Improving urgent and emergency care

Improving urgent and emergency care

9th December 2014

The findings of an independent six-month review of local urgent and emergency care have been welcomed by NHS and social care organisations in Leicester, Leicestershire and Rutland (LLR) and actions are already underway to make improvements.

Providing consistently high quality emergency and urgent care services has been a challenge for a number of years. As a result people often wait longer than the national 4-hour wait standard in the Leicester Royal Infirmary’s Emergency Department, stay in local acute and community hospitals longer than needed and aren’t always given care in the place best suited to their needs.

Several reviews over recent years have looked at how to address these issues in various parts of the system resulting in improvements in some areas. To build on this and to support major transformation work across health and social care over the next five years, East Leicestershire and Rutland,  Leicester City and  West Leicestershire Clinical Commissioning Groups and University Hospitals of Leicester NHS Trust commissioned a world renowned expert to look at the problems across the whole system.

Dr Ian Sturgess, a former senior consultant geriatrician who has helped improve more than 135 emergency care systems across the UK and overseas, spent time with clinicians and staff in primary care (GPs), acute and community hospitals, mental health services, NHS 111 and out of hours care, urgent care centres and social care teams between mid-May 2014 and mid-November 2014. 

His report found that the local system has the potential to be ‘high-performing’ but is ‘relatively fragmented with barriers to effective integrated working’.  It makes a number of recommendations for transformation including:

* calling for health and social care leaders and clinicians to develop a clearer vision of a high-quality responsive and integrated system;

* to ensure greater focus on anticipating care needs for the frail and those with long term conditions;

* to provide increased care in the community to avoid admissions to hospital in all but emergency cases, and

* to have plans in place to discharge people back to their homes or community care quickly wherever possible.

Professor Azhar Farooqi, Chair of Leicester City Clinical Commissioning Group (CCG) on behalf of the three CCGs representing Leicester, Leicestershire and Rutland said:  “Patients in Leicester, Leicestershire and Rutland deserve the best possible care. We welcome Dr Sturgess’ report and his support in working with the local health organisations to improve the care we provide for our patients. The report identifies areas where we can improve and it is reassuring that we are already working on many of them, alongside our colleagues at Leicester’s Hospitals and the organisations that provide health and social care.

“The four-hour target for patients waiting in A&E is a barometer for how the whole health and social care system is working together. It is important that we recognise the role that each health and social care provider plays in this. As CCGs, it is our role to help everyone to work together better. We have already started to demonstrate that this is possible in the work we have been doing to develop services in the community so that older people in particular can be treated at home and any time spent in hospital is kept to a minimum.”

Dr Sturgess’ report was finalised in mid-November but local NHS organisations and councils have not waited to take action, working closely with Dr Sturgess throughout the review period to tackle urgent issues.

Dr Kevin Harris, Medical Director at Leicester's Hospitals said: “This is a very useful document and we all appreciate Dr Sturgess’ work over the past six months.

“Dr Sturgess started his review in Leicester’s Hospitals when he arrived in May. This has enabled us to already implement some changes to our internal process.  It's encouraging to see that in the opening of his report he recognises that there has been some early improvement seen within Leicester's Hospitals.  Nevertheless, we recognise that, along with colleagues in the rest of the system, we have much more to do.

“We have identified nine key improvement themes which we believe will have the biggest impact and are working on ways to implement the other recommendations identified by Dr Sturgess.”

The key improvement themes for Leicester’s Hospitals are:

* Improving the interface between the Urgent Care Centre and Emergency Department at the Leicester Royal Infirmary

* Improving ambulance turnaround

* Making greater use of ambulatory care alternatives to admission

* Improving the capacity of the Emergency Department to cope with pressure

* Avoiding GP admissions going via the Emergency Department

* Speeding up senior clinical assessment on our admissions units

* Getting greater consistency in medical processes on our main wards

* Focussing on substantially reducing delays of all kinds in the patient’s journey

* Speeding up discharges by targeting things that delay them.

Many improvements designed to ensure people are treated in the places best suited to their needs such as via GPs, in their own homes or in community settings, have already been put in place by organisations across health and social care. Initiatives include:

* A multi-disciplinary team set up at the Leicester Royal Infirmary to avoid admissions wherever possible for patients who are frail and who have complex needs. Evidence shows that this approach, particularly when supported by a geriatrician, helps people to receive care better suited to their needs and in turn relieves pressure on the Emergency Department.

* GPs are stepping up use of combined health and social care solutions in the community so people are supported and treated by integrated health and social care services. Examples include night services extended across the county and GPs referring older patients and those with long term conditions to community health and social care teams who treat the patient at home so that they retain their independence in familiar surroundings.

A number of other improvements in response to Dr Sturgess’ recommendations are due to be in place within six months to help tackle the increased challenges over the winter months and to address the key themes highlighted in Dr Sturgess’ report. These include strengthening the existing winter resilience plan by increasing capacity in both primary and community care settings to avoid admission to hospital and to aid discharge, along with a focus on improving internal processes within the hospitals.

Improvements which relate to longer term transformation are being implemented via the area’s major 5-year transformation programme across health and social care, Better Care Together, which is ideally placed to drive the integration of services, partnership working and cross-system changes recommended in Dr Sturgess’ report.

Professor Farooqi added: “The review has confirmed a lot of what we already know about what’s not working in our system and the barriers to achieving the care we want to provide. While many of these things are already being tackled or were planned, the report has helped us to re-focus our efforts. In particular the findings have highlighted areas where we can improve our efforts to integrate and collaborate.

“Already the review is sparking discussion and a deeper recognition of the scale of behaviour and culture change needed to deliver the improvements in care and patient and experience we aspire to. Our challenge now is to take that debate and drive for change to the thousands of staff and clinicians across the health and care system and to work together to make change happen. While we recognise this will take time, we have every confidence we can achieve better care for our patients.”

Dr Harris added: “We have a lot of work to do and there is a great desire in our organisation to sustainably change the health care system. We want to provide a service that is more responsive to the needs of our patients. Providing a better emergency pathway is the number one priority for Leicester’s Hospitals.”

David Sharp, area director for NHS England in Leicestershire, said: “Our main aim is to improve the health outcomes for people in England. This report’s recommendations reflect what we want the NHS to be: open, evidence-based and inclusive, engaging with health professionals, patients and the general public in how the local health community operates and the decisions it makes.”

The findings of the review are being discussed in public session at the Governing Body meetings of all three local CCGs on Tuesday 9 December, at the University Hospitals of Leicester NHS Trust Board on Monday 22 December and at the Leicestershire Partnership NHS Trust Board on Thursday 29 January, 2015.

To see the full report, please use this link to our Board paper for Tuesday 9 December 2014.