1. Understanding the system of unscheduled care: revisited
Steve Kendrick
Emergency Access Delivery Team Networking Event
Beardmore Hotel. March 12th, 2009

2. I. A&E attendances: outcomes and the whole system

3. Outcomes: the target Reduce A&E attendances or more precisely
Reduce ‘more appropriately treated elsewhere’ A&E attendances
or more generally
Everyone treated
in the appropriate place in the system
at the appropriate level of the system

4. II. Unscheduled care as a system of causes and effects

5. What do you need to do to achieve an outcome?
a) Identify the various causal influences which combine to produce the outcome
b) Identify the opportunities to intervene to improve the outcome.
Leads to driver diagram.

6. Fewer ‘better treated elsewhere’ A&E attendances
Unscheduled care. Driver Diagram. Illustrative Only!
Outcome
Changes
Drivers
Fewer
‘better
treated
elsewhere’
A&E
attendances
e.g.
Morbidity
Patient
knowledge/
behaviour
Accessibility
of different
services
Triage
methods
Integration
of system
e.g
Prevention
Social
Marketing
Improved
access to
alternatives
algorithms/training
Sharing of data

7. III. Unscheduled care as a system of patient flows

8. Flows into A&E. Orders of magnitude!
Ambulance
250 40
“999”
220
NHS24
800 70
A&E
600
Self-referral
Public
600 30
OOH
1000
attendances 80
In hours
primary care

9. IV. Relating flows to causes/drivers to improvement.

10. How do we relate ‘flows’ to ‘causes/drivers’
Each of the flows is a result of decisions made by particular agents at particular points in system
Many of the changes we need to make are improvements in decision-making. Making sure patients are in the right flows.
Plus right balance of services to support those improved decisions.

11. The potential for improvement
To a large extent defined by the number of patients who are in the wrong flows
End up being treated at too intensive a level of the system
e.g. treated A&E when could have been ‘more appropriately treated elsewhere’

12. How do we assess this potential for improvement. (e. g
How do we assess this potential for improvement? (e.g. potential for reducing A&E attendances)
Need a much more detailed picture of patient characteristics in each of the flows
Which are the groups of patients with the greatest potential for diverting to a more appropriate flow/treatment point?

13. V. Immediate priority: better understanding of who is attending A&E

14. The task attempted since December
Better understanding of the patients attending A&E
Could we characterise A&E attenders in terms of meaningful groups which e.g.
help us assess potential for alternative care?
given current set-up
given better alternatives
help us assess potential for prevention
help us assess the potential for improved services
help us assess potential for reducing A&E attendances

15. Examples of the kind of patient groups it would be useful to identify and quantify
Elderly falls
Minor illnesses who don’t need to be at A&E
Behavioural/psychological ‘chaotic lifestyle’
Alcohol related
Admissions from care homes
Frail elderly in general
Exacerbations of LTCs e.g. COPD
????

16. How have we done?
High ambitions for January especially – (to inform provisional targets)
Admirable progress but ...…
….. not a royal road
….. difficult circumstances

17. Routes tried (I) Existing electronic data
diagnostic/presenting symptoms items – not easy to classify into meaningful groups
but worth exploring e.g. Manchester triage data
worth looking further into cross-classification with age

18. Routes tried (II) Analysis of A&E cards/notes Lanarkshire exercise
rich source of insight

19. Route to discuss Survey methods to understand why people come to A&E
Digest results of e.g. Welsh survey; social marketing research

20. Information Network: what has emerged?
Variety of emerging insights/ perspectives on A&E attenders e.g.
- variation by GP practice
- proximity
- deprivation
- age
- patterns of ‘discharge no review’
Hear about them later

21. Information Network: directions for coming months
Keep the different analytical approaches moving forward, working together
Continue quest to identify ‘meaningful groupings’ – but perhaps ask more specific questions
Let’s not neglect basic description e.g. age profile, referral source
Share our knowledge