Analysis: How Northumbria is redesigning urgent care

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Mike Waites examines how Northumbria Specialist Emergency Care Hospital is transforming emergency care provision in the North East, but not without significant teething problems

For cardiologist Colin Doig, the opening of the Northumbria Specialist Emergency Care Hospital last year has led to the biggest improvements in care in his 25 years treating heart patients.

The purpose built £75m centre has seven day working, emergency consultants and full diagnostic services available around the clock, and specialist consultant opinion onsite 8am-8pm each day.

The development is seen as the future of urgent care set out by NHS England medical director Sir Bruce Keogh in his 2013 blueprint to create 40-70 major emergency centres across the country.

More than 50 other trusts have visited the centre to see it in action in the 12 months since it opened.

Key elements such as seven day working have been in place for some years at the trust, which previously ran three accident and emergency units – but the old model of an acute medical admissions unit is gone.

What has gone right

Instead patients get an early opinion from an emergency medicine specialist, have quick access to diagnostics and are transferred on to the specialty ward they need.

Dr Doig told HSJ: “The big thing is the speed of everything – it all happens faster – and people are going out of hospital much quicker than anticipated.”

Prior to the switch, patients suffering heart failure on Friday afternoon might have been discharged the following Wednesday or Thursday. Now, he said, they could be home the next day with a future plan for their care.

He said in his career “nothing comes close” – including new treatments – to the impact of the changes, leading to a 14 per cent fall in emergency admissions in its first 10 months.

Although full data is still awaited, early signs show NSTEMI (non-ST segment elevation myocardial infarction) mortality rates improving significantly since the centre opened, moving the trust from average to an outlier, he added.

An important factor is early access to diagnostics, particularly radiology. “It’s fair to say all of the clinicians have been blown away about how brilliant that has been,” Dr Doig said.

Vanguard plots more transformation

Further changes are being planned under the region’s new care model vanguard project, as the focus turns towards improving primary care.

Work to create integrated care hub models in the four GP localities in Northumberland aims to maximise use of general and community hospitals, and explore the potential for new networks of GPs practices to work together to make better use of the under pressure workforce, including delivering urgent primary care services over extended hours seven days a week.

A single “accountable care organisation” is also planned, though there are concerns the complex finance, governance and accountability structures will not be in place for the projected start date in April 2017.

Under the programme, there will be a dozen health outcomes to be monitored over 5-7 years, set out by the local CCG and council as the “strategic” commissioner.

The “tactical” commissioner of all providers – the ACO – including primary care, social care and local foundation trusts, will make day to day commissioning decisions.

He said the design of the building was important but the key had been changes to ways of working – although he suggested the national focus on the new centre had stalled the search in other parts of the NHS for their own solutions.

“Local problems require local solutions and should be owned by local people and deliverers of care,” he said.

What needs to improve

However, there have been teething problems, including a surge in ambulance handover delays as emergency patients head to one centre instead of three. Figures show 40 per cent of all 30 minute handover breaches in the North East occurred at the hospital in March, with 597 delays compared to 15 at Newcastle’s Royal Victoria Infirmary.

Inappropriate use of ambulances by GPs and community hospitals has been blamed, as well as a surge in demand – the trust saw 43,000 emergency attendances from January to March, up 9,000 on the same quarter of 2015.

Trust leaders say it is likely a redesign at the front door of the emergency department is needed to allow quicker handovers to create space for patients to be managed.

The hospital is also seeing unexpectedly large numbers of walk-in patients. Protocols used by NHS 111 have been changed after it was discovered patients were being directed there rather than the urgent care centres at Wansbeck, North Tyneside and Hexham.

These sites see nearly half the trust’s urgent patients but activity is low at times and commissioners are looking at whether they are viable round the clock. Both Northumberland and North Tyneside clinical commissioning groups are in deficit and looking to make savings.

Northumberland’s chief operating officer, Alistair Blair, said it was clear the new model was leading to better care, fewer admissions and shorter lengths of stay, and the CCGs’ finances would have been worse without the changes.

“In terms of the deal that patients get, I would say both as a commissioner and a GP that generally people have been full of praise for the care they’ve received in hospital,” he said.