1. 12 March 2009 Dr Brian Montgomery Associate Medical Director NHS Lothian Emergency Access Delivery Team

3. Accessing Healthcare New GMS (50/168) NHS24 24/7 consumer society Heightened anxiety & urgency Complexity of options A&E is the only “open” door

6. Total Hospital Stay (Days) Hospital Admissions 2006/07 Actual Hospital Lengths of Stay Admissions

7. Sources of referral (monthly average 2008) SourceRIE (A&E PAA) SJH (A&E MAU) WGH ( ARAUT) Self3990248075 999241570145 GP1135440945 LUCS2203555 NHS2453535048 Police9570 Other Hospital4027 Minor Injury Unit6010 Review28518035 Other12557580 Total890042001420 Front Door Admissions 27801050765 WGH Minor Injuries Unit - 1415

8. Who attends A&E 100,000 attendances per annum (RIE) –Six month audit Oct 06 – Mar 07 57 patients with > 10 attendances totalling 720 visits –Case management reduced attendances for this group to 499 in the next six months (Apr 07 – Sep 07) –Six month audit Feb 08 – Jul 08 63 patients with > 10 attendances totalling 957 visits –Very little overlap in the two populations

9. Who attends A&E (RIE study) Male to female ratio 2:1 Mean age 43 Commonest problems and diagnoses –Alcohol related problems 46% –Mental health problems 37% –Chronic complaints (eg abdo or chest pain) 40% Homeless patients 7 Not registered with a GP 2%

10. Who attends A&E 50,000 attendances per annum (SJH) –Six month audit Feb 08 – Jul 08 15 patients with > 10 attendances totalling 196 visits 30 patients with > 8 attendances totalling 323 visits

11. Frequent Flyers Account for 1.5% of A&E attendances Case management reduced attendances by 31% (221 visits) Behaviour is not sustained over long periods but reflects periods of crisis The people change

12. 50/168 – Supply / Demand / Need Hours of Business Activity Time ? Hours of Business ?? Hours of Business

13. 50/168 – Supply / Demand / Need Supply ≠ Demand People expect extended hours Combination of extended hours and shifted hours Differentiate between assessment and treatment Balancing of scheduled and unscheduled activity

14. Lothian Unscheduled Care Service 300 patients transferred from A&E to LUCS –Coded as discharges LUCS 200 direct referrals to medicine or surgery

15. Patient 999 GP Care Home Walk-in Pharmacy SPOC (BB) SPOC (BB) Urgent (Hot) OP appt Medical Opinion Eg. Stroke Line BED Day Hospital appt Pathways into Healthcare – possible FUTURE state Identified area of concern/ Opportunity for redesign A&E ARU PAA MAU A&E ARU PAA MAU See & Treat teams Mobile Diagnostics Diagnostics Patient Transport NHS 24 Falls Prevention Access Team Reablement Service Augmented Care Intermediate Care (inc. Crisis Care) Domiciliary Care Social care teams 24h Mental Health Assessment Intensive Home Treatment District Nurse – eve & night Community Respiratory Team IMPACT nurses Community care teams LUCS Minor Injuries GP Walk-in

16. LOCAL PROVISION / ALTERNATIVES TO ADMISSION presentNHS24LUCSA&E PAA/ MAU admit Anticipatory Care Community Pharmacists Long Term Conditions Rapid Response Teams Shifting the Balance of Care Diagnostic and Assessment Centres

17. Priority Areas Single point of contact Review of Day Hospitals Rapid access assessment and diagnostics Unscheduled Care Services Patient flows

18. Conclusions A&E has become an open access point of triage Current arrangements are not user friendly The way we deliver service does not meet expectation (?need) Our current responses reinforce behaviour Current arrangements are not fit for purpose

19. Lothian’s Trajectory

20. Pathways into Healthcare The challenge: Change the demand Or Meet the demand appropriately