1. Changing How Patients Use A&E
M. Usman Niazi
July 2015
Instructions: Prepare a presentation for Module 2 at Yale University July 12-17th.
Submit to by July 3rd
Presentation should be 10 minutes and will include 10 minutes of Q&A, followed by written and in-person feedback from Yale faculty and your peers in the program.

2. Current State
In Ipswich & East Suffolk CCG there are 392,000 patients with one acute hospital based in the main town of Ipswich (population 100,000). Nine wards in the town of Ipswich are in the 10% most deprived in England and there is a significant shortage of Primary Care doctors in Ipswich GP Practices.
During the course of Q (Winter 2014) there was an increase of 13.6% in total non-major attendances compared to the same period the previous year (Winter 2013). A summary of the analysis can be seen below broken down by age group:
The increase in activity place a significant financial burden on the CCG; the level of the increase caused severe operational pressures within the wider healthcare system.

3. Problem Definition & Objective
A&E attendances at Ipswich Hospital for non-major conditions increased by 13.6% in Winter 2014 compared with the same period in the previous year.
Objective:
To ensure A&E attendances for non-major conditions at Ipswich Hospital are 10% lower in Winter 2015 than the 2014 period.

4. Root Cause Analysis (Appendix 1)
Demographic changes – The population in Suffolk is ageing between 2012 and 2020 the number of over 75s will have grown by 20%, this cohort of patients made up 10% of the population in 2014/15 but consumed 40% of the healthcare resources.
Access – There is both a real & perceived problem getting rapid access to appointments with local GPs especially in the Ipswich area near the hospital. A survey of 976 walk-in patients attending A&E over a week long period in September showed that 21% of respondents were at the A&E department as they could not get a GP appointment. More significant is that 79% did not attempt to get an appointment. 30% of patients arrived at A&E between 4pm & 9pm when GP appointments are not currently available.
Trust – The current payment mechanisms incentivise hospitals to treat as many people as possible regardless of appropriateness.
Social Care – Cuts of c30% to social care budgets have seen a number of services including meals on wheels, day centres, and help at home services significantly reduced or removed. The over 75’s who make up the majority of users for these services are also one of the primary drivers of increased activity in A&E.

5. Potential Strategy Options
Root Cause – Trust
Work with Ipswich Hospital to review attendance thresholds and to support them in diverting patients to more appropriate care settings. Change local payment mechanisms to remove incentives to treat patients who could be seen elsewhere in the system.
Root Cause – Access
Increase access to GP’s in the evenings and on weekends across Ipswich and East Suffolk or given staffing problems increase access in Ipswich only to start with.
Root Cause – Social Care
Work with social care to help safeguard the services that reduce social isolation and keep older people independent and safe in their own homes. Use the developing Better Care Fund to direct money in a more targeted way.

6. Strategy Option Evaluation

7. Selected Strategy
The preferred strategic option was Option 3 – increase access to GPs in Ipswich in the evenings and over the weekend, there were a number of reasons for this:
Option 3 was the only effective option that could be implemented in time for Winter Evidence from the survey showed that not being able to get a GP appointment was clearly a primary reason for people going to the A&E department. More worryingly was the number of people who simply did not attempt to get a GP appointment as they felt there was no point.
Option 3 will have an immediate impact in increasing the availability of GP appointments however it is hoped that more significantly patients will begin to change their perceptions of primary care and question their need to go to A&E.
While all options reviewed would likely have some impact on the problem and options 2 & 4 in particular will continue to be pursued over the longer term, but for the immediate goal of reducing A&E attendances in Winter 2015 only Option 3 gave an immediate opportunity to tackle one of the key root causes.

8. Implementation Plan
I led a series of joint meetings between the local federation of GPs and CCG operational colleagues during December 2014 to design and agree the implementation plan which focused on identifying the appropriate location, staffing, technical infrastructure and funding for the project which was later called Ipswich GP Plus.
The key challenge faced in the implementation of the project was financial as the project required £2m to proceed and the CCG executive were clear that while they support the project they could not afford to fund it. I therefore looked to other sources of funding and in conjunction with the GP Federation of Suffolk successfully bid for £2m of funding from Prime Ministers Challenge Fund.

9. Evaluation Plan
From the outset the intention was to limit the number of overall KPI’s to reduce unnecessary bureaucracy and in addition focus them on outcomes. The KPI’s listed below are still being finalised but will form the principal measures the CCG will monitor against.
For the Ipswich GP Plus project the KPI’s have even more importance as the funding we have secured from the PM Challenge fund is only for 1 year. The CCG will only fund the project on an on-going basis if there is clear evidence that the service is reducing the number of patients going to A&E.

10. Learning Leadership & Problem Solving:
One of the key lessons for me has been how much easier it is when you have a systematic and methodical approach to problem solving that is easily explainable to everyone involved. The simplicity of the problem statement and objective allowed me to continuously bring people back to the core issue rather than get diverted down tangents.
The root cause analysis and strategy evaluation both proved to be much more challenging and controversial than I initially expected. The process was at times frustratingly slow but the time taken allowed all the stakeholders to have their views and opinions heard and, I think that having expressed their views, once a final decision was made they did not resist the chosen option.
Key Takeaway
I confess the key learning for me has been how little real research has been done into this subject the national, regional and local discourse is focused on dealing with the consequences of increased attendances rather than asking why they are increasing.
While the project is currently in implementation phase I am separately now starting a project working with the local council to try and create some empirical evidence to support the hypothesis that cuts to social care services have resulted in people, especially the over 75’s, using healthcare services more than they previously did.

11. Appendix 1 – Root Cause Analysis