The Challenge of Emergency Medical Care

1. The Challenge of Emergency Medical Care Dr Richard Grocott-Mason Consultant Cardiologist Joint Medical Director

3. What is the crisis? • Increasing attendances • Increasing emergency admissions • Worse performance against 4 hour target • Stress on ED staff • Morale, vacancies, turnover, sickness rates • Financial costs • Public/politician expectation

4. National Audit Office (2013) • There is limited evidence on what works in reducing avoidable emergency admissions. • Many local initiatives to prevent avoidable emergency admissions including risk prediction tools, case management, hospital alternatives and telemedicine, but limited evidence on what works. • Estimate that at least 20% admissions could be managed effectively in the community

5. NAO analysis • Financial incentives across the system are not aligned. • Better integration across health services is seen as key to managing emergency admissions. • Local oversight is needed to bring about change across the health system. • The proportion of a hospital’s activity that is emergencies may be a major factor in the financial performance of some trusts.

10. Deterioration in 4 hour performance 4 hour target remains the main politically important measure of the ED/Trust performance.

11. Older age – the problem or not ? Slide courtesy of Prof Derek Bell Prof of Acute Medicine Imperial College, London

12. Variation in England in Emergency Admissions 2012-13

13. A&E activity & GP practice NHS England 2013

14. NHS England Keogh review evidence base http://www.nhs.uk/NHSEngland/keogh-review/

15. Simplistic view of process of unscheduled care

16. Why is so difficult to sort? • Scale of numbers • Poor integration of services • Poor IT systems • Increasingly complex patients • Availability of senior staff • Lack of evidence in system planning • Rising expectations

17. Why do patients access unscheduled care? • New onset of symptoms/illness • Severity of that symptom • Worry that something serious is wrong • Deterioration in chronic medical condition • Failure of symptoms to settle • Inability to cope with condition • Convenience • Inability to get appointment with GP • GP appointment too distant

18. Where is unscheduled care delivered? • NHS Direct • 111 • Urgent care centre • Emergency Department

19. Scale of activity • ~500,000 total deaths in UK/yr • ~ 550 deaths per day after emergency admission • ~14,500 emergency admissions/day • (~2,700 of these are readmissions within 30 days of discharge) • 820,000 GP contacts per day • 25,000 calls to 999/day • 5,500 hits to NHS Direct mobile app (2011) • ~20,000 calls/day to 111 (Sept 2013) • 1.6 million visits to pharmacy/day • ~425,000 A&E/UCC attends/day (England)

20. GP Primary Care (Consul-tations) Outpatient Attendances Self Care Primary Care 230m 14 4 2 2 1.4billion Elective Day Cases Emergency admissions Elective admissions Health Incident 2 billion (99-00)) Flow to Repeat Outpatients Self to A&E 31m 2 = A&E Attendances 3 13 999 6 A&E GP 9 HOSPITAL CARE SECTOR Fast Access Primary Care (NHS Direct and Walk in Centres) In Hospital Intermediate Care Community Pharmacy 340m Residential & Nursing Home Care Home Care Health Incidents Pharmacy Health and Social Care Whole System Overview of Patient Flows(Figures in millions of cases per year) 10 Slide courtesy of Prof Derek Bell Prof of Acute Medicine Imperial College, London

21. Organisations involved in delivering unscheduled care in Hillingdon borough ?

22. Confusing branding

23. How urgent is unscheduled care? Actual Risk? Symptoms - type, - severity, - duration, - combination - duration Patient factors - previous history - current treatments Immediately life threatening None Treatments can be critically time-dependent (mins) e.g meningococcal sepsis, heart attack, stroke, trauma Other treatments much less time-dependent.

24. How does risk behaviour relate to activity?

26. Patient outcomes from acute illness • Full recovery with no medical treatment required • Full recovery with medical treatment • Partial recovery with medical treatment • Long term disability • Death (Avoidable or inevitable)

27. NHS England review (Nov 2013)

28. What may work better? • More use of appropriate self treatment • Better use of technology to support patients and clinical staff • Simpler system with less duplication and more integration • Fewer hospital admissions more use of ambulatory emergency care pathways • Less variability • Better evidence, data and understanding of whole system • Spend less on people who don’t need it, so resources concentrated on those who do.

29. What could be different? • An elderly patient recently discharged from hospital with a care package who is struggling to cope at home one evening after a fall. Current • refer back to hospital, readmission and re-evaluate home care package. The future? • clinical assessment at patient’s home (paramedic, carer, community nurse) • telemedical link to either own GP or one in UCC, with full access to patient’s care plan from recent admission and medical records • Increased package of care/monitoring at home overnight • Further review by GP/Community Nurse/carers next day

30. It’s a Grand Challenge • Complex issue • Complex system • Plenty of data • Potential for technology/industry to help • Is the Cumberland Initiative up to the challenge?