NHS Greater Glasgow

1. Workshop 27th November 2002 NHS Greater Glasgow Review of Acute Admissions (Medical Specialties)

2. Objectives of the Project • Produce an accurate forecast of future activity • Identify & implement systems/process changes to improve management of acute medical admissions in the short-term • Identify & implement systems/process changes to support the long-term reduction of acute receiving sites • Confirm the capacity & infrastructure required to accommodate acute admissions & investment needed • Develop & implement a change management plan to support the development of new service models

3. Approach to the Project Draft circulated for discussion Articulate Desired Service Principles Ongoing analysis Understand Current Processes & Resources Understand Facts About Patient Demand Understand Causes of Delays & Blockages Ideas From Elsewhere Design New Model(s) of Service Ideas From GG Stakeholders Stage 2 Nov 02 – Feb 03

4. Site Visits • Assessed the patient journey from admission via A&E, through medical receiving, specialist wards and discharge from the acute hospital • Interviewed clinicians, nurses, managers,bed managers • Undertook informal ward rounds in receiving units and specialist wards. • All staff extremely helpful • Further visit to GRI required (post-ERC)

5. The current admission/receiving models The patient journey through the hospital(s) Current “core” problems – process, people, systems, buildings etc. Initial Findings

6. The Current Receiving Models Location Primary Care Accident & Emergency 1 Site Assessment Unit Receiving Wards Specialist Wards (including surgery) Phase Assessment Admission & Treatment Discharge Investigation & Diagnosis

7. A A U Primary care A&E ARU Specialist Wards Primary Care Increasing Admissions from primary care All admissions via A&E Demand greater than capacity - patients cannot move through. Occupancy too high Occupancy too high, patients cannot get a bed in the right place Limited social care and insufficient capacity of long term care beds GP referrals should go directly to medical assessment Limited demand management Patients in beds who do not need an acute ward Few alternatives to admission The Patient Journey Process Admission Discharge Some hospitals have an assessment unit but its function is no different to acute receiving ward

8. Interface Between Primary Care and A & E • At present all emergency medical admissions come via A&E on all sites • Inequality of status of medical staff favours flow of patients into hospital • There are some excellent examples of Admission Avoidance/ Intermediate Care services but are not yet well developed or pan Glasgow (IRIS DART) • Chronic disease management is not yet well developed • Particular patient groups have to be admitted as there are no other appropriate services to treat them • Increase in 999 calls

9. Accident & Emergency • Lack of arrival planning for ambulances • Patient waits in A&E around 4-5 hrs on average • 10-15% of arrivals are children, but no RSCNs or facilities • All GP referrals have to be triaged, causing extra patients to be in an area where they do not need to be • Patients cannot move in to AMR wards because of lack of available beds • Imaging and clinical support services run 9 - 5 Monday to Friday, resulting in patients having to be admitted for tests after hours e.g ultrasound, VQ

10. Acute Receiving Wards • All patients go to receiving wards (except for critical care) • Acute receiving beds often taken by patients who no longer need to be in this high dependency environment • LOS appears to be shorter in units where medical cover is over a four day period • Staff working incredibly hard in very poor conditions • Patients cannot move out of AMR wards because of lack of available beds • Other issues: • JHOs in acute receiving • Lack of care routes, care pathways • Ward rounds – frequency & timing

11. Many patients in beds awaiting investigations or results Many could go home with early discharge support Many beds housing patients awaiting long term care beds (e.g. 15 out of 25 on one ward) Lack of social services resources throughout the system cause bottlenecks - 30 day social care assessment “rule” seen as a minimum Conditions on many wards poor CCUs have particular problems with throughput Beds closed because of nursing shortages Beds closed for health & safety reasons Specialist Wards

12. The Hospital Capacity Issue Reduce Reduce Medical Specialties >100% Number of Patients in Hospital Length of Stay X Bed Occupancy Rate = Number of Beds Available Number of Days Beds Are Available X Should be circa 82% Free Up Max. 365

13. Some Key Messages • The current model of acute care delivery is not sustainable for much longer - staff cannot work any harder • Rising numbers of medical admissions cannot be dealt with any more efficiently or effectively within the constraints of the current model • Bed managers do a marvellous juggling act, but we need them because the system cannot work properly at current occupancy levels

14. Some Key Messages • Emergency receiving will not improve unless a whole systems approach is employed • Tinkering with parts of the system will have little effect and may cause problems elsewhere • The new model needs to begin and end in primary care and involve social services, and the independent care sector

15. Emergency Care in the U.K. • ‘Shortage of beds in hospital’ • ‘Absence of diagnostic tests out of hours’ • ‘Cancelled operations’ • ‘Delays in patients being able to leave hospital’ • ‘Fundamental problems with the way emergency care services are organised’ (Reforming Emergency Care, DoH, 2001)

16. Emergency Care in the U.K. ‘Many health systems have improved patient flow by considering the whole patient journey, spanning all aspects of the emergency system, rather than concentrating on improving the component parts.’ (Improving the Flow of Emergency Admissions, Modernisation Agency, 2002)