Urgent and Emergency Care Review - and the pharmacy role Keith Willett Shaping Pharmacy Future 2014 I If its really serious I want specialist care Treat me as close to my home as possible please Help me to help myself and not bother the NHS If only they could talk to my GP?

UEC 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

Current provision of urgent and emergency care services 3 >100 million calls or visits to urgent and emergency services annually: 438 million health-related visits to pharmacies (2008/09) Self-care and self management 24 million calls to NHS urgent and emergency care telephone services Telephone care 300 million consultations in general practice (20010/11) Face to face care 7 million emergency ambulance journeys 999 services 14.9 million attendances at major / specialty A&E departments (2012/13) 6.9 million attendances at Minor Injury Units, Walk in Centres etc (2013/13) A&E departments 5.3 million emergency admissions to England’s hospitals (2012/13) Emergency admissions

UECR: The Why? – Care closer to home

Helping people help themselves Self care: Better and easily accessible information about self-treatment options – patient and specialist groups, NHS Choices, pharmacies 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 (SCR, care plan) Comprehensive Directory of Services Improve levels of clinical input (mental health, dental heath, paramedic, pharmacist, GP) Booking systems for GPs, into UCC or A&E, dentist, pharmacy 5

NHS 111 Call Volume – front end to urgent care Patients are predominately referred to lower urgency settings 6www.england.nhs.uk Referral 111 Caller dials 111 Demo- graphics taken Pathways triage 85% Call handler answers Clinician takes transfer transfer 21% 999 Ambulance A&E / UCC GP OOH GP in hours Pharmacy Community service Dental 1% 7% 1% 14% National 11% 7% 62% Dispositions callers (where callers are referred to) 111

Summary Care Record: Creating the records SCRs are an electronic record containing key information from the patient’s GP practice As a minimum SCRs contain medication, allergies and adverse reactions Improved functionality coming soon to make it easier for GPs to create SCRs with additional information for those patients that need them most. 45m SCRs created (80%) 2m SCRs created last month Close to To find out more or enable SCR:

Highly responsive urgent care service close to home, outside of hospital 8 Faster, convenient, enhanced service: Same day, every day access to general practice services, primary care and community services Harness the skills and accessibility of community pharmacy 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 centres. Develop 999 ambulances so they become mobile urgent community treatment services, not just urgent transport services

Ambulance Services Transport  Treatment: Community-based provider of mobile urgent and emergency healthcare, fully integrated within Urgent Care Networks. Principles to underpin this transformation would include: Emphasis on supported treatment in community settings Single consistent triage system, DoS and universal referral rights Successful “hear and treat” - closer integration with 111, timely access to relevant patient information and care plans, support of interdisciplinary clinical hub (current low 3.4% high 10%) “see and treat”, inter-disciplinary working across traditional organisational and professional boundaries, with guaranteed timely access to primary care, mental health provision, social care and specialist clinical advice 24/7 (current low 27.4% high 51.5%) Development of the ambulance workforce, education programmes coupled with changes to organisational culture, will be essential to long-term success 9

Urgent Care Centres Community-based primary care facilities providing access to urgent care for a local population. To encompass Walk-in Centres, Minor Injuries Units, “Darzi” Centres etc, including those currently designated as “Type 3 A&E Departments”. A consistent nomenclature should be accompanied by a consistent service, so that patients are clear about what they can expect from all Urgent Care Centres To achieve this it is suggested that two important principles underpin the development of Urgent Care Centres: access to a full range of urgent care services part of the Urgent Care Network Access to the clinical advice hub 10

Serious and life threatening conditions – expertise and facilities 11 Identify available services in hospital based emergency centres Emergency hospital Centres* - capable of assessing and initiating treatment for all patients Specialist Emergency hospital Centres* - capable of assessing and initiating treatment for all patients, and providing specialist services (direct, transfer or bypass) (- estimated larger units) Emergency Care Networks Connecting all services together into a cohesive network so the overall system becomes more than just the sum of its parts Strategic and Operational

Urgent Care Networks Networks would focus on: effective, pathways of care across boundaries for physical and mental health irrespective of entry portal all patients managed to agreed pathways mutual trust in system no clinical decision made in isolation Networks would function at two levels: 1.Operational Urgent Care Networks would describe local communities of clinicians (System Resilience Group) who work together to achieve the best outcomes for patients within the urgent care system 2.Strategic Urgent Care Networks would operate over large populations encompassing specialist provision, all severity and complexity, all relevant stakeholders to plan, oversee and monitor network performance 12

Shape and structure of the new system and key constituent parts…

Progress update 14 Continue to “build in public” 8 Work Programmes: WHOLE SYSTEM PLANNING AND PAYMENT, COMMISSIONING AND ACCOUNTABILITY PRIMARY CARE ACCESS – NHSE strategy 111 service specification and standards DATA, INFORMATION AND CARE PLANNING COMMUNITY PHARMACIES – Call for Action EMERGENCY DEPARTMENTS and EMERGENCY CARE NETWORKS AMBULANCE TREATMENT SERVICE WORKFORCE (HEE) ITERATIVEITERATIVE

UECR: What – Big Tickets

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Progress: from design to delivery Implementation phase of the Review: Now convert the work done so far into a national framework to guide commissioning of UEC services: Update report Delivery Group own and describe the key national products from the Stage 1 Report – give primacy to out-of-hospital Regional roadshows June-Sept 2014 Working with System Resilience Groups, CCG and NHSE Ops Teams as they develop 2 and 5 year operational and strategic plans Working through the NHS Commissioning Assembly to co-produce commissioning guidance and specifications (throughout 2014/15) Release guidance, standards and outcome metrics for Commissioners regarding UEC Networks, centres, and clinical models and for Ambulance Services (after 5 year Forward View) 17

Consulting and testing Design to Delivery: NHSIQ mapping support/pilots testing ideas and models (Integration Pioneers, PM Challenge, 111 pilots and 7DS early adopters) New Commissioning Standards for NHS 111: Clinician access to relevant patient’s medical and care information Access and treat to specific care plan where available Increased clinical advice to support call handlers to book appointments with urgent or emergency care providers Developing new system metrics – credible to public, clinicians, providers and commissioners 18

Future payment options for UEC Proposal suggests that the way forward could be a single, consistent payment approach for every type of service in the system, made up of 3 elements and linked to quality metrics and part of 3-5 year contracts: Core capacity element: substantial and fixed in-year, to reflect the ‘always on’ nature of urgent and emergency care: Facilities and service standards Volume-based and variable, to limit the impact of unpredictable fluctuations in demand on individual providers across the system; Process measures – formative not summative Incentives and sanctions: Using provider-specific and system-wide quality metrics as eligibility criteria for different rates of fixed and volume-based funding, and as the basis for bonuses and penalties, to support service change and promote quality improvement: Patient outcome measures (transfers of care, residence, PROMs) Patient safety and experience measures (mortality, SAEs, PREMs)

The greatest challenges 1.Payment system reform 2.Information sharing 3.Workforce and skills shift 20

The role of pharmacy beyond winter pressures Part of the General Practice team Supporting 999 dispatch and 111 call centre Pharmacist in A&E, MAUs, ACS Part of Network Clinical Advice hub Minor Ailment Service Direct Professional care

Urgent and Emergency Care Review Progress: DEFINITELY.... BUT ONLY THROUGH YOU I I’m alive cos I had specialist care really fast I feel so much better for not having to go all the way to hospital It’s great to share and learn so much with this group It’s like everyone knows all about me