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07 CHAPTER SEVEN ACCESS TO THE RIGHT LEVEL OF UNSCHEDULED CARE AS LOCALLY AS POSSIBLE

01 Of all the issues raised in our public consultation, the most contentious was emergency care.

02 There were concerns about NHS 24 and about new out-of-hours (OoH) services with local GPs opting out. But the biggest concern centred on the perceived downgrading of Accident and Emergency Units in local hospitals. This section of the report seeks to address those concerns.

03 The challenges are significant. As we know from the drivers for change outlined earlier (Chapter 3), the rise in emergency admissions to hospital has been the biggest pressure on the NHS. In the last 20 years or so, the balance between planned and unplanned care has shifted dramatically. In 1983, 59% of bed days were occupied by emergency patients. Now, the figure is closer to 80%.

04 We will not resolve these pressures simply by improving our unscheduled care system. We need to better manage patients with long-term conditions to prevent them becoming unscheduled admissions; and provide the right level of care in the community to prevent admission to hospital by default. This is dealt with elsewhere in this report. Nevertheless, a more structured and systematic approach to unscheduled care that gets people access to the right care, first time, can and will help.

Unscheduled care

05 It is worth considering what we mean by unscheduled care. We have used the following definition:

' NHS care which cannot reasonably be foreseen or planned in advance of contact with the relevant healthcare professional, or is care which, unavoidably, is outwith the core working period of NHS Scotland. It follows that such demand can occur at any time and that services to meet this demand must be available 24 hours a day.'

06 In his report 'Securing Future Practice', Sir John Temple concluded: 'To comply with working time regulations by 2009, we will not have sufficient doctors across all grades to provide 24/7/52 care in every locality and unit functioning today...A major challenge is the delivery of emergency primary and secondary care. This is likely to impact more on doctors than on other care staff hence their particular interest in seeing how care is provided around the clock. It matters also to the public and patients, who need to have confidence in a 24/7/52 quality acute service. With the limitations on medical staff time, this is a powerful lever for service redesign. Decisions on the localities and clinical situations for which triage and transfer arrangements are appropriate must be made on the basis of patient safety, balancing issues of speed of access to specialised medical services against what will be possible to provide and sustain locally. We recommend that this is addressed urgently and realistically, as in many situations the status quo cannot survive.' (Scottish Executive, 2004)

07 We agree with Sir John's focus on service redesign. Service change and improvement is at the heart of our proposals to retain local services wherever possible. But those services will have to be redesigned, and will require new roles and high-quality teams.

08 Care must be taken not to characterise NHS Scotland as a purely medically-skilled service. In fact, the vast majority of unscheduled care contacts do not require on-site medical skills. The focus must be on fostering a multidisciplinary clinical team approach that enables flexibility to meet the needs of patients. Doctors are not required in every unit functioning today, and a significant proportion of those currently attending Accident and Emergency departments could in fact be seen close to home by different members of the healthcare team.

09 It is true that highly-specialist medical skills will be required to deal with true emergency 'life and limb-threatening' unscheduled care cases. Dealing with these cases requires appropriately staffed and well-resourced emergency services, which in turn may need to be provided in fewer locations that can concentrate on these cases.

10 In 2001, there were 1.68 hospital medical staff per 1000 people in Scotland, compared with 1.35 in England (Civitas, 2004). However these medical staff in Scotland are currently spread over a far greater number of acute receiving hospitals and Accident and Emergency departments per head of population. Scotland has 34 Accident and Emergency departments or one for every 149,000 people, compared with 209 equivalent Accident and Emergency departments in England or one for every 239,000 of the population.

11 Given the restrictions on doctors' working hours imposed by the European Working Time Directive (which will be fully in place by 2009) and the move away from independent junior doctor working (represented in Modernising Medical Careers), NHS Scotland has no option but to redesign its unscheduled care services to allow for the concentration of medical staff in emergency centres with Working Time Directive-compliant rotas and where genuine emergencies will be treated by highly-skilled teams. This will mean using the non-medical workforce to maintain or extend local unscheduled care services, building on existing best practice in the UK.

12 In order to reach a view about how to deliver unscheduled care in the future, we have sought to understand more fully the nature of current demand. By far the largest group of patients who require unscheduled care avoid Accident and Emergency services. They may have their unscheduled care need met through one of the following routes:

• by getting an urgent appointment with their GP
• by getting advice from NHS 24
• by referral to the Out-of-Hours service (by NHS 24).

13 In the Out-of-Hours period, NHS 24 fronts all primary care Out-of-Hours services. For every 100 callers to NHS 24, 40 will be given advice to self-care or be directed to the appropriate in-hours scheduled care service, five will be directed to Accident and Emergency, two will have an emergency ambulance sent to them, and the remaining 53 will be seen face to face by local OoH services. These figures relate only to the out-of-hours period, and do not take into account Scottish Ambulance Service 999 callers or those who present at Accident and Emergency directly.

Accident and Emergency

14 What about those who do attend Accident and Emergency: do they need to be there? Our analysis suggests that many people do not. They could be safely and appropriately treated in, or close to, their local community.

Table 7.1
Indicative workload proportions attending current Accident and Emergency services, mapped against severity of clinical need

These workload proportions are indicative. They are based on 'live' data captured over an extended period in NHS Forth Valley.

15 We can categorise demand for unscheduled care at Accident and Emergency departments as follows:

• patients requiring assessment and treatment for 'minor' or 'routine' injury and illnesses (the first two rows in Table 7.1)
• patients requiring assessment and diagnosis ahead of potential admission to hospital for surgical or medical treatment
• acutely unwell patients requiring resuscitation.

16 The majority of patients attending A&E are those with minor or routine ailments and injuries which do not require admission to an acute hospital, and in fact do not need to be treated in a traditional Accident and Emergency department. The reasons for their attendance at Accident and Emergency are not clear. It may be that the alternatives are not sufficiently well known to the public, are considered to be less attractive, or because sufficient alternative provision has not been made.

17 Approximately one-third of all current attendances at Accident and Emergency in the area we considered are for some form of minor injury - a deep cut, a sprain, a straightforward fracture - which can be treated by appropriately-trained non-medical clinical staff in a range of settings. These injuries do need to be assessed carefully and managed according to clear agreed protocols, but they can be managed very effectively by an appropriately-trained GP, nurse or paramedic. They do not need the direct (and scarce) input of an Accident and Emergency consultant.

18 Approximately another one-third of Accident and Emergency attendances are for some form of minor or routine illness which needs assessment, diagnosis and treatment, but does not require admission to a hospital. These are often the kinds of condition - a cough, cold or 'flu-like illness' - for which patients would normally seek attention from their local GP practice but, for a variety of reasons, choose not to on occasion. These are patients who do not necessarily need to be treated in an acute hospital facility if appropriate alternatives are in place. Thus minor injuries and ailments constitute a significant proportion of the work at A&Es - all of which could be seen elsewhere if alternative provision were made.

19 A third group of patients is identified requiring (or potentially requiring) admission for forms of treatment which cannot be provided anywhere but in an acute hospital. These patients constitute approximately 20-30% of all attendances at Accident and Emergency departments in the NHS Board we considered.

20 This group might include, for example, those patients who require admission to a coronary care unit following a heart attack, or the older patient who needs further investigation of chest pain. These constitute the 'medical' component.

21 This group of patients also includes those who are brought into hospital for emergency surgical procedures such as repair of a major blood vessel, pinning of a lower limb fracture or abdominal surgery.

22 In most cases in this broad third 'admissions' group, patients would ideally be admitted, diagnosed, treated and discharged from their local hospital quickly. There is, however, a paucity of step-down units and facilities outwith hospitals which must be dealt with as a matter of urgency for this to become the reality. There is a role for community hospitals in providing this facility. (see Chapter 10).

23NHS Scotland is only one part of the whole system of care. Stronger links with social care are required, as a matter of priority, to help provide alternatives to emergency admission and appropriate care in the community for those who no longer require services in an acute setting. Problems in this area have long been recognised but persist and must be addressed as a matter of urgency.

Critically unwell patients

24 The patients who rightly generate the most public interest and anxiety are those acutely unwell patients requiring 'resuscitation'. These patients need very specialised care for acutely life-threatening conditions and problems that might arise as a result of, for example, a car crash, a heart attack, a ruptured aneurysm, or a similarly urgent healthcare need.

25 Patients such as these constitute approximately 3% of attendances at Accident and
Emergency departments.

26 Acutely unwell patients requiring resuscitation need treatment in an Emergency Department that is both well-staffed and well equipped.

27 In some cases, however, the need for specialised treatment requires transfer to another hospital for further treatment. This is particularly true of patients requiring treatment for a less common health problem such as emergency cardiac surgery or neuro-surgery. We believe that numbers of patients who would require transfer from a District General Hospital to a more specialised facility is in the order of 1.5%.

Accident and Emergency workload

28 The evidence gathered demonstrates that the majority of current Accident and Emergency work could be carried out in every local hospital: but much of it will be dealt with in a different way than at present. If we are to keep services locally available, we will need to redesign them in a way that is less reliant on doctors and much more multidisciplinary in nature.

29 In some areas, this might mean a re-profiling of existing services from Accident and Emergency departments dealing with all-comers to a combination of community casualty departments dealing with less serious injuries and ailments and appropriately staffed and resourced emergency centres offering world-class treatment for genuine emergencies and for those likely to require hospital admission.

30 The NHS in Scotland has an opportunity to reconfigure services to better match service provision to the nature of the demand. We have an opportunity to:

• better meet the needs of patients
• reduce pressure on busy Accident and Emergency departments
• deploy medical staff so as to make the most of their skills and remain in accordance with the European Working Time Directive.
• deliver the vast majority of unscheduled care locally.

31 These are opportunities the system must take.

Preventing avoidable emergency admissions

32 Considerable work has been undertaken within NHS Scotland on the prevention of avoidable emergency admission, most notably the Emergency Medical Admissions Scoping Group Final Report ( NHSQIS, 2004). This report represented an important breakthrough for NHS Scotland, highlighting several key issues which require resolution.

33 Foremost among these issues is that the number of admissions to medical and surgical specialties in Scotland has risen consistently over the last 20 years, particularly medical admissions. This appears to have arisen as a direct result of the number of long-staying admissions, particularly among the over-80 age group and those patients who have multiple admissions within the same 12-month period. More emphasis on admission avoidance supported by improved diagnostic support and increased primary care-based support is required. These principles also apply to general surgical admissions, another major stream of activity.

34 Service planners and clinicians in NHS Scotland must now take these messages on board and develop local treatment strategies to keep patients out of hospital unless absolutely necessary. Working across organisational and professional boundaries will be necessary. A clear role can be identified for the emerging Community Health Partnerships, given their requirement to integrate primary care with secondary care, local authorities and other statutory and non-statutory agencies.

35 The emphasis on prevention of avoidable admission by assessing, diagnosing, and treating patients as locally as possible should be a matter of priority for the Centre for Change and Innovation's Unscheduled Care Collaborative. The work will be supported by a new measurement of Accident and Emergency performance.

A Tiered model of care

36 We describe in the following section a tiered model of unscheduled care. This model represents a single unscheduled care system for NHS Scotland. We make clear where planning responsibility lies for each level. We present here a summary of the far more detailed work of the Unscheduled Care group. This should be read in conjunction with the report of that group which can be found at www.show.scot.nhs.uk/sehd/nationalframework

37 The model concentrates on providing the vast majority of care at local and community levels, thereby preventing inappropriate travel to, and unnecessary stays in, hospital. It implies a need for fewer of the traditional all-encompassing 'admitting emergency units' and suggests that the type of services they provide will change.

38 We believe that current configurations do not appropriately match supply with demand and that highly-trained consultants should focus more on true emergencies, based in well-staffed and resourced departments.

39 'Routine' injuries and ailments will be dealt with in local, dedicated facilities. These will be available in all general hospitals; in many community hospitals; and perhaps in hybrid facilities alongside primary care and OoH services. They may also be located alongside a unit designed to handle emergency admissions. In this case patients will be streamed on arrival to the dedicated 'routine' facilities.

40NHS Scotland must provide a better balance between local unscheduled care services and unscheduled care services for life and limb-threatening conditions.

41 The adoption of the tiered model is necessary to ensure sustainability, given the drivers for change outlined in Chapter 3 and more specifically in the Unscheduled Care Action Team report. The model represents a better use of resources, and, crucially in the light of public demands, maintains services for the vast majority of unscheduled presentations at a local level - in some cases more locally than at present.

42 We worked through the logic of the tiered model of unscheduled care using activity data from the population of NHS Forth Valley. For every 100 residents of Forth Valley requiring unscheduled care:

• at least 50 will have appropriate care provided by NHS 24, the Scottish Ambulance Service and GP OoH unscheduled care services: this does not include 'in hour' primary careattendances
• up to 35 may have to travel a short distance to be assessed or treated for a minor ailment or injury in a local facility with appropriate equipment and staffing
• 12 may have to be admitted to a local general hospital
• 2 would have to travel to a regional centre for diagnosis and treatment for an uncommon, but not rare, health condition
• 1 may have to travel to one of two or three national centres for a less common test or treatment.

The unscheduled care model is shown in Figure 7.2 as a pyramid of care. More detail can be found at in the Unscheduled Care Action Team Report which can be found at www.show.scot.nhs.uk/sehd/nationalframework

Figure 7.2
Tiered Model of Unscheduled Care

43 It is important to be clear about the services patients can expect at each of these levels; the competencies they can expect the members of staff providing care to have; and where we think the services can and should be safely provided.

44 As ever, our approach is to deliver care as locally as possible, but we have to recognise that we need to make the skills of Accident and Emergency consultants available to local facilities in more imaginative ways. For example, evidence suggests that it is unlikely that a 24/7/52 rota for a high-intensity specialty such as acute medicine, general surgery or orthopaedics could be sustained with any less than an average of ten doctors as a result of the need to secure compliance with the European Working Time Directive by 2009. Many of the services in Scotland are currently staffed by less than this, and not all will be able to recruit the necessary additional staff.

45 Even if sufficient numbers of staff can be recruited, the throughput of patients will not be sufficient to maintain the skills of all staff in some areas. Innovative networking solutions will therefore need to be found if these services are to be maintained. The work on the Rural General Hospital in Chapter 10 provides some guidance on this question.

The model levels

46 Level 1 services are those currently provided on an assessment, diagnosis and treatment basis by GPs, pharmacy, the Scottish Ambulance Service, district and community nurses and NHS 24.

47 These services will provide more unscheduled care in future than at present, especially for minor illness in the community. They will act as the first point of contact to the NHS Scotland Unscheduled Care System, and to this end every attempt should be made to harmonise the protocols and diagnostic algorithms used by each service. In simple terms, patients should be directed, following assessment, to the most appropriate part of the service, no matter whom they contact initially.

48 Clinical staff at this level should have the following core competencies:

• history-taking
• rapid assessment of severity of clinical need
• understanding of patient pathways for onward referral
• prescribing of appropriate basic medicines, such as those used for pain management
• utilisation of basic diagnostic technologies, including tele-medicine
• utilisation of basic patient record systems
• basic resuscitation techniques (such as cardiopulmonary resuscitation ( CPR)) and first aid (splinting, for instance)
• basic pain management.

49 Further work on these competencies should be developed by NHS Education for Scotland ( NES) building on the work carried out to date to support the reconfiguration of NHS Board Out-of-Hours services and NHS 24.

50 Staff at this level should be able to access quickly and precisely the services provided at other levels of the system.

51 These services will form a significant growth area in the context of unscheduled care in Scotland. They will have a significant role in utilising appropriate assessment and diagnostic techniques to redirect work currently carried out on an unscheduled basis to a scheduled setting. In particular, we see great potential here in applying the new GMS contract and the forthcoming Community Pharmacy contract to tackle illness assessment, chronic disease management and the proactive management of older patients so that reactive emergency/unscheduled attendances are reduced.

52 Level 2 facilities will represent the lynchpin of the unscheduled care framework. These practitioner or GP led 'Casualty' facilities will deliver the vast majority of treatments currently available in Accident and Emergency services. They will deliver them locally in communities without requiring the additional travel often associated with service reconfiguration. They are capable of being delivered 24 hours per day, seven days per week in any local hospital or hybrid healthcare facility.

53 Level 2 facilities should work very closely with Level 1 and Level 3 services. A crucial role will be the identification of cases that require referral to another part of the service. Appropriate risk management and quality standards will need to be put in place. Again, there is a role here for NHS Quality Improvement Scotland ( NHSQIS) and NHS Education for Scotland ( NES).

54 This level of service should include assessment, diagnosis, and treatment for routine injuries and ailments. In most areas, the service will be co-located with Out-of-Hours services, forming multidisciplinary teams.

55NHS Boards will be expected to ensure that appropriate diagnostic and treatment facilities are in place for the delivery of Level 2 services. Each local facility will have a tele-medicine link to a consultant-led unit where advice can be sought as necessary.

56 The following basic competencies would be required by staff working in these facilities:

• history-taking
• assessment of severity of clinical need
• understanding of patient pathways for onward referral
• prescribing of basic medicines
• utilisation of basic diagnostic technologies, including tele-medicine
• utilisation of basic patient record systems
• basic resuscitation techniques ( CPR) and first aid (splinting)
• basic pain management
• stabilisation and transfer of critically ill patients.

For routine injuries:

• requesting and interpreting x-rays and other basic diagnostic tests
• use of tele-medical technology
• suturing
• pain management and prescribing of basic medicines
• decision-making
• organisation of follow-up information, appointments and diagnostics as appropriate
• plastering and application of splints.

For routine ailments:

• ordering and interpretation of diagnostic tests such as bloods and clinical chemistry
• observation of conditions and patients
• utilisation of early warning protocols and procedures
• redirecting of patient to 'lower' level of care, if appropriate.

57 Level 3a represents the core of admitting services for acute assessment and medical and surgical admission. NHS Boards will need to make sensible, pragmatic decisions about how services can be sustained. To this end, the following services should be provided:

• General Surgical 24/7 receiving services
• General Medical 24/7 receiving services (including provision for admissions of older people)
• Orthopaedic Surgery 24/7 receiving services
• Anaesthetic services on a 24/7 basis, including general critical care services
• Radiology services on a 24/7 basis.

58 In addition, these services may be supported by one or more of the following services, depending on local demand:

• Paediatric receiving services
• Obstetric receiving services
• Gynaecology receiving services.

59 These services together will allow appropriate assessment, diagnosis and treatment for the majority of admission or potential admission cases. In addition, this will allow for the appropriate transfer for further sub-specialised treatment if so required.

60 These services should be provided by medical practitioners conforming to the definition of trained practitioners outlined in Securing Future Practice (Scottish Executive, 2004)

61 It is important to be clear about what this means for hospital services as we currently conceive them. Not every hospital currently defined as a District General Hospital will be able to support these services. They will all be able to sustain Level 2 services, but not necessarily Level 3. This means that the vast majority of cases will still be dealt with at least as locally as at present.

62 In planning the location of Level 3 care, it will be important to consider the recommendations of the Planned Care Action Team for setting up a range of hospitals focused on elective services. Each of these should provide Level 2 services but few, if any, will provide Level 3.

63 Level 3b services are those required to accurately diagnose and treat certain less-common conditions in an emergency situation. They are required in a much smaller proportion of cases; consequently, they require a smaller workforce, and a much larger population is required to provide an appropriate critical mass. These services should therefore be planned on a regional basis.

64 Level 3b services could be provided in one of two ways. There could be a network between sites providing Level 3a services, or in areas with high populations and high population densities, they could be concentrated on a site with Level 3a services.

65 These services should also provide robust assessment and diagnosis links to Levels 1, 2, and 3a. Services covered might include:

• Vascular Surgical services
• Burns and Plastic Surgery
• Oral and Maxillo-facial services
• Urological services
• Interventional Cardiology services.

66 L evel 4 services are those that can only be provided in a very limited number of locations in Scotland. They are highly specialised, providing services for rare or particularly complex conditions, and will include the following:

• Cardiac Surgery
• Thoracic Surgery
• Neurosurgery
• sub-specialised critical care (for example, a renal Intensive Care Unit)
• sub-specialised diagnostic services (such as Magnetic Resonance Imaging ( MRI), Positron Emission Tomography ( PET), full vascular intervention including neurovascular (coiling) and transendoscopic ultrasound ( TEUS)).

67 For each of the levels of system, standards based on quality and sustainability should be developed and monitored centrally within NHS Scotland. This process should include Regional Planning Groups, current NHS Boards, NES, NHSQIS, Royal Colleges and recognised professional bodies.

68 Another key issue must be fed into service planning of unscheduled care. As Chapter 10 of our report shows, Scotland has large rural areas with dispersed populations. It should be a matter of urgent priority for NHS Boards covering these remote and rural areas to consider how unscheduled care services should be provided in line with the tiered model. The model of the Rural General Hospital described in Chapter 10 is relevant here, and combines a mixture of Level 2 and Level 3a services.

69 This process is about configuring unscheduled care services to most effectively meet need while maximising the use of all staff. The needs of remote and rural communities (including issues of travel time) are likely to mean that emergency care at a given level will be provided for smaller populations than would be reasonable in urban areas.

70 We believe that the unscheduled care service must be planned in a more effective way than at present, particularly with reference to decision-making across NHS Board area boundaries.

71 Levels 1 and 2 of the pyramid of care should be planned within current NHS Board areas, with the exception of NHS 24 and the Scottish Ambulance Service which, while Level 1 services, are planned nationally.

72 Level 3 services and above should be planned collaboratively with Regional Planning Groups working alongside NHS Boards (on Levels 3a and 3b) and working with the Scottish Executive to plan national services at Level 4.

Summary of recommendations

01NHS Scotland should work to ensure that as much unscheduled care as possible is delivered in or near the home by NHS 24, the Scottish Ambulance Service or local unscheduled care providers (including local casualty units).

02NHS Scotland should continue to invest in triage and assessment systems to ensure that patients can be directed to the most appropriate service for their needs, minimising unnecessary travel. NHS Scotland should move towards presenting a unified point of entry into the system. This unified 'front end' will assist patients in accessing the appropriate service, be it the ambulance service, telephone clinical triage ( NHS 24) or patients' information services. Clinical skills should be integrated into these systems as appropriate.

03 The Scottish Ambulance Service should continue to expand the range of 'on-site' treatments paramedics can deliver to prevent unnecessary travel to unscheduled care facilities and develop the 'hospital-at-home' model. This will entail improving communications between the first healthcare professional to attend a patient and the rest of the unscheduled care team.

04NHS Scotland should work to:

• Maximise the number of patients requiring unscheduled care who can be safely and effectively treated by triage services without having to leave their homes.
• Provide services capable of dealing with patients with non-complex injury and illness on a local level, potentially in hybrid facilities bringing together GP and minor injury services. These should have access to appropriate diagnostic services and should be linked to other levels of the service by tele-health links to facilitate local assessment.
• Reconfigure admission services to more appropriately serve the population. Planning of services should emphasise the prevention of admission where this is safe and adequate services can be provided out of hospital. These services should be supported by appropriate diagnostics and critical care.
• Plan unscheduled emergency admitting services on a regional basis. These services are sub-specialised and have poorly-distributed workforces which need to be more appropriately deployed throughout Scotland.
• Work towards the provision of a single telephone point of entry for unscheduled care services 24 hours a day. This will be a multi-disciplinary triage system that will allow callers access to appropriate advice as early as possible, with patients being referred on as appropriate.
• Develop a system of integrated decision-making support. The current organisation of health services does not always facilitate communication between clinical and care teams. Autonomous decision making is a factor in over-referral to hospital. Investment in information and communications technologies ( ICT) (including electronic patient records and tele-medicine) is a necessary first step in delivering the necessary support to the service. The system will need to be supported by continuous audit of, and feedback on, referral patterns to hospitals.

05 These proposals will be supported by:

• Further development and increased utilisation of the Scottish Ambulance Service, not solely to provide transport, but as an element of 'a hospital at home'.
• Improved training programmes for all NHS Scotland staff. NES has carried out excellent work on skills for staff involved in the provision of primary care OoH. NES should be charged with developing competency-based education frameworks to support these recommendations.
• The full exploitation of information and communication technologies, including maximising telephone assessment and telephone management, tele-medical linkages and remote diagnostic technologies. The group sees considerable scope for further integrating this with NHS 24 and the Scottish Ambulance Service, building an assessment, diagnostic and management network on a pan-Scotland basis. This network should be supported by
  appropriate incentives for its use and audit of referral patterns to hospital.

References

Civitas (2004) England vs Scotland: Does more money mean better health?

NHSQIS (2004) Emergency Medical Admissions Scoping Group: Final Report. July 2004. http://www.nhshealthquality.org/nhsqis/files/EMAReportFINALVERSION_160704.pdf

Scottish Executive (2004) Securing Future Practice: Shaping the New Medical Workforce for Scotland. The Report of a Short Life Working Group Commissioned by the Scottish Executive. June 2004.

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