1. Annual National Crisis Care Concordat Summit
Urgent and Emergency Care Review
Annual National Crisis Care Concordat Summit
November 2015
Keith Willett
Director of Acute Care

2. Annual National Crisis Care Concordat Summit
update on UECR review
establishment of UEC Networks
Crisis Care access & waiting time standards
winter readiness programme
UEC vanguards to lead the way
General Update on UECR review
Routemap, Enablers
and 4 key challenges
Outcomes – MH indicators run throughout
Data – SCR to have access to crisis care plans, Access to service information/ DoS link to MH services
Payments - MH included in new payment model
Workforce
Mental health embedded throughout these programmes
Delivery – establishment of networks
Vanguards –leading the way
Winter planning- winter planning - SRG assurance is for first time asking 5 key mandatory questions on MH - including a requirement to work with local CCC groups
********-the enthusiasm and interest he has personally witnessed about MH crisis care from UEC roadshows across the country
CSS Workstream Scoping Session

4. Urgent and Emergency Care Review Vision
For those people with urgent but non-life threatening needs:
We must provide highly responsive, effective and personalised services outside of hospital, and
Deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families
For those people with more serious or life threatening emergency needs:
We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery
CQC thematic review on crisis care acted as a wake up call about the current picture of crisis services nationally
Mental and physical health

5. UEC Review – 5 key system changes
Mental health
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
Provide highly responsive urgent care services outside of hospital so people no longer choose to queue in A&E
Ensure that those people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery
Ensure that the urgent and emergency care system becomes more than just the sum of its parts through the creation of urgent care: create UEC networks  

6. Helping people help themselves
Self care:
Better and easily accessible information about self-treatment options
– patient and specialist groups, NHS111 on a digital platform as part of NHS Choices (nhs.uk)
Accelerated development of advance care planning
Right advice or treatment first time - enhanced NHS the “smart call” to make:
Improve patient information for call responders (ESCR, care plan)
Comprehensive Directory of Services (mobile application)
Greater levels of clinical input (mental health, dental heath, paramedic, pharmacist, GP)
Booking systems for GPs, into UCCs, dentists, pharmacy
The whole review is based on a patient’s perception of urgent need
A patient should be asked to do no more than do TWO things:
Phone before they move, “talk before you walk”
Dial 999 if they think its life threatening or 111 if not
If a patient has belly ache they don’t know if its indigestion,
appendicitis or blocked bowel – and why should they,

7. Highly responsive urgent care service close to home, outside of hospital
Faster, convenient, enhanced service:
Same day, every day access to general practice, primary care and community services advice
Harness the skills of community pharmacy, minor ailment service
24/7 clinical decision-support for GPs, paramedics, community teams from (hospital) specialists – no decision in isolation
Support the co-location of community-based urgent care services in Urgent Care Centres and Ambulatory Care,
Develop 999 ambulances so they become mobile urgent community treatment services, not just urgent transport services
Single Point of Access with Community and Social Care
The whole review is based on a patient’s perception of urgent need
A patient should be asked to do no more than do TWO things:
Phone before they move, “talk before you walk”
Dial 999 if they think its life threatening or 111 if not
If a patient has belly ache they don’t know if its indigestion,
appendicitis or blocked bowel – and why should they,

8. From life threatening to local – where is the expertise and facilities?
Identify and designate available services in hospital based emergency centres
Urgent Care Centres – primary care, consistent, access to network
Emergency Hospital Centres - capable of assessing and initiating treatment for all patients
Emergency Hospital Centres with Specialist services - capable of assessing and initiating treatment for all patients, and providing specialist services: transfer or bypass access, 24/7 specialist network support
Emergency Care Networks:
Connecting all services together into a cohesive network
overall system becomes more than just the sum of its parts
The whole review is based on a patient’s perception of urgent need
A patient should be asked to do no more than do TWO things:
Phone before they move, “talk before you walk”
Dial 999 if they think its life threatening or 111 if not
If a patient has belly ache they don’t know if its indigestion,
appendicitis or blocked bowel – and why should they,

9. Emergency Centre with Specialist Services
Parity of esteem for mental health
Emergency Centre with Specialist Services

10. UEC Review: arriving here
Three phases to the programme :
Examined the challenges the UEC system faces, and what principles and objectives a new system should be based on COMPLETED
Translation of ‘what’ needs to happen into ‘how’ these ideas can be operationalised COMPLETED
NOW the final phase is focused on implementing those new models of care and ways of working
Phase 1 DESIGN
Jan – Oct 2013
Phase 2 PRODUCT DELIVERY
Nov 13 – Dec 14
Phase 3 IMPLEMENTATION
Jan 15 – now

11. UEC national enablers:
Self-care initiatives
Realising the value, ‘Self-care for Life’
NHS 111 as portal to out-of-hours integrated service
mental health key component of clinical hubs
New system-wide indicators and measures
UEC outcomes for both mental/physical health
Local capacity planning tool
testing with vanguards: includes mental health
Note it is self care week 16 – 22 November - ‘Self-Care for Life’ and aims to help people understand what they can do to better look after their own health and that of their family, as well as living as healthily as possible. For more information visit the Self-Care Forum website or
The Realising the Value programme, funded by NHS England, seeks to enable people to take an active role in their health and care. The aim is to develop evidence-based approaches and tools to support the implementation of person centred care. Programme partners are currently seeking applications from local sites with existing implementation experience to work with them. The deadline for responses is 13 October 2015.

12. UEC products – published help
‘Transforming urgent and emergency care in England’
Role & establishment of UECNs, published
Safer, Faster Better published
Clinical models for ambulance service
publication end 2015
Improving referral pathways between
urgent and emergency services in England
publication pending
Financial modelling methodology publication end 2015
Commissioning guidance for Urgent Care Centres, Emergency Centres and Emergency Centres with specialist services publication end 2015
Note it is self care week 16 – 22 November - ‘Self-Care for Life’ and aims to help people understand what they can do to better look after their own health and that of their family, as well as living as healthily as possible. For more information visit the Self-Care Forum website or
The Realising the Value programme, funded by NHS England, seeks to enable people to take an active role in their health and care. The aim is to develop evidence-based approaches and tools to support the implementation of person centred care. Programme partners are currently seeking applications from local sites with existing implementation experience to work with them. The deadline for responses is 13 October 2015.

13. The four greatest challenges
Payment system reform
Information sharing
System measures
Workforce and skills shift

14. Proposed new payment model
A coordinated and consistent payment approach across all parts of the UEC network
Making use of three elements:
future-proofed
mental health included in all UEC networks and payment approaches
Quality
Core – Facilities and service standards
Volume - Process measures formative not summative
Incentives and Sanctions –
Patient outcome measures (ToC, PROMs)
Patient safety and experience measures (mortality, SAEs, PREMs)
Capacity - Core
Fixed in-year cost
“always on”
Volume
variable
Acting throughout
payment
Key Message: The UEC reform proposals are part of the overall longer term direction of travel for payment reform to enable the models of care in the 5YFV. The key aims are to provide a financial platform for coordination and planning of care delivery, commissioning for quality and outcomes, and sharing in outcomes across UEC networks over multiple years.
The UEC payment reforms are part of the long term direction of travel for payment reform is to make necessary changes to enable models of care in the 5YFV. Reformed payment system will:
Differ according to model of care that best meets patient needs
Be increasingly linked to quality and outcomes
Potentially, cover multiple years to provide greater scope for planning and investment
To enable the UEC reforms, a coordinated and consistent approach to payment across the UEC network is needed to improve on the current siloed approach. This means that:
The way each service in in the network is paid for is aligned with coordinated care planning and delivery. The current conflicting financial signals towards network wide coordinated planning and working are lessened, and removed where possible.
Payment for all components of the network make use of three elements of payment to reflect planned capacity, actual volume of services delivered, as well as performance of the network in terms of quality and outcomes (including access, clinical quality, outcomes and patient experience)
The scope of the consistent payment approach has to match the scope of the coordinated care delivery network:
All unscheduled care: in the long term including urgent primary care and telephone advice (GP OOH and NHS 111), as well as community pharmacy services. Also includes non-elective pathways of hospital based care, not just the emergency departments of hospitals.
The boundaries between payment for other models of care – such as where the MCP and PAC models are in use to coordinate care for selected population groups – will be worked out.
At minimum, to begin with, will cover all emergency services and hospital based urgent care services.
The three elements are needed in combination to:
Capacity element – a fixed portion of payment to reflect the ‘always on’ nature of UEC, the core funding for component of the network irrespective of activity, and in particular to facilitate coordinated planning of capacity and activity shifts across the UEC network over multiple years. A key part of planned and coordinated implementation of UEC Review, to enable payment to follow planned reconfiguration.
Volume based element – to reflect actual types and volumes of care delivered and maintain link to patient choice, and in particular to limit the impact of unpredictable fluctuations in demand on individual providers in the network. (In other words, because fully fixed payment would not be suitable.) Also, provides a mechanism for network wide sharing in performance, through marginal rates or as part of gain/loss share mechanism.
Quality and incentives – to enable commissioning for outcomes achieved across the network, as well as by individual providers. In particular, to ensure that 1) the various performance and quality metrics are brought together and rationalised so that they are not in conflict, 2) to help drive network wide incentives for reform. In addition to bonus/incentive payments on outcome metrics, could act as a qualifying criteria to determine providers eligibility for level of payment.
In summary, the benefits are:
Aligned incentives across the network
Allow individual providers to benefit from savings generated for the network as a whole
Reflect the nature of services and costs (particularly differences between small rural and large sub-urban providers) and facilitate capacity planning across the network
[Emphasise due to CEM co-chairing of event: We are clear that the approach will be designed to make use of the improving data available nationally – it will not be a way to gloss over or lock in existing concerns]

15. To find out more or enable SCR: scr.comms@hscic.gov.uk or @NHSSCR
Summary Care Record: Creating the records
SCRs are an electronic record of key information from the patient’s GP practice
As a minimum contain medication, allergies and adverse reactions
Improved functionality with additional information including crisis care plans GPs need to obtain consent
55m
SCRs
created
(96%)
> 2.5m
contacts in last year
12 secs
To find out more or enable SCR: or @NHSSCR

16. Mobile access to the Directory of Services
Testing with vanguard sites during winter 2015/16

17. System wide outcomes Outcomes, standards and specifications
Shift to outcome measurement for whole system
List of indicators developed under 3 domains:
Clinical Pathway
Patient Experience
Staff Experience
All will measure physical and mental health

18. Establishing Urgent and Emergency Care Networks – the purpose
24 networks based on geographies required to give strategic oversight of urgent and emergency care on a regional footprint
1 - 5million population based on population rurality, local services
To improve consistency of quality, access and set objectives for UEC by bringing together SRG members and other stakeholders to address challenges that are greater than a single SRGs can solve in isolation
Access protocols to specialist services
Ambulance protocol
Clinical decision support hub
NHS 111 services
Uniform approach to mental health crisis

19. Programme: 2015/16: Crisis Care access standards
Where do people present with urgent MH needs and what response should be expected in the first 24 hrs? (Phase 1)
ACCESS standards developed during 2016, not ‘just’ a waiting time’, but setting up the system to:
Describe the standards – access time + NICE concordant care
Agree how to measure
Where are we starting from? - a baseline
What will it take to get to where we need to be? - gap analysis
How? - commissioning guides
Drive quality improvement
Adapt the workforce
Build a payment model
Report openly
USE OF DIGITAL TECHNOLOGY
SELF MGT & CARE PLANNNG
Primary care response (in and OoH)
111 (and the DoS) and 999
24/7 MH crisis line (tele-triage & tele-health) and 24/7 community-based crisis response
Blue light response, transport hub, S135/136 response & health based places of safety
Urgent and emergency Liaison MH services (+ alcohol care teams)
Ensure joined up approach for people with co-existing MH and substance misuse conditions…

20. UEC winter readiness Assurance process for System Resilience Groups
(8 high impact interventions) SRGs provided detailed capacity plans:
Community care beds (nursing residential and dementia beds, specialist Elderly Mental Infirm beds) intermediate care (bed-based and home-based), district nurses and community matrons, and allied health professionals
From this year, 5 mandatory mental health indictors included for first time:
Join up between SRGs and local Concordat groups
24/7 crisis resolution and home treatment teams
24/7 on site urgent and emergency liaison mental health
S.136 health-based places of safety
Up to date mental health Directories of Service
The inclusion of Concordat groups in winter readiness is a particular sign of success of the Concordat, showing the increasing influence the local Concordat groups are having on NHS planning and policy

21. UEC vanguards
Focus on i) local health systems with strongest network progress and ii) addressing greatest operational challenges
Accelerate pace of change
Drive new ways of working across organisation boundaries
Tripartite support for implementation, help remove barriers
Test beds for new UEC initiatives (relationships, workforce, clinical decision support hubs, payment model, new indicators, mental health)
Meet explicit requirements on implementing best practice and national policy expectations
£4m pump prime investment to UEC vanguards to test and evaluate innovative models of mental health crisis care for children and young people, and incorporating mental health crisis in testing of payment models

22. A single number – NHS 111 – for all your urgent health needs
A new strong consumer offer to the public:
NHS urgent care starts to look like what the patients tell us they want, not what we have historically offered
A single number – NHS 111 – for all your urgent health needs
Be able to speak to a clinician if needed
That your health records are always available to clinicians treating you wherever you are (111, 999, community, hospital)
To be booked into right service for you when convenient to you
Care close to home (at home) unless need a specialist service
Provide specialist decision support and care through a network
…….. we will change patient and staff behaviour through experiential learning

23. Urgent and Emergency Care Review the new offer
It’s great to share so much with this group about my depression
It’s like everyone knows all about my problem I
I’m so pleased my mum got specialist care really fast and I didn’t lose her
I feel so much better for not having to go all the way to hospital every time I need help

24. CQC thematic review:
Some excellent examples of innovation and practice;
Concordat means every single area now has multi-agency commitment and a plan of action.
However CQC found that…..
variation ‘unacceptable’ - only 14% of people felt they were provided with the right response when in crisis – a particularly stark finding;
More than 50% of areas unable to offer 24/7 support – MH crises mostly occur at between 11pm-7am - parity?
Crisis resolution and home treatment teams not meeting core service expectations;
Only 36% of people with urgent mental health needs had a good experience in A&E - ‘unacceptably low’;
Overstretched/insufficient community MH teams;
Bed occupancy around 95% (85% is the recommended maximum) – 1/5th people admitted over 20km away;
People waiting too long or turned away from health-based places of safety

25. Outcomes, standards and specifications
Nationally there is a need for standards and specifications to:
help describe the networked system
to enable commissioners to have the information to commission for system-wide outcomes
monitor and improve performance
This will build upon and align existing resources, standards and clinical quality indicators.
whilst developing new specifications for community hospitals, NHS111, GPs OOHs, ambulance services, Urgent Care Centres, Emergency Centres and other system components.

26. Where we are now
Delivery – Urgent and Emergency Care Networks (strategic oversight).
Vanguard Early Implementers
North East Urgent Care Network
West Yorkshire Urgent Care Network
Greater Nottingham SRG
Leicestershire & Rutland SRG
Solihull Together for better lives
Cambridge and Peterborough CCG
Barking & Dagenham, Havering and Redbridge CCGs.
South Devon & Torbay SRG
Deliverable
Progress
Next milestone
Network footprints established
complete
All footprints finalised by end October
Network meetings
Inaugural Network meetings in September and October
Membership and ToR finalised by end October
UEC facilities stocktake
Stocktake of urgent and emergency care facilities within each network setup
All stocktakes to taking place in November
Dependencies mapped
High-level critical pathway to map dependencies for delivery of the route map of products and tools of the Review - underway
Currently in draft – to be finalised in coming months
Regional workshops to map critical pathways
Series of workshops with regions and networks to map their local critical pathways and develop local delivery plans
PMO to lead leading – all events to be held in January
UECN delivery plans
All Urgent and Emergency Care Network delivery plans to be developed by early 2016, aligned to five year strategic plans
For completion by end January 2016
UEC Networks are forming. At least one Mental Health Trust must be represented on each UEC network, and latest intelligence shows that is the case for the vast majority