Help shape local NHS urgent care services17 April - 29 May 2015

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What is urgent care?Urgent care is for health issues that:

• Arise unexpectedly• Require immediate attention• Range in severity from very serious (i.e. threaten loss of life or limb) to less serious

Urgent care services therefore need to be:

• Easy to access• Available 24 hours a day, 7 days a week• A range of services, capable of dealing with the very serious to the less serious

In common with the rest of NHS services, urgent care services also need to be safe, effective, value for money and a good experience for patients.

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What is urgent care? cont’dIn Waltham Forest, our urgent care services are:

•Pharmacists provide advice and treatment on a range of minor ailmentsPharmacy First

•This varies between GP practices, but most offer some emergency appointments that can be booked on the dayEmergency GP appointments

•A telephone advice service for people who have, or think they have, an urgent health needNHS 111

•If you call your GP surgery when it isn’t open, you will be redirected to an ‘out-of-hours’ GP serviceGP out-of-hours service

•Service based in Leyton, where people from across Waltham Forest and beyond can access urgent GP and nurse appointmentsOliver Road walk-in service

•For urgent care needs that are less serious (i.e. don’t threaten loss of life or limb)Whipps Cross urgent care centre

•For the most serious urgent and emergency care needs, i.e. issues that threaten loss of life or limbWhipps Cross A&E

Most of the time you can access services outside your home borough. Accessing GPs in this way can be tricky, but many will see people as temporary patients.

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What you might have heard about urgent care recently…

The A&E crisis deepened today as Britain’s biggest NHS trust revealed that one of its hospitals ran out of beds and had asked ambulances to stay away … Today the Standard can reveal that Barts Health — the

country’s biggest group of hospitals — had 36 patients in Whipps Cross’ casualty department awaiting admission to a ward at 6am on Tuesday but nowhere to put them.

(London Evening Standard, 9 January 2015)

A surge in patients sent to accident and emergency units by unqualified call handlers was blamed last night for helping to tip hospitals into “meltdown”. Operators on the non-emergency NHS 111 helpline, who

have no medical training, were needlessly advising callers to attend A&E in what has become a “huge problem”, experts said.

(The Times, 7 January 2015)

Whipps Cross University Hospital in east London has been rated as inadequate by the Care Quality Commission, which noted “serious concerns” about poor leadership, culture of bullying and low staffing

levels. The majority of the hospital’s services – including urgent and emergency care, care for older people, children and young people, and outpatients – require “significant improvements”, said the

regulator in a report published today. (Nursing Times, 17 March 2015)

• Is there a national crisis? Is there a crisis in Waltham Forest? • Let’s look at the national and local pictures.

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The national picture• To understand the national picture, it may help to look at this animation from the King’s Fund:

www.kingsfund.org.uk/projects/urgent-emergency-care/alternative-guide-urgent-and-emergency-care-system-england

• King’s Fund identify some issues that are true for Waltham Forest, and some that are not true for Waltham Forest (but are true in other areas of the country).

• Let’s explore the picture in Waltham Forest.

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The Waltham Forest pictureIn common with the rest of the UK, numbers of people going to A&E in Waltham Forest are roughly stable.

But we cannot be complacent about this, because:

• The pressure on A&E creates pressure on beds in the rest of the hospital, which then in turn creates pressure on A&E (i.e. patients need to stay longer in A&E because there are no beds on wards)

• Sometimes people go to A&E because they haven’t been able to get the right care in the community, which is often the best place for them to access care

• Sometimes people living in care homes are taken to A&E because the homes don’t feel they have the skills to look after some minor illnesses

• Sometimes people aren’t registered with a GP, and A&E is the only place they think they can access care

• Often people go to A&E when they don’t need to. This is because:• They don’t know what other urgent care services are available• They can’t, or don’t try to, get an appointment with their GP• They don’t feel confident about managing their health issues

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The Waltham Forest picture cont’dIn addition to these issues, in Waltham Forest:

• There are high levels of attendance from children under-5 and people aged 19-30

• Our IT systems and data-sharing processes need to be more joined up, so that staff in A&E can see GP care plans for patients, and give care in line with those plans

• Our GPs, nurses and ambulance services need more and different support to be able to care for people at home (this will ensure that people are only referred onto urgent care services when absolutely necessary)

• Our population has high rates of admission for alcohol, and these rates are increasing

• Our population has high rates of admission for mental health issues

• Whipps Cross Hospital has been inspected by the Care Quality Commission recently, and as a result its urgent and emergency services have been required to improve significantly

All these problems contribute to waiting times at Whipps A&E being a problem. The Whipps A&E consistently does not meet the 4-hour wait target.

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The future in Waltham ForestAs well as considering the current picture in Waltham Forest, we also need to consider likely healthcare needs in the future.

The 2011 census predicts that by 2021:

• There will be a notable population increase (12.6%)

• There will be a significant rise in the number of children (age 0-14)

• There will be a significant rise in older people (over 65), some of whom have complex needs

In addition, when the planned closure of the A&E department at King George’s Hospital in Redbridge happens, we know we will see increased demand at Whipps A&E.

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Our response: the urgent care strategyWe have developed our urgent care strategy to respond to this current and future picture in Waltham Forest.

This strategy has 3 main elements:

1. Responses that target particular issues2. Responses that focus on improving the urgent care system overall, rather than

particular issues3. Responses that focus on helping Whipps Cross improve the overall quality of

emergency care it provides

These are outlined in detail on the following slides.

Note: in the following slides we will also mention other CCG programmes (e.g. Transforming Services Together, integrated care etc.) These programmes are not part of the urgent care strategy, but their work overlaps and supports the work of the urgent care strategy. When an activity is part of another programme, we have marked it with italics.

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Targeted responsesThe issue Our response

The pressure on A&E creates pressure on beds in the rest of the hospital, which then in turn creates pressure on A&E (i.e. patients need to stay longer in A&E because there are no beds on wards)

• Improve patient flows around the system, focussing on frequent attenders

• Train hospital staff to focus on improving discharge rates

Sometimes people go to A&E because they haven’t been able to get the right care in the community, which is often the best place for them to access care

• Improve rehabilitation and reablement services, so they can support people to get up to full strength

• Improve end of life services: so that more people can die at home if they choose to do so

Sometimes people living in care homes are taken to A&E because the homes don’t feel they have the skills to look after some minor illnesses

• Train care home workers to be more confident in managing risk

• Put more support into care homes: to help them look after more people

Sometimes people aren’t registered with a GP, and A&E is the only place they think they can access care

• Primary Care strategy: as part of this strategy, we will increase people’s awareness of the primary care system, including how to register with a GP

Often people go to A&E when they don’t need to, because they don’t know what other urgent care services are available

• Improve people’s knowledge and understanding of the urgent care system, so they know where to go when

• Update 111 directory of services, and link to the community services single point of access

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Targeted responses cont’dThe issue Our response

Often people go to A&E when they don’t need to, because they can’t, or don’t try to, get an appointment with their GP

• Increase availability of urgent GP appointments• Support local GPs to establish a provider

network: GPs will work together to provide evening and weekend appointments. We will publicise this widely, so people know about the change

Often people go to A&E when they don’t need to, because they don’t feel confident about managing their health issues

• Improve people’s knowledge of their health• Support people to self-manage their health

conditions

There are high levels of attendance from children under-5 and people aged 19-30

• Improve the paediatric urgent care pathway• Link health visitors and school nurses to the

urgent care system• Train GPs to be more confident in interacting

with parents of young children

Our IT systems and data-sharing processes need to be more joined up, so that staff in A&E can see GP care plans for patients, and give care in line with those plans

• IT strategy: align IT systems and data-sharing processes across Waltham Forest

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Targeted responses cont’dThe issue Our response

Our GPs, nurses and ambulance services need more and different support to be able to care for people at home

• Train GPs to be more confident in managing risk

• Work with ambulance colleagues to identify opportunities for people to be cared for at home

• Integrated care: increase investment in community services and workforce development

Our population has high rates of admission for alcohol and these rates are increasing

• Improve the alcohol urgent care pathway• Work with Public Health and our local

community, to improve understanding of the harmful effects of alcohol

Our population has high rates of admission for mental health issues

• Continue to improve the mental health urgent care pathway

There will be a notable population increase (12.6%)

• Increase availability of urgent GP appointments• Increase availability of other urgent care

services at A&E• Transforming Services Together: one of the

main drivers for this programme is the projected population growth in East London, and the need to find solutions within available resources. (This programme covers a range of hospital services, as well as primary care, mental health services and integrated care)

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Targeted responses cont’dThe issue Our response

There will be a significant rise in children (age 0-14)

• Improve the paediatric urgent care pathway• Link health visitors and school nurses to the

urgent care system• Train GPs to be more confident in interacting

with parents of young children

There will be a significant rise in older people (over 65), some of whom have complex needs

• Integrated care: development of specific integrated care initiatives, e.g. the Rapid Response service

• Increase availability of other urgent care services at A&E

When the planned closure of the A&E department at King George’s Hospital in Redbridge happens, we know we will see increased demand at Whipps A&E

• Increase availability of other urgent care services at A&E

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Improving urgent care: overall and Whipps-focussed

responsesOverall responses

These responses focus on improving the urgent care system overall, rather than addressing particular issues. They are:

• Transforming Services Together urgent and emergency care workstream. This will work towards aligning urgent care services across the boroughs of Waltham Forest, Newham and Tower Hamlets, to ensure a high-quality, consistent and whole-system approach across east London.

• Overall integrated care programme, including Better Care Fund. The integrated care programme aims to link health and social care services, and so improve experiences for patients. The Better Care Fund is a specific integrated care initiative, which involves health and social care services sharing some of their budget. The Better Care Fund aims to reduce unplanned admissions to hospital by 2.5%, and so will support the urgent care strategy in reducing pressure on Whipps A&E.

• Reviewing urgent care services to ensure they meet the current and future needs of the population.• Supporting local GPs to establish a provider network. GPs will work together to provide a wider range

of services.

Responses to help Whipps Cross improve quality

Whipps Cross has been inspected by the Care Quality Commission recently, and as a result its urgent and emergency services have been required to improve significantly. We will respond to this by working with Barts Health, CQC, NTDA and other CCGs to drive up quality at the hospital.

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VisionThese targeted, overall, and Whipps-focussed responses come together to form our vision for urgent care services in Waltham Forest:

“We will work with partners to develop a sustainable urgent care system, so that the people of Waltham Forest can access the most appropriate health and social care, advice and support, in the right place and at the right time.”

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Outcomes and challengesOutcomes: how will we measure success?

Over the next 3 years we will see:

• A marked improvement in achievement of 4-hour wait target at Whipps Cross A&E• 30% decrease in attendances at A&E

Challenges

• All of this change needs to be delivered within the current budget. (The current cost of urgent care in Waltham Forest is £25 million per year.)

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Next stepsOur urgent care strategy has been developed by:• Reviewing audits and performance data;• Researching local and national best practice;• Listening to stakeholder views at workshops;• Analysing results from a survey conducted by Healthwatch Waltham Forest;• Undertaking a snapshot of patients attending A&E and the urgent care centre at Whipps Cross, to

understand their reasons for attending and their knowledge of other urgent care services; and• Reviewing feedback from the CCG’s Annual General Meeting in September 2014.

Now we want to hear your views!

The questions we would particularly like feedback on are:

1. Do you think our strategy addresses the main problems facing urgent care services in Waltham Forest? If not, please explain why.

2. Do you agree we need all of the targeted, overall and Whipps-focussed responses?3. If you don’t agree we need all of the responses, which ones do you think we should we remove? And

why?4. Do you think we have missed anything in our strategy?5. Can you think of any ways that you, or your organisation, could help us deliver this strategy?6. Do you have any other comments?

Please tell us your views by 29 May 2015. If you would like us to update you on the progress of our strategy, please include your email and/or postal address.