Written Statement: Redesigning access to urgent and emergency care services

The unprecedented challenges we have experienced in planning and delivering all aspects of health and care services during the COVID-19 pandemic have acted as a catalyst for testing innovative, outcome focused approaches. This has brought a new focus to how we deliver safe, person-centred services in these exceptional circumstances, and an opportunity to take learning and modernise, with a view to future-proofing our services.

We have followed closely how people have behaved differently when accessing urgent and emergency care services, in response to the risks and restrictions the pandemic has brought. The NHS has also had to adapt quickly to respond to the pandemic, while keeping staff and patients safe and continuing to deliver the urgent and emergency care services people need.

Activity at Emergency Departments across Wales reduced significantly during the first months of the COVID-19 pandemic, at times 60% below the ‘normal range’. There were concerns expressed during these early stages of the pandemic about patients delaying seeking treatment due to the risk of exposure to COVID-19, and presenting at Emergency Departments too late to optimise their outcome, and there have sadly been isolated serious incidents reported to evidence this hypothesis albeit small in number.

However, evidence suggests a proportion of patients who present at Emergency Departments do not require urgent care and would benefit from either self-care or accessing advice, health or social care in other parts of the system. There is also emerging evidence that suggests the reduction in attendances over the course of the pandemic related in greater number to ‘lower risk’ patients, where experience and outcomes would have benefited from accessing advice or care elsewhere.

Since June, we have seen a gradual return to the ‘normal range’ of activity at Emergency Departments. Health Boards are increasingly beginning to operate at higher levels of operational escalation as a direct result of rising pressure on Emergency Departments and the associated risk to quality of care and patient safety. Some Health Boards have begun to report queues of patients outside departments caused by reduced space within the department as a result of compliance with physical distancing guidance. To provide context, activity at Emergency Departments in Wales has increased by around 34% since 2009, and over 1 million presentations are now recorded annually.

The Royal College of Emergency Medicine (RCEM) and the Royal College of Physicians have also expressed concern in recent weeks about the safety of patients and staff, should Emergency Departments become over-crowded.

RCEM has reflected on an urgent need to change from a service model that sees an unlimited number of patients attending Emergency Departments in an uncoordinated way, making it difficult to keep patients safe. The College argues that the most vulnerable patients attending Emergency Departments are at most risk if they do pick up COVID-19 in ‘over-crowded’ departments.

In view of these challenges, we are taking a range of actions in response as part of a redesign of the urgent and emergency care system. Collectively these will provide a better, more appropriate care offer to patients, they include

• A National Video Consultation Service has been rolled out across all health sectors in Wales. Over 15,000 consultations have already been undertaken across Primary, Secondary and Community Care settings and feedback from patients and staff who have used the service have been overwhelmingly positive.
• £650,000 has been invested to establish a new system to connect health care professionals in the community with specialist consultants to enable safe decisions about preventing unnecessary ambulance transport and admission to hospital. Wales is the first UK country to offer all NHS primary care clinicians with this technology
• Health Boards are working with the Welsh Ambulance Services NHS Trust to develop alternative, community based pathways for patients with respiratory complaints to prevent unnecessary admission to hospital
• Given the limited size and scale of Emergency Department footprints, Health Boards have been asked to consider necessary changes to the physical environment of departments that must be flexible and sustainable as demand changes during the pandemic and over winter, and
• Health Boards are working with their partners to deliver ‘discharge to recover then assess’ pathways, enabling people who are ready to leave hospital to return to their local community without unnecessary delay. £10 million funding was allocated to Regional Partnership Boards in April to support delivery. This will be crucial to enable flow of patients through the hospital system to avoid overcrowding in Emergency Departments.

Much like the ambulance service, Emergency Departments are accessible at any time, to anyone - 24 hours, 7 days a week, 365 days a year – but we know they are not always the most appropriate services to meet everyone’s needs.

In line with A Healthier Wales, we are committed to ensuring people will only go to a general hospital when that is essential and, with physical distancing requirements in place, achieving this outcome has never been so prescient.

We want people who need urgent support, care or treatment that can be safely delivered in the community to be able to access a range of services which are seamless, and delivered as close to home as possible.

As a key element of the redesign of urgent and emergency care, we will work with the public, Health Boards and their partners to develop a new approach for people who think they may need to access the Emergency Department but are unsure of where to go.

Building on the principles of the successful changes to the ambulance clinical response model, the new approach will ensure patients get a clear direction of what they need to do and where they need to go in order to resolve their issue.

I would like to make it clear at the outset that this approach is not intended to prevent people from attending Emergency Departments, if this is the right service for their clinical need. Access to emergency care services for people with life-threatening or serious conditions will not change, nor will there be any change to how 999 calls for these high priority patients are dealt with.

Under the emerging model, people with non-life threatening and non-serious conditions will be able to access clear, professional advice on which service is best suited to meet their needs. They will be assessed remotely by a suitably qualified doctor or a nurse and, depending on the severity of the condition, they may be:

• encouraged to self-care
• signposted to a more appropriate service in their local community, or
• directly booked in to an appointment in an Emergency Department if they need further assessment and treatment.

Crucially, this will help ensure that those with life-threatening and serious complaints are treated immediately within the Emergency Department to optimise their outcomes. It will also enable people with less severe conditions to safely remain at home and only attend the Emergency Department if it is necessary for them to do so, and at a time when they can expect to be seen.

I expect this service to be beneficial for parents of young children and people for whom attending a busy Emergency Department may be an uncomfortable or distressing experience. It will also be particularly helpful in protecting people who are at risk, vulnerable or have been shielding, by reducing the time they spend in the Department.

It is essential that this service is accessible to everyone. I have made clear my expectation that any changes made under this model must ensure people who have sensory loss, may find it difficult to access services by telephone or where English is not their first language will receive equitable access.

We also want to move towards a system where patients can expect the same experience, whether they choose to go online or call their general practice, NHS Wales 111 or any other local number.

The new ‘CAV 24/7’ phone service will be launched in the Cardiff and Vale University Health Board area this Summer, as part of a ‘pathfinder’ for this new approach in Wales. A clinical review of patients accessing the Emergency Department at University Hospital Wales, Cardiff was undertaken as part of local development work. The review found 60% of total patient attendances were suitable for the ‘CAV 24/7’ pathfinder model, with 21% of patient presentations suitable for self-care, advice or assessment in an alternative setting.

Surveys previously commissioned by Welsh Government and NHS Wales on access to emergency care services have found the significant majority (88%) of those surveyed thought it was important to provide medical advice on the phone where possible if that avoided the need for an escalation in care (i.e. an ambulance response).

There is clearly opportunity to collaboratively redesign the way people access services when they need – or want – advice or treatment.

The Cardiff and the Vale UHB pathfinder approach has been developed locally by clinical leaders from across primary, community and emergency care and will be the source of an extensive marketing campaign targeted at residents of Cardiff and the Vale of Glamorgan to commence shortly.

The pathfinder approach will enable other Health Boards to consider and, if appropriate, evolve similar models. The intent is to scale to a national once for Wales approach subject to robust evaluation of staff and patient experience which will be central to further development and implementation.

I will release a further statement in the Autumn to update Members on progress on the broader redesign of these essential services.

This statement is being issued during recess in order to keep members informed. Should members wish me to make a further statement or to answer questions on this when the Senedd returns I would be happy to do so.