Embed Size (px)
DESCRIPTION
The Challenge of Emergency Medical Care. Dr Richard Grocott-Mason Consultant Cardiologist Joint Medical Director. What is the crisis?. Increasing attendances Increasing emergency admissions Worse performance against 4 hour target Stress on ED staff - PowerPoint PPT Presentation
Citation preview
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?
