Dr Marilyn Plant Clinical Director, Unscheduled Care Project Denise Chaffer Clinical Advisory Group

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Dr Marilyn PlantClinical Director, Unscheduled
Care ProjectDenise ChafferClinical Advisory
Group member, Healthcare for London 25 November
2008
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Unscheduled care

• Any unplanned contact with the NHS by a person
  requiring or seeking help, care or advice
• It follows that such demand can occur at any
  time, and that services must be available to meet
  this demand 24 hours a day
• Unscheduled care includes urgent care and
  emergency care.

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The projects approach
Empirical research
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Proximity and speed of access are key factors
for patients in choosing where to go for
unscheduled care
Why people interviewed attended AE
Why people interviewed attended a GP surgery
Why people interviewed attended a Walk-in-Centre
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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Patients know about and are willing to attend
alternative access points to AE but do not
always do so

• Approximately 1/3 said they could have been
  treated by their GP
• 43 of patients stated AE was the only
  appropriate place for them to seek care
• A smaller, but nonetheless significant,
  proportion of patients knew about local WICs and
  MIUs

AE
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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Many patients attend AE with needs that could be
met in primary care
Only 1 in 3 patients attending AE departments
with minor illness/injuries were assessed by GPs
to require an AE clinician in the appropriate
skill mix to treat them
Nearly 2/3 could be seen by a GP
of patients who GPs assessed could be
treated by different skill-mix options
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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Improving access - top 10 conditions presenting
at AE by age
A significant proportions of 0-4 year olds
present with gastrointestinal and respiratory
conditions, while a large proportion of elderly
patients present with lacerations, urological and
cardiac conditions.
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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Improving access - top 10 conditions presenting
at AE by ethnicity
The profile of ethnicity is relatively consistent
across the top condition types, although the data
indicates that patients presenting with
respiratory, gastrointestinal and ENT conditions
are more likely to be from a BME community
compared to patients with other condition types.
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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Repeat attendances appear to be fairly high in
most access points
Around 1/3 of people interviewed had sought
treatment for their condition in the previous 7
days this represents a significant number of
repeat visits and/or flow of patients between
different service providers
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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25 of unscheduled patients visiting their GP
could potentially be seen in scheduled
appointments
Patients could be requesting an unscheduled slot
because of their perceived urgency, for their
convenience or as a consequence of a GP practice
only offering same day appointments
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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Skill-mix changes could increase primary care
capacity

• 10-14 of patients attending GP surgeries for
  unscheduled care could potentially be seen by a
  nurse, nurse specialist or pharmacist, or could
  self treat
• The large volumes in primary care mean that even
  a small proportion of patients moving to a
  different setting could have a significant impact
  on the system

of patients who GPs assessed could be treated
by different skill-mix options
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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Better access to diagnostics and support services
would improve speed of diagnosis and reduce steps
in a patients journey
The most common reason for GP referral (40) was
because the patients required tests
The most common tests required for patients
referred by GPs were blood tests and ECG
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In summary - complex system, many different
services and access points, a high level of
repeat attendance and poor links across the system
13 of patients visiting WICs had also seen their
GPs previously
20 of patients visiting AE had been to see
their GP within the previous three days
7 of patients in AE have been to an AE
department three days previously
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Most unscheduled care needs are met in primary
care
15-25
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Services do not work well as a whole system in
particular data collection and sharing is poor
23 of patients seeking pharmacist advice/
treatment had previously seen their GP
Key access points, quantified flows and repeat
attendance between access points for patient
seeking treatment for the same condition within a
3 day period.
Source PA Consulting Group Study of Unscheduled
Care in 6 PCTs, Feb - Apr 2008
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In summary what needs to improve

• More can be done to prevent people choosing to
  enter or defaulting to the unscheduled care
  system
• Access to care needs to improve and be more
  responsive to patients needs and expectations
• The system needs to be less complex to understand
  and navigate for patients (and staff) it should
  be designed around patients not organisational
  boundaries or institutions
• Standards and quality should be more consistent
  and improved across the whole spectrum of care in
  community and hospital sited services
• Integrating the way the system works as a whole
  will improve care, patient experience, make
  better use of resources and provide enhanced
  opportunities for training
• Interlinking work streams are already being
  implemented (e.g. polyclinics, GP-led health
  centres, extended GP access) and require
  integration or complexity will increase further
• There needs to be an improved response for people
  with particular needs (mental health, substance
  misuse, learning disabilities, children and young
  people, obstetrics)
• Inequalities need to be addressed
• Consistency in emphasis of policy drivers,
  related strategies (e.g. workforce) and data
  findings

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Key features of an ideal pathway of care
24/7 consistent and rigorous assessment of the
urgency of peoples needs and an appropriate and
prompt response
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A new delivery model and commissioning framework
for unscheduled care the concept is a tiered
approach within a whole system
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How unscheduled care links with other projects

• Emergency response
• Major trauma and stroke projects include
  improving the emergency response through
  proposals to designate specialised centres
• Urgent response
• Urgent care services in the community will be
  provided through polyclinic centres these should
  be networked to hospital services and an
  emergency department for professional support,
  clinical supervision, training and advice on
  standard setting and outcome
• Rapid/moderate response
• Increasingly the rapid/moderate response will be
  delivered through polyclinics

The unscheduled care delivery model provides a
framework for improved care pathways developed in
other projects e.g. mental health, children and
young people, long-term conditions and maternity
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Moving from design to implementation

• The London Commissioning Group has endorsed the
  model as the framework for commissioning
  unscheduled care
• It aims for consistency in approach one size
  does not fit all, however there are many common
  features which should be present in every system
• PCTs to develop 5-year commissioning strategies
  with milestones - priorities to be agreed locally
• The next stage of the project will develop a set
  of tools/guidance to support commissioners
  (shaped by the projects commissioning group)

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Key challenges

• Implementation of the model will challenge (and
  change) professional and organisational
  boundaries, require a change in some behaviours
  and confound the forces of conservatism
• How to achieve real and sustainable change,
  consistency and improvement at a whole system
  level with multiple and sometimes conflicting
  accountabilities
• Identifying and aligning the right incentives and
  enablers to deliver key changes and bond
  stakeholders behind shared goals
• Workforce development and transformation will be
  key
• More integrated teams working across primary and
  secondary care in care delivery, governance and
  training
• Focus on competencies (assessment and clinical
  decision-making) rather than type of professional
  
• Scope for development of new and extended roles

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Next steps for the project

• Developing a commissioning toolkit for
  unscheduled care
• An evidence base of good practice for
  commissioning services aimed at reducing demand
  for unscheduled care and enabling rapid discharge
  following unscheduled care admissions including
  guidance on achieving greater integration with
  social care
• A core service specification for an Urgent Care
  Centre informed by existing models in London and
  elsewhere
• Guidance on governance arrangements for urgent
  care service provision across primary care and
  secondary care
• Service standards, outcome measures and guidance
  on benchmarking to support commissioning of
  unscheduled care services
• Guidance on assessing and quantifying the costs
  and benefits of the delivery model informed by an
  initial assessment of the implications of the new
  AE tariff
• Development of enablers to support the delivery
  model
• Scoping a pilot for a single point of telephone
  access for non-emergency care

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Current challenges or opportunities ?

• Urgent/ unscheduled care (where and by whom)
• Reduced length of stay
• Elective (non complex) work elsewhere
• Reducing infection
• Increase of community services
• Work force changes
• Emerging professionals
• Focus on clinical outcomes / patient experience
• Practice based commissioning
• Foundation Trusts
• Community Trusts / GP Federations/Social
  Enterprises

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What that means for you ?

• More choices of work setting
• More networking between organisations
• More than one employer with more flexibility
• More performance monitoring / key performance
  indicators for safety and quality
• You need to more politically aware and informed