1. NHS Pathways Integrating Urgent and Emergency Care Jackie Shears Programme Head, NHS Pathways CMS

2. Urgent and Emergency Care Today 999 Not emergency? Queue and nurse ring back/re-triage Refer to Primary care via manual search of (paper) information NHSD Emergency? Transfer to 999 and re- triage GP Urgent? Transfer and re-triage Other? Prioritised Queue and nurse ring back/re-triage Refer via manual search of own directory GP Out of Hours Emergency? Transfer to 999 and re- triage Not emergency? Queue and nurse ring back/re-triage Tend not to refer to many other primary care services 3am – what to do?

3. For example 999 Initial prioritisation - LOW Queue (20mins – 1 hour) 999 Clinician Triage and assessment (patient repeats details, different system used) GP Service Ring back from nurse Triage and assessment (patient repeats details, different system used) Manual Search of paper info on services GP Appointment (Home or Clinic)

4. Summary Good practice hampered by technology Reinforces silos Poor data on real demand Restricts patients being matched to appropriate service Relies on multiple efforts to gather and maintain data – much repetition and duplication

5. Urgent and Emergency Care: Integrated Access 111/116 (Nurse or call handler)

6. Benefits to date in pilot areas Patients go to ‘Right Place First Time’ – improved patient journey and experience Better use of available services Cost base for assessment and referral to care much reduced - £8-10/call instead of £15-20/call 2000 inappropriate ambulance journeys per MONTH are being avoided = 4 fully staffed extra vehicles on every 12 hours shift 10% Reduction in 999 calls received and 4% decrease in A&E attendances Gives commissioners world class data on what services are needed

7. Impact on A&E

8. For Commissioners: All searches on the directory are recorded providing commissioners with real demand data – clinical skills needed by time of day and post code

9. Clinical Safety and Clinical Support Extensive piloting – 1.7 million patient calls safely assessed across 4 different sites– No adverse incidents Academic evaluation by 3 universities – ‘safe and appropriate’ Ministerial license for use granted February 2009 BMA and Royal Colleges – overt support National Clinical Governance Group chaired by RCGP

10. What’s the catch? Culture change – common assessment and standards Training and performance management Clinical Supervision v call handler assessment Using the data – the tools to improve commissioning, not a panacea Cutting corners is positively harmful Whole system change – stakeholder Involvement Health Economy-wide leadership

11. Workflow options Call handler prioritisation (80% of 999 calls) Nurse Assessment and manual directory search (20% of calls) Call handler assessment and auto DoS search (99.7% of 999 calls) Nurse Assessment and auto DoS Search (0.3% of calls) plus clinical supervision and audit Nurse Assessment and auto Dos Search (up to 100% of calls) Can set transfer to nurse to take place at any place. Other sites NHS Pathways 999 Sites (UK) NHS Pathways Sites (nurse led)

12. Next steps with NHS Pathways Supporting non-conveyance: Paramedic Face to face assessment: Trials commence in next 2 months Supports clinical assessment and referral to primary care AT SCENE