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Providers welcome ‘fundamental redesign’ of urgent and emergency care

NHS England published yesterday (1 September) ‘Safer, faster, better’ guidance on improving patient flow in urgent and emergency care, which has been welcomed by organisations as a “sensible” step forward.

The guidance seeks to transform urgent care through a complete redesign of services, “fundamentally shifting” the way they are provided to people of all ages.

It details proposals on improving out-of-hospital services to deliver care closer to home and to reduce hospital admissions and attendance, particularly by developing responsive, seven-day physical and mental health services.

The changes include providing better self-care support, helping people get the right advice, and ensuring those with serious or life-threatening needs are treated in appropriate centres with necessary expertise and facilities.

Furthermore it puts forward plans to connect all urgent and emergency care services so the physical and mental health and social care system becomes “more than just the sum of its parts”.

These changes would be made possible through collaboration with patients and partners across the system to develop a “suite of guidance documents and tools” to promote excellent practice and new models of care.

This will include establishing urgent and emergency care networks (UECNs), tackling clinical models for ambulance services, improving referral pathways between urgent and emergency services, and rethinking the financial modelling methodology.

NHS Clinical Commissioners (NHSCC) welcomed the proposals, with co-chair Dr Amanda Doyle noting it could lead to more responsive care that is “designed to meet the needs of local patients, with more happening in out of hospital settings and closer to home” – if joined with sensible guiding principles and helpful practice.

She added: “NHS England are right when they say that this cannot be done within individual organisations, and it will need whole systems to work together to build on existing groups and networks to ensure all sectors are played in – from primary care through to mental health services.

“No one structure will be right for all areas, so it will be key to build in flexibility to allow for local variation.”

Fellow NHSCC co-chair, Dr Steve Kell, said the guidance delivers “many examples that providers and commissioners can learn from”.

But he said successful implementation of new models and timetables will need to consider the “financial challenges that we are all wrestling with”, as well as having a positive impact on those challenges.

Dr Kell said: “Further strain on our budgets will bring any transformation to a halt rather than speed it up.

“Safer, Better, Faster places a lot of weight on primary care and is reliant on a stable and strong general practice and a sufficient and resilient workforce. I think it’s fair to say more time, resources and investment is required in those areas to support them to manage the current demand levels and we have to ensure that is that start of a process to transform urgent and emergency care and isn’t used as a performance management tool for the current emergency care pressures.”

He added that being “able to break out” of the one-year planning cycle CCGs face is a “really positive proposal”, as they are already determined to “shift funding to community services and primary care” and make services more effective.

In our July/August edition, Dr Caron Morton, co-chair of the Urgent and Emergency National Steering Group, stressed the importance of “fundamentally” changing urgent care, ensuring it is no longer focused on A&E.

Giving an update at the Commissioning Show 2015, she said last winter’s pressures showed the system was on edge already and added: “The surge problem isn’t about attendances, it’s about admissions – and the fact that community [services are] full. Everyone says it’s the old people in A&E causing pressures on the system – it isn’t, it’s all of us. The attendances and admissions have grown in every age group.

“Everyone says we keep patients in hospital too long. We aren’t; length of stay has reduced dramatically. It’s the balance that we’re not able to get.”

President of the Royal College of Emergency Medicine (RCEM), Dr Cliff Mann, also commented on the changes to A&E services outlined in yesterday’s document: “We welcome in particular the emphasis on the co-location of primary care services with A&E departments, so that patients can be streamed immediately to the best point of care; and the recognition by NHS England of the impact crowding in A&E has on patient outcomes.

“The guidance issued in relation to improving community and out-of-hospital care, if implemented, will mean fewer people need to attend A&E unnecessarily; and the recommendations that all hospitals should have adequate bed numbers, and that hospital discharge arrangements should be improved, mean that flow through the whole urgent and emergency care system will be greatly improved.”

Last week, NHE revealed that more than 2,000 mental health patients had to travel outside their local region of an inpatient bed due to local shortages, according to figures from the Health and Social Care Information Centre.

In July, the Crisp Commission had found that delayed discharges from hospitals, unsuitable living conditions and inappropriate services were also behind bed shortages for mental health patients. The majority of consultants in 122 acute wards said they treated patients who could have been treated elsewhere if appropriate services had been available.

Furthermore, poorly managed hospital discharges were shown to cost the NHS billions of pounds a year, aggravating the ill-health of patients and ultimately causing thousands of readmissions.

Chair of the Care and Support Alliance, Vicky McDermott, also emphasised the importance of social care in supporting discharge from hospital after emergency treatment, included in the guidance.

“However, we know that all too often social care isn’t able to play its part fully because of high eligibility thresholds and chronic underfunding. If the government is serious about making the right changes to our health service, it needs to ensure that it is properly supporting adult social care as well as health. Anything else is a false economy,” she added.

(Top image c. Peter Byrne)


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