1. What’s wrong with emergency care in Aneurin Bevan Health Board? Dr Danny Antebi & Dr Julie Vile

2. “We have seen an increase in the 85+ age group” “The acuity of our patients is increasing” What do we know / think? TOO MUCH DEMAND PROCESSES ARE TOO SLOW IN HOSPITAL LACK OF CAPACITY TO TAKE PATIENTS OUT OF SYSTEM “The system is in crisis” With increased demand, bed cuts and no immediate prospect of additional funding, we need a FUNDAMENTAL change if we hope to deliver a high quality service

3. Demand for A&E services

4. Demand by age band

5. A&E age profile (adults)

6. A&E outcome – admitted

7. Hospital profile: co-morbidities

8. Hospital profile: age & beddays

9. Projections for 65+ AB residents with dementia

10. The 4 hour target

11. The 8 hour target

12. 4 hr Breaches & Death Rate

13. Ideas for modelling/ alleviating the problem TOO MUCH DEMAND PROCESSES ARE TOO SLOW IN HOSPITAL LACK OF CAPACITY TO TAKE PATIENTS OUT OF SYSTEM Admission avoidance strategies Better community model Role of WAST Consultant at front end Alternative pathway for elderly/ frail patients Co-locate MIU Better computational facilities Discharge patients earlier Bring in elective patients later 24/7 working Patient boarding

15. Ideas for modelling/ alleviating the problem TOO MUCH DEMAND PROCESSES ARE TOO SLOW IN HOSPITAL LACK OF CAPACITY TO TAKE PATIENTS OUT OF SYSTEM Admission avoidance strategies Better community model Role of WAST Consultant at front end Alternative pathway for elderly/ frail patients Co-locate MIU Better computational facilities Discharge patients earlier Bring in elective patients later 24/7 working Patient boarding

16. Choluteca Bridge

17. The problem Evidence of repeated escalation, increased clinical incidents, stories of poor care, queues of ambulances. So…  Case for change  Organisational focus  Conceptual framework

18. Case for change Internal to health, partners in delivery, public and politicians Making the case  Data  Hearts and minds  Patient safety

19. Organisational focus Leadership Whole system approach Prioritise Emergency Care

20. S afe T imely E ffective E fficient E quitable P atient Centred S ystemic C ollaborative D ialogue Improvement Innovation

21. Conceptual framework Flow Complexity Networks and Matrices

22. Flow Poor flow harms and kills (Kate Sylvester-mortality by day of admission) Poor flow wastes resources Demoralises staff Impacts on other departments

23. Complicated or complex Simple - following a recipe Complicated - building a space rocket  First 48 hours CVA, cardiac surgery Complex - raising a child  Chronic conditions, plus dementia plus NOF

24. Slide on differences

25. Production lines and pathways Acute chest pain  Expertise, latest equipment, excellent process, minimal collaboration, safe environment Complicated pathway/Organisational ownership Chronic cardiac failure and cognitive impairment  Stay at home, response, support, advice when I need it, a lot of collaboration, engage my family, friends and the milkman, occasional high tech Complex approach/Shared ownership

26. Networks and matrices Resilient communities public/private/3 rd sector – with a shared agenda and priority ? integration IT, budgets, management

27. Research and modelling Flow - patient safety, risk, right person, right place, right time, right expertise, pull not push Complexity – process measures less outcome measures, dignity, patients who can’t report Networks – organisational collaboration, resilient and robust community and primary care, risk assessment and management, EOL/anticipatory care.

28. Thank you for listening! Email: Danny.antebi@wales.nhs.uk julie.vile@wales.nhs.uk Any questions?