Urgent and emergency care remains a high priority across the NHS as demand, length of stay and variation in practice continues to increase. NHS Improvement has worked with a number of acute hospital sites to understand the complexity of urgent and emergency care attendances, and admissions. “Making connections with the challenges of unscheduled care” shares the issues, the outcomes and identifies some tried and tested solutions that can ease the burden of unscheduled care

1. NHS
CANCER
NHS Improvement
DIAGNOSTICS Making connections with the
challenges of unscheduled care
HEART
Sharing knowledge - Delivering benefits
LUNG
STROKE

2. How big is the problem?
Definition of Urgent Care: A condition that requires an assessment and planned intervention within
seven days, or which is likely to lead to an emergency within four weeks
Definition of Emergency Care: Not always life threatening, but needs prompt assessment and a
planned intervention within 24 hours
5,135,794 emergency hospital 35% over a 37% increase 40% of rising emergency
admissions in England in third are in emergency admissions can be explained
2009/10 (Hospital Episodes classified as hospital by the ageing population
Statistics (HES) emergency admissions
hospital over the last
admissions 10 years
The majority of accident and Patients admitted as an emergency at
emergency attendances are weekends have a higher mortality than those
for medical conditions admitted on weekdays - Is this a failure to
rescue or failure to access?
For cancer patients - There is significant variation
Haematological, Lung and in emergency admissions,
Urological tumours are the bed days and length of stay
highest users of emergency between NHS Trusts and
cancer bed days between PCT’s
Resouces and references
www.rightcare.nhs.uk/atlas/downloads/nonPBC_AoV_2011.pdf
www.cqc.org.uk/sites/default/files/media/documents/ip11_national_summary_final.pdf
www.kingsfund.org.uk/document.rm?id=9524
www.ncepod.org.uk/2007report1/Downloads/EA_report.pdf
www.rcplondon.ac.uk/sites/default/files/documents/hospitals-on-the-edge-report.pdf

3. Understand the real issues before you put in solutions
14 COMMON ISSUES
1. VARIATION IN CLINICAL PRACTICE 2. NO CLEAR DEFINED PATHWAYS OF
CARE 3. OUT OF HOURS ACCESS, KNOWLEDGE AND INFORMATION
4. VARIATION IN TIMELY SENIOR CLINICAL DECISION MAKING AT THE POINT
OF ENTRY 5. MULTIPLE ENTRY ROUTES OF SINGLE ACCESS 6. LACK OF
INTEGRATION AND COORDINATION ALONG THE CARE PATHWAY, LONG LENGTHS
OF STAY 7. DISEASE SILOS, DISEASE THINKING ‘V’ WHOLE PATIENT, PERSON
APPROACH 8. LACK OF SYMPTOM BASED PATHWAYS 9. REACTIVE CARE –
CRISIS MANAGEMENT, FOUR HOUR WAITS 10. POOR RISK MANAGEMENT/
RISK STRATIFICATION BEFORE AND AFTER ADMISSION 11. THE EMERGENCY
MINDSET CAUSING A NUMBER OF MISCONCEPTIONS 12. FREQUENT
ATTENDERS, READMISSIONS 13. LACK OF OWNERSHIP OF CASE MANAGEMENT
ACROSS BOUNDARIES, PRIMARY, COMMUNITY AND ACUTE CARE
14. PATIENTS KNOWN TO THE SYSTEM BUT THE SYSTEM DOES NOT KNOW
THE PATIENTS
6 COMMON POOR OUTCOMES
DEATH: COMPLAINTS: PATIENT DISSATISFACTION, LOSS OF CONFIDENCE,
WASTED RESOURCES: COMPLICATIONS: STAFF DISSATISFACTION

4. Triage, Treat, Transfer – Developing the right
response to meet the need
Challenge: Do you know if patients are assessed
appropriately prior to the decision to admit?
There are a selection of tried and
tested solutions, e.g. senior clinical Whole Pathway Approach
decision making, defined symptom
TRIAGE
pathways, communication alerts,
seven day services that allow Patient self Test the urgency of your symptoms Single call
management number
patients to be assessed and treated NHS 111
in a timely way; which has an impact
on quality improvement, efficiency TREAT
Senior clinical decision making
Defined symptom pathways
and the patients' experience.
Communication alerts
Ambulance Out of Community General
Seven day services
services hours services e.g. practice
Emergency care Walk in District Nurse,
Unscheduled admissions
practioners Social Care
should be the exception
not the norm TRANSFER
Hospice Day Rapid Straight Assessment Emergency
or care case or access to test unit department
8,000 strokes per year
home inpatient clinic 24 hours 4 hours
ward outpatients
could be prevented by DISCHARGE HOME
using the GRASP-AF tool - Avoid unnecessary admission Proactive clinical decisions improve outcomes Reduce length of stay and readmissions
This could save the
NHS £96m
Resouces and references
www.improvement.nhs.uk/communicationalerts
www.improvement.nhs.uk/definedemergencypathways

5. Test the urgency of the symptoms = Patient
self-management
Challenge: Do you know how you can encourage
your patients and carers to self-manage ?
Patient and carers need to know about their condition Neutropenic sepsis CD
and symptoms to encourage self-management, choice Blackpool, Fylde and Wyre Hospitals NHS
and to know who, where and when to access services.
Foundation Trust
Tested solution – Patient informed of symptoms
WHY
by use of DVD.
• Empowers patient and carers to act
• Increases knowledge to understand symptoms Stratified Pathways of Care
and make choices Survivorship test sites from five acute trusts tested
• Manages patients and carers expectation stratified pathways of follow up care and discovered
• Increases independency an expected 70% of breast cancer patients were
• Increases confidence predicted to be suitable for a supported self-
• Reduces patient/carer anxiety management pathway
• Reduces professional dependency
Pleural effusion symptom alert card: Case study
Peterborough and Stamford Hospitals NHS
Aligning patient expectations with those Foundation Trust
Tested solution – Patients with recurring pleural
who are delivering the service is critical effusions from lung cancer are given an alert card
to success informing them of symptoms.
Impact
• Inpatient length of stay for pleural effusion
Resouces and references ranged from 0 to 4 days - is now managed as an
Eight top tips for patient empowerment attendance.
www.improvement.nhs.uk/documents/eight_top_tips.pdf
NHS Improvement Case Studies
www.improvement.nhs.uk/urgentcare/casestudies Fulfilling the Potential: A better journey for patients and a
better deal for the NHS
Eight Top Tips for Patient Empowerment - www.improvement.nhs.uk/documents/er_better_journey.pdf
www.improvement.nhs.uk/documents/patientempowerment.pdf
Stratified Pathways of Care
My role and my responsiblities in helping to improve my recovery www.improvement.nhs.uk/documents/survivorship/
www.improvement.nhs.uk/documents/er_my_role.pdf Stratified_Pathways_of_Care.pdf

6. NHS 111 – When it’s less urgent than 999
Challenge: Are your services aligned to the local
Directory of Service that informs patients where to
go to access services in your area?
NHS 111, the urgent care number for patients, will be
rolled out across England in 2013. NHS Pathways is one Lung and Urology clinical reference groups
of a number of clinical management systems for assessing The development of symptom pathways for NHS
patients that delivers a single clinical assessment tool Pathways/NHS 111 has drawn on clinical expertise
that provides effective triage over the telephone. from around the country. Cancer Clinical Advisors
NHS 111 will accommodate patients to go to the right place, from Lung and Urology (high cancer emergency bed
first time, it is based on symptom pathways, not disease day users, HES) have been involved in developing
specific pathways, and it also aligns itself to patient specific symptom pathways for pain, shortness of breath,
protocols. pleural effusions, retention of urine/renal failure,
visible haematuria with or without retention and
Clinical Commissioning Groups (CCGs) will lead on the design catheter, cough and coughing up blood.
of urgent care service provision accessible in each area
through NHS 111. The choice of provider and clinical Patients who have been treated by chemotherapy
assessment services available will be aligned to a local can also be identified. Some urgent admissions can
Directory of Service (DOS). be due to the effects of treatment, having a tagged
question: “Have you had treatment for cancer in the
last year?” ensures the patient is directed onto the
right pathway and is seen by the right person.
Ensuring the alignment and positioning
of initiatives (e.g. 24 hour help lines)
are critical; They need to be included in Resouces and references
regional plans, Clinical Commissioning www.nhs.uk/NHSEngland/AboutNHSservices/Emergency
andurgentcareservices/Pages/NHS-111.aspx
Groups and local Directory of Services http://webarchive.nationalarchives.gov.uk/+/www.dh.
(DOS) that link to NHS 111. gov.uk/en/MediaCentre/FAQ/DH_119189
‘Getting to grips with integrated 24/7 emergency and
urgent care’ - NHS Alliance, 2012

7. Contact - Response - Action = Timely senior clinical
decision making
Challenge: Do you have a communication alert
process in place and do you know how timely your
senior clinical decision making is?
The provision of timely senior clinical decision making
can have a significant impact on quality improvement,
efficiency and the patients' experience.
Communication alerts let nominated clinicians know
that patients have arrived, where they are, and where
they may be admitted to.
The key in any alert system is ensuring
the responsibility for placing and taking
of alerts and ensuring they get acted on.
Alerts at Sandwell and Birmingham
Hospitals released 3,500 bed days and
reduced admission rates by 12%
Resouces and references
www.improvement.nhs.uk/documents/
CommunicationsAlerts.pdf

8. Delivering safe care - seven days a week
Challenge: Would extending your services across
seven days improve your outcomes? Do you know
how many deaths happen at weekends? Are you
doing enhanced recovery for your emergency
patients?
Extending services across the whole week, improves Seven day whole care pathway approach to
equality of treatment and outcome regardless of the enhance recovery of emergency and elective
day of the week. patients
South Devon Healthcare NHS Foundation Trust
No ‘one size fits all’. There are different service models Emergency ward rounds carried out twice a day, seven
to ensure flow of patients along care pathways from a days a week in medicine.
whole hospital wide approach to a departmental
Moving from a six to a seven day all day trauma list and
approach.
identifying a surgical consultant of the week improved
patient care, quality and efficiency.
Clinical decision making through consultant presence
Shouldn’t every one of us have provides earlier diagnosis, management and discharge.
the best chance possible, no Impact
• Earlier diagnosis with 24 hour radiology and
matter what time of day or day reporting and timely decision making
• Reduction in emergency fracture neck of femur
of week it is? LOS from 10 to 5 days.
Patient Representative
Consultant led one-stop TIA service
University Hospital of Leicester NHS Trust
Patients are assessed and receive appropriate
investigations, diagnosis and treatment, including
Resouces and references referral for carotid intervention, in a single visit to
www.improvement.nhs.uk/sevendayservices the hospital seven days a week.
Impact
• 70% of patients are now seen within 24 hours
compared to baseline of 33%.

9. Achieving integrated care
Challenge: Is their willingness and determination
to achieve integrated care across whole systems
within your health community?
Integrated care is what the NHS,
social care and the voluntary sector The integration between hospital and community services for Whittington
thrive for, however in reality it Health has made it easier to provide ambulatory care for people that
previously may have needed an emergency admission. District nurses and
stretches many organisations, and
community matrons visit emergency departments and acute medical units
is not easy to achieve. daily to identify patients who can be better managed at home. An example
of this is providing IV antibiotics at home rather than as an inpatient.
Celia Ingham Clark, Associate Medical Director, Whittington Health and NHS London
Recommendations to
achieve integration
Communication:
To ensure Direction: Establish
engagement develop steering groups to drive
robust communication the work
mechanisms
Time: Without Engagement and Evaluate and
investment in time, ownership: Identify measure: Need to
and people integration the common demonstrate outcomes
is unlikely to be denominators across in quality, efficiency
successful all organisations and patient
Leadership: You Assumptions: Test
need executive, them out, solutions
operation and clinical that work in one area
leadership across ALL many not work in
organisations another, adapt
Patients and carer Stability and
Win - Win: Align
involvement: Listen, sustainability:
the integration to
they know what Continue to test the
organisations strategic
happens, it happens strength of the
objectives
to them integration

10. NHS
CANCER
NHS Improvement
DIAGNOSTICS
HEART
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