Use multidisciplinary teams to meet the A&E crisis

This winter’s accident and emergency crisis is a manifestation of a much larger problem in the NHS – a failure to acknowledge that actually, in some places, the NHS is doing really well. The development of good, innovative, effective practices are lost in the maelstrom of panic that surrounds the NHS and as such they fail to be recognised and rolled out across the organisation.

Tackling the pressure on hospitals and A&E requires a three pronged approach – widening the awareness of the different disciplines within health and social care and utilising their expertise at a primary care level, expanding a multidisciplinary response to frontline situations and ensuring smooth transitions between health and social care services. 

Primary care

It’s an old saying, but one that resonates across this debate with increasing volume. Prevention is better than cure. If we can identify patients on GP registers who are at high risk of a hospital admission then we can take preventive action to reduce the risk of them having to go to hospital.

In talking to our members, we have discovered examples of innovative practice in primary care using occupational therapy to prevent patients needing to go to hospital.

Wales is leading in embedding occupational therapists across GP clusters to take a targeted, proactive approach in giving vulnerable patients advice and guidance on managing their health and daily activities or tailoring support to maintain independence. Projects such as Healthy Prestatyn and Pembroke Docks should be common place and have the added advantage of freeing up GPs’ time to direct their expertise where needed.

If we can identify patients on GP registers who are at high risk of a hospital admission then we can take preventive action to reduce the risk of them having to go to hospital

The occupational therapists in Prestatyn run self management groups for people with diabetes, COPD, anxiety and depression and lower back pain and work with people individually in areas such as advising and developing return to work plans.

In Pembroke Docks following occupational therapy, patients’ average number of visits in a month to see their GP have either halved or been reduced by up to 72 per cent.

Acute care

We have found that pairing traditional frontline services, such as the ambulance service, with occupational therapists, can prevent people who have called 999 as a result of a fall from being taken to A&E.

The Falls Response Service in East Lancashire has treated 76 per cent of patients at home. Previously, 70 per cent of these people would have been conveyed to the emergency department. In a year from April 2016, this has meant a reduction by 552 attendances.

Taking into account the ED tariff and conveyance cost, this equates to a saving of £197,000. When you consider that 40 per cent of 999 calls are as a result of a fall, this represents a huge amount of pressure being taken off A&E, and a significant cost saving too. Further savings have been made in a similar partnership to prevent falls in Norfolk where they have prevented 75 per cent of admissions.

Pairing traditional frontline services with occupational therapists, can prevent people who have called 999 as a result of a fall from being taken to A&E

In addition, in both cases, the occupational therapists have made changes to the home and established home care support for patients when needed. One 82 year old lady has gone from calling the East of England Ambulance Service 20 times in 12 months, resulting in various hospital admissions, to two calls which EEAST safely closed with telephone advice.

Timely discharge

Much of the focus on the crisis in hospital care is on A&E but also on what is often described as “bed blocking”. Patients that appear to get stuck in the system are older patients with a range of health and social care needs.

Blame for delayed discharges swings from social care cuts to delays in community NHS services. Ensuring an accurate assessment of a person’s needs and having staff skilled at navigating the community and social care sectors are key elements in ensuring successful flow through the hospital system and transition back into the community.

An accurate assessment of a person’s needs and staff skilled at navigating the community and social care sectors are key elements in ensuring successful transition back into the community 

Occupational therapists and physiotherapists working in EDs are ensuring that many people are discharged directly from the department. When the Royal College of Occupational Therapists scoped the impact of these therapy teams, the percentage of direct discharges ranged from 67-83 per cent.

Assessments looking at the person’s routine, mobility, home environment, use of adaptive equipment, cognition and care needs are essential to safe decision making. 

Pre-operative assessments

Equally, therapy led discharge planning for planned admissions ensures that services and support are put in place to minimise the number of days in hospital. At the Royal Marsden Foundation Trust occupational therapists, as part of a multidisciplinary approach, carry out pre-operative assessments of patients who are scheduled to undergo surgery for cancer treatment.

The occupational therapists are able to correctly predict the level and type of need for support 91 per cent of the time. 

Therapy led discharge planning for planned admissions ensures that services and support are put in place to minimise the number of days in hospital

And what about people with dementia that often get lost in the system and experience deep distress? Mental health liaison teams must ensure a multidisciplinary mix to identify needs and to provide recommendations for discharge. 

Cwm Taf University Health Board Mental Health Liaison Team has, on average, reduced the hospital length of stay by three days as a result of tailored assessments and more accurate identification of needs. 

Widening the multidisciplinary approach

More and more people are turning to EDs and hospitals as increasing numbers are living with a complex range of needs. As yet, we have not developed primary and community services that are able to intervene early.

Doctors and nurses are essential to acute healthcare but recognising that these people with complex needs require a more holistic approach requires a wider multidisciplinary approach.

Occupational therapists are not the panacea but are clearly part of the solution. Think tanks, such as the King’s Fund, have identified models of best practice but these fail to roll out nationally.

Perhaps the public needs to be asking for access to a range of health and social care professions but this won’t happen if the media and policy is only focused on medical aspects of care.