Transcript No Slide Title

Emergency Access Delivery Team
12 March 2009
Dr Brian Montgomery
Associate Medical Director
NHS Lothian
Town
Lothian NHS Board Area
Primary Route
Motorway
Regional/CHP boundary
Urban Area
North
North Berwick
Berwick
City of Edinburgh
Dunbar
Dunbar
Linlithgow
Linlithgow
Leith
Leith
Davidson's
Davidson's Mains
Mains
Craigmillar
Craigmillar
Bathgate
Bathgate
Livingston
Livingston
Livingston
Tranent
Tranent
Haddington
Haddington
Morningside
Morningside
Dalkeith
Dalkeith
Bonnyrigg
Bonnyrigg
Penicuik
Penicuik
A701
© Automobile Association Developments Limited 2005 All rights reserved. This product includes mapping data licensed from Ordnance Survey © Crown Copyright 2005. All rights reserved. Licence Number 399221
By Mette Tranter, HIPU, Lothian Health Board, 6th February 2006
Accessing Healthcare
•
•
•
•
•
•
New GMS (50/168)
NHS24
24/7 consumer society
Heightened anxiety & urgency
Complexity of options
A&E is the only “open” door
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
Front-door Emergency Activity at RIE, SJH and WGH, 2002-2007
10000
9000
8000
7000
6000
5000
RIE Activity
4000
SJH Activity
3000
WGH Activity
2000
1000
0
2002
2003
2004
2005
2006
2007
2008
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
Front-door Emergency Activity at RIE, SJH and WGH, 2002-2007
10000
9000
8000
7000
6000
5000
RIE Activity
SJH Activity
4000
RIE Admissions
WGH Activity
3000
WGH Admissions
2000
SJH Admissions
1000
0
2002
2003
2004
2005
2006
2007
2008
Hospital Admissions 2006/07
Actual Hospital Lengths of Stay
Admissions
550
500
450
400
350
300
250
200
150
100
50
0
0
3
6
9
12
15
18
21
24
27
30
33
36
39
Total Hospital Stay (Days)
42
45
49
52
56
61
70
79
Sources of referral (monthly average 2008)
Source
Self
999
GP
LUCS
NHS24
Police
Other Hospital
Minor Injury Unit
Review
Other
RIE (A&E PAA)
3990
2415
1135
220
535
95
40
60
285
125
SJH (A&E MAU)
2480
70
440
35
350
70
WGH (ARAUT)
180
575
27
10
35
80
Total
8900
4200
1420
Front Door
Admissions
2780
1050
765
75
145
945
55
48
WGH Minor Injuries Unit - 1415
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
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%
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
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
50/168 – Supply / Demand / Need
Activity
?? Hours of Business
? Hours of Business
Hours of Business
Time
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
Lothian Unscheduled Care Service
• 300 patients transferred from A&E to LUCS
– Coded as discharges
• LUCS 200 direct referrals to medicine or
surgery
Pathways into Healthcare – possible FUTURE state
BED
See &
Treat
teams
999
Community care teams
Care
Home
24h Mental
Health
Assessment
Intensive
Home
Treatment
District Nurse
– eve & night
Community
Respiratory
Team
Mobile
Diagnostics
Diagnostics
IMPACT
nurses
Patient
ARU
PAA
MAU
SPOC
GP
Social care teams
NHS 24
(BB)
Falls
Prevention
Access Team
Medical
Opinion
Reablement
Service
Augmented
Care
Eg. Stroke
Line
Intermediate
Care (inc.
Crisis Care)
Walk-in
Pharmacy
A&E
Urgent
(Hot)
OP appt
Domiciliary
Care
LUCS
Minor Injuries
GP Walk-in
Patient
Transport
Day
Hospital
appt
Identified area of concern/
Opportunity for redesign
present
NHS24
LUCS
A&E
PAA/
MAU
LOCAL PROVISION / ALTERNATIVES TO ADMISSION
Anticipatory Care
Community Pharmacists
Long Term Conditions
Rapid Response Teams
Shifting the Balance of Care
Diagnostic and Assessment Centres
admit
Priority Areas
•
•
•
•
•
Single point of contact
Review of Day Hospitals
Rapid access assessment and diagnostics
Unscheduled Care Services
Patient flows
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
Lothian’s Trajectory
NHS Lothian T10 Trajectory
(based on 2% reduction in A&E attendance rate per 100,000
between 2007/08 to 2010/11 )
2,500
2,450
2,350
2,300
2,250
2,200
2,150
2,100
2,050
ar
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M 8
ay
-0
8
Ju
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Se 8
p0
No 8
v0
Ja 8
n0
M 9
ar
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M 9
ay
-0
9
Ju
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Se 9
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No 9
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Ja 9
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M 0
ar
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M 0
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-1
0
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No 0
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Ja 0
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M 1
ar
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1
2,000
M
Rate of Attendance
2,400
Pathways into Healthcare
The challenge:
Change the demand
Or
Meet the demand appropriately