12 March 2009Dr Brian Montgomery

Associate Medical DirectorNHS Lothian

Emergency Access Delivery Team

M8

M9A902

A720

A1

A68

A7

A701

A702A71

MorningsideMorningsideMorningsideMorningsideMorningsideMorningsideMorningsideMorningsideMorningside

Davidson's MainsDavidson's MainsDavidson's MainsDavidson's MainsDavidson's MainsDavidson's MainsDavidson's MainsDavidson's MainsDavidson's Mains

City of Edinburgh

BathgateBathgateBathgateBathgateBathgateBathgateBathgateBathgateBathgate

BonnyriggBonnyriggBonnyriggBonnyriggBonnyriggBonnyriggBonnyriggBonnyriggBonnyrigg

CraigmillarCraigmillarCraigmillarCraigmillarCraigmillarCraigmillarCraigmillarCraigmillarCraigmillar

DalkeithDalkeithDalkeithDalkeithDalkeithDalkeithDalkeithDalkeithDalkeith

DunbarDunbarDunbarDunbarDunbarDunbarDunbarDunbarDunbar

HaddingtonHaddingtonHaddingtonHaddingtonHaddingtonHaddingtonHaddingtonHaddingtonHaddington

LeithLeithLeithLeithLeithLeithLeithLeithLeithLinlithgowLinlithgowLinlithgowLinlithgowLinlithgowLinlithgowLinlithgowLinlithgowLinlithgow

LivingstonLivingstonLivingstonLivingstonLivingstonLivingstonLivingstonLivingstonLivingston

North BerwickNorth BerwickNorth BerwickNorth BerwickNorth BerwickNorth BerwickNorth BerwickNorth BerwickNorth Berwick

PenicuikPenicuikPenicuikPenicuikPenicuikPenicuikPenicuikPenicuikPenicuik

TranentTranentTranentTranentTranentTranentTranentTranentTranent

Urban Area

Regional/CHP boundary

Motorway

Primary Route

Town

© Automobile Association Developments Limited 2005 All rights reserved. This product includes mapping data licensed from Ordnance Survey © Crown Copyright 2005. All rights reserved. Licence Number 399221 By Mette Tranter, HIPU, Lothian Health Board, 6th February 2006

Lothian NHS Board Area

Accessing Healthcare • New GMS (50/168)• NHS24• 24/7 consumer society• Heightened anxiety & urgency• Complexity of options• A&E is the only “open” door

Front-door Emergency Activity at RIE, SJH and WGH, 2002-2007

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2002 2003 2004 2005 2006 2007 2008

RIE Activity

SJH Activity

WGH Activity

Front-door Emergency Activity at RIE, SJH and WGH, 2002-2007

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2002 2003 2004 2005 2006 2007 2008

RIE Activity

SJH Activity

RIE Admissions

WGH Activity

WGH Admissions

SJH Admissions

Total Hospital Stay (Days)

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 49 52 56 61 70 790

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Hospital Admissions 2006/07

Actual Hospital Lengths of Stay

Admissions

Sources of referral (monthly average 2008)

Source RIE (A&E PAA) SJH (A&E MAU) WGH (ARAUT)

Self 3990 2480 75999 2415 70 145GP 1135 440 945LUCS 220 35 55NHS24 535 350 48Police 95 70Other Hospital 40 27Minor Injury Unit

60 10

Review 285 180 35Other 125 575 80Total 8900 4200 1420Front Door Admissions

2780 1050 765WGH Minor Injuries Unit - 1415

Who attends A&E • 100,000 attendances per annum (RIE)

– Six month audit Oct 06 – Mar 07• 57 patients with > 10 attendances totalling 720 visits

– Case management reduced attendances for this group to 499 in the next six months (Apr 07 – Sep 07)

– Six month audit Feb 08 – Jul 08• 63 patients with > 10 attendances totalling 957 visits

– Very little overlap in the two populations

Who attends A&E (RIE study) • Male to female ratio 2:1• Mean age 43• Commonest problems and diagnoses

– Alcohol related problems 46%– Mental health problems 37%– Chronic complaints (eg abdo or chest pain) 40%

• Homeless patients 7• Not registered with a GP 2%

Who attends A&E • 50,000 attendances per annum (SJH)

– Six month audit Feb 08 – Jul 08• 15 patients with > 10 attendances totalling 196 visits• 30 patients with > 8 attendances totalling 323 visits

Frequent Flyers • Account for 1.5% of A&E attendances• Case management reduced

attendances by 31% (221 visits)• Behaviour is not sustained over long

periods but reflects periods of crisis• The people change

50/168 – Supply / Demand / Need

Hours of Business

Activity

Time

? Hours of Business

?? Hours of Business

50/168 – Supply / Demand / Need

• Supply ≠ Demand• People expect extended hours• Combination of extended hours

and shifted hours• Differentiate between assessment

and treatment• Balancing of scheduled and

unscheduled activity

Lothian Unscheduled Care Service • 300 patients transferred from A&E to

LUCS– Coded as discharges

• LUCS 200 direct referrals to medicine or surgery

Patient

999

GP

Care Home

Walk-in Pharmacy

SPOC(BB)

Urgent (Hot)

OP appt

Medical OpinionEg. Stroke

Line

BED

Day Hospital

appt

Pathways into Healthcare – possible FUTURE statePathways into Healthcare – possible FUTURE state

Identified area of concern/ Opportunity for redesign

A&EARUPAAMAU

See & Treat teams

Mobile Diagnostics

Diagnostics

Patient Transport

NHS 24

Falls Prevention Access Team

ReablementService

Augmented Care

Intermediate Care (inc.

Crisis Care)

Domiciliary Care

Social care teams

24h Mental Health

Assessment

Intensive Home

Treatment

District Nurse – eve & night

Community Respiratory

Team

IMPACT nurses

Community care teams

LUCS

Minor Injuries

GP Walk-in

LOCAL PROVISION / ALTERNATIVES TO ADMISSION

present NHS24 LUCS A&E PAA/MAU admit

Anticipatory CareCommunity PharmacistsLong Term Conditions

Rapid Response TeamsShifting the Balance of Care

Diagnostic and Assessment Centres

Priority Areas• Single point of contact• Review of Day Hospitals• Rapid access assessment and

diagnostics• Unscheduled Care Services• Patient flows

Conclusions• A&E has become an open access point of

triage• Current arrangements are not user friendly• The way we deliver service does not meet

expectation (?need)• Our current responses reinforce behaviour• Current arrangements are not fit for purpose

NHS Lothian T10 Trajectory (based on 2% reduction in A&E attendance rate per 100,000

between 2007/08 to 2010/11 )

2,000

2,050

2,100

2,150

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2,300

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2,500

Mar-08

May-08

Jul-0

8

Sep-0

8

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Jan-0

9

Mar-09

May-09

Jul-0

9

Sep-0

9

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Jan-1

0

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May-10

Jul-1

0

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Jan-1

1

Mar-11

Rate

of A

ttend

ance

Lothian’s Trajectory

Pathways into HealthcareThe challenge:

Change the demand

Or

Meet the demand appropriately