Inside England’s first accident and emergency department for older people

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I knew I liked Martyn Patel the first time I met him. This was partly because of the 80s movie references he kept shoehorning into his presentation on patient flow. But it was mostly because he was talking about accident and emergency (A&E) performance in a way I didn’t recognise.

In recent years, I have looked at A&E performance using a deficit model. In this frame of mind, if you say ‘A&E’ I think about endemic workforce shortages, a punishing Australian winter flu season reaching UK shores and a summer ‘recovery’ in A&E performance that didn’t materialise in 2019.

Martyn, the service director for older people’s medicine at Norfolk and Norwich University Hospitals NHS Foundation Trust, made it clear that his organisation has a far more asset-based view of A&E services – based on what is working and where the strengths, possibilities and opportunities lie. He invited us over to Norfolk to see their vision in action.

A familiar start to the story

Like most places, Norfolk and Norwich University Hospital’s A&E department is under pressure from rising demand. And performance against the four-hour A&E waiting time standard remains far below the national target (Figure 1).

Figure 1

Source: The King’s Fund analysis of NHS England data.

Notes: The national standard is for 95 per cent of patients to be admitted, transferred or discharged within four hours of arrival at A&E. Data are for performance for Type 1 (major consultant-led) A&E departments only. Each line represents a trust. Trusts in the Norfolk and Waveney region have been highlighted. Data for the first quarter (April to June) of each year.

Some of this pressure – particularly at Norfolk and Norwich University Hospital – can be explained by older patients accounting for a growing share of A&E attendances. These patients often require more complex and specialist care to avoid admission to hospital, which can take time to arrange, meaning older patients wait longer in A&E or end up being admitted to hospital unnecessarily.

But this is where Norfolk and Norwich’s journey diverges from most other trusts, because instead of trying to constantly pull geriatric specialists down to A&E, they built an older person’s emergency department (OPED).

OPED in action

The OPED is a dedicated unit staffed by specialists in geriatrics and emergency medicine, located 20 metres down the corridor from the main emergency department. By providing earlier access to these specialist skills it is hoped that older patients can receive faster and better care, and avoid the need for admission to hospital.

Since 2016, patients attending the main A&E department can be redirected to the OPED unit if they are 80 years old or older and potentially frail. Initially open 9.00am–5.00pm Monday–Friday, by December 2017 opening hours had been expanded to 12 hours a day Monday–Friday, and now an additional 12-hour service is also available on Sundays. The OPED has specially designed environments for older people with dementia-friendly assessment cubicles, corridors and toilets.

The four-hour A&E waiting time target still applies to patients in OPED – so the department does not become a ‘holding area’ for older patients in hospital. And the OPED plugs in effectively with other related services. If patients require further support after discharge, the OPED can also book them into a clinic within 48 hours. Contrast this with the normal 6–8 week booking process for arranging an outpatient follow-up appointment, by which time the patient could already be readmitted to hospital as an inpatient. OPED staff can also be bolder in discharging patients because of the timeliness and effectiveness of these wraparound services.

A more formal evaluation is underway to review the project, but the early impact of the OPED is encouraging. Older patients attending A&E are now less likely to be admitted to hospital and have shorter waits to see a geriatric specialist. Feedback suggests staff feel more in control of their workloads both in the OPED and the main A&E department.

Delivering this new approach

For decades, specialist emergency departments have been operating to provide children with the specialist paediatric expertise they need. So why have so few trusts adopted this idea for older patients? Or, if we take a more asset-based approach, what did Norfolk and Norwich have to build upon?

For starters, they had some serendipity with their estate. A programme to reduce length of stay in hospital allowed the hospital to close a ward, opening up some empty space next to the main A&E department. The trust had also invested considerable effort into raising awareness of how frail older patients attending the A&E department were. And because of a higher-than-average share of older patients attending A&E (Figure 2), the trust had a clear case for change that more capacity was needed.

Made with Flourish

The trust was also relatively well-resourced with geriatric specialists who could staff both the new OPED and geriatric inpatient wards. And the trust has good relationships with the university across the road, providing a fertile recruitment pool for future staff.

But the going still wasn’t easy. Staff were asked to work harder and longer on inpatient wards to give their colleagues time to set up the OPED. Considerable effort was also made to ensure geriatric specialist staff moving down to OPED would not be pulled into areas beyond their clinical competency. The concept of OPED may have started from a rational analysis, but it was built because of goodwill, leaps of faith, and time to work through these teething issues.

What can we learn from Norfolk and Norwich?

Stepping back from the detail, three broader issues stand out from their story.

First, you can deliver positive change even in challenging circumstances. Norfolk and Norwich – like other hospitals in the area – has been through the wringer. The organisation is still in special measures for quality failings. Its financial deficit doubled to £60 million in 2018/19. And it has received multiple warning notices from the Care Quality Commission (CQC) for its A&E services. Despite all this, rather than blaming other organisations or external factors for their challenges, when frontline staff saw an opportunity to improve services for patients they leapt at it by focusing on what was within their control.

Second, a phone number can be the start of a relationship. Among all the clinical protocols and operational diagrams, what struck me most about our visit was the OPED staff making themselves consistently and personally available to other professionals – GPs, care home managers, ambulance liaison officers – who could simply call them up to say ‘I need a bit of advice with this patient – what do you think?’.

Third, what a sting in the tail it was to hear Martyn question if he could have built OPED now because of changes to how NHS pensions work. At the time OPED was being set up, consultants were asked to do more shifts on the understanding they would get paid more and have a better model of care for patients at the end. But recent changes to pensions policy mean this type of working arrangement is much less attractive to NHS staff. This only adds further grist to the mill of those calling for greater flexibility in how these pension rules are applied.

Follow the model, or build your own?

The relentless focus on ‘pace and scale’ has led to attempts at atomising, blueprinting and replicating service innovation in the NHS. Could others do what Norfolk and Norwich University Hospital has done? Maybe. But you would have to have the right physics (physical space, enough staff, training links with universities) and the right chemistry (staff at all levels willing to take a managed risk).

Case studies in the NHS can sometimes be met with scepticism. No doubt some will look at what Norfolk and Norwich University Hospital has done and say ‘it isn’t that new’ (that this is simply a frailty unit that sits just before, rather than just after, admission to hospital); ‘it isn’t that good’ (the trust’s A&E services has penalty notices from CQC); ‘it isn’t enough’ (performance against the A&E four-hour target has continued to fall despite OPED opening); and ‘alright for some’ (the trust had enough geriatricians and physical space to make the model work).

I can understand that view. But for me, this somewhat misses the point of the story. Perhaps it’s better to take a more generic lesson from the story. An organisation in special measures that is losing £60 million a year could have easily been risk averse and stuck with the existing way of doing things. Instead they looked at the needs of their patients and the assets they had, and with a sense of purpose and agency they tried to improve services for their patients. That’s the story.

Comments

Caroline Gichero

Position
Nurse consultant older people,
Organisation
Frimley NHs trust
Comment date
21 September 2019

I think this is a very fantastic idea for older people having to wait upto 6 hours to be seen by ED staff and ensure patient flow

Olumide Adeotoye

Position
Consultant Geriatrician,
Organisation
NELFT/BHRUT
Comment date
28 September 2019

This is a brilliant idea but as stated in the article, the trust has to have the space and the personnel. Also the current pension allowance tax means that existing consultants may not be able to take on extra sessions.

Mary Higgins

Position
Consultant Emergency Medicine,
Organisation
NHS
Comment date
07 October 2019

I am disheartened at the mislabelling of the 'A+E waiting time'. The specialty is Emergency Medicine and has been for ten years now. The correct title of the standard is the '4-hour Emergency Care Standard'. This reinforces that it is a whole-system indicator of emergency care, from pre-hospital to discharge and not an 'A+E target'. Please correct your report.

Siva Anandaciva

Position
Chief Analyst,
Organisation
The King's Fund
Comment date
08 October 2019

Mary

Thanks for your comment - though I'm sorry you are disheartened.

I'm afraid I disagree on what the correct title of the standard is - I think the standard is the 'A&E standard' not the 'emergency care standard'. The NHS Plan back in 2000, the NHS Constitution, and the current Clinical Review of Standards all refer to A&E. The scope of the standard also concerns A&E rather than what happens in other parts of the emergency care pathway (from ambulance call-out to MAU to discharge).

But I agree with your point that achieving the four-hour standard is dependent on many factors that are outside the control of an A&E department - including bed availability, specialist in-reach, GP urgent referrals, ambulance batching - the list goes on and on.

To be honest, I don't know how the nomenclature and measure interact. Would relabelling the A&E standard make it clearer that this is a whole-system indicator? Perhaps. But at the same time, if we were going to label something as an 'emergency care standard' I would expect it to measure more of the emergency care pathway than just A&E - eg some of the SAM measures of flow through MAU.

So I hope you understand why I am not changing the report but email me if you still disagree.

Best,
Siva

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