NHS Pathways (Nov 2009) Dr Peter Fox Deputy Clinical Director NHS Connecting for Health

Current NHS position Direction of travel for urgent care, DH 2006 Urgent Care Position Statement, RCGP 2007 Very different clinical triage processes depending on the setting Patient and provider confusion Niche products used to support triage e.g. ambulance dispatch, out of hours, NHS Direct Many are built on US model of care and adapted for UK use Systems do not communicate and limited success in attempts to bolt systems together – poor clinical continuity, duplication, inconsistency Lack of a common content/variable outcomes/quality NHS reliance on local standards, expertise and knowledge –national assessment and local referral difficult to harmonise 52% of the public unaware of out of hours services and do not know who to contact for urgent care Worst scenario:- caller passed from pillar to post

Current ambulance service and out of hours model Call handler Model follows available ‘bolt together’ tools Queuing, handover and retriage inevitable No consistency of outcomes High clinician dependency High cost Traditional telephone triage Clinician

Everyone acknowledges but ….

The ideal…. Taking healthcare to the patient: Transforming NHS ambulance services, DH 2005 Urgent Care, RCGP position statement, 2007 Guidance And Competences For The Provision Of Services Using Practitioners With Special Interests RCGP, 2008 One common process of triage One UK determined set of clinical content One set of clinical performance measurement and management tools across different organisations One approach enabling clinical data transfer between providers One key tool to support commissioners of urgent and emergency care which also offers gap analysis One accreditation and training package for users Clinical content tailored to local delivery of the most appropriate skills in the most appropriate time frames One system supports single point of access concept One dynamic directory of service

Pathways telephone triage NHS Pathways model Common clinical content enables seamless links within and between services Call handler role extended Consistent outcomes Consistent standards monitoring Call handler Pathways telephone triage Clinician

Pathways – The clinical concept NHS For a given symptom, list the conditions that cause it Assemble conditions into a hierarchy of risk Progressively exclude the conditions considered by asking the minimum number of structured questions Stop the process of triage when a condition cannot be excluded Then refer the individual to a pre-determined clinical skill set and timeframe delivered by a locally determined provider Offer tailored care advice to support the caller Build in sophisticated reporting and QA tools Aim use to be by specially trained call-handlers and clinicians Support the whole with a high quality evidence base Constantly review and upgrade

NHS Pathways – The operational model Appropriate care Caller 999 Caller Urgent Caller NHSD NHS PATHWAYS clinical assessment Clinical need and timeframe (plus postcode/age/gender) Integrated Directory of Skills and Services Appropriate care

Pathways – Linked Directory of Service NHS

The dynamic directory of services Pathways Disposition Service capacity Local options for delivery presented in commissioner agreed order The dynamic directory of services

NHS Pathways – The DH Evaluation (Janette Kay Turner, Professor Val Lattimer, Professor Helen Snooks) “At least as safe as any similar system” “Performs at least as well as any comparable system” “A strength of NHS Pathways is the robust evidence base. A long term aim should be to develop a systematic method and process to ensure this evidence base is kept up to date”

Cohorts of new users Operations reporting

PERFORMANCE RESULTING IN 999 DISPOSITIONS Individual reporting

Pathways – Maintenance? NHS “A strength of NHS Pathways is the robust evidence base. A long term aim should be to develop a systematic method and process to ensure this evidence base is kept up to date” (Jeanette Turner)

Pathways – National Governance Group NHS The RCGP will lead the national governance group of colleges and key organisations The group will oversee the clinical content development of NHS Pathways as a common telephone triage system for the NHS.

NHS North East Ambulance Service County Durham & Darlington SPA Pathways – Where in use? NHS North East Ambulance Service County Durham & Darlington SPA Fylde Coast Medical Service

Pathways – Where next? NHS NHS Direct 3DN Pilots Other OOH Services

NHS System – eg Cleric, Adastra, TPP End User - Service Training Pathways – Licensing NHS System – eg Cleric, Adastra, TPP End User - Service Training Cost – Pathways content free

NHS Pathways (Nov 2009) Dr Peter Fox Deputy Clinical Director NHS Connecting for Health