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Document Information
Title / Ten High Impact Unscheduled (USC) Care Transformational StepsDate / May 2011
Purpose / This document is a product of the Unscheduled Care Programme Board. It highlights the key steps to transform the unscheduled care pathway, and is a resource to support improvement changes, generate ideas and create the climate of innovation required to deliver safe, effective and efficient services for unscheduled care in 2011 and beyond.
Sponsor / Trevor Purt
Chief Executive
Hywel Dda Local Health Board
Richard Bowen
Director of NHS Operations
Welsh Government
Joint Chairs of the Unscheduled Care Programme Board
Attention / Local Health Boards within NHS Wales and Partner Organisations:
· Chief Executives
· Directors of Planning and/or Operations
· Directors of Primary, Community and Mental Health
· Medical Directors
· Directors of Nursing
· Divisional/CPG Directors
Further Information / Dr Brendan Boylan
Assistant Medical Director
Aneurin Bevan Health Board
Tel: 01633 623602
E-mail:
Andrea Hughes
Head of Unscheduled Care
Welsh Government
Tel: 0300 062 5559
E-mail:
Please note if printing out in black and white, you may need to embed fonts under your printer settings.
Introduction
Levels of Unscheduled Care (USC) activity can be viewed as the barometer of how effective and efficient the health and social care system is. Over-reliance on USC indicates at the very least that the health and social care environment is being reactive, rather than proactive in the management of the patient journey.
Economically, USC is more expensive than preventative and planned care. The reason for this is that planned care is usually provided within a defined infrastructure, whereas the uncertainty around USC inevitably carries a premium.
The work to develop this paper has been sponsored by the National USC Programme. It presents clinical leaders’ opinion on what 10 key steps are required to transform USC services. The principle is to reduce preventable admissions and to make necessary admissions as effective, efficient and safe as possible for patients and their carers.
Put simply the current system is confusing for Patients and complicated to navigate for both clinicians and the public. Building on the excellent work on Choose Well and Chronic Disease Management, we need a service more clearly conceived of as an integrated, designed, planned and managed model, where the different elements interlock logically and the public understand better how to use it.
The 10 Steps are not intended to be all-encompassing, they aim to support key work programmes such as the imminent Blueprint for the Future of Unscheduled Care in Wales and the December 2009 Wales Audit Office report (‘Unscheduled Care: Developing a Whole Systems Approach’) and reflect USC service user and workers’ needs.
Nationally and locally the NHS is undertaking initiatives to improve clinical outcomes and the patient experience. The Annual Quality Framework has a clear focus on improving outcomes by providing an environment where the wider and longer term impact on the patient is measured, helping to promote a seamless holistic approach which captures the opportunities of integrated care. New indicators have been developed with the Welsh Ambulance Service and more will be developed for other components of USC.
One option is for Health Boards to use the 10 Steps as the stem for a local USC system driver diagram with work plans and implementation growing from relevant, individual steps.
Rebalancing the System of Care, from Acute Hospital Settings to Community and Primary Care Provision.
The USC system needs to move away from the current acute-focussed system where patients attend what appears to be the most obvious place of safety: for instance by calling 999 or presenting to an Emergency Department (ED).
This can result in unnecessary investigations being performed, the wrong pathway being followed and, sometimes, the collapse of the frail elderly person’s social fabric and support system. Patients can find themselves unnecessarily in too acute a setting from where a gradual step-down is then required.
Collectively we must ensure that the future service model becomes more scheduled, a step-up process with successive community-based stages of care applying the support required to maintain people safely in the community whenever possible, with the knowledge that when clinically appropriate a fast, efficient, effective response is available for life-threatening conditions.
Ten Unscheduled Care Transformational Steps
Content / PageStep 1: Agree a Shared Vision for Unscheduled Care Services / 5
Step 2: Define How Improvement is to be Measured Across the Whole System. / 8
Step 3: Improve Telephony and Care Co-ordination / 9
Step 4: Improve Urgent Primary Care Access / 11
Step 5: Expand and Integrate Out of Hours Services / 13
Step 6: Get the Right Message Out to Service Users /Health & Social Care Workers / 14
Step 7: Target Frequent User Groups / 15
Step 8: Improving the Flow Through ED / 17
Step 9: Improve Discharge Planning / 20
Step 10: Target the Most Important Pathways / 21
Patient Stories / 22
Performance Management/Prerequisites to Success / 22
Transformational Step: 1
Health and Social Service partners agree a shared vision for unscheduled care services in their area, based on local assessment of need.
Intended Outcome: Service planning, re-design, and simplification of access to the USC system, in order to reduce variation of patient experience and improve the appropriateness of care at the right time in the right place.
The existing state of the USC system is represented in the diagram above. It is appreciated that this diagram is only a partial view and does not reflect the contribution of all NHS and non-NHS providers (e.g. Local Authorities, Third Sector, Pharmacy, Dentistry, Optometry etc) whilst some of the numbers quoted may not be 100% accurate, they are a close approximation. Of particular note are the following:
· The public are presented with a confusing variety of telephone numbers and different routes into the system.
· A huge amount of USC activity happens in Primary Care/General Practice with approximately 5.5 million USC encounters per annum in Wales.
· There are relatively small flows between other Community Services and Acute Hospital Services.
The intended future state is depicted below:
Health Boards will need to work with local Public Health and clinical teams in order to populate this high level service plan with patient flows (by time of day, day of week, holiday periods etc) and high volume/high impact tracker conditions.
In this way, the services that are required (and times of their availability) can be defined and provided. National negotiation of future terms of service will need to reflect this move away from an In/Out of Hours split to a situation where whole system service (including workforce) capacity matches demand.
Access: New Three Digits Urgent Care Telephone Number for Wales
It is well recognised that access to the USC system needs to be simplified and that large numbers of unnecessary 999 calls are created due to a confusing system and the lack of an alternative to the 999 service.
A new three digit number would be used when help is needed quickly but the situation is not a 999 emergency and the patient/ caller does not know who to call. This is consistent with both the development of ”Setting the Direction” Communication Hubs and Welsh Ambulance Service Trust’s intention to reduce the number of unnecessary 999 journeys’ to Acute Hospital Services.
The safety of this initiative will be enhanced by generic processes for identifying genuine 999s at all points of USC access. It can also be informed by the learning from similar initiatives elsewhere.
Access: Common Filtering, Triage & Signposting and Process
USC ‘front end’ with standard process of:Filtering:
· Rapid, robust filtering of Immediately Life Threatening (ILT) calls
· Generic telephone answer message/excellent telephone access
Clinical triage of higher risk groups only e.g.
· Sick children
· Frail elderly, acute social care problems
· End of life care
· Home visit requests
Sign post +/- schedule lower risk callers
· Increase trust of the patient/carer’s judgement
· Empowering/pulling through to appropriate service
Clinicians have indicated the need for a front end to the USC system that consists of a standard filtering, signposting and triage process rather than the existing state with wide variance (between very little triage to enforced, ‘triage for all’). Essential features will include:
· Filtering:
Ø Generic telephone answer messages/excellent telephone access (with Communication Hubs able to provide this for community services)
Ø Rapid, robust identification and filtering of possible Immediately Life Threatening (ILT) calls
· Clinical triage of selected groups who are at higher risk because either there is a clinical need or (with undue delay) they may default unnecessarily into a clinically inappropriate disposition (e.g. 999 or self- transport into an Emergency Department); such as:
Ø Sick children
Ø Frail elderly/ acute social care problems
Ø End of life care
Ø Home visit requests
· Lower risk callers will be sign posted (and where possible scheduled) to the appropriate pathway or service thus reducing annoying duplication and demonstrating increased trust of the patient/ carer’s judgement, while pulling them through the system.
Transformational Step: 2
Agree across the Health community what data/information is required to measure the success of local and national clinical outcomes
Intended outcome: Improved Quality of USC Services as Evidenced by Whole System USC Clinical Outcome Measures
High level outcome measures indicated nationally e.g.· Access time sensitive conditions (e.g. MI, stroke, major trauma, sepsis, fractured neck of femur)
· Ambulatory Care sensitive conditions (e.g. Chronic Disease exacerbations)
LHB process measures developed locally mindful of:
· Learning from 1000 Lives methodology
· Learning from Stroke integrated care pathway/early intelligent targets work.
We are told by clinicians that, if we are serious about transforming USC, there is an expectation that USC targets evolve to reflect the pursuit of excellence in clinical care.
The 2011/12 AQF has embedded this agenda and paid particular attention to:
· Patient experience.
· Access-time critical conditions such as MI, stroke, major trauma, sepsis, fractured neck of femur.
· Ambulatory Care Conditions, i.e. those individual conditions or patient profiles that, with adequate effort and community services available are more appropriately cared for in a non-hospital setting. These can be subdivided into:
Ø Chronic Disease type exacerbations e.g. mental health, COPD, asthma, heart failure, diabetes, epilepsy, end of life care, frail elderly, some falls.
Ø Acute social care.
Ø Acute medical conditions e.g. cellulitis, DVT, chest infection.
Using clinical outcomes can help measure the success of the whole system from Chronic Disease Management, through Intermediate Care to Acute Hospital Services.
The challenge for Health Boards is to develop reliable, contemporaneous local process and outcome data which can be scrutinised by clinical teams in order to stimulate the maintenance and continual improvement of high quality services.
There is significant learning to be had, on the use of a care bundle approach to achieve these outcomes, from the 1,000 Lives Plus programme and the Intelligent Target approach to acute stroke care.
Transformational Step: 3
Develop the clinical model for Welsh Ambulance Service Trust which fits with the LHB communication hubs, and supports the principle of non-conveyance.
Intended Outcome: That patients will receive a timely, co-ordinated clinically appropriate response to their needs.
WAST & LHB Access/Care Co-ordination
Call CentresWAST 999 Clinical Contact Centres
· WAST/National USC Programme
· Minimise the number of false positive 999 calls
LHB Based Communication Hubs
· Primary, Community & CDM Programme. Layers:
· Directory of services (including access to self-care)
· Call handling/sign posting (including ‘bed bureau’)
· Scheduling (? In Primary, Community, Secondary care)
· Care co-ordination of Ambulatory Care Sensitive (ACS) conditions e.g.
Ø Chronic Disease exacerbation: COPD/asthma, heart failure, diabetes, epilepsy, end of life, frail elderly, falls
Ø Acute social care
Ø Acute medical e.g. cellulitis, DVT, chest infection
Ø Mental health
WAST 999 Clinical Contact Centres
In partnership with the National USC Programme Board, WAST will be building on its work with triage of Category C 999 requests by developing multi-professional triage of appropriate 999 requests from its Clinical Contact Centres.
This will minimise the number of clinically unnecessary 999 journeys, improve response times where 999 calls are clinically necessary and complement the development of the alternative three digit urgent care number.
LHB-Based Setting the Direction Communication Hubs
In parallel to this the National Primary & Community Care Programme is progressing the development of LHB-based Communication Hubs capable of dealing with non-999 urgent calls and providing several protective layers to safely maintain patients in the community. These layers will consist of,
· An LHB Directory of Services (including access to self-care. This is being scoped on a national basis but with the intention to have local adaption and updating to ensure accuracy).
· Call handling/ sign-posting (including ‘bed bureau/ hospital access’ functionality) in order to pull people towards the most appropriate service.
· Scheduling. This could potentially include Secondary, Community and Primary Care. There are clearly very significant issues of both trust and proof of the ability of the Communication Hubs to direct non-appropriate USC encounters away from Primary Care (in order to create capacity and limited access to appointments). However, considering the scale and robustness of the systems that the Hubs will require, it would be wrong not to mention this as an option, should it become mutually beneficial to both independent contractors and LHBs.
· Care Co-ordination of Ambulatory Care Sensitive conditions (as indicated previously), including re-admissions.
Transformational Step: 4
Local Models of Care are developed and supported to enhance their capacity to meet core hours demand in order to deliver services aimed at maintaining patients safely in the community.
Intended Outcome: That when appropriate, patients will access their GP as a first point of advice and contact, and receive unscheduled care services outside of secondary care.
Locality & Neighbouring Access
Support GP Practices in reducing variance in same day/urgent access and management of home visit requests:· Implementation of the evidence base (Primary Care Foundation’s Urgent Care, a practical guide to transforming same-day care in General Practice).
· Filtering, signposting and appropriate triage model.
· Improvement in working circumstances for Practices via capacity demand modelling.
· Review of USC activity data sets.
As previously indicated a considerable number of USC encounters happen in General Practice and the gearing effect of this on the wider system is significant. The Primary Care Foundation (including Dr David Carson) undertook a review (‘Urgent Care, a practical guide to transforming same-day care in General Practice’ www.primarycarefoundation.co.uk and developed a series of recommendations to maximise the quality of both the care provided to patients with urgent care needs and the day to day working circumstances of clinicians (and support staff) working in General Practice. The report was supported by The Royal College of General Practitioners and the General Practitioners Committee.