The Challenge of Emergency Medical Care

The Challenge of Emergency Medical Care

Dr Richard Grocott-MasonConsultant CardiologistJoint Medical Director

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

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

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.

Deterioration in 4 hour performance

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

Older age – the problem or not ?

Slide courtesy of Prof Derek BellProf of Acute Medicine Imperial College, London

Variation in England in Emergency Admissions 2012-13

A&E activity & GP practice

NHS England 2013

http://www.nhs.uk/NHSEngland/keogh-review/

NHS England Keogh review evidence base

Simplistic view of process of unscheduled care

Patient/Public Problem Solution

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

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

Where is unscheduled care delivered?• Friends/family• Self-help medical books• Internet sites

Self treatment

• Pharmacist• GP (own or out of hours)• Community matron/nurse/carer

Community clinician

National Help line

• 999 callAmbulance

service

Hospital-based services

• NHS Direct• 111

• Urgent care centre• Emergency Department

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)

Health and Social Care Whole System Overview of Patient Flows

(Figures in millions of cases per year)

Self toA&E

999

A&EAttendances

OutpatientAttendances

Emergencyadmissions

In Hospital Intermediate Care

Residential &Nursing Home Care

HomeCare

Fast Access Primary Care(NHS Direct and Walk in Centres)

Pharmacy

GP PrimaryCare (Consul-tations)

Self Care

Elective admissions

ElectiveDay Cases

31mFlow to RepeatOutpatients =

GP913

HOSPITAL CARESECTOR

2 2

2

14

A&E

1.4 billion

Community Pharmacy 340m

Primary Care 230m

HealthIncident2 billion(99-00))

HealthIncidents

4

36

10

20Slide courtesy of Prof Derek BellProf of Acute Medicine Imperial College, London

Patient

THH NHS FTAcute

hospitalHarefield

Heart Attack Centre

NWL Hospital

Acute Stroke unit

CNWLCommunity

ServicesIntermediate

Care

LBHHome Carers

Social Workers

GP

Care UKOut of hours GP service

LASAmbulance

service

111service

Greenbrook/Ealing NHS

TrustUrgent Care

Centre

?

Organisations involved in delivering unscheduled care in Hillingdon borough

Confusing branding

Actual Risk?

Symptoms - type, - severity, - duration, - combination - duration

Patient factors - previous history - current treatments

How urgent is unscheduled care?

None Immediately life threatening

Treatments can be critically time-dependent (mins)e.g meningococcal sepsis, heart attack, stroke, trauma

Other treatments much less time-dependent.

Activity

Risk aversion/

confidence

How does risk behaviour relate to activity?

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)

NHS England review (Nov 2013)

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.

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

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?