and experienced CAMHS workforce; and

e taking a number of specific steps to address situations where service providers are putting children and young people

at risk.


76

Our ongoing follow-up report seeks to assess whether the response by the Assembly Government, NHS

bodies and local authorities has been sufficient to address the gaps and variations in service provision that

we identified previously.

For further details, please contact project manager Steve Ashcroft ([email protected]/

02920 320500).

Informing Healthcare

Informing Healthcare is a 10-year national programme, which is intended to develop new ICT methods,

tools and information technologies. This study sets out to answer the question – ‘Is the Informing

Healthcare programme set up for success?’.

The study will be looking at the effectiveness of the programme’s strategy, whether the programme has the

means for delivering the strategy and whether the programme is being reviewed effectively.

For further details, please contact project manager Mandy Townsend ([email protected]/

01244 525975).




Appendix 3 - Detailed findings regarding out-of-hours

unscheduled care services

1 This appendix provides our detailed findings

on unscheduled care services provided out of

hours. We have not reported separately on

out-of-hours care, or provided detailed

recommendations, because the key

conclusions of our overall review of

unscheduled care relate to the overall design

and delivery of the whole range of

unscheduled care services. Consequently,

the future design and role of out-of-hours

care needs to be considered in the context

of the design of the overall system. This

appendix sets out the key issues in terms

of out-of-hours care.

Arrangements for out-of-hours primary and

social care are not consistent

2 Most health and social care is delivered

during the working day. The most common

services are those for primary care and social

care. Currently, more than three million people

are registered with a general practice in

Wales and account for roughly 17 million

primary care consultations during normal

working hours each year65 while

approximately 150,000 people are supported

with social care services66. Sometimes

individuals need care outside the normal

working day and such care is known as

out-of-hours care.

3 The aim of primary care out-of-hours services

is to ensure individuals with urgent primary

care needs, which cannot wait until the next

available in-hours surgery, are met and that

other patients accessing the service are given

appropriate advice and information.

Social services’ emergency duty teams

provide support outside office hours by

responding to referrals about individuals,

who may be, or may not be, known to them

or the social service department. Local

authorities responding to our survey told us

that the emergency duty teams aim to ensure

the safety of individuals until the next working

day, when the full range of services is

available.

4 The primary care out-of-hours period is

defined as from 6:30pm until 8:00am on

weekdays, and all weekends, bank holidays

and public holidays. Data for one of our study

sites shows that the greatest demand for

primary care out-of-hours services is at

weekends (Figure 10), with two-thirds

(66.5 per cent) of the calls logged by the

primary care out-of-hours service occurring at

the weekend. The social care out-of-hours

period is similar to that for primary care

services but starts generally an hour earlier.

5 The arrangements for the emergency duty

teams vary across local authority areas. Four

local authorities have their own dedicated

emergency duty teams, who are office based,

while three rely on daytime social workers to

work a rota to provide cover out of hours, with

65 The Primary Care Foundation’s report ‘Urgent care - a practical guide to transforming same-day care in general practice’, published in 2009, estimates that 300 million primary

care consultations take place each year across 9,000 practices in England. There are 53.9 million patients registered with GP practices in England, which equates to an average

of 5.6 consultations per registered patient per year. There are roughly 3.1 million registered patients in Wales and if we assume that the rate of patient consultations is the same,

then there are approximately 17 million primary care consultations each year in Wales.

66 Welsh Assembly Government, A Strategy for Social Services in Wales Over the Next Decade, Fulfilled Lives, Supportive Communities, February 2007


78

some on call from their own homes. Fifteen

local authorities collaborate by commissioning

or jointly funding the emergency duty teams.

6 The arrangements for providing primary care

out-of-hours services differ across Wales,

ranging from LHB provision, GP

co-operatives, commercial organisations

or a combination of service provision,

such as those in Swansea, Gwynedd and

Anglesey where NHS Direct Wales provides

the call handling and telephone triage. Like

some local authorities, some of the former

LHBs collaborated to contract jointly for

primary care out-of-hours services or to

directly provide these services.

Understanding of demand for out-of-hours

primary and social care services is

activity-driven rather than based on a full

understanding of demand across the system

7 In many areas, demand for social services

formed part of the needs assessment more

generally for the Health, Social Care and

Wellbeing Strategy or the Community Service

Plan. Several local authorities responding to

our survey told us that they had carried out an

analysis of demand when establishing their

emergency duty teams but there is little

evidence that local authorities undertake a

holistic analysis of need or demand for social

care out of hours.


Figure 10 - Number of calls logged by one primary care out-of-hours provider between 1 February

2009 and 28 February 2009

0

20

40

60

80

100

120

140

160

Sun

Mon

Tues

Wed

Thur

s

Fri

Sat

Sun

Mon

Tues

Wed

Thur

s

Fri

Sat

Sun

Mon

Tues

Wed

Thur

s

Fri

Sat

Sun

Mon

Tues

Wed

Thur

s

Fri

Sat

N=1,542

Source: Wales Audit Office analysis of data provided by one former LHB



8 Most local authorities have a system in place

to collect and monitor data on activity,

including the number of referrals and analysis

of types of activity. There are also formal

reporting arrangements, for example to heads

of services and directors. In Pembrokeshire,

for example, monthly statistics are compiled

on the number of requests for unplanned,

urgent or emergency care packages or

requests for accommodation out of hours and

at weekends.

9 The former LHBs responding to our survey

perceived out-of-hours social services as

neither effective nor ineffective but some

expressed concerns about the availability of

social services particularly over the holidays

and the inability to put new packages of care

in place out of hours. Local authorities told us

that additional support out-of-hours can be

provided in an emergency for individuals

already in receipt of home care services by

calling out home care staff overnight if

necessary.

10 There is little evidence that needs

assessments, or demand analysis, for primary

care out-of-hours services is undertaken in a

systematic way with the former LHBs waiting

until such time as the need arises to

reconfigure services or when tendering for

services. Instead, the former LHBs tended to

monitor the demand for out-of-hours services

based on the volumes of calls to service

providers and subsequent attendances at

out-of-hours primary care centres. However,

the nature of the demand or reasons for

contacting primary care out-of-hours services

is often unknown. Based on data provided by

one primary care out-of-hours service

provider, the three top symptoms experienced

by patients were abdominal pain, coughs and

fevers (Figure 11).

11 In addition to monitoring the volume of activity

of out-of-hours providers, LHBs, working with

local A&E departments and minor injury units,

tried to quantify the number of A&E

attendances that might be seen more

appropriately by primary care professionals.

For example, an audit of attendances at the

Prince Charles Hospital A&E department

Figure 11 - Top 12 symptoms of patients calling

one primary care out-of-hours service areas

during 2008-09

Symptoms Percentage of calls

Abdominal pain 6.4%

Cough 4.9%

Fever 4.8%

Rash 4.5%

Breathing difficulty 4.3%

Vomiting 4.0%

Sore throat 3.7%

Ear ache 2.9%

Chest pain 2.4%

Back pain 2.0%

Medication enquiry 2.0%

Diarrhoea 2.0%

Total calls triaged 47,786

Source: Wales Audit Office analysis of data provided by one primarycare out-of-hours service


80

found that 10 per cent of the 1,175

attendances between Monday 7 October and

Sunday 13 October 2008 would have been

more appropriately managed in primary care.

Most of these primary care related

attendances took place within GP opening

hours between 8am and 6.30pm.

12 We asked the former LHBs what factors they

believed reduced or increased demand for

primary care out-of-hours services in their

area. The main factor cited was a lack of

alternative services at weekends, bank

holidays and evenings, in particular

community nursing services provided by

trusts. However, former LHBs also cited

limited access to out-of-hours pharmacy

services and dental services and difficulties

accessing in-hours primary care services, all

of which the LHBs commissioned. In relation

to in-hours access, the former LHBs had

worked with their out-of-hours providers to

identify those practices where demand for

out-of-hours access is high and where

demand surges at the start of the

out-of-hours period.

13 We asked local authorities to tell us what they

believed were the biggest problems for

people when trying to access seamless, safe

and effective unscheduled health or social

care in their areas. The main problems cited

include:

a an absence of a single point of access;

b the duplication rather than the integration

of services across health and social care;

c the lack of services 24-hours a day, seven

days a week, or the lack of services very

late at night, to support people in their own

homes, like night sitting services or home

care support;

d the lack of universal recording and

availability of client information;

e difficulties getting an ambulance to

respond to calls to nursing or residential

homes when residents with poor mobility

needed to be admitted to hospital;

f difficulties getting an ambulance to

respond when an individual needed to be

admitted to hospital under the Mental

Health Act; and

g the lack of formal arrangements with the

NHS in order for social workers to access

NHS step up/step down beds.

14 Reliable information on the total demand for

primary care out-of-hours services is

compromised by the way some calls are

recorded. We know of at least one provider

that does not routinely measure the total

number of calls to the service, instead

focusing on calls that result in clinical triage.

Other providers do measure the total

demand on the out-of-hours service but

cannot differentiate between the LHBs

covered until calls are answered and logged

onto the system.

15 Information provided by the former LHBs at

the time of our audit show that providers of

primary care out-of-hours services answered

more than half a million calls during 2007-08,

which represents three per cent of the total

number of all primary care consultations.

There was considerable variation across the

former LHBs in relation to the number of calls

per 1,000 registered patients, which is not

easily explained and might be due to

differences in the age and gender of callers

(Figure 12). A previous study showed that call

rates were lower in more rural areas and

higher in more deprived urban areas67.


67 Joanne Turnbull, David Martin, Val Lattimer, Catherine Pope and David Culliford, (2008), Does distance matter? Geographical variation in GP out-of-hours service use: an observational study. British Journal of General Practice: 58: 471–477



Figure 12 - Comparison of the number of calls answered by primary care out-of-hours providers

in 2007-08

Former local health boards* Total number of calls

answered

Number of calls

answered per 1,000

registered patients

Bridgend 20,311 133.7

Gwynedd and Anglesey 27,448 143.9

Swansea 35,338 144.1

Ceredigion 14,574 154.2

Neath Port Talbot 21,354 154.5

Gwent – Blaenau Gwent, Torfaen, Caerphilly, Newport and

Monmouthshire92,413 157.3

Flintshire 24,981 169.8

Carmarthenshire 30,121 173.1

Rhondda Cynon Taf and Merthyr Tydfil 52,158 174.4

Conwy and Denbighshire 37,956 176.5

Vale of Glamorgan 21,544 185.8

Wrexham 26,631 188.2

Cardiff 68,001 189.2

Pembrokeshire 25,931 220.5

Powys 31,334 228.9

Wales 530,095 170.2

*Some of the former LHBs worked collaboratively to commission or provide primary care out-of-hours services. Consequently, data were provided for the whole community.

Source: Wales Audit Office analysis of data provided by the former LHBs; registered populations derived from Welsh Assembly Government,General Medical Practitioners in Wales, September 2008, SDR 44/2009


82

However, rates in Pembrokeshire and Powys

are higher with a high proportion of calls

resulting in a home visit (see Figure 14).

The high rate in Cardiff may reflect ease of

access in relation to the shorter distances to

primary care centres and the subsequent

lower proportion of home visits.

16 Primary care out-of-hours services need to

provide timely and effective clinical triage.

It is essential that patients are provided with

the appropriate intervention either over the

phone, at the out-of-hours centre or in their

own home. Clinical assessment or triage

should then determine whether it is

necessary to:

a make a referral to the appropriate

professional;

b advise the individual to contact their GP

practice the next day; or

c provide advice and information for self care

over the phone.

The process may end at this point if the

triage does not identify the need for further

clinical input.

17 Individuals are normally expected to attend

primary care centres when notified of an

appointment time. Home visits are generally

reserved for people who are housebound,

or when travelling to the primary care centre

is clinically inappropriate or otherwise

undesirable. Home visits are made in

emergency cases, or where exceptional social

circumstances exist, for example for frail

elderly people or those who are terminally ill.

Approximately, one in eight calls to the

primary care out-of-hours services results in a

home visit (Figure 13) and based on data

from one of our study sites more than half of

the home visits were categorised as

non-urgent. There is considerable variation

across the former LHBs (Figure 14) and may

account for some of the difference in service

costs (See Figure 17), where home visits in

more rural areas have a long job-cycle time

due to distance and poor road networks with

low average speeds.

18 It is difficult to estimate the total demand on

emergency duty teams across Wales in

relation to the number of referrals each year.

Just under half of the local authorities

responding to our survey provided data on the

number of referrals to social service

emergency duty teams. There were at least

26,000 out-of-hours referrals to emergency

duty teams across 10 local authorities where

data are available68.

19 Figure 15 shows a downward trend in the

number of referrals to two local authorities

visited as part of our audit. Three-quarters of

referrals were made by clients or their

relatives (32 per cent), departmental social

workers (20 per cent), healthcare services


Figure 13 - Outcome of contacts made with

primary care out-of-hours services

Calls to primary care

out-of-hours services

that resulted in:

Percentage

An attendance at a primary care centre 47

Telephone advice 38

A home visit 12

Advice to go to A&E 2

999 referral 1

Source: Wales Audit Office analysis of data provided by former LHBs

68 These local authorities are Blaenau Gwent, Caerphilly, Torfaen, Newport, Monmouthshire, Rhondda Cynon Taf, Merthyr Tydfil, Bridgend, Swansea and Conwy.



(13 per cent) and the police (nine per cent)

(Figure 16). Only a small proportion of

referrals from Rhondda Cynon Taf and

Merthyr Tydfil (five per cent and eight per cent

respectively) result in a visit with most of

these visits related to mental health, child

protection and youth offending.

Annual expenditure on out-of-hours services

for primary and social care is estimated at over

£35 million, with rurality and geographical

factors driving some of the cost

20 Expenditure on all personal social services

totalled £1.3 billion in 2007-0869. However, the

proportion of expenditure on the element of

services provided out of hours for example,

night sitting or domiciliary care packages, is

not easily identifiable because it is subsumed

within the wider costs of social care packages

for individuals. Of the £1.3 billion expenditure

on personal social services, we estimate that

0.3 per cent (£4.3 million) was spent on the

direct costs of the emergency duty teams with

costs ranging from £83,000 to £385,000

across local authority areas.

21 Expenditure on primary care out-of-hours

services totalled £31.45 million in 2008-09,

ranging from £528,000 to £2.7 million across

the 22 former LHBs (median expenditure

totalled £1.2 million). Expenditure on primary

Figure 14 - Percentage of contacts with

primary care out-of-hours services that resulted

in a home visit in 2007-08

*Data provided by Powys tLHB for April 2009 suggest that 15.7 per cent of calls

answered by primary care out-of-hours services result in a home visit.

Source: Wales Audit Office analysis of data provided by former LHBs

Former local health

boards

Percentage of

contacts with primary

care out-of-hours

services that result in

a home visit

Swansea 6.0

Rhondda Cynon Taf and

Merthyr Tydfil6.9

Cardiff 7.5

Wrexham 10.6

Flintshire 10.6

Conwy and Denbighshire 11.1

Bridgend 12.1

Vale of Glamorgan 12.2

Gwynedd and Anglesey 12.2

Pembrokeshire 13.4

Carmarthenshire 13.7

Neath Port Talbot 13.8

Gwent (Blaenau Gwent,

Torfaen, Caerphilly, Newport

and Monmouthshire)

15.4

Ceredigion 16.1

Powys* Not available

Wales 12.0

Figure 15 - Trend in the numbers of referrals to

the social work emergency duty team in two

local authorities

Local authority 2006-07 2007-08 2008-09

Rhondda Cynon Taf 5,050 4,713 4,144

Merthyr Tydfil 924 965 933

Source: Data derived from the report Social Work Emergency DutyTeam, Review of Referral Trends over a Three-year Period, From April2006-07 to March 2008-09

69 http://dissemination.dataunitwales.gov.uk/webview/index.jsp?language=en


84

care out-of-hours accounted for seven per

cent of the total £445 million expenditure on

GMS even though the out-of-hours period

represents nearly 70 per cent of the time each

week. The cost of primary care out-of-hours

services is higher in more rural and larger

geographical areas with the average cost per

registered patient £10.10, ranging from £7.25

in Swansea to £19.68 in Pembrokeshire

(Figure 17). The variation in costs is similar to

that seen in Scotland, with higher costs in

more remote or rural areas70. Apart from

rurality and geographical spread and high

demand, as measured by calls per 1000

registered patients (see Figure 12), some

variation in costs might arise from differences

in the scope of the contracts. For example, in

Powys the contract includes medical cover for

community hospitals.


Figure 16 - Source of referrals to the social work emergency duty team in Rhondda Cynon Taf and

Merthyr Tydfil for the second half of 2008-09

0% 5% 10% 15% 20% 25% 30%

Merthyr Tydfil (n=543)

Rhondda Cynon Taf (n=2,346)

Homecare (local authority)

Private agency adults

Residential establishment (Children)

Other social workers (eg NSPCC)

Residential establishment (other)

Others

Neighbour

Health service (community)

Client

Foster care (local authority)

Private agency (children)

Health service (hospitals)

Relative

Police

Deparmental social workers and support staff

Source: Data derived from the report Social Work Emergency Duty Team, Second Half, Weeks 27-52, 2008-09

70 Audit Scotland, Primary care out-of-hours service, August 2007



There are weaknesses in monitoring the

performance of primary care out-of-hours

services because the focus is on time standards

rather than outcomes

22 Providers of primary care out-of-hours

services need to deliver high quality services.

Under the primary medical care contract

introduced in April 2004, all those providing

out-of-hours services were required to meet

eight minimum quality standards until a more

comprehensive set of standards was

developed71. The former LHBs could specify

additional clinical standards within their own

contract.

23 Subsequent revisions to the Out-of-hours

Quality Standards were made in 2006 and a

more detailed set of standards was

developed, the ‘Wales Quality and Monitoring

Standards in the Delivery of Out-of-Hours

Services’. Figure 18 compares the 2004

standards with those proposed in 2006. The

most notable inclusion is the requirement to

audit the patient experience, which some

former LHBs, like Gwynedd and Anglesey,

were already doing and more detail about the

face-to-face contact. However, the 22

standards proposed in 2006 were not formally

adopted, but some out-of-hours providers are

using them.

Figure 17 - Expenditure on primary care out-of-hours services per registered patient in 2008-09

0

5

10

15

20

25

Pem

brok

eshi

re

Pow

ys

Cer

edig

ion

Car

mar

then

shire

Mon

mou

thsh

ire

Ang

lese

y

Bla

enau

Gw

ent

Con

wy

Gw

yned

d

Cae

rphi

lly

Den

bigh

shire

Torfa

en

Mer

thyr

Tyd

fil

Flin

tshi

re

Nea

th P

ort T

albo

t

New

port

Vale

of G

lam

orga

n

Wre

xham

Rho

ndda

Cyn

on T

af

Brid

gend

Car

diff

Sw

anse

a

Wal

es

Exp

endi

ture

on

prim

ary

care

out

-of-h

ours

se

rvic

es p

er re

gist

ered

pat

ient

(£) i

n 20

08-0

9

Source: Wales Audit Office analysis of data from the consolidated accounts of former LHBs; registered populations derived from Welsh AssemblyGovernment, General Medical Practitioners in Wales, September 2008, SDR 44/2009

71 http://www.wales.nhs.uk/sites3/Documents/480/OutofHoursQualityStandards.pdf



Figure 18 - Comparison of Out-of-hours Quality Standards in 2004 and 2006

Out-of-hours Quality Standards

2004 2006 (proposed)

Governance arrangements

Review of out-of-hours records

a Providers must review a one per cent sample of records

relating to out-of-hours treatment to ensure they meet

appropriate standards. The review should be carried out

by a suitably experienced primary care practitioner.

Review of out-of-hours records

a Providers must regularly audit a random sample of patient

contacts. The audit must be led by a clinician with

suitable experience in providing out-of-hours care.

Transmission of out-of-hours data to GP practices

a Ninety per cent of transmissions must be sent by 9.00am

and all transmissions by 10.00am the following morning.

The schedule should include details of how clinically

urgent contacts are advised to the appropriate GPs.

Transmission of out-of-hours data to GP practices

a providers must send details of all out-of-hours

consultations (including appropriate clinical information) to

the practice where the patient is registered by 9am the

next working day; and

b providers must have systems in place to support and

encourage the regular exchange of up-to-date and

comprehensive information between all those who may be

providing care to patients with predefined needs, for

example patients with a terminal illness.

Not included Patient experience

a Providers must regularly audit a random sample of

patients’ experiences of the service (for example one per

cent per quarter) and appropriate action must be taken on

the results of those audits.

Employment checks

a for doctors, inclusion on an LHB Welsh Medical

Performers List;

b for nurses UKCC registration; and

c for drivers, checks on driving licences, medical

contraindications and annual rechecks on licences.

Employment checks

a Providers must undertake all appropriate employment

checks and ensure professionally qualified staff are

registered with the appropriate bodies and require that all

employed professionals abide by relevant published codes

of professional practice.

Communication

a patients unable to communicate effectively in English or

Welsh will be provided with an interpretation service within

15 minutes of initial contact; and

b providers must comply with the requirements of the Welsh

language and when requested provide bilingual

information to patients.




Governance arrangements

Meeting needs of patients with disabilities or impairments

a Providers must also make appropriate provision for

patients with impaired hearing or impaired sight and meet

the requirements of the Disability Discrimination Act.

Education and training

a LHBs and their providers must ensure that a process is in

place to allow GP Registrars to undertake appropriate

training in out-of-hours provision; and

b providers must be able to demonstrate a commitment to

staff development and training commensurate with their

work:

- appropriately recruited, trained and qualified for the

work they undertake;

- participate in mandatory training programmes; and

- participate in further professional and occupational

development.

Complaints procedure

(Must follow the recognised standards for acknowledgements

and full responses as detailed in the NHS complaints

procedures.)

Complaints procedure

(Consistent with the principles of the NHS Complaints

Procedure.)

Significant effect reporting

(Model advised by the Royal College of General Practitioners

or similar.)

Patient safety incidents

a Process and procedures to identify and learn from patient

safety incidents and other reportable incidents.

Timely access and high quality and safe services

Number of abandoned calls

a no more than 0.5 per cent calls engaged; and

b no more than five per cent calls abandoned.

Call handling

a seventy-five per cent of calls to be answered within 60

seconds; and

b all calls to be answered within 120 seconds.

Initial telephone call:

Abandoned calls:a no more than five per cent of calls abandoned after 60

seconds.

Time taken for the call to be answered by a person:a ninety per cent of calls must be answered within 60

seconds of the end of the introductory message, which

should normally be no more than 30 seconds long;

b where there is no introductory message, 90 per cent calls

must be answered within 30 seconds; and

c all calls must be answered within 180 seconds.





Identification of life threatening conditions

a one hundred per cent identified within five

minutes.

Telephone clinical assessment (triage)

Identification of immediate life threatening conditions;a Providers must have a robust system for identifying all immediate

life-threatening conditions and, once identified, those calls must be

passed to the ambulance service within a maximum of three

minutes.

Definitive clinical assessment

a providers that can demonstrate that they have a clinically safe and

effective system for prioritising calls, must meet the following

standards:

- start definitive clinical assessment for urgent calls within 20

minutes of the call being answered by a person;

- start definitive clinical assessment for all other calls within 60

minutes of the call being answered by a person; and

- providers that do not have such a system, must start definitive

clinical assessment for all calls within 20 minutes of the call

being answered by a person.

Outcome

a At the end of the assessment, the patient must be clear of the

outcome, including (where appropriate) the timescale within which

further action will be taken and the location of any face-to-face

consultation.

Time taken until patient seen by healthcare

professional

a emergency/very urgent episodes within one hour;

b urgent episodes within two hours; and

c less urgent episodes with six hours.

Face-to-face clinical assessment (Triage)

Identification of immediate life-threatening conditionsa providers must have a robust system for identifying all immediate

life-threatening conditions and, once identified, those patients must

be passed to the most appropriate acute response (including the

ambulance service) within a maximum of three minutes.

Definitive clinical assessmenta providers that can demonstrate that they have a clinically safe and

effective system for prioritising patients, must meet the following

standards:

- start definitive clinical assessment for patients with urgent

needs within 20 minutes of the patient arriving in the centre;

and

- start definitive clinical assessment for all other patients within

60 minutes of the patient arriving in the centre.

b providers that do not have such a system, must start definitive

clinical assessment for all patients within 20 minutes of the

patients arriving in the centre.

Outcomea At the end of the assessment, the patient must be clear of the

outcome, including (where appropriate) the timescale within which

further action will be taken and the location of any face-to-face

consultation.



24 The out-of-hours quality standards measure

the processes and procedures underpinning

the delivery of primary care out of hours

rather than necessarily measuring the quality

of services provided to patients. The

measures are numerous and highly detailed

which risks over-specifying the system rather

than providing professional staff with sufficient

room to exercise appropriate clinical

judgements. A system of clear performance

indicators focused on patient care out of

hours is not yet in place, and among the

former LHBs while half perceived the quality

standards to be adequate, a number of

concerns were raised, namely:

a the standards are not necessarily

measured in the same way to allow

meaningful comparisons across LHBs or

service providers;

b additional measures should be included to

measure the extent of integration, such as

the number and percentage of patient

transfers between A&E and out-of-hours

services; and

c the standards need to include clinical

quality or outcome measures.

25 There is no national benchmarking and

performance monitoring of primary care

out-of-hours services. During the first 12

months of the contract, LHBs reported

achievement against the quality standards to

the regional offices, who in turn reported

periodically to the Assembly Government.

Subsequently, performance has been

monitored through clinical governance

processes and standards for primary care

out-of-hours services are not included in the

NHS annual performance management

framework. The former LHBs responding to

our survey did tell us that they discussed

performance against the quality standards

with their Assembly Government regional

office but discussions were infrequent and for

some this was by exception.

26 Former LHBs told us that they receive

monthly information in relation to compliance

with the quality standards from their

out-of-hours providers but examples of these

reports were limited to achievement in relation

to response times and call outcome rather

than the quality of clinical care based on the

audit of records. Former LHBs also took

different approaches to disseminating the

information internally, with some for example

including out-of-hours activity in monthly

performance reports to the former LHB



Face-to-face consultations (whether in a centre or in the

patient’s place of residence) must be started within the following

timescales, after the definitive clinical assessment has been

completed:

a very urgent: within one hour;

b urgent: within two hours; and

c less urgent: within a maximum of six hours.


90

boards while others prepared quarterly

reports for commissioning groups or

community health councils. In England,

the Care Quality Commission is undertaking

a review of one provider of primary care

out-of-hours services following the death of

patient in 2008. It found that although PCTs

monitored response times, they did not look

closely enough at the quality of clinical

decisions72. In light of the Care Quality

Commission’s early findings, health boards

should assure themselves that current

reporting arrangements are adequate.

27 A survey conducted during 2007-08 by the

Board of Community Health Councils in

Wales found that nearly half of the

respondents believed that primary care

out-of-hours services were excellent,

while the overall number of complaints was

relatively low73, totalling 194 in 2007-08.

This is the equivalent of 3.8 complaints

per 10,000 calls answered. Reasons for

complaints made to the primary care

out-of-hours provider in one of our study

sites included delays in the provision of

care, staff attitude and poor clinical care.

There are disjointed information flows between

health and social care out-of-hours services

28 Effective communication is important between

staff providing social care services in hours

and those providing services out of hours.

For example, day-time staff may need to pass

on contingency plans to the emergency duty

team or contact details when responding to

emergencies out of hours. It is often more

straightforward to communicate with

out-of-hours services which have an office

base, a full-time team and which work with

only one local authority. In those areas where

there is a shared service, there may be

difficulties in accessing information from all

the local authorities involved. In those areas

which rely on daytime staff doing occasional

sessions and working from home, such as

Powys, communication may be more

problematic.

29 A report in 2009, Review of the CareProgramme Approach in Wales74, found that

information management arrangements did

not effectively support the delivery of care.

Social workers were reportedly unable to

access health records and similarly

healthcare staff were unable to access social

services records. This is problematic during

times of crisis and out of hours when client

information is required promptly. The report

was calling for information sharing protocols

to be implemented to improve care.


72 http://www.cqc.org.uk/newsandevents/pressreleases.cfm?cit_id=35381&FAArea1=customWidgets.content_view_1&usecache=false

73 Welsh Assembly Government, Complaints about Family Health Services by LHB (http://www.statswales.wales.gov.uk/TableViewer/tableView.aspx)74 Welsh Assembly Government Delivery Support Unit and the National Leadership and Innovation Agency for Healthcare, Review of the Care Programme Approach in Wales 2009



Appendix 4 - Detailed analysis of ambulance trust

performance

1 Our previous reports on the Welsh Ambulance

Services NHS Trust have highlighted some

serious concerns about the responsiveness

of ambulance services75 76 77. This appendix

provides more up-to-date information

regarding the performance of the

ambulance trust.

2 The main response time target that the

Assembly Government has set for the

ambulance trust is that it should, at an

all-Wales level, respond to 65 per cent of

Category ‘A’ (life-threatening) calls within

eight minutes. The eight minutes is not an

arbitrary timeframe but is derived from

evidence that patients with specific

emergency medical conditions are more

likely to have a positive outcome if they

receive care within eight minutes.

3 In the last of our reports on the ambulance

trust, we found that performance had dipped

significantly across a range of measures since

June 2008. However, Figure 19 shows that

compliance with the eight-minute Category ‘A’

target has improved since December 2008,

and the 65 per cent target was achieved

consistently between March 2009 and

October 2009 except during July and

August 2009.

Figure 19 - The proportion of Category ‘A’ incidents to which the ambulance trust responded to

within eight minutes across Wales has improved since December 2008

Jan

08

Feb

08

Mar

08

Apr

08

May

08

June

08

July

08

Aug

08

Sep

08

Oct

08

Nov

08

Dec

08

Jan

09

Feb

09

Mar

09

Apr

09

May

09

June

09

80

70

60

50

40

30

20

10

0

Welsh Assembly Government target

Per

cent

age

of C

ateg

ory

‘A’ c

alls

re

spon

ded

to w

ithin

eig

ht m

inut

es

July

09

Aug

09

Sep

09

Oct

09

Source: Wales Audit Office analysis of Assembly Government data

75 Auditor General for Wales, Ambulance services in Wales, December 2006

76 Auditor General for Wales, Follow up review – Ambulance services in Wales, June 2008

77 Auditor General for Wales, Ambulance services in Wales – further update to the National Assembly for Wales’ Audit Committee, March 2009


92

4 Despite the improved Category ‘A’

performance at an all-Wales level, there

remains significant variation between and

within the 22 unitary authority areas. In April

2008, the Assembly Government set a target

that the Trust should respond to 60 per cent

of Category ‘A’ calls within eight minutes in

each of the 22 unitary authority areas in

Wales. Figure 20 shows that in many unitary

authority areas between January 2008 and

June 2009, there was considerable variation

between the highest and the lowest monthly

performance. The figure also shows that

there remains considerable variation in

performance between different unitary

authority areas. Whilst four areas

consistently met the 60 per cent target,

two areas did not meet the target during

any month over this period.

5 To its credit, the ambulance trust has taken

the positive step of measuring the proportion

of cardiac arrest and chest pain calls that it

responds to within four minutes. Again, this

four-minute timeframe is not arbitrary, it is

based on evidence that these patients are

more likely to have a positive outcome if they

receive the necessary treatment within four

minutes. Figure 21 shows that the trust’s

performance regarding these calls has

improved since December 2008.


Figure 20 - There was considerable variation in the highest and lowest monthly Category ‘A’

response time performance in unitary authority areas between January 2008 and June 2009

Mon

thly

per

cent

age

of C

ateg

ory

‘A’

resp

onse

s w

ithin

eig

ht m

inut

es

0

10

20

30

40

50

60

70

80

90

Welsh Assembly Governmenttarget




6 The ambulance trust often provides an initial

response through service models other than

sending a double-crewed ambulance, for

example by using single-crewed rapid

response vehicles or community responders

to reach people as quickly as possible.

Consequently, additional targets exist for the

timeliness with which a fully equipped

ambulance backs up the Trust’s initial

response, with variable timescales to provide

backup according to whether the area is

urban, rural or sparsely populated. Figure 22

shows that since December 2008, the trust

has improved performance towards the 95

per cent target of providing fully equipped

ambulance responses within either 14, 18

or 21 minutes.

Figure 21 - Since December 2008, the trust has improved its performance of responding to

incidents of cardiac arrest and chest pain calls within four minutes

27

24

21

18

Jun

07

Aug

07

Oct

07

Dec

07

Feb

08

Apr

08

Jun

08

Aug

08

Oct

08

Dec

08

Feb

09

Apr

09P

erce

ntag

e of

car

diac

ar

rest

/che

st p

ain

resp

onse

s w

ithin

four

min

ute

Cat A4 - codes 9 and 10

Source: Welsh Ambulance Services NHS Trust, Trust Board Operational Performance – July 2009



Figure 22 - The trust has improved its performance towards its target to provide fully equipped

ambulance responses

Feb

08

Mar

08

Apr

08

May

08

June

08

July

08

Aug

08

Sep

08

Oct

08

Nov

08

Dec

08

Jan

09

Feb

09

Mar

09

Apr

09

May

09

June

09

July

09

95

90

85

80

75

70

65

60


Average for Wales, fully equipped ambulance response to Category ‘A’ incidents within 14, 18, 21 minutes

Per

cent

age

of C

ateg

ory

‘A’ i

ncid

ents

w

ithin

14,

18,

21

min

utes

Source: Wales Audit Office analysis of data from the Welsh Ambulance Services NHS Trust



Appendix 5 - Detailed analysis of access to emergency

departments and staffing

1 In this appendix we expand on the issues

introduced in paragraphs 1.24 to 1.27 to

consider the factors that can affect access

to hospital emergency departments.

We have also included further data

and discussion regarding emergency

department staffing levels.

2 Analysis of the average waiting time that

people face in emergency departments from

arrival to admission, transfer or discharge,

shows a positive trend in performance.

Figure 23 shows that the average waiting time

reduced in seven major emergency

departments between 2003-04 and 2007-08.

Figure 23 - The average waiting time has decreased in seven major emergency departments

since 2003-04

0

50

100

150

200

250

2007 - 082003 - 04

Aver

age

time

take

n fro

m a

rriv

al to

dep

artu

re (m

inut

es)

Note: Data from the Acute Hospital Portfolio for 2003-04 was not available for Princess of Wales Hospital. Trusts were unable to provide data for 2007-08 for Bronglais General

Hospital, University Hospital of Wales and West Wales General Hospital.

Source: Wales Audit Office survey of NHS trust chief executives and Acute Hospital Portfolio 2003-04


96

3 Performance against the national target for

emergency department waiting times dipped

significantly during 2008 but there have been

improvements during 2009. The Assembly

Government’s Annual Operating Framework

includes targets for the NHS stating that 99

per cent of patients should spend no more

than eight hours in a major emergency

department awaiting admission, transfer or

discharge78. The target also states that 95 per

cent of all new patients in these departments

should spend no longer than four hours from

arrival until admission, transfer or discharge.

Figure 24 shows that all-Wales performance

against the four-hour target has increased

from a low base during 2009 but remains

well below the target level.

4 The Welsh Emergency Care Access

Collaborative (WECAC) was a two-year

programme delivered by NLIAH that had the

overarching aim of improving access to

emergency care. The programme involved

local organisations carrying out project work

focusing on improving access. Data

presented within the collaborative’s final

report in October 2006 suggested that the

programme had contributed to an

improvement in the all-Wales compliance

with the four and eight hour access targets79.

Figure 25 shows that in major Welsh

emergency departments, compliance with

both targets improved over the duration of the

programme. But the figure also shows that

since the end of the programme, all-Wales

performance has deteriorated, almost to

pre-programme levels.


Figure 24 - The performance of emergency departments against the four-hour access target

has improved during 2009 but remains below target

96

94

92

90

88

86

84

82

80


June

06

Aug

06

Oct

06

Dec

06

Feb

07

Apr

07

Jun

07

Aug

07

Oct

07

Dec

07

Feb

08

Apr

08

Jun

08

Aug

08

Oct

08

Dec

08

Feb

09

Apr

09

June

09P

erce

ntag

e of

pat

ient

s w

ho le

ft th

e de

partm

ent

with

in fo

ur h

ours


78 Welsh Assembly Government, NHS Wales: Annual Operating Framework 2009/2010, AOF 7, December 2008.

79 National Leadership and Innovation Agency for Healthcare, Welsh Emergency Care Access Collaborative, Final Report: April 2004 – March 2006, October 2006.



5 The College of Emergency Medicine

considers proper staffing to be the single

most important factor in providing high quality,

timely and clinically effective care in

emergency departments80. We found that

issues with staffing in emergency departments

may be contributing to delays for patients.

A common theme emerging from our

fieldwork interviews was that senior clinical

decision making is not happening early

enough within the emergency department.

The delay in decision making adds to the time

patients spend in emergency departments

and delays patients from receiving the

treatment they need. Data regarding the

hours of cover provided by consultants within

emergency departments show considerable

gaps in the availability of these senior

decision makers. Figure 26 shows that the

presence of consultants in major emergency

departments is often reduced outside normal

working hours and considerably reduced at

the weekend.

6 Whilst we have not carried out a detailed

assessment of whether low staffing levels are

affecting emergency department waiting

times, we have identified shortfalls in staffing

when compared with recommendations made

by the College of Emergency Medicine.

These recommendations were made within

the college’s 2008 document The Way Ahead

2008-2012 and the recommended number of

staff varies for departments of different

sizes81. The document provides

recommended staffing levels as part of a

template for local interpretation and says that

any workforce calculations should take into

account broader workload considerations

such as the case mix, working style of the

department and support available to the

decision-making clinician. Therefore, if an

emergency department’s staffing level is

shown to fall short of the recommended

levels, this should only be taken as an

indication that staffing levels may be

inadequate and further analysis should be

carried out to better understand the local

staffing issues. When carrying out this

comparison between current staffing levels

and the levels recommended by the college,

Figure 27 shows that all major emergency

departments in Wales do not have the

recommended number of consultants, five

departments do not have the recommended

number of middle grade doctors and 10 do

not have the recommended number of junior

Figure 25 - Overall compliance with the

emergency department access targets has

reduced since the end of the Welsh Emergency

Care Access Collaborative

Percentage of patients

who spend less than

the target time in the

emergency department

from arrival to transfer,

admission or discharge

Four-hour

target

Eight-hour

target

Baseline used for WECAC

final report - September

2003 to March 2004

88 97.5

Data relating to the end of

the WECAC programme –

September 2005 to March

2006

92 99.1

September 2008 to March

2009 (Stats Wales)89 98

Source: WECAC final report and Wales Audit Office analysis of StatsWales data

80 The College of Emergency Medicine, The Way Ahead 2008-2012: Strategy and guidance for Emergency Medicine in the United Kingdom and the Republic of Ireland,December 2008

81 The College of Emergency Medicine, The Way Ahead 2008-2012: Strategy and guidance for Emergency Medicine in the United Kingdom and the Republic of Ireland, December 2008


98

doctors. The College of Emergency Medicine

is currently revising its recommended staffing

levels to state that emergency departments

seeing between 50,000 and 60,000 patients

per year should have a minimum of 10

consultants.

7 An additional staffing problem that Welsh

emergency departments are currently facing

is a high level of vacancies for middle grade

doctors. Figure 28 shows that five of the

emergency departments had vacant middle

grade posts at 31 March 2008. The situation

was particularly severe at the Royal Gwent

Hospital where 14.7 out of the 22.8


Figure 26 - There are some considerable gaps in the availability of consultants within hospital

emergency departments, particularly at weekends

0 300 600 900 1200 1500 1800 2100

Wrexham Maelor Hospital (Weekday)Wrexham Maelor Hospital (Weekend)Princess of Wales Hospital (Weekday)Princess of Wales Hospital (Weekend)

Royal Gwent Hospital (Weekday)Royal Gwent Hospital (Weekend)

Withybush General Hospital (Weekday)Withybush General Hospital (Weekend)

Prince Charles Hospital (Weekday)Prince Charles Hospital (Weekend)

University Hospital of Wales (Weekday)University Hospital of Wales (Weekend)

Ysbyty Gwynedd (Weekday)Ysbyty Gwynedd (Weekend)

Royal Glamorgan Hospital (Weekday)Royal Glamorgan Hospital (Weekend)

West Wales General Hospital (Weekday)West Wales General Hospital (Weekend)

Bronglais General Hospital (Weekday)Bronglais General Hospital (Weekdend)

Morriston Hospital (Weekday)Morriston Hospital (Weekend)Ysbyty Glan Clwyd (Weekday)Ysbyty Glan Clwyd (Weekend)Nevill Hall Hospital (Weekday)Nevill Hall Hospital (Weekend)

Duration of consultant cover in emergency department (time of day)

Note: These data were correct as of 31 March 2008. At this time, consultant cover in the emergency department at Withybush General Hospital was being trialled between 9am and

5pm. This trial has now ended and there is currently no consultant cover in the department at weekends. The consultant coverage at UHW at weekends is not during set hours but

eight hours of cover are provided. One session of consultant cover is provided at Morriston Hospital every Saturday and Sunday. Nevill Hall has approximately seven hours of cover

on weekdays and has consultant cover for one session on Saturday and Sunday. Consultant cover at the Royal Gwent Hospital is between 9am and 3pm on Saturdays and between

9am and 5pm on Sundays. There is no consultant cover at weekends at Bronglais General, West Wales General, Prince Charles and the Royal Glamorgan hospitals.

Source: Wales Audit Office analysis of NHS trust survey returns



Figure 27 - A simple comparison between the recommended and actual staffing levels in

emergency departments suggests further analysis is required to ensure adequate staffing

Consultants Middle grades Junior doctors

Recommended

number

Actual number

(WTE –

establishment)

Recommended

number

Actual number

(WTE –

establishment)

Recommended

number

Actual number

(WTE –

establishment)

Smaller units

Withybush General

Hospital4 3 8 6 8 6

Bronglais General

Hospital4 1 8 0 8 7

West Wales

General Hospital4 2 8 3 8 9

Medium units

Princess of Wales

Hospital8 4 8 8.2 12 9

Wrexham Maelor

Hospital8 4 8 9.2 12 10

Prince Charles

Hospital8 3 8 5 12 9

Royal Glamorgan 8 2 8 11 12 8

Ysbyty Gwynedd 8 3 8 8 12 8

Ysbyty Glan Clwyd 8 3.2 8 8.26 12 11

Nevill Hall Hospital 8 3 8 7.8 12 7

Morriston Hospital 8 3.7 8 9 12 15

Royal Gwent

Hospital8 5.6 8 21.8 12 12

Very large units

University Hospital

of Wales16 7 8 13.3 20 16

Note: The college defines ‘middle grade’ as a doctor with the equivalent training in emergency medicine at ST4 level or above. These doctors may be senior emergency medicine

trainees or SAS grade doctors in grades 4-8. Junior doctors are defined as post-registration doctors who have less than three years’ training in emergency medicine or emergency

medicine-related specialties. An emergency nurse practitioner is defined as an emergency medicine nurse who has undertaken formal training in the ambulatory care of patients with

injury (and/or illness) and has had an assessment of competency allowing a degree of autonomous practice. Medical staffing at the emergency department at Royal Gwent Hospital

has changed since our sample period and the department now has 6.6 consultants, 12 middle grades and 16 junior doctors, correct as of 9 November 2009. The consultant staffing

for the Royal Gwent Hospital also includes cover for Caerphilly District Miners’ Hospital. Staffing levels at Nevill Hall Hospital, as of 9 November 2009 included 4 consultants, four

middle grades and nine junior doctors.

Source: The Way Ahead and NHS trust responses to a survey from the Wales Audit Office. The data were correct as of 31 March 2008


100

establishment posts were vacant, and in the

University Hospital of Wales where 6 out of

the 13.3 establishment posts were vacant.

Three hospitals, the University Hospital of

Wales, Nevill Hall Hospital and Withybush

General Hospital were carrying consultant

vacancies in their emergency departments as

of 31 March 2008. Ysbyty Glan Clwyd was

carrying three junior doctor vacancies whilst

the Royal Gwent Hospital and Withybush

General Hospital were each carrying one

junior doctor vacancy.

8 The College of Emergency Medicine’s

document, The Way Ahead 2008-2012, also

provides recommended levels of emergency

nurse practitioners within emergency

departments. We have not compared actual

levels of these staff with the recommended

levels because of the wide variation that

exists in the definitions of these roles across

Wales82. And whilst we have not carried out

any further analysis of nurse staffing levels in

emergency departments, NHS trust chief

executives responding to our survey generally

agreed that there are too few nurses working

in their emergency departments and that the

skill mix of the nursing staff is inappropriate.


Figure 28 - Middle grade vacancies are a problem in Wales, particularly in the two busiest

emergency departments

0 10 20 30

Bronglais General Hospital

Prince Charles Hospital

Withybush General Hospital

Nevill Hall Hospital

West Wales General Hospital

Ysbyty Gwynedd

Princess of Wales Hospital

Ysbyty Glan Clwyd

Morriston Hospital

Wrexham Maelor Hospital

Royal Glamorgan Hospital

University Hospital of Wales

Royal Gwent Hospital

Posts filled

Posts vacant

Total number of middle grade doctor posts in the emergency department of each hospital

Note: These data reflect the situation at 31 March 2008.

Source: Wales Audit Office survey of NHS trust chief executives

82 Welsh Emergency Departments Federation Nurses Group Scoping Exercise of Emergency Nurses Prescribing Practices in Wales.



9 Effective use of short-stay assessment and

observation areas can have benefits for the

quality of care and efficiency within the

emergency department. However, our review

highlighted some weaknesses in the way that

such short-stay units are being used in Wales.

Our fieldwork in Pembrokeshire showed that

there was scope to considerably improve the

functioning of the new clinical decision unit at

Withybush General Hospital. Whilst the trust

is now carrying out urgent work to use the

unit as a multi-specialty adult clinical decision

unit, at the time of our fieldwork the trust had

not yet secured cultural acceptance for new

ways of working within the unit. Therefore

instead of the unit providing rapid assessment

and decisions regarding patient care, some

consultants were using the unit similarly to an

additional medical ward, with little vetting of

which patients should go to the unit and with

some patients remaining within the unit for

prolonged periods of time.

10 We also found potential problems for the

clinical decision unit that was being built as

part of the redevelopment of Wrexham Maelor

Hospital’s emergency department, entitled the

North East Wales Emergency Response Area

(NEWERA) project. Staff were concerned that

if the clinical decision was managed by

general medicine rather than by the

emergency department, it would function as

another medical ward rather than a short-stay

observation and assessment area. Our

interviews in Cardiff and Vale NHS Trust

suggested that some staff felt there was a

need to extend the hours of cover provided by

senior clinical decision makers at the trust’s

medical assessment units and that certain

inpatient specialty consultants can often be

delayed in responding to requests to attend

the medical assessment units to provide their

opinion. Since our fieldwork, Cardiff and Vale

University Health Board has revised the

arrangements for senior decision-making

presence in the medical assessment unit at

the University Hospital of Wales. There is

now a named physician with 24-hour

responsibility for making decisions about the

appropriateness of patients being brought to

the unit and the board is also considering

increasing the numbers of consultants and

acute physicians working within the

emergency department and medical

assessment unit.

11 Healthcare Inspectorate Wales’s review of the

Healthcare Standards for Wales raised

concerns about high activity levels and long

waiting times for patients in certain

supposedly short stay units83. Healthcare

Inspectorate Wales said that at the medical

assessment units at Ysbyty Glan Clwyd,

Wrexham Maelor Hospital, Prince Charles

Hospital and the University Hospital of Wales,

staff had concerns that the high throughput of

patients compromised privacy and dignity.

At Prince Charles Hospital, patients were

found to be remaining in the medical

assessment for long periods of time.

Healthcare Inspectorate Wales also found

that the medical assessment unit at

Llandough Hospital experienced significant

delays in admitting and treating service users.

These delays resulted in some patients

having to wait more than 12 hours to be

treated at Llandough.

12 In response to our survey, three trust chief

executives raised concerns about issues

regarding short stay observation or

assessment areas. These concerns included

their trust not having such areas but needing

them, insufficient capacity within these areas

and assessment areas not being located

closely enough to the emergency department.

The case studies below give details of two

different models for clinical decisions units

that have had benefits for the trusts involved.

83 Healthcare Inspectorate Wales, Reviews of the Healthcare Standards for Wales in various NHS trusts, September 2009.



Case Study M - Leeds General Infirmary’s clinical decisions unit

The clinical decisions unit (CDU) at Leeds General Infirmary is a multi-award winning assessment area run by Leeds Teaching

Hospitals NHS Trust. The unit was opened in 2001 with the aim of reducing long waiting times in the emergency department.

The unit aims to assess, observe and rapidly investigate patients with specific conditions. There are strict inclusion and

exclusion criteria to ensure only appropriate patients, with a likelihood of early discharge from hospital, are sent to the CDU.

Gate-keeping and senior medical staff decision making are therefore critical to ensuring the CDU is not just used as an

additional step in admitting patients to the wards.

Evidence-based protocols are used to assess and manage patients with conditions such as chest pain, asthma, minor head

injuries and renal colic. Each protocol gives details of all tests required and algorithms for discharge and referral. The

availability of diagnostics 24 hours a day is critical to ensuring patient flow.

Another key success factor is the availability of senior decision making. Junior doctors must discuss their decisions with senior

doctors and consultants are available in the emergency department and CDU between 8am and 10pm. As the consultants do

not have offices on the unit, the consultants are always available for clinical work when they are working in the unit. Senior

doctor ward rounds are frequent:

a Morning – registrar and junior doctor;

b Lunchtime – consultant ward round;

c Evening – trouble shooting rounds; and

d Ad hoc – additional rounds are carried out if the CDU is full.

Many of the changes required significant cultural change and executive buy-in. An example of this cultural change resulted

from the Trust’s decision to give senior emergency doctors the powers to decide, unilaterally, where their patients can be

admitted within the hospital. This decision removed the problems where there were disagreements between specialties about

who should be responsible for individual patients’ care.

The unit is run by a dedicated team of nursing staff, clinical support workers and CDU fellows with senior medical input.

The nursing staff include a nurse consultant and the protocols are designed to be nurse-driven.

The original plan was for the unit to be nurse-led but early on, the Trust recognised that medical advice would be needed for

more complex patients. Now, entry and exit to the unit is doctor-led with nurses working to protocol for deep vein thrombosis

assessment and cellulitis.

The CDU is set up exactly like a ward with 18 beds but there are also a number of comfortable chairs for people awaiting

diagnostics who do not need a bed.

Patients referred urgently by their GP do not go to the CDU: they go to either the MAU or the receiving ward but at times there

can be spill over if the MAU is full. The CDU will then receive the patient and will start assessment / treatment whilst awaiting

receiving team. In the early days the CDU would direct patients from CDU to MAU but it just created a significant bottleneck.

This was changed by sending patients directly to wards. On occasions, if patients are ready for admission but there is no bed,

care is handed over to the receiving physician and they must manage the patient within the CDU.

On average, between 80 and 100 patients are admitted to the wards per day from the emergency department or from GPs, of

whom approximately 60 are medical patients. The CDU admits approximately 10 to 15 patients per day and has a 17 per cent

rate of admission to the wards with 83 per cent of patients being sent home. But all patients coming into the CDU are admitted

on the hospital system and the Trust is paid for these episodes as a short stay admission. The median length of stay is 15

hours but some patients may stay in for 2 to 3 days. An initial assessment of the unit’s performance between April 2001 and the

end of March 2003 showed that 5,754 admissions were prevented. No other formal evaluation has been completed.

The unit has suffered some problems when the rest of the hospital is under pressure. Initially, the plan was to prevent CDU

capacity being used for outliers when the rest of the hospital is full. However, this decision was reversed and resulted in the

unit having to deal with large numbers of patients that did not meet the unit’s criteria. Now, when the hospital is full, patients

may still be sent to the CDU but CDU staff are involved in the decision which has resulted in more appropriate patients being

cared for in the CDU.

Maintenance of the CDU database is a vital part of the unit’s work. This records the length of stay to the hour and assists with

ongoing development, audit and research.




Case Study N - Remodelling the front door at the Princess of Wales Hospital

Work started to remodel the ‘front door’ at the Princess of Wales Hospital in 2004. The aim was to streamline the patient

experience within the emergency unit and to assist the then Bro Morgannwg NHS Trust in meeting the four-hour access target.

At that time, the medical assessment unit was frequently full and there was a high number of unnecessary admissions because

GPs were directly referring patients to the wards.

As part of the national Welsh Emergency Care Access Collaborative (WECAC) the trust developed the Bro Morgannwg

Emergency Services Transformation (BEST) programme. This programme involved in-depth analysis of the problems within the

current model at the hospital, followed by a wide range of improvement initiatives.

Diagnosis and research involved mapping the existing processes within the emergency unit and identifying constraints, delays

and duplication in the way that patients move through the hospital. Further analysis was carried out including a review of the

reasons for four-hour breaches and detailed snapshot audits of inpatient flow throughout the hospital.

The programme was driven by an executive-level champion and senior clinical leaders. The approach taken was one of

stepped change through a series of Plan, Do, Study, Act (PDSA) cycles. All changes had to be made within existing resources.

The programme was established with the principle that the four-hour target is a hospital-wide target and not just an emergency

unit target. And the model that the trust chose was one where all admissions to the hospital would go through the emergency

unit, therefore giving greater control and earlier decision making at the front door. Once inside the unit, patients would be

streamed into different in-hospital pathways early on in their journey. This required senior decision-making early on in the

pathway and rapid access to diagnostics.

Processes for streaming patients were introduced before any change to the fabric of the building. Protocols were agreed for

specific patient groups, the working patterns of consultant staff were redesigned and there was extended support provided from

diagnostic and therapeutic services.

Once the new processes were in place, the trust began to improve the working environment. The emergency unit now consists

of the emergency department, clinical decisions unit (CDU), ambulatory care unit and a specific assessment area called

BRATZ (Bridgend Rapid Assessment and Treatment Zone). These areas are situated next to one another to assist in joint

working.

Most majors (patients with serious illness or injuries) go through the BRATZ area where they quickly undergo specific tests.

This area is run by a dedicated senior doctor, nurse and physician’s assistant. Following their assessment within BRATZ,

patients often move to a trolley area to await results and further diagnosis. Patients should stay in the trolley area for less than

four hours. The CDU consists of a 24-hour observation area and a 48-hour observation area.

A specific acute care physician drives the pathway within the CDU and ambulatory unit and works closely with the medical

team within the emergency department.

These changes have been accompanied by significant improvements to IT systems within the emergency unit and within the

rest of the hospital. The improvements allow clinicians to see live information about the location and status of all patients in the

hospital.

The programme team recognised that improved efficiency in bringing people through the hospital could not be maximised until

the hospital’s discharge processes were improved. Therefore, the programme has involved the introduction of ward rounds

seven days per week, discharge planning from day one, introduction of discharge lounges, ensuring medication is ready for

patients to take home and the introduction of discharge facilitators.

The programme has also succeeded in ensuring there is early involvement from social services when required. One way of

achieving earlier social services involvement has been through the use of ‘trigger length of stay’ meetings. Each ward/specialty

sets a trigger length of stay for each of their patients and meetings are held every Tuesday to discuss cases where a patient’s

stay in hospital has reached their trigger point. These meetings help identify issues that are preventing a patient’s safe

discharge. If the patient is awaiting a social worker assessment, the case is escalated and a response is required from social

services. These meetings are held in addition to delayed transfers of care meetings that discuss only the patients who are

classified as delayed transfers of care or are due to become classified as such,

Whilst an internal evaluation of the programme suggests that the changes have resulted in greater compliance with the

emergency department access targets, the unit being under pressure less frequently and positive feedback from staff and

patients, the trust acknowledges that the model is far from perfect. Capacity problems in the rest of the hospital can result in

the short-stay areas being used inappropriately for patients who required admission to the wards. The trust’s ongoing

evaluation of the model aims to ensure continued improvements in efficiency and patient care.

