Understanding the system of unscheduled care: revisited Steve Kendrick steve.kendrick@scotland.gsi.gov.uk Emergency Access Delivery Team Networking Event Beardmore Hotel. March 12th, 2009

I. A&E attendances: outcomes and the whole system

Outcomes: the target Reduce A&E attendances or more precisely Reduce ‘more appropriately treated elsewhere’ A&E attendances or more generally Everyone treated in the appropriate place in the system at the appropriate level of the system

II. Unscheduled care as a system of causes and effects

What do you need to do to achieve an outcome? a) Identify the various causal influences which combine to produce the outcome b) Identify the opportunities to intervene to improve the outcome. Leads to driver diagram.

Fewer ‘better treated elsewhere’ A&E attendances Unscheduled care. Driver Diagram. Illustrative Only! Outcome Changes Drivers Fewer ‘better treated elsewhere’ A&E attendances e.g. Morbidity Patient knowledge/ behaviour Accessibility of different services Triage methods Integration of system e.g Prevention Social Marketing Improved access to alternatives algorithms/training Sharing of data

III. Unscheduled care as a system of patient flows

Flows into A&E. Orders of magnitude! Ambulance 250 40 “999” 220 NHS24 800 70 A&E 600 Self-referral Public 600 30 OOH 1000 attendances 80 In hours primary care

IV. Relating flows to causes/drivers to improvement.

How do we relate ‘flows’ to ‘causes/drivers’ Each of the flows is a result of decisions made by particular agents at particular points in system Many of the changes we need to make are improvements in decision-making. Making sure patients are in the right flows. Plus right balance of services to support those improved decisions.

The potential for improvement To a large extent defined by the number of patients who are in the wrong flows End up being treated at too intensive a level of the system e.g. treated A&E when could have been ‘more appropriately treated elsewhere’

How do we assess this potential for improvement. (e. g How do we assess this potential for improvement? (e.g. potential for reducing A&E attendances) Need a much more detailed picture of patient characteristics in each of the flows Which are the groups of patients with the greatest potential for diverting to a more appropriate flow/treatment point?

V. Immediate priority: better understanding of who is attending A&E

The task attempted since December Better understanding of the patients attending A&E Could we characterise A&E attenders in terms of meaningful groups which e.g. help us assess potential for alternative care? given current set-up given better alternatives help us assess potential for prevention help us assess the potential for improved services help us assess potential for reducing A&E attendances

Examples of the kind of patient groups it would be useful to identify and quantify Elderly falls Minor illnesses who don’t need to be at A&E Behavioural/psychological ‘chaotic lifestyle’ Alcohol related Admissions from care homes Frail elderly in general Exacerbations of LTCs e.g. COPD ????

How have we done? High ambitions for January especially – (to inform provisional targets) Admirable progress but ...… ….. not a royal road ….. difficult circumstances

Routes tried (I) Existing electronic data diagnostic/presenting symptoms items – not easy to classify into meaningful groups but worth exploring e.g. Manchester triage data worth looking further into cross-classification with age

Routes tried (II) Analysis of A&E cards/notes Lanarkshire exercise rich source of insight

Route to discuss Survey methods to understand why people come to A&E Digest results of e.g. Welsh survey; social marketing research

Information Network: what has emerged? Variety of emerging insights/ perspectives on A&E attenders e.g. - variation by GP practice - proximity - deprivation - age - patterns of ‘discharge no review’ Hear about them later

Information Network: directions for coming months Keep the different analytical approaches moving forward, working together Continue quest to identify ‘meaningful groupings’ – but perhaps ask more specific questions Let’s not neglect basic description e.g. age profile, referral source Share our knowledge