ࡱ> kmj#` mMbjbj\.\. ;v>D>DD*nnn8TL*%RR(zzzzzz@%B%B%B%B%B%B%$G'h)f%zzf%zz{%1!1!1!zz@%1!@%1!1!##zF p`n#,%%0%#,u*Bu*##u*$z>,1!$zzzf%f% jzzz%***Dn***n***  This 41 page document was published in October 2006. The Rt. Hon the Lord Warner, Minister of State for NHS Reform, has written the foreword. Views are called for by 5th January so the DH can be clear on the proposals for action set outfor driving change. There are six principles and no fewer than 54 albeit very repetitive questions to answer. It is claimed that the proposals have come from, inter alia, the consultation exercise after the White Paper Our Health, Our Care, Our Say with the derived principles of care no more important than when [the] care need is urgent. Stress is laid on the consistency of assessing need when services are contacted urgently. Although it is accepted that different solutions will apply in different settings they should all be based on the same criteria and evidence of what works best and offers the highest quality. The strategy is to focus on improving experience of service-users and reducing unnecessary hospital admissions. One factor to be welcomed is that the new definition of urgent as opposed to other unsatisfactory terms (including unscheduled, emergency et al) is that social services are to be explicitly involved. The six principles are 1. My voice as a service user or carer is clearly heard and acted on. 2. I know how to access services if I have an urgent need. 3. If I have an urgent need I can access care quickly and simply. 4. My safety is paramount to everyone who cares for me. 5. I can rely on getting the right care (including support for self-care), whenever I need it and whoever I am. 6. The care I receive meets my needs appropriately, taking account of the urgency and value for money (sic). Q.1 Do you agree that delivery of urgent care services can be centred around this set of principles? Q.2 Would you want to add to them or change anything? Q.3 If so, please explain briefly what you would change. Q.4 Are there any issues specific to ethnicity, age, disability or gender that we need to consider in developing urgent care services? Q.5 If so, what are they? The document proposes a definition of urgent care: the range of responses that health and care services provide to people who require or who perceive the need for urgent advice, care, treatment or diagnosis. People using services and carers should expect 24/7 consistent and rigorous assessment of the urgency of their care need and an appropriate and prompt response to that need. It then asks; Q.6 Do you agree with this definition of urgent care? Q.7 If not, what would you change about it? Q.8 Is it right to remove the distinction between in-hours and out-of-hours urgent care so that people have access to a consistent and rigorous assessment of the urgency of their need at any time of day or night? Q.9 Please explain briefly why you agreed or disagreed. Q.10 Do you think health and social care services need to work better together to deliver an effective 24/7 urgent care service? Q.11 If so, please explain briefly how this could be achieved. Members will want to consider whether there are references towards general practices to be inferred from the phrases underlined. Working from the definition and principles the DH has developed a conceptual model of the way in which urgent care should be delivered. This image of an integrated, high-quality urgent care service is conceptual in the sense that it takes no account of the particular services which would deliver each part of the model in a particular local health economy. The point made over and over again is of consistent assessment of urgent care need on the telephone or face-to-face. The responses listed are emergency on site or ambulance despatch, urgent face-to-face, a booked appointment or advice on self-care. So, for example, even if the contact is made directly with a hospital A&E, reconfiguration should ensure that care in the community should be aimed for when appropriate. Q.12 Do you agree with the model? Q.13 If not, please explain briefly what you would change about it. The next substantive section concerns turning the model into reality and deals with each of the six principles in turn. 1. My voice as a service user or carer is clearly heard and acted on. People should be in control and informed of choices in care. Providers should regularly assess users experiences and share the information with commissioners as well as making it public and reporting on the steps taken to improve in the light of experience. Members of the community and service users should be involved at every level in urgent care provision bringing insight to formulation and implementation of policy and to the clinical and corporate governance of the service. Q.14 Do you agree with the description of where we should be for principle one? Q.15 If not, briefly explain what you would add or change about it. Q.16 Have we identified the right national and local actions to address where we should be? Q.17 If not, briefly explain what you would add or change about them. Q.18 What else would make this difficult to deliver? Q.19 Can you tell us about any examples where people or services are already doing? I know how to access services if I have an urgent need. People may be confused by the plethora of different and new services (MIUs, ECCs) and practitioners (ECPs) although they do, of course, find them helpful. Practitioners themselves may be confused about what services are available when. Redirection from service to service leads to frustration with unnecessary duplication and a disjointed journey to the care they need. Commissioners should therefore provide clear, accurate and up-to-date information (what else?) to local healthcare and social care staff as well as to the community. Patients with chronic conditions should hold agreed personalised care plans complete with contact details. Care should be taken to review the language used to describe facilities, there should be the facilitation of the seamless patching of information between providers including exploring the idea of a single national telephone number for 24/7 access to the assessment of the urgency of need consistently and rigorously. There should be communication templates for effective local information (press adverts., posters, leaflets) and postcode-based information of local services available online. Q.20 Do you agree with the description of where we should be for principle two? Q.21 If not, briefly explain what you would add or change about it. Q.22 Have we identified the right national and local actions to address where we should be? Q.23 If not, briefly explain what you would add or change about them. Q.24 What else would make this difficult to deliver? Q.25 Can you tell us about any examples where people or services are already doing things like this? (Please include contact details) If I have an urgent need I can access care quickly and simply With a clearer understanding of urgent care commissioners should map demand and so develop a range of local services including new diagnostic and treatment services closer to home and services that are culturally sensitive delivered by flexible workforces in multidisciplinary teams. There will be centrally-issued guidance on best practice and workforce development. Not only should these teams have local knowledge but they would also be able to work across boundaries. There is much repetition concerning access to assessment of need and services being easily available quickly and simply via a well-known telephone number or easy to reach centres. Cross service referrals should be minimised with the first contact meeting needs wherever possible and, where not, the second service should always complete the episode. Q.26 Do you agree with the description of where we should be for principle three? Q.27 If not, briefly explain what you would add or change about it. Q.28 Have we identified the right national and local actions to address where we should be? Q.29 If not, briefly explain what you would add or change about them. Q.30 What else would make this difficult to deliver? Q.31 Can you tell us about any examples where people or services are already doing things like this? (Please include contact details) My safety is paramount to everyone who cares for me. With a variety of different standards applying across services, multiple hand-offs (sic) between professionals, limited access to records and to drugs OOH (especially in end-of-life care) care may be compromised. Standards for Better Health (Our journey towards high quality health care in England) 2004 included a section on urgent care setting out minimum standards. Services should be jointly commissioned as close to home as possible as is consistent with safety and quality and there should, of course, be appropriate governance arrangements. Care histories should easily accessible with information transferred electronically through integrated IT systems and especially in chronic cases and in palliative care when they should be held by the patient. Medicines should be provided in a full course (from an OOH formulary) and the information entered into the practice medical record. Consistent and rigorous needs assessment will also help. Q.32 Do you agree with the description of where we should be for principle four? Q.33 If not, briefly explain what you would add or change about it. Q.34 Have we identified the right national and local actions to address where we should be? Q.35 If not, briefly explain what you would add or change about them. Q.36 What else would make this difficult to deliver? Q.37 Can you tell us about any examples where people or services are already doing things like this? (Please include contact details) 5. I can rely on getting the right care (including support for self-care), whenever I need it and whoever I am. It is correctly stated that some services at present are better than others OOH and that mental health and social services are often patchy. We should be working towards correcting this with locally-tailored 24/7 access to consistent and rigorous assessment of the urgency of care needs but also increasing understanding that self-care or a routine appointment might be an appropriate outcome, helping people to take more responsibility for their own health. There will be national media campaigns. Services should also be commissioned to meet the needs of particularly disadvantaged groups with commissioners and providers working together to enable these to make effective use of the services they have gone to all that trouble to make for them (OK, that last bit was my reading). Q.38 Do you agree with the description of where we should be for principle five? Q.39 If not, briefly explain what you would add or change about it. Q.40 Have we identified the right national and local actions to address where we should be? Q.41 If not, briefly explain what you would add or change about them. Q.42 What else would make this difficult to deliver? Q.43 Can you tell us about any examples where people or services are already doing things like this? (Please include contact details) 6. The care I receive meets my needs appropriately, taking account of the urgency and value for money (sic). Urgent services do not always respond appropriately in that needs may not be consistently and rigorously assessed, access to care may be incomplete and inequitable, hospital admission may be unnecessary. Commissioners, armed with the new definition of urgent care should be able to correct all this, providing a first time solution, often based in the community. Mapping behaviour will enable services to be suited to local needs, for example building an UCC next to an A&E popular with those who attend but who not really need that hospital service. Joint commissioning, PbR and other systems will shift the balance away from hospitals, simplify access and improve value for money, especially with regular benchmarking* of cost and quality of services ("Benchmarking is simply about making comparisons with other organisations and then learning the lessons that those comparisons throw up" The European Benchmarking Code of Conduct). Q 44 Do you agree with the description of where we should be for principle six? Q.45 If not, briefly explain what you would add or change about it. Q.46 Have we identified the right national and local actions to address where we should be? Q.47 If not, briefly explain what you would add or change about them. Q.48 What else would make this difficult to deliver? Q.49 Can you tell us about any examples where people or services are already doing things like this? (Please include contact details) Finally we are asked to consider attitudes to risk because some people say that protocols that assess needs are risk adverse and lead to unnecessary referral. Attitudes to risk may be important for clinical governance and so professionals need to agree risk assessment and risk management processes including in designing the initial protocols. No detail is given. Integrated service responses might needs to include other services, such as housing and rural and urban communities have different needs, transport being key. Q.50 How can we at national level (the Department of Health or other national organisations) best help local communities to implement change? Q.51 Are there sufficient system levers for change in place (e.g. voice, payment by results, commissioning, standards and quality requirements, governance) and, if not, how could they best be supplemented? Q.52 What, if anything, do we need to do nationally or locally on approaches to risk? Q.53 What do you see as the major differences between delivering urgent care in rural and urban settings? Q.54 How can we address some of these issues (e.g. transport issues) to help deliver improved urgent care? As an appendix we add some informative case studies, said to be based on real experiences, illustrating failings in existing systems. Although not unlikely these are informative mainly for what they reveal about the DHs knowledge of real practice. The first describes a young woman dying of a brain tumour being cared for by her parents and the problems they encounter in obtaining drugs for her over a weekend. The drug concerned is referred to as to midozalam throughout. In the new system an updated care plan is shared with the OOH service and extra drugs that might be needed are prescribed, dispensed and kept at home. The next concerns a confused elderly lady whose children live away but who relies on an elderly friend, refusing all other help. Unfortunately a fire breaks out in her home one Saturday. She is taken to A&E but discharges herself despite her (GP) daughters remote efforts. Next day the said daughter arrives in person to find her mother immobile and doubly incontinent in an uninhabitable house. Luckily her mothers own GP is somehow able to arrange a nursing home bed that Sunday but, sadly, the old lady has a heart attack the next day. If only a community health or social care practitioner could have drawn up an anticipatory care plan conveyed it to the OOH service who could then have arranged her direct transfer from A&E to an intermediary care bed or old age specialist team for investigation. Then a long-term support plan could have been agreed by all parties within six weeks. A depressed teacher makes a suicide attempt and arrives in A&E in the early evening where a nurse takes her history in public. Four hours later she is finally seen by a doctor (thus fulfilling the access target) who, bizarrely, tells her blood test results will be sent to her own GP. Returning home she contacts a hard-pressed OOH doctor who promises to get back to her. Hours later, feeling better and having gone to bed, she is disturbed by two police officers checking she has not hurt herself and then by representatives of the crisis resolution team who she refuses to see as they have no means of identification. A detailed care plan could have given her the ability to contact the team directly. In the final case young Jack falls ill whilst spending a week with his father. He is misdiagnosed by a pharmacist and two days later his father decides to contact his GP but the surgery is closed (sic). NHSD predictably recommend A&E where a nurse diagnoses a viral illness. The following day a GP refers the by now dehydrated little boy to a paediatrician, who diagnoses measles. A hospital admission is necessary. If only carers and health professionals had better knowledge of common childhood illnesses, if there were minor ailment protocols agreed and if pharmacists and walk-in centres had access to professionals with specific experience in paediatrics. Next there are two examples of models of better provision. The Maidstone Emergency Care Centre where patients are filtered into specific separate areas, major or the mostly nurse-led walk-in centre where patients are seen in GP-style consultation rooms. The OOH hub is based behind the ECC and a social services manager is based there. The Harrogate Fast Response Team is a multidisciplinary group that aims to prevent avoidable admissions and help bring about early discharge. It deals with ill patients in their homes, who present to A&E, those just discharged and those with an identified nursing need extending OOH. It sounds really impressive.     Direction of Travel for Urgent Care: a discussion document BCM Page  PAGE 1  DATE \@ "dd/MM/yyyy" 14/12/2006 47st 2 I ] ^ _ ~  _ j Y g l m ŹṭŀŭpcŹWhZCJOJQJaJhZ6CJOJQJaJh"h"6CJOJQJaJh+5Uh+5U6CJOJQJaJh_6CJOJQJaJh_h_6CJOJQJaJh"CJOJQJaJh_CJOJQJaJh+5UCJOJQJaJh_h_CJH*OJQJaJh3CJOJQJaJh_h_CJOJQJaJh_^ _  B 0w>y gd" 0^`0gd"`gd"gd+5U$a$gdZ$a$gd_LlM  B E 03 -45STzn_n_nPhZhZCJOJQJaJh"hZCJOJQJaJhZCJOJQJaJh"CJOJQJaJh"h"CJOJQJaJhakh"OJQJ"h"h"56CJOJQJaJh+5U56CJOJQJaJh"56CJOJQJaJ"h"h+5U56CJOJQJaJh+5Uh+5U5CJOJQJaJh"5CJOJQJaJKI]tuvy?@¶znbbSGSGSGhrCJOJQJaJhrhrCJOJQJaJh_DCJOJQJaJhL CJOJQJaJh"hZCJOJQJaJhL OJQJhakhZ5>*OJQJhakhZ5OJQJhakhZOJQJh"CJOJQJaJhZCJOJQJaJ"hZhZ5>*CJOJQJaJhZhZCJOJQJaJhZhZ6CJOJQJaJ*vwxynopgd@8S$a$gdAgdr $  a$gdr$a$gdZ 0^`0gdZgdZgd" opsmnoŹŭŁtiŹYtMAh#CJOJQJaJhoCJOJQJaJh+5Uho5CJOJQJaJhakhoOJQJho5CJOJQJaJhQh@8SCJOJQJaJh+5Uh@8S5CJOJQJaJh@8S5CJOJQJaJhuyCJOJQJaJh_DCJOJQJaJh@8SCJOJQJaJhakhrOJQJhrCJOJQJaJhZCJOJQJaJhACJOJQJaJ8mno"!#!$!%!&!z!!"$a$gd#$a$gdo & Fgdo 0^`0gdo`gdogdo$a$gdAq !!"!#!%!&!%#&#(#)#*#g#h#i#&&&(Ĺyl`QD9hakhsOJQJh#5CJOJQJaJhshyYCJOJQJaJhsCJOJQJaJhyY5CJOJQJaJhV5CJOJQJaJh+5Uh#5CJOJQJaJhoh_DCJOJQJaJhoCJOJQJaJhakOJQJhakh#OJQJh-OJQJhuyOJQJh#h#CJOJQJaJh#CJOJQJaJh#h#5CJOJQJaJ" "h"""(#)#*#h#i#&&&A''''!(v( $`a$gds$a$gds$a$gd#$a$gdyY $ & Fa$gd#$a$gdo $^a$gdyYgd# $`a$gd#((((((((8);))))))*7*8*Y*,ŵũ~jVIV8!h0zCJOJQJ\aJmH sH h0zOJQJ\mH sH 'h0zh0zCJOJQJ\aJmH sH 'h0zhKCJOJQJ\aJmH sH h0zhKCJOJQJaJhKCJOJQJaJhv'hv'6CJOJQJaJhv'CJOJQJaJh+5Uhv'5CJOJQJaJhv'5CJOJQJaJh_DCJOJQJaJh#CJOJQJaJhakhsOJQJhakhc8OJQJv((((((,,,7----.l..../`gd0zgd0z$a$gduy $^a$gd0z $`a$gd0z$a$gd0z$a$gdv'gdv' & Fgdv'$a$gd# $^a$gds,......//'2'4(4)4+4,4-404444̿ꗈyl\J;hc856CJOJQJaJ"h"hc856CJOJQJaJh+5Uhc85CJOJQJaJhc85CJOJQJaJh0zh0zCJOJQJaJhc8hc8CJOJQJaJhc8CJOJQJaJhD <CJOJQJaJh+5Uh0z5CJOJQJaJh0z5CJOJQJaJh_D5CJOJQJaJ!h0zCJOJQJ\aJmH sH hakhc8OJQJhakh0zOJQJ//&2'2|223"3j333*4+4-4t444I8J8 $  a$gdak $  a$gdr`gdc8gdc8 $^a$gdc8 $`a$gdc8$a$gdc8$a$gd0z`gd0z44*7p7q7s778F8J8K:M:]<b<g<<<==$>%>>>>>ֻxh]U]U]U]U]U]FhMhMOJQJmH sH hMOJQJhMhMOJQJhMCJOJQJaJmH sH hakhakOJQJ!hak6CJOJQJaJmH sH 'hakhak6CJOJQJaJmH sH $hakhakCJOJQJaJmH sH hakCJOJQJaJhakhakCJOJQJaJhakh)CCJOJQJaJhakhc8CJOJQJaJhrCJOJQJaJJ88879D999:K:M:\<]<<<U===>w>>>>>`gdMgdM $  a$gdak $  a$gdM`gdakgdak>>??tAuADDGGWJXJLLLLLLLLLLLM1M2MjMgd_$a$gd_D $  a$gdr>>???a@p@sAtAuAzA}AAAAABBBgBhBjBkBCC!C)CDDDEEGGGHHIILLLLLLLLLLLLM髣h_h@5CJOJQJaJh6jh6Uh_Dh_DCJOJQJaJh_Dh_D6OJQJh!OJQJh_Dh!OJQJh-OJQJh_DOJQJh_Dh_DOJQJh+5UCJOJQJaJ3MM1M2M;My   * v w x y nop8mno"#$%&z h()*hiA! v $$$7%%%%&l&&&&''&*'*|**+"+j+++*,+,-,t,,,I0J00071D1112K2M2\4]444U5556w66666677t9u9<<??WBXBDDDDDDDDDDDE1E2EjEkEnE00000000000000000000000000000000000000000000000000000000 00000000000000000 00000000000000 000000000000000000000000000000000000000000000000000000000000000000000h00h00h00h00h00h00h00h00h00h00h00l@h00h00l@h00 II (,4>MmM'*+-/13589"v(/J8>jMmM(,.02467:lM)RY[]t!K4 K6 K: KD; %%""nE''""nE8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplaceB*urn:schemas-microsoft-com:office:smarttagscountry-region @2..7788 BBBBBBDDDDDDDDDDDDD;EEEFEiEkEnE 36wzv | ,!1!%%l&r&&&++++0,3,t,w,71=122o4q444U5b555p6u6w6z66666DDDDDDDDDDDDEEkEnE3333333333333333333333333333347st2I^_mm / / I ] y y no00#&  &&336DDDDDDDDDDDD0E2E;EEEkEnE BBDDDDDDDDDDDDDkEnE4(2lAl^`lo(. tt^t`hH. DLD^D`LhH.   ^ `hH.   ^ `hH. L^`LhH. ^`hH. TT^T`hH. $L$^$`LhH.4(ʩ        wijK ddjK 8)r4jK dd 84jjK dd%$VL s!v'`1RD8c8C9D <)CM@8S+5U0zakOq_6Q3KyYao#x@"_D<A#Z_uyr-DnEy0@L mE@UnknownGz Times New Roman5Symbol3& z Arial7GeorgiaW, rBaskervilleCourier New?5 z Courier New"1hQrQrH :#}H :#} 4DD2QHP ?_2=This 41 page document was published in October 2006 by the RtUser Dr Anne Hicks Oh+'0( @L l x @This 41 page document was published in October 2006 by the RtUser Normal.dotDr Anne Hicks2Microsoft Office Word@^в@`@`H :՜.+,0$ hp|  }#D >This 41 page document was published in October 2006 by the Rt Title  !"#$%&'()*+,-./0123456789:;=>?@ABCEFGHIJKLMNOPQRSTUVWXY[\]^_`acdefghilRoot Entry FPƜ`nData <1TableD*WordDocument;vSummaryInformation(ZDocumentSummaryInformation8bCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q