1. Redirection from A&E to Primary Care
CCF SEPTEMBER 2018

2. Introduction
Redirection is the act of sending patients away (off-site) from a hospital to other parts of the health and care system including other parts of the urgent and emergency care system, specialist services and community and primary care services. The purpose of redirection is to ensure patients receive the most appropriate care in the most appropriate setting, there is no expectation of redirection as a target. Redirection is a key feature of streaming and maximises use of alternative services available. But importantly redirection assists with longer term behavioural change and essentially encourages the concept of ‘GP first’ for patients with primary care needs, so in many cases this is not about the ‘today’ but more about ‘next time’. This discussion with CCF focuses on redirecting patients from A&E to their own GP Practice.

3. London Guidance
The recommendations from the Streaming and Redirection: The London Model relevant to redirection to primary care
Recommendation
Additional Guidance
3b. Redirection should be to an alternative care setting which can be accessed at the time the patient needs the service
i. If appropriate stream is one that needs an appointment, the appointment should be booked - either by the streamer or non-clinical navigator (see recommendation 3f). If that appointment cannot be made, the patient will be seen in the UTC
ii. The streamer should have access to the IUC “Directory of Services” (DoS). The CCG will be responsible for the DoS.
iii. The redirection system should be able to book appointment where an appointment is required (e.g. general practice or dental)
iv. As expected, appropriate safety netting advice should be given to all patients redirected away off site
3c. Commissioners should ensure that direct access to alternative services is in place to support redirection
i. It is recommended that arrangements are made within the local UEC system and primary care, community services, and GP Hubs to allow for direct access to booking appointments such as: A set number of slots per day within practices; Locally agreed protocols on what services will accept patients when and how
ii. National targets for direct booking of integrated urgent care systems should be taken into account
iii. A clear escalation protocol should be in place for when systems/alternatives are full

4. Current Position
Resources required to deliver full streaming and redirection at HUH not yet in place
HUH set up a small pilot during July to test streaming during peak hours (pilot too small to warrant consultation). Intention is to test process and understand benefits before implementing more widely.
Successful implementation in longer term will require Primary Care support.

5. Redirection Pathway
Inclusion criteria would be all patients aged 16 and over who walk in via the ED entrance. Any patient that looks unwell and is obviously requiring immediate resuscitation or the patient’s condition requires an immediate assessment in a Majors or Injuries cubicle, as well as children under the age of 16 and all patients who had been directed to ED such as GP referrals, would be excluded from the pathway.

6. Discussion with CCF
ED will only redirect patients back to GP practices if they can get an appointment within a safe time frame. In order to explore and develop a local model of redirection from A&E into primary care with Homerton and the Royal London we need to understand the commitment from City and Hackney GP Practices to offer timed booked appointments.

7. Extended Access Hubs
The GP Confederation has agreed that while hub activity designated for 111 is underutilised, weekend slots can be offered up to be shared across 111 and A&E for redirection as a pilot.
This could potentially be extended to weekdays depending on review.
Any available weekend hub appointments which are not booked up by COP on the Friday could also be released for A&E redirection.
If direct booking from 111 increases and full modelled capacity needs to be made available then additional slots will need to be offered by the hubs to enable redirection. The number of slots will be decided upon if/when required.
Proposal would be for appointments to be booked via EMIS Community so that A&E can view and book appointments in advance and outside hours of operation.
RLH currently have EMIS Community in place. A workaround at HUH until this could be installed could be to call and book hub appointments directly.

8. How could you see redirection working with your GP Practices?
During pilot at HUH Non-Clinical Navigators (NCNs) called receptionists and Practice Managers to book appointments, is this the best route?
How would re-directed patients work with your practice triage services? (Like Doctor First system)
Other areas have given access for A&E patients to be directly booked into GP Practice appointments, could you ever see this working?