Emergency care - steady progress, urgent need

One year ago the health and social care community in eastern and coastal Kent signed up to a programme to transform the way urgent care is delivered.

A year later the programme is being implemented and tested. There are new intermediate care beds run by social services and Eastern and Coastal Kent primary care trust, for example, to improve discharge planning. GPs are working within an accident and emergency department to test whether they can treat the primary care needs that arrive at the hospital.

It would be tempting to ask why it took so long. But that would be to miss the point. This is not piecemeal interference with urgent care but a three to five-year programme that should completely change the way patients receive care.

It is a complex system, as Kent county council adult social services head Anne Tidmarsh points out: "You change something here and something else pops up over there. I would really not underestimate just how complex it is."

Bounced around

The nub of the problem is that patients with urgent care needs access the system in a multitude of channels, such as 999, out of hours, their GP, NHS Direct and social services, and once in the system their needs are met in a variety of ways but not always the best one in the best place.

PCT assistant commissioning director Michelle Ford says: "The reports we had from patients were that the system was complex and difficult and you end up being bounced around. We wanted to simplify it."

This was something that everyone knew but no one was able to address alone. The idea of making this a case for system reform began to be formalised by the Fit for the Future reform programme, through which the PCT and partners in Kent county council, East Kent Hospitals trust and others identified urgent care as a priority.

The question then was what to do about it. The PCT applied to become a health reform demonstrator site and to join the Integrated Service Improvement Programme. Approval for both came through in late 2006, with ISIP providing a full time change consultant.

With some strong partnerships already in place it was not so difficult to establish the governance structures and by February 2007 the PCT had assigned a senior responsible officer, chief executive Ann Sutton. It has also set up a programme board, with the PCT, acute trust, ambulance trust, practice-based commissioners, social services, GP out-of-hours service, NHS Direct, voluntary sector and patients all represented.

Eliminate inequity

The partners spent the first five months finding a common language and agreeing a model. "We did not move ahead until we had complete agreement," says Ms Ford.

Do not underestimate how long it takes to get to that agreement, says Ms Tidmarsh. "For example, everyone had different ideas of what 24/7 means," she points out.

The long, iterative process resulted in a primary care-focused urgent care model.

Wherever the patient is assisted they should get the same outcome, says Helen Belcher, clinical services manager at East Kent Hospitals trust. "Whether you go to person A or person B and you need diagnostic tests or you need some medication or a device, you get the same outcome delivered by the appropriate professional but not necessarily in the acute setting."

"The other key principle is to eliminate the real inequity in the system," adds Ms Ford. "The outcome you get often depends on what day of the week you present and what time of day."

It is, of course, impossible to introduce such a model overnight in a big bang and this is where the improvement programme process of setting up project teams, running pilots, taking the metrics, assessing and readjusting came in.

With the model agreed (involving a stakeholder engagement programme), the programme board set up 11 workstreams with associated projects. Each would be run according to integrated service improvements promulgated by ISIP and overseen by the programme board. Each works to a project mandate with a project lead, workstream plans, measures, communication plans and risk strategies. They all have common documentation, clinical engagement and patient participation.

The first of these kicked off at the William Harvey Hospital in Ashford in October 2007. It is a 16-week pilot to test assumptions about the number of patients who could be seen or treated by primary care professionals in an urgent care setting.

The PCT commissioned a new service in collaboration with South East Health, a local out-of-hours provider, placing a GP and nurse practitioner within A&E all day every day.

All ambulatory and self-presenting patients see the GP service first and are then treated or directed to the appropriate place.

"This is not front-ending A&E," says Ms Ford. "The GP-led service manages the A&E workings. They are streaming patients to the appropriate place."

That might mean the minor treatment room where GPs or primary care nurses work alongside A&E staff. It might mean the major treatment department for patients who need x-rays or blood tests to which the GPs do not have access.

And since this is a whole-system pilot, which cannot work without community services, that might also mean directing people to social services-run intermediate care beds that are now open 24/7. The PCT even commissioned 24-hour patient transport service to get them home.

Lesley White is the emergency care manager at the hospital and the project lead. "The PCT made it easy for us to do the project," she says. "We were not asked: 'What would you like to do?'. We knew what we were expected to deliver, we were given the parameters and we knew we had to have metrics that were deliverable."

Difficult discussions

In case that sounds like an imposed model, she points out that as project lead she has been in charge of making sure staff at the trust are involved and feel they own it.

Broader co-operation has also been essential for success, according to Dr Robert Stewart, PCT clinical executive chair and medical director of the urgent care project. Dr Stewart says: "This has been achieved by strong commissioning but only with fantastic collaboration from all the providers. Yes, it has been driven by the PCT but could not have happened without the enthusiasm and determination of everyone to improve patient care."

The results are now filtering through. The first dataset seems to show that attendance has remained the same at the A&E department but that more people are being treated in minors, fewer in majors and admissions are down.

"We have learned a lot from the GPs," adds Ms White. "Everything in the acute side is protocol driven so where we would always admit a child with a bump on their head, GPs would risk-assess and send appropriate children home."

Likewise, GPs have learned from the hospital staff. For example, nurses feel they have done a good job advising GPs about domestic violence.

At the time of writing, the pilot was still running. The next step will be evaluation, learning the lessons and embedding them in the contracting process, implementing new contracts from April 2009.

"We are changing the service that we commission and changing the way we commission services, underpinned by the workforce that actually delivers it," says Ms Ford.

The other 10 workstreams and projects will fit in the same way over the next year or two. Add to that work with practice-based commissioners to examine six ambulatory care pathways and other work going on in the local health economy under the whole-system demonstrator programme and the partnership for older people project and by 2009 a new urgent care system should begin to emerge.

All agree that real changes are already happening. "That's the really interesting thing about using the improvement programme methodology," says Ms Tidmarsh. "It is a really good way to move things forward rather than sitting and writing documents."

They all know they are in a honeymoon period. While Fit for the Future in many places in the South East has become tied to A&E closure, in eastern Kent the PCT has tried to frame the debate in terms of improvements, not cuts. Even so, the partners recognise there will be difficult discussions about unbundling the tariff.

"I think we have prepared for that," says Ms Ford. "We have already started to have some discussions about locally agreed tariffs. More importantly, we have in place the foundations of relationships that could be good enough to have these difficult conversations honestly and finish them on good terms."

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