1. A&E in the Bradford and Airedale district Andrew Snell Public Health Registrar This represents my personal interpretation and opinion only

2. There’s something about A&E  It is a political hot potato, especially so since the four hour standard was introduced  Expert drive since the birth of the specialty (now RCEM!)  For the public it is the health care highway on which the journey is always emotionally +/- physically challenging ► A&E performance prompted the national UEC review ► It has become the litmus test for the whole UEC system ► Most severe clinical need in UEC is seen in A&E ► It’s the most apparent influencer of secondary care pressures This represents my personal interpretation and opinion only

3. What was done … ► Discussion with stakeholders ► Health care needs assessment model but  Demand not need  Mixed methods (epi and corp)  Limited data (A&E attendance)  Limited literature (especially around cost-effectiveness) How common How cost-effective Existing services This represents my personal interpretation and opinion only

4. What was found … … A lot of stuff we already knew and generally in line with study findings and national figures going as far back as 1990’s ► General trend in attendances increased but only slightly above population growth (AGH versus BRI) ► Highest volume is from the healthiest age-groups (up to around 40 years of age) ► Important high volume low risk groups: 0-4, school-aged after school surge, 15-35’s, injuries ► What about the winter pressures ► What about the chronic, complex and elderly … Are any of these avoidable or for care elsewhere? This represents my personal interpretation and opinion only

5. 60% emergencies. This is the proportion of national attendances which Keogh review suggests received some investigation or treatment during their attendance. 25% urgent. Keogh review describes 40% of attendances are discharged without intervention, but CEM state only 15% are primary care.. Is this remainder for ‘urgent care’? 15% non- urgent. According to CEM president (HSJ 22 May, 2014). Inappr’t and reversible Total current A&E demand in England. Preventable. Injuries, alcohol & drugs and a portion of exacerbations of chronic disease are preventable, reducing demand in the most sustainable way, but this requires investment into ‘self-care’ and prevention. Better community mental health care and social care could provide more appropriate care for patients for whom the hectic A&E can be harmful. Requiring emergency assessment ± intervention Requiring urgent care within 24-72 hours but not emergency care Inappr’t but non- reversible Through education around health care use. Not feasible to reverse due to uncertainties in legitimacy of urgent needs and difficulties in total behaviour change. This represents my personal interpretation and opinion only

6. ► Attendance rate higher in those living nearby and those from deprived areas ► This association disappears when focus on just those that arrived by ambulance ► Also disappears when focus on only those that were subsequently admitted … Is this all access issue rather than severity? This represents my personal interpretation and opinion only

7. A&E demand in a district in England with two acute trusts demonstrates higher attendance rates (marked in darker shades) are associated with living near to A&E or living in more deprived areas The association disappears when only attendances resulting in admission are considered, suggesting high rates are not related to severity but to access – those living nearby attend due to convenient access and those in deprived areas due to a lack of access to alternatives A&E To improve urgent care access for non-severe non-emergencies and to reduce the A&E demand these patients pose, urgent care centres should not be established in hospitals alongside existing A&E (where they will enhance unfair access and induce ‘inappropriate’ demand), but rather target need using a selection of community facilities such as GP surgeries staffed by nurse practitioners and community pharmacies A&E A case against co-locating urgent care centres in A&E … Don’t misinterpret Keogh This represents my personal interpretation and opinion only

8. So is it all about people’s responsibility to Choose well? No! More about the health service’s response to people who feel the need to use the service This represents my personal interpretation and opinion only

9. Phase 1 Report – 5 priorities. ► ► Provide better support for people to self-care ► ► Help people with urgent care needs to get the right advice in the right place, first time by enhancing NHS 111 ► ► Provide highly responsive urgent care services outside of hospital so people no longer choose to queue in A&E ► ► More serious or life threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery ► ► Connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts This represents my personal interpretation and opinion only

10. What does this mean for VCS and engaging in the communities … … You tell me! Time for a discussion … This represents my personal interpretation and opinion only

11. Thank you End of presentation to VCS forum 16 th Feb 2015 This represents my personal interpretation and opinion only