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Understanding the system of unscheduled care: revisited. Steve Kendrick steve.kendrick@scotland.gsi.gov.uk Emergency Access Delivery Team Networking Event Beardmore Hotel. March 12th, 2009. I. A&E attendances: outcomes and the whole system. Outcomes: the target.

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understanding the system of unscheduled care revisited

Understanding the system of unscheduled care: revisited

Steve Kendrick

steve.kendrick@scotland.gsi.gov.uk

Emergency Access Delivery Team Networking Event

Beardmore Hotel. March 12th, 2009

outcomes the target
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

what do you need to do to achieve an outcome
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.

slide6

Drivers

Changes

Outcome

e.g

Prevention

Social

Marketing

Improved

access to

alternatives

Improved

algorithms/training

Sharing of data

e.g.

Morbidity

Patient

knowledge/

behaviour

Accessibility

of different

services

Triage

methods

Integration

of system

Fewer

‘better

treated

elsewhere’

A&E

attendances

Unscheduled care. Driver Diagram. Illustrative Only!

slide8

Flows into A&E. Orders of magnitude!

Ambulance

250

40

“999”

220

NHS24

70

800

A&E

600

Self-referral

Public

600

30

OOH

1000

attendances

80

In hours

primary care

how do we relate flows to causes drivers
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.
the potential for improvement
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’
how do we assess this potential for improvement e g potential for reducing a e attendances
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?
the task attempted since december
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
examples of the kind of patient groups it would be useful to identify and quantify
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
  • ????
how have we done
How have we done?
  • High ambitions for January especially – (to inform provisional targets)
  • Admirable progress but ...…

….. not a royal road

….. difficult circumstances

routes tried i
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
routes tried ii
Routes tried (II)
  • Analysis of A&E cards/notes
  • Lanarkshire exercise
    • rich source of insight
route to discuss
Route to discuss
  • Survey methods to understand why people come to A&E
  • Digest results of e.g. Welsh survey; social marketing research
information network what has emerged
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

information network directions for coming months
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