As the focus for urgent care moves towards prevention, self care, and better treatment of long-term conditions, Drs David Hambleton and Mark Lambert explain how their new collaborative and localised approach is starting to make an impact.
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Managing demand for urgent care is one of the key challenges facing the NHS. Until now, efforts have tended to concentrate on fixing individual areas of the urgent care system rather than looking at the overall direction of travel.
It feels like we are trying to collect hundreds of pieces of paper in a force 10 gale, but no one is asking what direction the wind is blowing.
At NHS South of Tyne and Wear - a cluster organisation responsible for primary care trusts in Gateshead, Sunderland and South Tyneside - we have used lean management techniques to encourage what we believe is a unique multi-agency approach to the problem.
We knew that in order to achieve a step-change in performance and improve outcomes for patients we needed to really understand what was actually driving the system. We recognised that we didn’t always have a clear view of exactly what was going wrong - different parts of the system tending to blame one another for failures.
So, GPs, the community services provider, the ambulance service, A&E staff and NHS South of Tyne and Wear came together as the urgent care board and used the Model for Improvement - an approach promoted by the NHS Institute and the Institute of Healthcare Improvement - to agree a set of measures that could be used to check the health of the whole system.
Relying on national performance indicators wasn’t giving us the information we needed, plus it was actually stifling any local dialogue. We’ve now developed our own set of indicators which are far more meaningful for our local situation and actually tell us whether things are changing in line with our intentions.
Local health organisations also collaborated on the development of a shared vision for the future of urgent care and set some very stretching goals for service improvement. Working together has ensured that all healthcare professionals are committed to a common goal that has been developed collaboratively, rather than one which has been imposed from above.
It has taken us around two years to get this far, which reflects the complex and multifaceted nature of urgent care and the sheer number of organisations involved in its delivery. However, there is now a shared understanding of where we are going and we have the tools we need to effect some real change in the system.
At the moment, the local health organisations are working to develop and support solutions with the aim of achieving significant system changes. In the long term, the expectation is that patients will benefit from a better coordinated urgent care system, with more support available for people to receive treatment in their own homes rather than in hospital.
As part of this work the urgent care board identified intermediate care as an influential part of the system and therefore an area of activity that required attention.
While a number of intermediate care teams have been established across the locality, their workload is growing primarily as a result of self-referrals by patients. GPs still refer people to hospital rather than using the intermediate teams to support patients in their own homes.
At the other end of the pathway, hospitals are not consistently making use of the teams to support early discharges. More appropriate use of intermediate care services by both GPs and hospital staff would have clear benefits for patients and help to ease pressures on acute services.
Working together, we have been able to establish a number of local indicators that are designed to increase the use of intermediate care teams and improve the rate of patient discharge to their usual place of residence.
This piece of work isn’t just about the intermediate care services themselves. Hospitals and GPs now understand that they need to make sure referrals are made wherever relevant.
The setting out of improvement indicators around this and other urgent care tasks will ensure that local policy makers can check things really are moving in the right direction. In addition, they provide a way for organisations to measure their own progress towards the achievement of agreed goals.
The emerging impact
One very concrete example of how this project has supported change is in the development of integrated services in Sunderland. The urgent care board has encouraged the use of the intermediate teams to both GPs and hospitals and, from the monitoring we had set, the extent to which GPs now use the service is clear.
The proportion of community teams’ workload driven by GPs in this locality has increased from 5 per cent to 20 per cent in a little over six months. This gives a strong signal that services are now becoming more integrated.
The project has had no direct costs associated with it to date and has fostered good will from all collaborative organisations.
None of the partners have asked for extra money or more people but they have taken on a commitment to transforming services and willingly, with that, a responsibility for change. We would be happy to talk to others about this work to confirm this approach.
We think there are lots of people focused on urgent care who are struggling to understand their system and the way it operates with only the national performance indicators as indication. We now think we have a much better handle on how we want to see things change.
Urgent care board core improvement indicators
Right place, right time, right outcome
Two indicators were chosen:
- Proportion of patients referred by ambulance service to minor injuries units or community teams.
- Proportion of inpatients discharged from hospital after an urgent admission to their usual place of residence (excluding those already identified as in residential or nursing home care) to increase the proportion able to return home to 95 per cent by April 2016.
See, treat and finish
The board wants to oversee a system where services are developed and marketed to match people with problems they can readily serve. In a well-functioning system there would be the need for relatively few referrals between services in the early stages following presentation.
Minor injuries units: Proportion seen, treated and discharge
The provisional goal is to increase the proportion discharged from 80 per cent to 90 per cent by May 2012.
Admission from accident and emergency attendance
The board wants to see a decrease in the proportion admitted from current mean of 24 per cent to 18 per cent by May 2012.
Integrated pathways of care
The board wants to see an increasing proportion of care being managed outside a hospital setting and where hospital based care is required, they want to see care passed on to other parts of the care system as soon as possible. Three indicators were chosen to reflect this aspiration:
Community teams: Proportion of patients referred from GP out of hours services
The board want to see this increase to 15 per cent of urgent care teams’ workload (currently 8-10 per cent) and 5 per cent of intermediate care teams’ workload (currently 1-2 per cent) by May 2012.
Community teams: Proportion of patients referred from hospital
The board wishes to see community teams building their work in referrals from hospital.
Number of admissions lasting 0-1 days, an agreed subset of HRGs
There is work underway with each foundation trust to agree a range of common presentations for them to work on to change the way these are managed, with a view to avoiding the need for admission.
Top tips for organisations looking to take this approach
Some things to secure from the outset:
- A partnership commitment at the most senior level to the overseeing of the work
- Involvement of all those involved in the “front line” of the pathway - including medical, nursing and ambulance staff from health services, and from relevant social care
- Appropriate technical expertise (on both diagnostic approach and relevant analysis)
- Integration with the organisations’ own approaches to service improvement
- Test the resources
- Set a deadline for completion
- Identify whether those who committed can participate in the intensive diagnostic phase - ideally done over two concentrated days
- Identify arrangements for overseeing implementation of a forward work programme
- If any of these tests are not met then return to your senior partnership oversight group
- Keep focused on measurement requirements for improvement and how this differs from both performance and research
- Ensure delivery of senior partnership group to the agreed timetable