1. 1 The Whole System of Unscheduled Care: causal mapping, flows and improvement Steve Kendrick steve.kendrick@scotland.gsi.gov.uk Emergency Access Delivery Team Networking Event Beardmore Hotel. Dec 18 th, 2008

2. 2 I. A&E attendances: outcomes and the whole system

3. 3 Outcomes: the target Reduce A&E attendances or more precisely or more precisely Reduce ‘better treated elsewhere’ A&E attendances or more generally or more generally Everyone treated in the appropriate place in the system at the appropriate level of the system at the appropriate level of the system

4. 4 Whole system/outcomes (BTE) A&E attendances as outcome of how whole system of unscheduled care is working: to reduce them you need to make the whole system work better.(BTE) A&E attendances as outcome of how whole system of unscheduled care is working: to reduce them you need to make the whole system work better. (BTE) A&E attendances as an indicator of how well the system is working: reflect degree of balance in system(BTE) A&E attendances as an indicator of how well the system is working: reflect degree of balance in system

5. 5 Useful ways of looking at the whole system of unscheduled care Patient perspective Patient perspective Organisational system Organisational system Data system Data system Real system Real system But today want to focus on a)A system of causes and effects b)As a system of patient flows

6. 6 II. Unscheduled care as a system of causes and effects

7. 7 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. Leads to driver diagram. What do you need to do to achieve an outcome?

8. 8 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 Improved algorithms/training Sharing of data Illustrative Only! Unscheduled care. Driver Diagram. Illustrative Only!

9. 9 III. Unscheduled care as a system of patient flows

10. 10 Public A&E Ambulance NHS24 OOH In hours primary care “999” Self-referral Orders of magnitude Flows into A&E. Orders of magnitude! 1000 attendances 80 30 600 70 220 40 250 800 600

11. 11 IV. Relating flows to causes/drivers to improvement.

12. 12 Each of the flows is a result of decisions made by particular agents at particular points in systemEach 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.Many of the changes we need to make are improvements in decision-making. Making sure patients are in the right flows. Plus services to support those improved decisions.Plus services to support those improved decisions. How do we relate ‘flows’ to ‘causes/drivers’

13. 13 The potential for improvement To a large extent defined by the number of patients who are in the wrong flowsTo 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 systemEnd up being treated at too intensive a level of the system e.g. treated A&E when could have been ‘better treated elsewhere’e.g. treated A&E when could have been ‘better treated elsewhere’

14. 14 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 flowsNeed 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?Which are the groups of patients with the greatest potential for diverting to a more appropriate flow/treatment point?

15. 15 V. Immediate priority: better understanding of who is attending A&E

16. 16 Immediate priority Better understanding of the patients attending A&EBetter understanding of the patients attending A&E Can we characterise A&E attenders in terms of meaningful groups which e.g.Can 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

17. 17 Examples of the kind of patient groups it would be useful to identify and quantify Elderly fallsElderly falls Minor illnesses who don’t need to be at A&EMinor illnesses who don’t need to be at A&E Behavioural/psychological ‘chaotic lifestyle’Behavioural/psychological ‘chaotic lifestyle’ Alcohol relatedAlcohol related Admissions from care homesAdmissions from care homes Frail elderly in generalFrail elderly in general Exacerbations of LTCs e.g. COPDExacerbations of LTCs e.g. COPD ????????

18. 18 Options for getting a better picture Existing electronic data: EDIS, Manchester Triage dataExisting electronic data: EDIS, Manchester Triage data Digging into ‘the cards’. Get information from A&E paper records.Digging into ‘the cards’. Get information from A&E paper records. Detailed survey of A&E attendersDetailed survey of A&E attenders

19. 19 Taking this forward Each method will give us a different and useful perspectiveEach method will give us a different and useful perspective Each NHS Board has different strengthsEach NHS Board has different strengthsTiming. January. Each Board to develop a picture using existing data: electronic, paper records /cardsJanuary. Each Board to develop a picture using existing data: electronic, paper records /cards Next couple of months: develop and do more detailed survey of A&E attendersNext couple of months: develop and do more detailed survey of A&E attenders

20. 20 Unscheduled Care Information Network Mutual support and sharing of expertiseMutual support and sharing of expertise So far involves NHS Boards, NHS24, SAS, SG, ISD.So far involves NHS Boards, NHS24, SAS, SG, ISD. Need lead information person from each BoardNeed lead information person from each Board Aiming for meeting late JanuaryAiming for meeting late January