Keith Willett: Designing the best solutions locally

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Keith Willett

Keith Willett, Medical Director for Acute Care at NHS England, discusses NHS England's work in implementing the Urgent and Emergency Care Review, and shares learning from the vanguards.

Keith Willett: Designing the best solutions locally

This presentation was recorded at our Urgent and emergency care conference on 27 September 2016.


In terms of the Urgent and Emergency Care Review, we are very much now into the phase of 'let’s just get on and do it'. We have talked a lot about what we can do, what we should do, what evidence we have got, what evidence we haven’t got, how we can do it, but we can’t just carry on talking. We have got to get to the phase now, and we are I am pleased to say, really starting to see implementation.  Hasn’t touched the demand curve yet, but we all have to believe it is going to, because none of you, and all I do has come from all of the people like you, there is nothing else in the box to suddenly jump out as the silver bullet.

So I am just going to give you an idea now about what it is that where we have got to in terms of the urgent emergency care review, how we are going to do the implementation, and what we have learnt from the vanguards which if you like were our accelerator sites. That photo is intentionally out of date, and poorly focused, and that is really what I think urgent emergency care in the NHS is. Everyone can focus on the car that has overheated, and if you are an emergency medicine consultant, you will see that as you.  If you are a GP you will see it as you, if you are a paramedic you will see it as you, and if you are social care actually you are not on the picture, you are down the road driving in first gear with steam pouring out of the engine causing the flow blockage in that section.  And that is a bit where we are, I won’t push the analogy any further, but I think we have to recognise this is a system wide problem.  And it is going to take intervention and improvement at every single step of the pathway that patients walk through, not just for their outcome, but for their experience, which is currently quite poor.

And you have seen this slide before I am sure, but this is where we started with the urgent emergency care review saying of those patients who are admitted to hospital, how many, but for the want of something better, at the front of the hospital, in the emergency department, or ambulatory care, need they not have been admitted. And then for those who actually ended up at the hospital front door, how many of those but for the want of something better that the paramedics could have worked with, did they not need to be conveyed? And you can work right back through that system to the very beginning of the pathway when the patient becomes ill.  But for the want of some advice, need they not have even contacted the NHS in the first place, which is what a lot of patients will tell you.  And there is about an enormous magnification as you go out, which is not reflected in that slide.

So we are somewhere around 5.4 million admissions to hospital, something like 22 million attendances in something that might be called an A&E or urgent care centre. We are up to 350 million primary care contacts, and up to 440 million pharmacy contacts. So the magnification effect shows that this has to be a system wide.  Because what we are looking for is the most efficient channel shift, in other words patients getting what they want, receiving the offer as close to their home as possible, which is most convenient for them, gives them the answers they want, and is in the lowest cost setting to create a sustainable NHS.  Because we can’t keep burning money in the way we are, with the government agenda that we have been set, it just doesn’t add up.  This is a really clumsy slide, but I like it because it helps me remind me of what I was going to say.  And that is if we start off with that, perhaps the example patient which I think really indicates how poor the system can be sometimes for some patients’ experience, and for family experiences.

You have an ill patient at home. Very often the medical problem is relatively straightforward. It may just be an exacerbation of one of their five or six co morbidities.  But actually unless we have a responsive system around them, we end up having a default.  So if the patient had a voluntary sector friend that could come in and do that little bit of support that the GP in an out of hours was available in a responsive way, that community physical and mental health could respond in the way and rapidly enough that we could, in many cases, support that patient in an environment.  Because once they get on that slippery slope towards hospital, then it becomes increasingly difficult to prevent that patient becoming an admission.  And once they are in hospital, they are isolated from their family, from their carers, they are isolated usually from anybody who knows about their medical history, and they are actually at risk, because it is a strange environment.  They are immobile, and within 48 hours they have got measurable muscle loss, we call it Sarcopenia, and they are at risk of falls and other problems.

And they are all those things that we were talking about at the start, we then try and mobilise them in some sort of order, to get the patient back home, when now the assessment is much more difficult. So it is all about trying to get that decision making as far upstream as possible, because we have a default when we can’t offer what the patient needs in the environment that they are in. The NHS default is to move them to a higher cost, higher acuity setting, even if that is not what the patient needs.  And that is not a good experience, and it is not good care.  But that is where we currently are, so that is what we have got to unpick, and those green bits, the community social care out of hospital, that response.

How many people in this audience are from a health background? How many people from community or social care background? One of the fundamental problems that the Health Service has, is it does not understand social care in the community.  It sees it as some amorphous homogeneous blob at the end of the pathway that sucks things in.  More people work in adult social care alone, than the whole of the NHS.  1.55 million people in adult social care, there is only 1.3 million people employed in the NHS.  We struggle to try and understand what happened in primary care, and why we got general practice into such a difficult position, because they work as independent providers, and we haven’t collected the data in the same way that we should have done.  There is only 7,600 GP practices, there are 18,000 care homes, 8,500 community providers, and the majority of those are in the independent sector, and the majority of those, 80% are family businesses.  That is why we have real problems, and people in health just don’t understand it, they say ‘Social care is the problem’, they don’t know what social care is.

We have got an awful lot to learn in health about social care, and the sooner we bring those two together in a meaningful way, through the STPs, through the A&E delivery boards, through the local health economies coming together, the better. But I bet you there will be one or two social care people and community care people in the room, and there will be 30 people from health. It’s alright, I just had to say that bit, because it makes me feel better, because it is where I have got to in my journey of trying to make this system change.  The other thing is, while I am on it, is we ask our call handles in health on 111 and 909 to respond in seconds, and we penalise them if they don’t.  We ask our ambulance services to respond in minutes, we ask our emergency department to respond in hours, our hospitals normally respond in days, and our community and social care often it is several days or weeks before they respond.  So how can we do what we desperately need to do?  We have designed a system that we performance manage in a way that actually encourages exactly the reverse flow we are looking for.

So what I am going to do now is just quickly talk through just what we are doing nationally in terms of driving this all out. There is a bunch of things that within the urgent emergency care network which are now aligned to the STPs, the strategic transformational plans, that you are aware of. We have established 23 urgent emergency care networks around the country, a bit like we did for major trauma, to bring all the people together, to start to look at that bigger footprint, and say what do we need to do, particularly around the sort of specialist end of healthcare?  But also that comes down, and we have built that model around the STPs as well so they are not coterminous in terms of the size, but they are all aligned.  We are looking to put in place by autumn 2017 that there will be urgent care networks for the five things to start with that we know that with the right care, centralised in specialist centres, we change survival rates, and we change outcomes, which are stroke, stemi heart attack, vascular surgery, major trauma, and paediatric intensive care.  There is no question medically about that, and we would be wrong to deny our populations access to them.  But clearly if we are going to do that, then whether you get there on your Saturday with your heart attack, you shouldn’t wait until Monday to see a consultant.  So seven day service standards are going to need to go into those.

Integrated urgent care I will talk about a bit more, but that is about creating this composite structure, so that out of hours services, 111, out of hours general practice, and the clinical advice that sits behind them, is significantly enhanced. I won’t talk about enhanced access to primary care and general practice, but that is clearly something that we are majoring on as well. And the other thing I will mention somewhat is there are various other things in there we want to really make progress on, and I was delighted with the amount of funding that has gone in, and the dedicated way to mental health, and in particular into children’s mental health crisis care.  Because I was involved in the crisis care Concordat, and I was very convinced by the need to try and get mental health some degree of parity, if not primacy.

So what is integrated urgent care? Well at the moment, in the NHS, out of hours, we have a 999 service with a bit of clinical advice behind it, usually some nurses and paramedics, occasionally a doctor. We have a 111 service which has a variable level of clinical advice behind it, may have a few nurses, may have a GP, and then we have out of hours general practice which has nurses and GPs.  They are all on call at the same time, but none of those services are hooked up, and none of them provide the breadth of clinical advice we need, mental health teams not in many of them, dental health response, is there a prescribing pharmacist?  What have we got in there that would really start to manage the demand without having to make the disposition, go to A&E or call an ambulance?  If they are going to have clinicians involved then they have to have access to the clinical information, so they have to have at least a summary care record, but in most places we need to move to an extract from the full GP record.  And they need to be able to book into the services that they say.

It is no point saying to a patient ‘Oh go and find a dentist’, you need to have some bookability, that you can offer the patient something that they actually need. So that is a real key central plank in managing demand. The national vanguard.  So we have urgent emergency care vanguards, they are different really to many of the other vanguards.  Our vanguards are very much accelerator sites for the major interventions that we have developed with you around urgent emergency care.  So for the integrated urgent emergency care we have described four criteria that we want them to have, to meet, to give this integrated emergency care is the things I have just described, and that slide, I will come and talk to that about in a second.  The other one is we have done a lot of work modelling, and we are now doing actual practical work in tracking it as we are implementing, what happens when you put an intervention in?

How many patients for instance, how many patients, who phoned 11, who currently are sent to the emergency department, because that is what the algorithm says, have they been able to speak to a nurse, or an emergency medicine clinician or somebody else, could they have a different disposition that was more convenient for them, more efficient for the NHS, and did they actually follow it? And we are now putting that in place. So we have done both the financial modelling and the activity modelling, and now we are tracking that as the integrated urgent care is put into place.  New models of crisis care, we have been able to fund a lot in the vanguards, to build these new models of crisis care.  It is totally wrong for mental health patients who are sectioned to end up in police cells, and desperately wrong if that looks anything particularly in for younger people.  It clearly is not where we need to be.

And then if we are going to talk about a whole system shift, then we are going to have to measure it in a different way. The idea that four hours for A&E, and eight minutes for ambulance services and whatever, that doesn’t make any sense, because people end up just building their operational systems around those targets. We need something that measures how the whole system is going, so we have done a lot of work, and I will just briefly mention that.  So where have we got to?  With integrated urgent care, that combination of bringing the out of hours contract together with a 111 contract, either physically as a contract, or organisationally in terms of a relationship.  We were set by the Department of Health a target on that that we need to have 20% of the population should be covered by those eight criteria that I slightly discussed, for that integrated care model by next March.  So that was the number.  We also are at the moment, 22% of calls nationally that go to 111 are warm transferred to a clinician, so the clinician then speaks to the patient, or calls them back very promptly.  We have been asked to make that 30% by next March.

So that work is out there, plus the work I described about, saying as we do this, and in the whole of the north east which is about 2.6 million population, we are actually tracking patients because they have got a very good software system, and we can track them through the system, not with any personal details, but we can track a patient. So if somebody phoned 111 we can then see an anonymised way where that patient ended up appearing, did they actually follow the advice? And that would be really powerful to be able to share with the rest of the people designing systems to understand which of the interventions are really going to make the changes they need in their area.  We have just had, and clearly this is just an assurance, but in our last enquiry of the 209 CCGs about where they were got to for this, were we on plan to hit that 20% figure, in fact they are indicating they expect 38% of the country to be there by next March.  And I think this is testament to the fact that we have had local health economies starting to come together, and thinking much bigger than their institution, which is something we desperately needed to do.  The intention is obviously the whole of the country will be covered in due course.

We have done some modelling. So there is a list of intervention there, which I won’t go through, but these were the interventions that you as service users, you as clinicians, you as managers, commissioners in the system, said you believed there was evidence to support doing them, and that they would have an impact. So now we have done work to actually test those interventions in our vanguards, to see whether or not they do yield the sort of shifts we want, and what the cost advantage or not is, because quite clearly we aren’t going to be able to do this with lots of new money.  So that is really important, and we will share that with people later this year when that comes through, because again that will be really useful for local health economies to look at from their particular perspective about how beneficial it is.

I have to talk about mental health, because I think this is probably one of the most important things that has come through in the last two years. A real commitment to additional money into crisis resolution, both at home and for those patients who come into the system through either home response, crisis resolution in the home, or through liaison mental health services in the hospitals. So that is really important, and I think is very encouraging, and I am delighted that the vanguards have really taken that up as an opportunity, and with a particular focus on young people.  But there has been this real commitment to do this, and I think that is essential.  Those of us who have worked close to the front door of hospitals are more than aware of how difficult it is to be able to give the right care to the family and patients in these circumstances.

So new outcome measures. What do I mean by new outcome measures? How do we measure the system differently?  A lot of work has gone into this, but in essence it comes down to three things.  Are the patients moving through the clinical pathway, and getting what they want at the place that is most convenient for them, and giving them the right outcome that we should offer?  So it is about the clinical pathways and our patients meeting those.  So if you have...I think Bruce Keogh showed a video we had made this morning, I think for those of you here, what should happen if you are having a heart attack, what should be the process you go through in order to get as fast as you can to the specialist centre?  On the other hand, what is the pathway that should be following for the young girl who had the mental health issues that needed the right response?  So we need to be measuring the pathways.

We need to be measuring patient experience, but also very importantly staff experience. We have learnt I think from the Keogh Hospitals, from the failing hospitals, hospitals that have got into difficulty, and in fact not just hospitals, services that have got into difficulty, ambulance services, community services, the staff know first, the staff are the best thermometer. They know when the service they are working in is really not doing the right things, or working to the right level.  So we are working with that.  We have already trialled in the vanguards that to a certain extent we are going back out to another trial with some modifications having learnt from the first round, and we will bring that back in due course for people to see.  But importantly I want to move the whole system to a different way of measuring, and also therefore probably to a different way of paying, that we are not stuck on the measures, the payments we have.

So we have got to get it out there now. Everybody is moving across the country, the sustainability and transformation plans are the vehicle by which that will happen. Urgent emergency care in the first sort of drafts we have seen of those are included in just about every single STP as you would perhaps expect, given the pressures in the system, and we are very confident that that is a very good method for getting the whole lot coming together.  But by God it is going to be difficult, it really is going to be difficult.  Some people are meeting across health economies for the first time staggeringly, and you have had groups of people who have never met before, and yet they are sharing patient pathways.  So I am not belittling that at all.  We have got the network set up across the country which will facilitate that, each of them has mapped out all their services and know where they are, and we now need to start to bring all that together into a cohesive plan.

So from an NHS England point of view, we have put in an infrastructure and governance to support that. We now have set up four regional offices that will support the local STPs in delivering the urgent emergency care elements. As I said it is based around the STP footprints and drawing in from not just the urgent emergency vanguards, but all the other vanguards, accelerator sites, the PM champions and a whole variety of other experiences that we have learnt.  And we have got until 2020 to get this out there.  And that is my final word.  I can’t do much more.  I have done my bit, but now it has got to be the service.  My view is that the only people that can really understand what I have just said, and can really deliver it and take down the blinkers, and pull all this together, are the people in the service delivering it.  That is where the next level of healthcare efficiency has to come, from that your intellectual appreciation of the information and data around what happens to you as a patient, or you as a system organiser.  Thank you very much.


Senior Health care Assistant

I find this article encouraging and helpful for the nation, can it be possible to send more updates articles. Thank you

Senior Health care Assistant

I will interested to have more updates

#549306 Anna Waters
Digital Communications Assistant
The King's Fund

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