1. Emergency Care – in and out of hours Now and from 2008

2. Current provision for St Albans & Harpenden residents Pt A&E GP MIU SACH Self-presenter GP-heralded OOH

3. Emergency Activity 200520062007(projected) A&E attendances (Hemel) 521594784345832 Emergency admissions (Hemel) 806778718742 MIU153861468614567

4. Reduction in emergency activity within Acute Trust Emergency Admission is a “bad thing” Emergency Admission is a “bad thing” Admission avoidance – PCT target to reduce admissions by 5% Admission avoidance – PCT target to reduce admissions by 5% “Early Intervention Team” “Early Intervention Team” Alternative Care Pathways Alternative Care Pathways DVTDVT IV antibioticsIV antibiotics

5. Trust efforts to reduce emergency activity Avoid inappropriate admissions Avoid inappropriate admissions Reduce LOS Reduce LOS Efficient care pathwaysEfficient care pathways Social careSocial care Intermediate careIntermediate care Support at Home – “Hospital at home”Support at Home – “Hospital at home”

6. Inappropriate admissions 91 yr old NH resident 91 yr old NH resident Dementia + Parkinsonian features Dementia + Parkinsonian features Bed bound Bed bound Admitted because oral intake decreased & pt increasingly drowsy Admitted because oral intake decreased & pt increasingly drowsy

7. “Inappropriate Admission” Hospital perspective – palliative care most appropriate – and best delivered in NH setting Hospital perspective – palliative care most appropriate – and best delivered in NH setting NH – decision on end of life care not made. Concerns re ability to deliver best care in NH NH – decision on end of life care not made. Concerns re ability to deliver best care in NH Palliative care support to home to enable best decision to be made Palliative care support to home to enable best decision to be made

8. Delivery Acute Care NICE Acute Medicine NICE Acute Medicine RCP Delivery Acute Medical Care RCP Delivery Acute Medical Care NCePOD Report NCePOD Report Darzi Report Darzi Report

9. Access to urgent consultant opinion Outpatient Outpatient Elderly CareElderly Care Gastroenterology – jaundiceGastroenterology – jaundice Cardiology – RACPCCardiology – RACPC But most importantly for Pts presenting to Hospital

10. 2008 (October ?) Hemel A&E closes Hemel A&E closes AAU opens at Watford AAU opens at Watford Urgent Care Centre opens at Hemel Urgent Care Centre opens at Hemel MIU remains the same at SACH MIU remains the same at SACH

11. Pt MIU UCC AAU GP A&E New Model of working

12. UCC 65% current A&E attendances 65% current A&E attendances Walk-in minor injuries Walk-in minor injuries OOH GP OOH GP Access to investigations Access to investigations Referral & liaison to multidisciplinary services eg community mental health Referral & liaison to multidisciplinary services eg community mental health

13. AAU LEVEL 3 short stay (60 beds) LEVEL 2 – Cath labs x 2, CT scanner LEVEL 1 –assessment (<24hrs) Discharge Home GP A&E Home Admit to ward

14. Consultant – led service Consultant triage and management Consultant triage and management Acute PhysiciansAcute Physicians “Physicians of the Day” – working shifts“Physicians of the Day” – working shifts Reduce unnecessary admissionsReduce unnecessary admissions Best CareBest Care Reduced LOS (< 4 days?)Reduced LOS (< 4 days?)

15. Process to achieve this Agreed model of care Agreed model of care Probably not cheap –at least initially Probably not cheap –at least initially Supporting services Supporting services Intermediate careIntermediate care Social careSocial care Alternative pt pathways – eg DVTAlternative pt pathways – eg DVT

16. Risks/Barriers Sign –up from all parties to same model Sign –up from all parties to same model Intermediate care access Intermediate care access NH & RH provision NH & RH provision Bed-base At Watford Bed-base At Watford Money!!! Money!!!