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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2000
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6000
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10000
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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
50
100
150
200
250
300
350
400
450
500
550
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
2,200
2,250
2,300
2,350
2,400
2,450
2,500
Mar-08
May-08
Jul-0
8
Sep-0
8
Nov-08
Jan-0
9
Mar-09
May-09
Jul-0
9
Sep-0
9
Nov-09
Jan-1
0
Mar-10
May-10
Jul-1
0
Sep-1
0
Nov-10
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