1. Urgent and Emergency Care Review Unlocking the potential of Out of Hospital Care Ambulance Leadership Forum 2014 I If it’s really serious I want specialist care Treat me as close to my home as possible please Help me to help myself and not bother the NHS If only they could talk to my GP?

2. www.england.nhs.uk UEC Review Vision For those people with urgent but non-life threatening needs: We must provide highly responsive, effective and personalised services outside of hospital, and Deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families For those people with more serious or life threatening emergency needs: We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery

3. Current provision of urgent and emergency care services 3 >100 million calls or visits to urgent and emergency services annually: 438 million health-related visits to pharmacies (2008/09) Self-care and self management 24 million calls to NHS urgent and emergency care telephone services Telephone care 300 million consultations in general practice (20010/11) Face to face care 7 million emergency ambulance journeys 999 services 14.9 million attendances at major / specialty A&E departments (2012/13) 6.9 million attendances at Minor Injury Units, Walk in Centres etc (2013/13) A&E departments 5.3 million emergency admissions to England’s hospitals (2012/13) Emergency admissions Telephone care Face to face care 999 services A&E departments

4. www.england.nhs.uk UECR: The Why? – Care closer to home

5. Helping people help themselves Self care: Better and easily accessible information about self-treatment options – patient and specialist groups, NHS Choices, pharmacies Accelerated development of advance care planning Right advice or treatment first time - enhanced NHS 111 - the “smart call” to make: Improve patient information for call responders (SCR, care plan) Comprehensive Directory of Services Improve levels of clinical input (mental health, dental heath, paramedic, pharmacy,, GP) Booking systems for GPs, into UCC or A&E, dentist, pharmacy 5

6. Growth in NHS 111 Call Volume 6

7. NHS 111 Call Volume – front end to urgent care Patients are predominately referred to lower urgency settings 7www.england.nhs.uk Referral 111 Caller dials 111 Demo- graphics taken Pathways triage 85% Call handler answers Clinician takes transfer transfer 21% 999 Ambulance A&E / UCC GP OOH GP in hours Pharmacy Community service Dental 1% 7% 1% 14% National 11% 7% 62% Dispositions callers (where callers are referred to) 111

8. Summary Care Record: Creating the records SCRs are an electronic record containing key information from the patient’s GP practice As a minimum SCRs contain medication, allergies and adverse reactions Improved functionality coming soon to make it easier for GPs to create SCRs with additional information for those patients that need them most. 46m SCRs created (82%) 2m SCRs created last month Close to To find out more or enable SCR: scr.comms@hscic.gov.uk or @NHSSCR

9. Summary Care Record: Benefits To find out more or enable SCR: scr.comms@hscic.gov.uk or @NHSSCR

10. NHS 111 (service specification and standards) Enhanced 111 service: Smart call to make, helping people get the right advice or treatment in the right place, first time. This service will: Be an integral part of the Urgent Care Network Have knowledge about you and your medical problems, so the staff advising you can help you make the best decisions; PILOT Allow you to speak directly to a wider range of professionals ( e.g. nurse, doctor, paramedic, mental health team, pharmacist); PILOT (GP) If needed, directly book you an appointment at whichever urgent care service can deal with your problem, as close to home as possible; Still provide you with an immediate emergency response if your problem is more serious, with direct links to the 999 ambulance service, and the enhanced ability to book appointments at Emergency Centres. 10

11. Highly responsive urgent care service close to home, outside of hospital 11 Faster, convenient, enhanced service: Same day, every day access to general practitioners, primary care and community services Harness the skills and accessibility of community pharmacy 24/7 clinical decision-support for GPs, paramedics, community teams from (hospital) specialists – no decision in isolation Support the co-location of community-based urgent care services in Urgent Care Centres and Ambulatory Care centres. Develop 999 ambulances so they become mobile urgent community treatment services, not just urgent transport services

12. Ambulance Services Transport  Treatment: Community-based provider of mobile urgent and emergency healthcare, fully integrated within Urgent Care Networks. Principles to underpin this transformation would include: Emphasis on supported treatment in community settings Single consistent triage system, DoS and universal referral rights Successful “hear and treat” - closer integration with 111, timely access to relevant patient information and care plans, support of interdisciplinary clinical hub (current low 3.4% high 10%) “see and treat”, inter-disciplinary working across traditional organisational and professional boundaries, with guaranteed timely access to primary care, mental health provision, social care and specialist clinical advice 24/7 (current low 27.4% high 51.5%) Development of the ambulance workforce, education programmes coupled with changes to organisational culture, will be essential to long-term success 12

13. Urgent Care Centres Community-based primary care facilities providing access to urgent care for a local population. To encompass Walk-in Centres, Minor Injuries Units, “Darzi” Centres etc, including those currently designated as “Type 3 A&E Departments”. A consistent nomenclature should be accompanied by a consistent service, so that patients are clear about what they can expect from all Urgent Care Centres To achieve this it is suggested that two important principles underpin the development of Urgent Care Centres: access to a full range of urgent care services 24/7 access to the Urgent Care Network 13

14. Serious and life threatening conditions – expertise and facilities 14 Two levels of hospital based emergency centres Emergency Centres* - capable of assessing and initiating treatment for all patients Specialist (Major) Emergency Centres* - 40-70 larger units, capable of assessing and initiating treatment for all patients, and providing a range of specialist services (direct, transfer or bypass). Emergency Care Networks Connecting all services together into a cohesive network so the overall system becomes more than just the sum of its parts Operational and Strategic

15. Urgent Care Networks Networks would function at two levels: Operational Urgent Care Networks would describe local communities of clinicians (System Resilience Group) who work together to achieve the best outcomes for patients within the urgent care system Strategic Urgent Care Networks would operate over large populations encompassing specialist provision, all severity and complexity, all relevant stakeholders to plan, oversee and monitor network performance Conveyance / bypass / critical care transfers become central component of effective network 15

16. www.england.nhs.uk Shape and structure of the new system and key constituent parts…

17. Progress update 17 Continue to “build in public” 8 Work Programmes: WHOLE SYSTEM PLANNING AND PAYMENT, COMMISSIONING AND ACCOUNTABILITY PRIMARY CARE ACCESS – NHSE strategy 111 service specification and standards DATA, INFORMATION AND CARE PLANNING COMMUNITY PHARMACIES – Call for Action EMERGENCY DEPARTMENTS and EMERGENCY CARE NETWORKS AMBULANCE TREATMENT SERVICE WORKFORCE (HEE) ITERATIVEITERATIVE

18. Progress update Implementation phase of the Review: Aims to convert the work done so far into a national framework to guide commissioning of UEC services: Update report Delivery Group own and describe the key national products from the Stage 1 Report – primacy to out-of-hospital Regional roadshows June-Sept 2014 Working with System Resilience Groups, CCG and NHSE Ops Teams as they develop 2 and 5 year operational and strategic plans Working through the NHS Commissioning Assembly to co-produce commissioning guidance and specifications (throughout 2014/15) Release guidance, standards and outcome metrics for Commissioners regarding UEC Networks, centres, and clinical models for Ambulance Services (after 5 year Forward View) 18

19. www.england.nhs.uk UECR: What – Big Tickets

20. www.england.nhs.uk UECR: Big Tickets 3.1.1 Guidance on clinical models for treatment on scene by ambulance services 3.1.2 Develop a new single curriculum for Paramedics Best practice/case studies on how GP advice best accessed/can add value to ambulance and A&E

21. www.england.nhs.uk UECR: Big Tickets 3.5.1 Provision of specialist hospital advice to other parts of the system 5.2.1 Deploy Summary Care Record Commissioning standards and procurement strategy for universal booking across the UEC system

22. Consulting and testing Design to Delivery: NHSIQ mapping support/pilots testing ideas and models (Integration Pioneers, PM Challenge, 111 pilots and 7DS early adopters) New Commissioning Standards for NHS 111: Clinician access to relevant patient’s medical and care information Access and treat to specific care plan where available Increased clinical advice to support call handlers to book appointments with urgent or emergency care providers 22

23. Future payment options for UEC Proposal suggests that the way forward could be a single, consistent payment approach for every type of service in the system, made up of 3 elements and linked to quality metrics and part of 3-5 year contracts: Core capacity element: substantial and fixed in-year, to reflect the ‘always on’ nature of urgent and emergency care:Facilities and service standards Volume-based and variable, to limit the impact of unpredictable fluctuations in demand on individual providers across the system; Process measures – formative not summative Incentives and sanctions: Using provider-specific and system-wide quality metrics as eligibility criteria for different rates of fixed and volume-based funding, and as the basis for bonuses and penalties, to support service change and promote quality improvement: Patient outcome measures (transfers of care, residence, PROMs) Patient safety and experience measures (mortality, SAEs, PREMs)

24. So your future ………. 24 More support for “hear and treat” and “see and treat” CLINICAL ADVICE HUB, protocols, shared metrics, ambulance service paramedics as recipient and contributor Integrate or better interoperability of 111 and 999 Shared patient information/care plans across all providers Universal booking rights into live Directory of Services Access to community support – primary care, falls services, mental health teams, community nurses, mental health team Paramedics much greater role in clinical advice, orchestrating community responses, in UCCs and EDs and for critical care transfers Ambulance services central to design of Strategic Urgent Care Networks

25. Cochrane Database Systematic Rev. 2013 Mar 25 Helicopter emergency medical services for adults with major trauma. Galvagno SM Jr Galvagno SM Jr 1, Thomas S, Stephens C, Haut ER, Hirshon JM, Floccare D, Pronovost P.Thomas SStephens CHaut ERHirshon JMFloccare D Pronovost P Due to the methodological weakness of the available literature, an accurate composite estimate of the benefit of HEMS could not be determined. Although five of the nine multivariate regression studies indicated improved survival associated with HEMS, the remainder did not. The question of which elements of HEMS may be beneficial for patients has not been fully answered. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.

26. The challenges fed back to us 1.Payment system reform and incentives (QP and nCQUINs) 2.Information sharing 3.Workforce and skills shift 4.New models of primary care 26

27. Urgent and Emergency Care Review Progress: DEFINITELY.... BUT ONLY THROUGH YOU I I’m alive cos I had specialist care really fast I feel so much better for not having to go all the way to hospital Its great to share and learn so much with this group It’s like everyone knows all about me