• Managing the Demand for Urgent Care: Community Based Integrated Care

• How can community based integrated care offer an alternative to hospital care? How would the governance and accountability of such a system work in practice?

• Professor David Colin-Thomé,

Current provision of urgent and emergency care services

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>100 million calls or visits to urgent and emergency services annually:

• 438 million health-related visits to pharmacies (2008/09)Self-care and self

management

• 24 million calls to NHS • urgent and emergency care telephone servicesTelephone care

• 300 million consultations in general practice (20010/11) NOW 340 millionFace to face care

• 7 million emergency ambulance journeys999 services

• 16 million attendances at major / specialty A&E • 5 million attendances at Minor Injury Units, Walk in Centres etc.

A&E departments

• 5.4 million emergency admissions to England’s hospitals Emergency admissions

• Surge in demand exacerbated the problems in a system we knew was already under strain

• In hospitals the surge “problem” is emergency admissions

• Strong upward trend in all contacts especially to NHS111

• Resilience, and availability, of community-based services and the important relationship with social care services compounds difficulties in the acute hospital sector – leading to unnecessary admissions and delayed discharges

What does the experience and data from recent winters tell us?

The Kings Fund Urgent and emergency care myth busters January 2015

• Myth one: A&E waiting times have risen dramatically• Myth two: The number of people going to A&E is

increasing• Myth three: Increases in A&E attendances are mainly a

result of reduced access to GPs• Myth four: A&E pressures are due to an inadequate

number/mix of staff• Myth five: Delays discharging patients from hospital are

increasing because of problems with social care

UEC Review VisionFor those people with urgent but non-life threatening needs:

•We must provide highly responsive, effective and personalised services outside of hospital, and•Deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families

For those people with more serious or life threatening emergency needs:

•We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery

Monitor;Exploring Acute Care Models 2014

• 1. A greater emphasis on ‘risk tiering’ in paediatric and intrapartum maternity care, supported by complementary networks of staff and organisations. For example, Sweden’s Stockholm County has a three-tier network of intrapartum maternity care, with different units caring for women and babies at different levels of risk. These risk-tiered systems are facilitated through shared clinical governance and formal patient transfers and protocols. (1/5 children to ED where no children’s IP services}

• 2. Increased use of technology. In some systems, technology is used to deliver complex care remotely. For instance, in the state of Arkansas, USA, specialist doctors deliver stroke care remotely to patients using video-links. Similarly, in the USA, spoke sites for intensive care can be supported remotely by an electronic intensive care unit (eICU) hub site. Technology is also being used to share patient records efficiently, leading to better integrated care, as seen in the single comprehensive electronic child health record used across primary and secondary care settings in Canada.

• 3. Greater use of GPs to deliver out-of-hours urgent care. This approach was prevalent in the Netherlands, where GPs are often the gatekeepers for emergency care. A&E attendances in the Netherlands are about 120 a year per 1,000 people, compared with 278 in England. In the Netherlands 39% of patients attending A&E are referred by GPs, compared with 5% in England

Immediate to doThe Hakin Letter and Keith Willett recomendations

– build upon and align existing resources, standards and clinical quality indicators: NHS 111, ambulance services, out of hours primary care, A&E

– whilst developing new specifications for community hospitals, Urgent Care Centres, Emergency Centres, Specialist Emergency Centres and other system components

– Prime commissioner who may devolve leadership responsibility but not accountability to a provider organisation or individual

– Integrate GP OOH and 111– Develop all hours general practice- so key role for GP

Federations– include a  wider group of professionals than currently part of the

front line eg pharmacists, mental health workers, social care– Develop locally framework/memorandum on expected behaviours

4 biggest challenges

• Payment system reform. See Next Slide• Information sharing. E.g, knowledge of me as a person and

knowledge of relevant clinical condition. So require digital platform for a system that recognises and then knows what the clinical condition and care needs are

• System measures e.g, integration-multi channel entry (access- ‘click, call or come in.), structured initial assessment (access and advice), multidiscipline clinical hub (further assessment, advice, treatment, referral), face to face care. So for instance need whole system for demand surges. Contracts must ensure interdependency, governance, value, safety

• Workforce and skill shift. Care needs to be personalised, integrated (coordinated) with a single trusted point of contact. Able to speak to a clinician with clinical decision support from hospital specialists 24/7

Payment System Reform

• Costs should be measured across the complete cycle of care for the condition/across a unit of time, if a long term condition

• Bundled payments: • Fundamentally differ from Fee-for-service, Global capitation, Block payments • Encompasses a single payment for a full cycle of care, with mandatory outcome

reporting • Incentivise providers to improve outcomes and lower costs across full care cycle • Are underpinned by contracts which allow for shared incentives between providers on

achievement of agreed outcomes • Issues- risk sharing/cohesion/patient flow to most appropriate. • Programme budget based on a defined population?• And held by a population based provider?

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• •

Urgent Care Commission

PHASE 1: Urgent and Important – The Future for Urgent Care in a 24/7 NHS

PHASE 2: Urgent and Important – Principles for a Network Approach to Urgent Care

Urgent Care Commission

• Strong and credible leadership• Clear lines of accountability• Patients involved in all parts of the system• A partnership approach to working• Agreeing a shared vision, across all contributors in the

network, underpinned by system-wide governance and metrics.

• Ensuring that relationships in the network are not only transactional but relational in nature.

• Agreeing shared incentives.

The NHS financial & service challenge will only be met by radically changing how care is provided:

– New localism;– Using current & future technologies;– Streamlining care & removing inefficiencies;– Integration of care across organisational boundaries.

• The innovation of GP Provider Companies / Federations are key to realising the above.

General Practice service delivery options

• Analysis of workload to assess practice clinical skill mix• Partnership model – GPs, practice nurses, practice manager,

Pharmacists• ‘Joint Ventures’ to deliver care for population groups- CHS, Social

Care, hospital staff• Role of GP ‘meso organisation’ in supporting above at practice

level.• MultiSpeciaity Community Providers eg ‘Primary Care Home’• Horizontal or Vertical Integration = PACS

The Primary Care ‘Home’

• Population based primary care is where the needs of the individual and of the community can be met

• Home for all PC providers (Pharmacists, Dentists, Optometrists), CHS and Social Care

• And potentially many currently working in hospitals• Delivering on;• Improved service quality and responsiveness to patients’ individual

requirements• Integrated Long Term Conditions care• Care closer to the patient’s home• The ‘home’ for extended skills and services• An alternative to hospital; centricity• Holding a population budget • Where bio-clinical focus and addressing the social determinants of

health can be the responsibility of one provider organisation • Importance of relationship with local government and third sector

‘Next to knowing when to seize an opportunity, the most important thing in life is to know

when to forego an advantage’

• Integration will depend on Health Economy behaviours• -the interests of patients and citizens trump those of institutions• -no disputes but ok if disagreements• -need to choose our leaders for their behavioural attributes not

only knowledge and experience• We need to focus on relationships underpinned by a contract, not

defined by the contract • A key focus for future commissioners as it is noticeably lacking

currently, is how to commission for individual patients• design, develop, test and implement system-wide outcome

measures for which all members are jointly held to account

The only way to get sustainable improvementis for the NHS to also be held to account by

individual patients

• A key focus for future commissioners as it is noticeably lacking currently, is how to commission for individual patients. On this in particular the NHS has much to learn from local government.

• There are at least two approaches focusing on those identified patients with complex problems;

• the devolution of defined personal healthcare and social care budgets to the individual

• And/or for those patients who have a clear care plan, for the provider to be held to account for their contribution to the care plan. The assessment of delivery of their care plan to be by the patient/carer/case manager. These patients many of them elderly and frail are of huge importance and relatively small in number as to warrant such individual attention. The concept could be expanded into other areas as locally appropriate.