Social prescribing within pre-hospital urgent and emergency care

Social prescribing within pre-hospital urgent and emergency care.
NIHR Emergency Care webinar, 7 October 2020

• This session is delivered by Dr Jason Scott, Senior Lecturer in Public Health, Northumbria University. Dr Scott is also the national academic lead for the Frequent Caller National Network (FreCaNN), which works across all ambulance services nationally. He provides an overview of the potential for social prescribing within emergency ambulance services (999) and NHS111, specifically focusing on suitable patient cohorts and the macro, meso and micro determinants to social prescribing within this setting.

Emergency admission risk stratification tools in UK primary care: a cross-sectional survey of availability and use.

Emergency admission risk stratification tools in UK primary care: a cross-sectional survey of availability and use.
Br J Gen Pract. 2020 Oct 1;70(699):e740-e748. doi: 10.3399/bjgp20X712793. PMID: 32958534; PMCID: PMC7510844.

• To describe availability and use of Early Admission Risk Stratification (EARS) tools across the UK, and identify factors perceived to influence implementation. An online survey identified 39 different EARS tools in use. Nearly 40% of areas using EARS tools reported introducing or realigning services as a result, but relatively few reported use for service evaluation.

How will we know if Integrated Care Systems reduce demand for urgent care?

How will we know if Integrated Care Systems reduce demand for urgent care?
Strategy Unit January 2020

• An examination of the implication of the "blended payment system" as a tool for determining the allocation of resources in Integrated Care Systems around urgent care.

Clinically-led Review of NHS Access Standards - progress report

Clinically-led Review of NHS Access Standards
NHS England 31 October 2019

• This is a progress report on the review of NHS access standards in urgent and emergency care, mental health services, cancer care and elective care. It
• 1. recaps on the proposed new standards in each of the four areas, the rationale for those proposals, and update on what we are finding through testing.
• 2. sets out the planned next steps in terms of continuing with testing and
• 3. outlines the timetable for making final recommendations and implementing any agreed new standards.
• "For urgent and emergency care, where the field testing has been running longer and will be able to conclude sooner, the intention is to support the NHS to implement any changes from 1 April 2020. For elective care and cancer, implementation is likely to be during mid 2020/21. In mental health, where completely new standards are being proposed, implementation will be to a longer timeframe, as testing is likely to continue in 2020/21 to ensure that the introduction of standards in these areas is sustainable. All timelines are subject to change and government agreement."
• The review is working in tandem with the National review of access to general practice services in England

Digital and online symptom checkers and assessment services for urgent care to inform a new digital platform: a systematic review.
Health Serv Deliv Res 2019;7(29) August 2019

• Major uncertainties surround the likely impact of 'digital 111' services on most of the important outcomes, but precedent suggests that once introduced their use may increase rapidly.

British Social Attitudes Survey - attitudes towards emergency care

British Social Attitudes Survey - attitudes towards emergency care
The National Centre for Social Research 14 August 2019

• The first ever large-scale research into attitudes towards emergency care from the most recent British Social Attitudes Survey reveals significant differences in perspectives by a range of socio-demographic factors, such as area deprivation, age, young children in the household and gender.
• People living in deprived areas are more likely to prefer A&E departments over their GP to get tests done quickly, find it more difficult to get an appointment with their GP and think A&E doctors are more knowledgeable than GPs.
• Parents with children under 5 are most likely to have used an A&E in the last year, to think it is hard to get an appointment with their GP, less likely to trust their GP but are also more likely to use the internet to try to decide what the problem might be.
• Men are less knowledgeable about how to contact a GP out of office hours and less likely to use the internet to research a health problem.
• Those aged 18-24 are twice as likely to both research a health problem online (62%) and to use the internet to decide what to do (47%), compared with those aged 75+.

Clinical review of NHS access standards

Clinical review of NHS access standards
NHS England

• The Clinical Review of NHS Access Standards Interim Report, published in March 2019, sets out the initial proposals for testing changes to access standards in mental health services, cancer care, elective care and urgent and emergency care.
• Field testing around Urgent and emergency care targets started in May 2019. Work on the (routine) elective care proposals starts across 12 hospitals during August, testing the use of an average (mean) wait measure for people on the waiting list as a potential alternative to a threshold target, currently set at 18-weeks, to see whether keeping the focus on patients at all stages of their pathway can help to reduce long waits.

NICE Resources for local partnerships

 Resources for local partnerships

• NICE has produced a set of resources for local partnerships designed to help systems work together to provide consistent, high-quality care, based on the best evidence. Each topic includes resources from PHE, NICE, Right Care, NHS England and others.
• Current resources are: CVD prevention (kidney management, risk assessment, NHS Health checks, hypertension, atrial fibrillation, diabetes); Frailty, Transfer of care, Making Every Contact Count, Medicines Optimisation and Urgent & emergency care.
• The Urgent and emergency care care resource includes detailed tables linking to appropriate guidelines, NICE Pathways, quality standards and quick guides relevant to each strand of work.

NHS App

NHS App
Department of Health and Social Care 2 July 2018

• A new NHS app, which will be available by December 2018, will give patients safe and secure access to their GP record. Patients will be able to use it to:
• make GP appointments
• order repeat prescriptions
• manage long-term conditions
• access 111 online for urgent medical queries
• See the NHS App library for "NHS approved" apps.
• The NHS app: will it work? - a blog from Kings Fund

Coordinate My Care launches online patient portal

Coordinate My Care launches online patient portal
NHS Digital 9 February 2018

• Coordinate My Care (CMC) is an NHS clinical service that informs GPs, hospitals, ambulance crews, 111 providers, care homes, hospices and out of hours services about a patient’s wishes for urgent and end of life care.
• The new myCMC portal, which uses InterSystems’ unified health informatics platform HealthShare, allows patients to arrange their own urgent care plans online for the first time.

A New Model of Urgent Care within Primary Care

A New Model of Urgent Care within Primary Care
Oxford AHSN December 2018

• Two audit reports of a new model of urgent care in Brookside Group Practice,West Berkshire, which aimed to provide a robust service model to appropriately treat patients requiring same-day appointments. The model eliminated the GP telephone triage system, and instead utilises the skills of the multi-disciplinary team, with support and overview from a supervising GP.
• The results from the first audit (December 2017) demonstrated that of the patients seen by non-GP staff 47% were seen and treated without the involvement of the supervising GP, compared to 29.5% in the second audit (December 2018). The impact of a Point of Care tool into the Urgent Care clinics and available to all clinicians is discussed.

Challenging Health Inequalities: Support for CCGs

Challenging Health Inequalities: Support for CCGs
NHS England 7 December 2017

• A guide created to help identify areas of variation in emergency admissions in more and less deprived CCGs and to promote a discussion where variation occurs.

Flow of patients between the NHS and social care - local performance metrics

Local area performance metrics
Department of Health, 29 November 2017

• A new dashboard which allows local areas of assess the flow of patients across the boundary between the NHS and social care. 
• It provides a set of six measures indicating how health and social care partners in every Local Authority area in England are performing at the interface between health and social care. Included in the dashboard is a breakdown of delayed days attributable to social care per 100,000 of the population and the equivalent for NHS-attributable delays. 
• The metrics are:
• Emergency Admissions (65+) per 100,000 65+ population 
• 90th percentile of length of stay for emergency admissions (65+) 
• TOTAL Delayed Days per day per 100,000 18+ population 
• Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/ rehabilitation services 
• Proportion of older people (65 and over) who are discharged from hospital who receive reablement/ rehabilitation services 
• Proportion of discharges (following emergency admissions) which occur at the weekend 

Next steps on the NHS Five Year Forward View - Urgent and emergency care

Next steps on the NHS Five Year Forward View - Urgent and emergency care
NHS England 31 March 2017

• Key deliverables for 2017/18 and 2018/19 to meet current UEC standards:
• every hospital must have comprehensive front-door clinical streaming (October 2017 )
• every hospital and its local health and social care partners must have adopted good practice to enable appropriate patient flow. (October 2017 )
• Hospitals, primary and community care and local councils should work together to reduce delayed transfers to community health and social care. Each trust has been informed of its target around freeing beds.
• 85% of all assessments for continuing health care funding must take place in the community setting. (March 2018 )
• Implement the High Impact Change Model for reducing DTOCs
• Spread of Specialist mental health care in AandEs (in nearly half of acute trusts by March 2019)
• Increase the proportion of NHS111 calls receiving clinical assessment to 30% or more (March 2018). Development of NHS111 online.
• Spread availability of evening and weekend GP appointments to 50% of the public by March 2018 and 100% (March 2019.)
• Strengthen support to care homes
• Roll-out of standardised new ‘Urgent Treatment Centres’ which will open 12 hours a day, seven days a week, integrated with local urgent care services. (150 will be treating patients by Spring 2018.)
• implementation of the recommendations of the Ambulance Response Programme (October 2017)

Shifting the balance of care: Great expectations

Shifting the balance of care: Great expectations
Nuffield Trust 1 March 2017

• Drawing on a review of the STPs and an in-depth literature review of 27 initiatives to move care out of hospital, the report looks their impact, particularly on cost, and what has contributed to their success or otherwise. ( A number of brief case studies are included)
•  It explores five key areas: elective care, urgent and emergency care, admission avoidance and easier discharge, at risk populations, and self-care.
• The analysis suggests that some STPs are targeting up to 30% reductions in some areas of hospital activity, including outpatient care, A&E attendances and emergency inpatient care over the next four years but at the same time suggests that the falls in hospital activity projected in many STPs will be extremely difficult to realise as the economic benefits are frequently overstated.
• Where schemes have been most successful, they have: targeted particular patient populations; improved access to specialist expertise in the community; provided active support to patients including continuity of care; appropriately supported and trained staff; and addressed a gap in services rather than duplicating existing work.
• The report concludes that, while out-of-hospital care may be better for patients, it is not likely to be cheaper for the NHS in the short to medium term – and certainly not within the tight timescales under which the STPs are expected to deliver change. The wider problem remains: more patient-centred, efficient and appropriate models of care require more investment than is likely to be possible given the current funding envelope. 

NAO on NHS Ambulance Services

NHS Ambulance Services
National Audit Office 26 January 2017

• This report examines the reasons behind the rising demand for Ambulance services.
• Contributing factors include increasing numbers of elderly patients with multiple conditions, an increasing number of alcohol- and mental health-driven issues, the availability of primary care services in the community and how patients seek help.
• It was noted that each of the 10 ambulance trusts in England has developed its own operating framework, with differences in workforce mix, fleet mix and estate. These differences have contributed to variations and inefficiencies in performance.

Challenging Health Inequalities - Support for CCGs

Challenging Health Inequalities: Support for CCGs
NHS England August 2016

• This guide aims to help CCGs identify areas of variation in access to, and outcomes from, emergency admissions based on levels of deprivation.
• The analysis is based on two indicators from the CCG Improvement and Assessment Framework: 
• 106a - Inequality in unplanned hospitalisation for chronic ambulatory care sensitive conditions and 
• 106b - Inequality in emergency admissions for urgent care sensitive conditions. 
• It includes a link to the CCG Inequality Indicators tool developed by the University of York, which provides comparative information about the 10 most similar CCGs for unplanned hospitalisation for chronic ambulatory care sensitive conditions. 
• See CCGs vary widely in how well they deliver healthcare, new measure shows. BMJ 2016;354:i4615 (NHS OpenAthens password required)

CCG Inequality Indicators - tool

CCG Inequality Indicators
Centre for Health Economics, University of York August 2016

• Benchmarking analysis tool around the relationship between inequalities and unplanned hospitalisation for chronic ambulatory care sensitive conditions data for 2015/16
• Part of the Challenging Health Inequalities support for CCGs 

The 'weekend effect' is about both admissions and mortality rates

Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission
J Health Serv Res Policy 1355819616649630, May 6, 2016 as doi:10.1177/1355819616649630

• This retrospective analysis of data from 2013-14 of hospital A&E and community admissions and mortality within 30 days of admission considers whether it is the number of deaths or the number of admissions that is driving the elevation of mortality rates at weekends.
• HSJ commentary by authors (Subscription required)

Abstract

• Objective Patients admitted as emergencies to hospitals at the weekend have higher death rates than patients admitted on weekdays. This may be because the restricted service availability at weekends leads to selection of patients with greater average severity of illness. We examined volumes and rates of hospital admissions and deaths across the week for patients presenting to emergency services through two routes: (a) hospital Accident and Emergency departments, which are open throughout the week; and (b) services in the community, for which availability is more restricted at weekends.
• Method Retrospective observational study of all 140 non-specialist acute hospital Trusts in England analyzing 12,670,788 Accident and Emergency attendances and 4,656,586 emergency admissions (940,859 direct admissions from primary care and 3,715,727 admissions through Accident and Emergency) between April 2013 and February 2014.Emergency attendances and admissions to hospital and deaths in any hospital within 30 days of attendance or admission were compared for weekdays and weekends.
• Results Similar numbers of patients attended Accident and Emergency on weekends and weekdays. There were similar numbers of deaths amongst patients attending Accident and Emergency on weekend days compared with weekdays (378.0 vs. 388.3). Attending Accident and Emergency at the weekend was not associated with a significantly higher probability of death (risk-adjusted OR: 1.010).
• Proportionately fewer patients who attended Accident and Emergency at weekend were admitted to hospital (27.5% vs. 30.0%) and it is only amongst the subset of patients attending Accident and Emergency who were selected for admission to hospital that the probability of dying was significantly higher at the weekend (risk-adjusted OR: 1.054).
• The average volume of direct admissions from services in the community was 61% lower on weekend days compared to weekdays (1317 vs. 3404). There were fewer deaths following direct admission on weekend days than weekdays (35.9 vs. 80.8). The mortality rate was significantly higher at weekends amongst direct admissions (risk-adjusted OR: 1.212) due to the proportionately greater reduction in admissions relative to deaths.
• Conclusions There are fewer deaths following hospital admission at weekends. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. The reduced availability of primary care services and the higher Accident and Emergency admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week. Extending services in hospitals and in the community at weekends may increase the number of emergency admissions and therefore lower mortality, but may not reduce the absolute number of deaths.

Preparing for industrial action

Preparing for industrial action
NHS England 18 December 2015

• NHS trusts and NHS England have been working with doctors and operational hospital staff to prepare for the potential of junior doctor industrial action. Their advice focuses on reducing demand in urgent and emergency care and practical steps to mitigate the loss of junior doctor capacity. Includes:
• NHS England guidance mitigating junior capacity
• NHS England Guidance reducing demand in UEC