Urgent care: improving patient flow – Kerryn Husk

This week, when others around were returning from Cape Town and the Global Evidence Summit (no jealousy), I travelled up to cloudy Manchester for a set of talks around Urgent Care and improving the way patients move through the health system. This is important for a range of reasons and is on the agenda for CCGs, Local Authorities, Trusts and (more importantly) patients – nobody wants to be in hospital. This topic is relevant for CPCRG also, with links to PenCLAHRC’s Reducing Paediatric Admissions, and the AAA project.

We kicked off with Sasha Karakusevic from NHSE arguing that, given peak occupancy of wards is often in the morning, we should move away from measuring capacity overnight and be more specific: can we measure length of stay in minutes? In the same theme, could we be more nuanced in our analysis when things go wrong (something discussed in coming seminars by Nick Axford) and shift from blame to curiosity around error?

The North East Ambulance service had much to report on their innovative clinical triage programme ‘Paramedic Pathfinder’ which transits to the best possible site, not necessarily ED. Gateshead Care Partnership also reported success in linking multiple services together and gaining block CCG funding to deliver all community-based services. NHS Improvement presented their new tool (Emergency Flow Improvement Tool) which aids the understanding of bottlenecks and whole system performance using existing routine Trust data.

Tim Gillatt (also from NHSI) reported on the, in my opinion brilliant, programme ‘#Red/Green days’. Two questions are at the heart of this approach:

• “If I saw this patient in outpatients now, in this physiological condition, would I admit them as an emergency admission?”
• “Can the interventions being planned for today be performed out of a hospital setting?”

If the answer to the first is ‘no’ and to the second ‘yes’ then the patient in hospital is experiencing a red day (effectively a waste of time), otherwise green. If we can maximise green days and reduce red we are thinking along the right lines.

This sounds trite but the central message here is one we should all focus on: it is time that is the unit of import, not beds. Beds are where patients wait for treatment that will aid their recovery and get them home, let’s move away from concentrating on bed counting and try to understand time usage.

Two other talks stood out. Firstly, the team from Sunderland CCG reported on their introduction of ‘Consultant Connect’, an advice and guidance line where GPs can contact a hospital specialist to determine if secondary care is necessary. This is something we are interested in at PenCLAHRC and have assessed advice and guidance lines in paediatrics, where there is positive impact on the system. In many settings however these are £10 pay as you go mobiles rather than an expensive private/corporate system; this should concern us.

Lastly a fantastic talk from David Smith who outlined the work undertaken by First Choice Homes in Oldham. This group of 27 housing providers felt little was being done to address housing issues experienced by those in urgent care settings and the impact on discharge planning and timing was acute. By investing significant time and resources the group placed an individual in the ED to discuss and plan (as well as conduct) adaptions or rehousing at the appropriate time, allowing prompt discharge. It is rare that for-profit organisations operate in this way and unsurprisingly the first question focussed on the business model. The answer was that the group felt it was the right thing to do and there should be a duty of care to improve this pathway in whatever way is possible, fantastic to hear and demonstrates the ability of complex systems to operate more smoothly with some goodwill.

Low points…well one of the presentations and most of the networking was a thinly disguised sales pitch by health device or health solutions companies. Not good.