EMERGENCY
ACCESS DELIVERY
TEAM
WORKSHOP
MONDAY
9 FEBRUARY 2009
1.
1.
Introduction
In its strategy paper issued to NHS Boards in February 2009, the national Emergency Access
Delivery Team identified it would work with NHS Boards over the course of the next two
years to deliver locally agreed improvements in access to emergency care. Success will be
evidenced by a number of factors, and ultimately an overall reduction in patients accessing
health care at Accident and Emergency Departments for assessment, diagnosis or treatment
where this would be available through another provider. The Emergency Access Delivery
Team will facilitate a shift in the balance of care from dependency and demand for
unscheduled care towards better self care, scheduled/ planned interventions and better
unscheduled care in the community.
Keen to learn from the experiences of others who had led on, or been actively involved in,
improvements in these areas, a workshop was held in early February 2009. This report is a
summary of the key issues discussed and the actions to be progressed.
2.
Key points from the presentations which stimulated the discussion at the
workshop:Professor Derek Bell



Do we know if demand is increasing: are patients more sick?
Is the variation in care driven by patients or the system?
Do we understand demand and capacity, and actions to take to better manage these?
Dr George Crooks




SAS demand increased between 2004- 08: was this a good use of resources?
What is the definition of an emergency?
The introduction of the target of 48 hour access to the Primary Care Team has had impact
on SAS and NHS 24: was this an intended consequence?
Has the introduction of extended hours in general practice delivered on the original
intention?
Professor Helen Snooks

This presentation provided an opportunity to hear about a recent study undertaken in
Wales, with the aim of understanding factors which influence members of the public
when they make emergency or unscheduled contact with health care services. Analysis of
the results is ongoing. Early learning which was shared was as follows:
 Triage needs to be systematic, accurate and consistent across the system
Demonising the public as irresponsible users of services is unhelpful
 Multiple service usage needs to be further explored – and addressed
 Alternative care pathways and support for self-care for LTCs may avoid
emergency contacts/admissions

Study Report: “Understanding How the Public Choose to Use Unscheduled Care
Services”
http://www.awardresearch.org.uk/documents/UPCUUCS_report_Final_July_2008.pdf
2.
Dr Josip Car

Within the context of Lord Darzi’s review of London health services, this presentation
outlined the framework for tendering for services, in a drive to create a single provider for
the entire unscheduled care pathway and simplify commissioning. The presentation also:
 Reflected whether people are rational in choosing how to access unscheduled care
 Challenged ease in navigating the way to, and through, access points
 Outlined opportunities for primary and secondary care services to work as an
integrated system
3.
Three presentations outlining the contribution primary care can make:
(i)
Dr A Crosswaite
Recognised the need to simplify access to unscheduled care, perhaps developing one
point of access for patients. Need to improve communication across the system to aid
practitioners to navigate their way through it, on behalf of patients. Opportunities for
closer collaboration between primary and secondary care.
(ii)
Dr D Carson
Outlined how to develop capacity in general practice to provide urgent care - with
benefits for the system. The presentation included a debate on the role of triage; it is
important to recognise that one service model does not fit all: urban/rural localities.
(iii)
Dr A Baker
Described integrated unscheduled care model developed in a rural locality – and
motivating factors for development which gained support from each part of the
system.
Dr V Connolly

Reflecting on the demands on A&E – and its ability to achieve the 4-hour wait target. The
presentation outlined the benefits of developing ambulatory emergency care. A selection
of clinical diagnoses which may be appropriate for such a service model were outlined –
together with the key success factors.
The key themes which came from the discussions during the course of the day are outlined in
sections 4 to 8 below.
4.
Access and Patient Engagement
Does it depend on geography – or the time of day?
It is considered good practice to give consumers of any service a choice – and this applies to
health services. It was suggested that practitioners should reflect on their own perception that
patients are ‘behaving badly’ when in fact the issue is a lack of clarity about services
available, and how to access these – where and when.
3.
The range of services provided in the unscheduled care pathway is complex to the point that
even practitioners within the service find it challenging to navigate their way successfully.
The public, patients and practitioners are not sufficiently knowledgeable about alternative
services available locally – with the result of defaulting to A&E Departments. It was
suggested that patients’ expectations are variable, and generally low.
The service configuration and variation within and across NHS Board areas in-hours and outof-hours can encourage patients to behave in a way that is counter to that anticipated by the
Service.
Mother with sick child, other siblings at home: child becomes unwell in late afternoon,
symptoms not life threatening. If the mother wishes to attend her GP surgery where an
appointment is available, she will need to take herself and all the children on a bus across
town to see the GP. At the surgery the mother is given a prescription which she is now
required to take to the pharmacy along the road, wait to have this dispensed and then get the
bus back home. Alternatively, she could wait until after 6pm; she may be sent a taxi to take
her to the out of hours centre, where she can consult with a GP and receive the prescription
there and then.
There was consensus that when making choices about how to access unscheduled care,
patients do behave rationally. In fact, individuals behave in a predictable way. On some
occasions patients will access more than one part of the unscheduled care system. Is the
challenge, then, to change the access to services or change behaviour – or will doing the
former lead to a change in behaviour in time?
A further point discussed was that the standards for different parts of the system are
incompatible and inconsistent:


48 hours for consultation with a member of primary care team in GP Practice
4 hour maximum wait in A&E for assessment
8 minutes for SAS, and 30 seconds for NHS 24 (life-threatening situations)
The length of time an individual is required to wait for a service will influence future
decision-making. It is suggested that this point requires further consideration if we are
seeking to deliver an efficient system.
Questions /issues discussed:

What’s the problem of people turning up at A&E if the service is well set-up to deal with
minors and can get them through the system in 30 minutes?

If referral to specialist staff – eg diabetic nurse, is only available 9am-5pm, where do
patients go if they have a problem out of hours?

Do we enter into a dialogue with patients who present at A&E with conditions they have
had for a period of time – and not attended their GP surgery?

What percentage of calls to NHS 24 for advice result in referral/ self presentation at A&E
for face to face consultation?
4.

If the demand for services out of hours is increasing, should we ‘beef up’ these services?

Rather than striving to meet the 4-hour maximum waiting time target, should we make
sure that A&E is used for what it’s meant for?
In addressing the issue of access and patient engagement we need to:




5.
Develop one point of access – for patients to be triaged (face to face by practitioner,
telephone, or other model).
Further develop social marketing: informing the public, patients and practitioners about
alternatives to A&E. NHS Grampian leading on national pilot of ‘Choose well’
campaign.
Realise that ‘one size does not fit all’, and solutions will vary depending on locality.
Address variation in standards for waiting times for different parts of the unscheduled
care system.
Data/Information Management & Systems
During the course of the discussion there were two schools of thought:(a)
Much work had been developed through the unscheduled care collaborative,
but here was a sense of frustration that this will require to be repeated before
moving forward – organisational inertia.
(b)
The other view was that the work developed through the unscheduled care
collaborative did not address the patient flows now being considered therefore analysis is required. This group also noted that much of the
organisational memory developed through the unscheduled care collaborative
has been or is being lost, as individuals move to new posts in the system or out
of the system altogether.
The discussions highlighted the inconsistencies in recording and use of data at local level.
The definition of ‘attendance’ means different things to different people.
It is important to identify the size of the population in the flows and seek to address the high
volume groupings. Use data available to identify conditions/illnesses.
Ensure data is available to inform decisions - need to take account of the impact on the
whole system and not just shift demand from one part to another.
A number of NHS Boards have begun to engage GP Practices in ownership of HEAT targets.
The development of further information in relation to patient attendances/referrals/admissions
etc, and dialogue with GP Practices and other partners, are components of good clinical and
corporate governance frameworks.
The current information systems do not facilitate system-wide data sharing, and therefore it
will not be possible to identify if a planned ‘shift’ has been possible. Any relationship in
changes in demand at two points in the system will not be easily captured.
5.
In addressing the issue of data/information management & systems:
Using the resources available from EADT, NHS Boards are encouraged to identify capacity
and capabilities to undertake the analysis of local activity and engage in system-wide
information sharing. Analysis of patient flows where patients could be equally well treated
elsewhere is a priority. [Patient flow 1 – minor injury and illness and flow 5:out of hospital].
This work is being progressed in a number of NHS Board areas – NHS Ayrshire & Arran,
Greater Glasgow & Clyde, and Lanarkshire.
The EADT should ensure that all NHS Boards develop model(s) describing local patient
pathways into and through unscheduled care; it is important these are developed with
engagement of all local partners. Work on this is underway in NHS Lothian.
The EADT should support Boards in engaging with GP Practices and other partners to
develop whole system commitment to the development of efficient local service models.
Work on this is underway in NHS Borders, Forth Valley and Lanarkshire.
Further work is required to develop system wide information recording/reporting to capture
evidence of the new ways of working. Work is also required on development of definitions.
6.
Service Models:
It was acknowledged that having a single, integrated unscheduled care service is important.
The discussion highlighted a lack of clarity around the different elements of unscheduled
care, and which clinical services are provided from which locations.
There was a view that greater blurring of roles and sharing knowledge across
primary/secondary care should be encouraged. To date this seems to have been more
successful in rural areas.
It was acknowledged that within and across NHS systems there is variation in practice. It is
not clear if this is occurring for legitimate reasons or not. There was a suggestion that service
developments have been ad hoc, based on local resources available and national policy, rather
than on evidence of local need. There is an opportunity for greater strategic planning and
prioritisation.
The key issues discussed in relation to service models were:



Benefits of GP involvement at the front door
Co-location of services – A&E, GP in-hours and Out of Hours Services – and in some
Board areas co-location also includes SAS and NHS 24. The journey of developing
A&E into a ‘referral only’ service was discussed. There are opportunities for primary
care and secondary care to work more closely together, in relation to referrals and
signposting up/downstream regardless of location
Provision of triage: face-to-face or by telephone, administered by nurse or medic.
There was much discussion on the benefits of the different models in different
localities.
It was recognised that where triage is being used it is important that
consistent, corporate standards are applied across the system: avoid mixed messages
and variation in outcomes
6.


Development of protocols to facilitate direct admission to avoid unnecessary
attendance at A&E which may add no value to the patient’s journey
Again it was recognised that there is no ‘one solution’ – perhaps an urban model and a
rural model could be developed to avoid inappropriate variations
In addressing the issue of service models it should be recognised that many other factors
will be dependent on this:



Development of workforce and multidisciplinary teams with appropriate skills
Development of IT and other elements of infrastructure
Social marketing
The Unscheduled Care Advisory Group should be requested to give a view of future service
models for urban and rural localities.
NHS Boards should be encouraged to learn from those systems which are in the process of
developing new models (notably NHS Forth Valley and NHS Grampian) where Emergency
Care Units are being developed, and also from NHS Borders which has developed GP input
to the A&E Unit in-hours and out-of-hours.
Linked to the issue of service models, two further issues were discussed:
Ambulatory Care: Further discussion on the development of ambulatory emergency care is
encouraged at a local and national level.
Mental health: Access to mental health services particularly during the out-of-hours period,
together with the provision of liaison psychiatric services, could be improved. These issues
are now being progressed through the EADT in conjunction with the Scottish Division of the
Royal College of Psychiatry and colleagues in the Scottish Government Health Directorates.
7.
Engagement with Primary Care
It was widely felt that the relationships between patients and GPs remain strong. However, it
was also
recognised that not everyone is registered with a GP, and usage of
primary/secondary care services can be influenced by cultural issues, so not everyone will
experience such a relationship.
The information available does not lend itself readily to identifying what the capacity is for
unscheduled care, what is currently being provided in general practice in hours, and the
standards applied.
It was recognised that Community Health Partnerships are ideally placed to facilitate social
marketing of the range of services available in each locality. They should also seek to
encourage information and knowledge sharing across primary care and secondary care. The
role of primary care practitioners was considered to be especially relevant in relation to
individuals with long term conditions.
7.
In addressing engagement with Primary Care:
Benchmarking for unscheduled care within general practice should be developed.
There needs to be recognition that previous incentives introduced in primary care (General
Practice) have not always delivered benefits for the whole system. Consideration should be
given to future development of incentives across the system. Incentives are not necessarily
financial and can have a huge impact on morale.
Community Health Partnerships should seek to develop local social marketing tools. They
should also encourage system-wide engagement in MCNs and other clinical networks.
8.
Leadership, Management Structures and Teamwork
There was a consistent view that there is no overall management structure for the system of
unscheduled care, and that the ability of individuals to influence and make decisions about a
part of the system outwith their own sphere of operational responsibility is limited (eg if
based in CHP, ability to make decisions in A&E is limited and vice-versa).
Robust clinical leadership is important to ensure decision-making processes are transparent
and based on sound evidence, and decisions are taken forward.
The blurring of roles and sharing of information across primary care and secondary care
should be encouraged.
Linking back to the issue of triage services and the need for consistency, it was recognised
that patients do not access services according to invisible NHS Board boundaries, so
consistency in roles/ designations will be important. One example - Extended Nurse
Practitioner – role and responsibilities of such posts vary across Scotland.
In addressing Leadership, Management Structures and Teamwork:
Strong organisational and clinical leadership at national and local level are considered as key
success factors. Individuals need to be given authority to lead on system-wide issues and
local management arrangements should support this.
Greater clarity and consistency on roles/designations, particularly of clinical staff, is required
as new roles are being developed [again recognising one size does not fit all].
All presentations from the workshop are available at:
http://www.shiftingthebalance.scot.nhs.uk/initiatives/sbc-initiatives/emergency-accessdelivery-programme/national-workshop-9-february-2009/
8.
APPENDIX 1
SCOTTISH GOVERNMENT HEALTH DIRECTORATES
EMERGENCY ACCESS WORKSHOP
REDUCING A&E ATTENDANCES
Monday 9 February 2009, Hilton Hotel, Edinburgh Airport
Aims:
 to debate the main issues affecting A&E attendances; and
 consider the best strategies for enabling reductions in the rates of
attendances.
PROGRAMME
Morning: understanding why patients, the public and professionals
access A&E. What does the research tell us?
Chair for morning session: Mr Tim Davison
1000
Welcome and introduction
Tim Davison
1010
Context for improvement
Prof Derek Bell
Dr George Crooks
1030
Understanding people
Prof Helen Snooks
1100
Evidence in decision making
Dr Josip Car
1130
Table discussion (coffee available)
6 Groups
1200
Feedback from table discussion
1215
LUNCH
9.
Afternoon: Identifying solutions and systems change. What
changes may have the biggest impact?
1300
Introduction to afternoon session
Kathleen Bessos
1310
Primary Care Contribution
In Hours and Out of Hours
Dr A Crosswaite
Dr David Carson
Dr Adrian Baker
1400
Acute medicine; an outpatient
specialty?
Dr Vincent Connolly
1420
Table discussion (tea available)
1500
Feedback from table discussion
1545
What next?
All
Discussion led by Tim Davison
1600
Close
HEAT TARGET: NHS Boards will achieve agreed reductions in the
rates of attendances at A&E from end 2007/08 to end 2010/11. A&E
attendances should decrease with better provision and use of
primary care services, better preventative and continuous care in
the home, and improved self care. The measure is intended to
indicate an outcome of a range of improvements relating to joined
up working and shifting the balance of care.
10.
APPENDIX 2
Workshop participants/speakers:
Dr. Adrian Baker, GP, Nairn, the Highlands
Adrian is a practising GP in the Highlands, working in a practice covering 200 square miles,
which has a community hospital and retains an integrated Out of Hours service for 14,500
patients. Having initially trained in Birmingham, Adrian then continued his work both
around the UK and abroad in India and the Western Isles. The draw of rural Scotland and the
associated outdoor opportunities led to his finally settling in Nairn. The delivery and
implementation of high quality healthcare interventions to a locality have been built on by his
team over the last decade. The local GPs cover A&E, Primary Care Emergency Centre and
Out of Hours, working to an integrated model of care.
Professor Derek Bell, Member of Emergency Access Delivery
Team. Professor of Acute Medicine, Imperial College, London.
Derek trained in Edinburgh and qualified in 1980, having trained in Chest Medicine and
General Medicine with an interest in Intensive Care. He was initially appointed as
Consultant at Central Middlesex Hospital in London, before moving to Edinburgh as a
Consultant in Acute Medicine and Chest Medicine. Subsequently, Derek was appointed to the
first Chair of Acute Medicine at Imperial College in 2006, based at Chelsea and Westminster
Hospital. While in Edinburgh, he occupied the position of Associate Medical Director for a
number of years, latterly holding the post of Medical Director for the Acute Operating
Division for Lothian. Derek serves on a number of National Committees and is particularly
involved in Acute Medicine training. He has worked with both the Modernisation Agency
and Centre for Change and Innovation as a National Clinical Lead.
Derek’s research interests primarily relate to quality of care, particularly in acute medical
care, and methods of delivery of care. Hi clinical interests are illness severity assessment,
pulmonary embolism and pneumonia.
Mrs. Kathleen Bessos, Member of Emergency Access Delivery
Team. Deputy Director, Shifting the Balance of Care, Primary &
Community Care Directorate, Scottish Government Health
Directorates
Kathleen joined the NHS as a National Management Trainee in 1980. She has held a number
of posts within the NHS, and from 1990 until 2000 was responsible for Executive and Non
Executive Director development in Scotland and primary care organisational development.
During this time she was also responsible for developing and implementing the strategy for
reducing the number of NHS Trusts in Scotland from 47 to 28. From 2000 she worked for
11.
three years with NHS Boards on strategic development to support the move in Scotland to a
fully integrated health service planning and delivery system.
Kathleen was seconded to write the White Paper "Partnership for Care", published in 2003,
and subsequently was responsible for the development of the policy and strategy on
Community Health Partnerships. She has responsibility within Scottish Government for
Shifting the Balance of Care, including delivery of the HEAT target on reducing A&E
attendances.
Dr. Josip Car, Medical Director and Chair of Professional
Executive Committee, Hammersmith and Fulham Primary Care
Trust & Director of eHealth Unit, Department of Primary Care
and Social Medicine, Imperial College, London
Dr Josip Car, a practicing family physician, is the director of eHealth Unit at Imperial
College London and a Medical Director of NHS Hammersmith and Fulham. He is a member
of clinical executive team for commissioning world-class healthcare in London. Dr Car’s
focuses of research include evaluation of the information and communication technology as a
vehicle for improving quality and safety of health care, investigation of management of longterm diseases in primary care, and health policy.
Dr Car undertook his medical training and a Masters in Family Medicine at University of
Ljubljana, Slovenia, where he is a visiting senior academic fellow. Subsequently he
completed a PhD at Imperial College. He has received several highly competitive national
research awards and was recently named a top ten peer-reviewer by the BMJ. Dr Car is also
an editor of the Cochrane Collaboration - Consumers and Communication group and an
adviser to the editor of the BMJ. He served as an expert adviser on eHealth to Organisation
for Economic Co-operation and Development (OECD) and is currently an expert group
member of WHO World Alliance for Patient Safety focusing on Information Technology. He
has published over 60 peer-reviewed publications.
Dr. David Carson, GP, Developed GP Out-of-Hours services, and
emergency care policy and performance for the Department of
Health
David was a GP for 10 years before spending 6 years in an inner London Health Authority,
leading primary care policy and performance. He spent 4 years developing GP Out-of-Hours
services, and emergency care policy and performance for the Department of Health. During
this time he published the seminal paper: “Raising Standards for Patients: New Partnerships
in Out-of-Hours Care” (known as The Carson Report). He was also the primary care lead on
the development of the national strategy ‘Reforming Emergency Care’.
The Primary Care Foundation has recently been working with A&E systems to improve
flows and productivity, supported acute medical assessment development, and supported
PCTs to develop whole system design of Emergency Care.
12.
The Foundation operates a national benchmark for GP Out of Hours Services and is engaged
with the department of health to research and develop the response of General Practice to
Urgent Care requests.
Dr. George Crooks, Medical Director NHS 24 and Scottish
Ambulance Service
George is currently the Medical Director/Chief Operating Officer for NHS 24 and Medical
Director for the Scottish Ambulance Service, where he is responsible for the quality, safety
and effectiveness of all clinical services and the development of new services in partnership
with other NHS organisations. He was a General Practitioner in Aberdeen for 22 years, and
his past appointments have included Director of Primary Care with NHS Grampian, where he
had responsibility for all community-based independent contractor services. He was
appointed Interim Chief Executive for NHS24 in September 2007, a post he held for 9
months. George has a particular interest in the field of unscheduled and emergency care,
particularly the development of common assessment and triage processes across the NHS and
the use of technology to support the delivery of high quality patient care to the population of
Scotland.
Dr. Alastair Crosswaite, GP and Physician, Edinburgh Royal
Infirmary
Alastair currently holds two posts: Principal GP in Morningside Medical Practice, and
Primary Care Physician at the Royal Infirmary of Edinburgh, where he is based in Combined
Assessment in Acute Medicine. There he is part of the multi-professional team, assessing
complex needs, usually in frail, elderly patients in acute medicine. Alastair was involved in
the development of the medical assessment model in Edinburgh.
Dr. Vincent Connolly, Consultant Physician, Chief of Service,
Medicine: The James Cook University Hospital, Middlesbrough
Vincent Connolly is an Acute Physician and endocrinologist at The James Cook University
Hospital, Middlesbrough. He qualified at the University of Glasgow and had training posts in
Glasgow and London, and subsequently was a senior Registrar in the North East of England.
He was awarded an MD in 1998 for his thesis on socio-economic factors and diabetes related
outcomes. Subsequently his research has focused on diabetes related mortality. He was
involved in the development of the Acute Assessment Unit in Middlesbrough in 1998. Since
that time the AAU has expanded to incorporate a Short Stay Ward and Ambulatory Care
Centre. He has published papers on the development and clinical outcomes from these
innovations. In 2004 the team won the Acute Medicine Team of the Year from Hospital
Doctor. He has contributed to the development of the NHSi guidance for the management of
Ambulatory Care, the Emergency Services Collaborative and to the development of NICE
guidance for Type 1 Diabetes. At present he is Chair of the Acute Care Pathway for Our
Vision, Our Future and is a member of the National Clinical Advisory Team.
13.
Mr. Tim Davison, Chair of Emergency Access Delivery Team,
Chief Executive NHS Lanarkshire
Tim joined the NHS as a National Management Trainee in 1983. Since then, he has worked
in all sectors of the NHS in Forth Valley, Lothian, Greater Glasgow and Lanarkshire.
Tim held posts as Chief Executive of Greater Glasgow Community and Mental Health
Services NHS Trust (1994-1999); Greater Glasgow Primary Care NHS Trust (1999-2002)
and North Glasgow University Hospitals NHS Trust (2002 – 2005), before taking up his
current post, as Chief Executive of NHS Lanarkshire, in May 2005.
Professor Helen Snooks, Centre for Health Information Research
and Evaluation, Swansea University
Currently holding a chair in Health Services Research at Swansea University’s School of
Medicine, Professor Snooks has worked both in the academic sector and in the health service,
in the areas of information management and clinical effectiveness. She leads the Welsh
Assembly Government funded Thematic Research network for emergency and UnScheduled
Treatment (TRUST: TRUSTresearch.org.uk) and chairs the Department of Health funded
999 EMS Research Forum. She also leads the All Wales Alliance for R&D in health and
social care in Mid and West Wales, a generic policy related research network. Professor
Snooks is currently leading a randomised controlled trial of computerised decision support
for paramedics in the care of older people who fall (SAFER trial) and managing a further trial
to assess the effectiveness of a public health intervention to support parents in deprived areas
of Wales (Family Links Nurturing Programme).
Professor Snooks’ main research interests and expertise lie in the fields of Emergency Prehospital and Unscheduled Care, Clinical Audit and Effectiveness, and research support.
14.