The Workings of Emergency Care

NetworksWilf Williams

Chief Executive

Canterbury & Coastal PCT

An Emergency Care Network

• How does it work?

• What benefits does the approach deliver?

• Key markers for success or failure

• Is this a solution?

The ContextThe East Kent Local Health Economy Organisations 4 PCTs, 1 acute trust, 1 mental health

trust, single social services department,

Population Approx. 600,000, dispersed semi-rural population, above average proportion

of older people

Hospitals 3 major acute sites with A&E, on-going programme of reconfiguration

Merger /new organisations Recent merger of acute trust (3 into 1), 4 PCTs (April 2002)

The immediate backdropWhat WEST found - 1

• “..concerned over the extent and level of partnership working demonstrated both within and between organisations….. this could ultimately lead to a dysfunctional system within which individuals work hard and conscientiously but where the net result is less than optimum clinical care”

• “..unable to detect a common ownership of emergencies as a priority within all parts of the health and social care community”

The immediate backdropWhat WEST found - 2

• “Acute sector capacity dominated many discussions and an increase in capacity was suggested as the solution to all current problems”

• “..little engagement of primary care and the community in the issue of emergency care compared to that seen in many other parts of the country”

The immediate backdropWhat WEST found - 3

• “..at present there is little relation in East Kent between policy for emergency care and its delivery. Attempts to innovate have been piecemeal, have increased complexity and made the process more inefficient and unwieldy”

• “..a number of excellent individual schemes, although we were unable to detect an overall strategy within the Trust and within the broader community for handling emergency pressures as a priority”

EKECN - How does it work?• Multi-agency team - encompasses emergency

leads from all partner organisations and professions: PCTs, social services, mental health, acute sector, ambulance service

• Clear brief and project structure - – Ensures the project is actively and effectively driven forward against

agreed milestones and timescales.

– Leads the implementation process of projects set out in action plans– Oversees re-design projects within defined objectives and parameters

Stages of development 1• Stage 1 - Establishing the whole systems focus and

engagement - structures, processes, terms of reference, project plan. Focusing on national policy objectives and aspirations - “Reforming Emergency Care”

• Stage 2 - Developing the immediate action plan - responding to WEST, establishing a whole systems perspective, focusing on solutions beyond organisational boundaries

Stages of development 2• Stage 3 - Implementing, monitoring and evaluating

action plans - tightly project managed, detailed exception reporting, flexible re-shaping of investments and developments

• Stage 4 - Developing wider engagement - programme to engage key stakeholders within acute sector, with wider health community, across social care, with broader range of stakeholders in voluntary and private sector

Stages of development 3• Stage 5 - Establishing redesign priorities and

processes, delivering changed services -

Identified redesign themes:

– Developing community capacity

– Design model for a Clinical Decision Unit

– Developing local access to unscheduled care

– Enhanced whole system chronic disease management

– Future roles for ambulance services, NHS Direct and other community resources

Stages of development 4• Stage 6 - Becoming forum for developing and

prioritising LDP proposals– Whole system scrutiny, review and prioritisation

– Clear route to channel proposals and bids

• Stage 7 - Reconfiguring network arrangements

– Separate forums, agendas and representation for strategic and operational matters

– Explicit linkages and relationships established with related workstreams, eg DTOC

Benefits of a network approach 1• Develop engagement and commitment - provides a

mechanism and an on-going forum for this purpose.

• Develop real partnerships - improved understanding, common efforts, joined-up planning and development.

• Communication - open, active, consistent lines. A place to bring issues.

Benefits of a network approach 2• Synergy - a means to pool the human resources and

knowledge of all partner organisations and professional groups, efficient utilisation of scarce resources

• Stimulate creativity and innovation - a forum for debate and sharing of ideas

• Sharing good practice and learning - core function of a network

Benefits of a network approach 3• Whole systems view - the network is the linkage for this.

Whole systems perspective brought to any issue.

• Facilitate changing roles and relationships - a means to move beyond traditional roles, functions and relationships

• Collaborative approach to re-design and change - working efficiently and effectively beyond artificial constraints of organisational and professional boundaries

Markers for success 1• Clarity of objectives, clear focus - a network will

otherwise drift and become a talking shop. External and internal drivers help reinforce this focus.

• Shared vision of how and where services are developed - this can only emerge over time and will need revisiting and amending in light of experience.

• Developing strong relationships - at personal, professional and organisational levels. Must be characterised by openness and trust based on mutual understanding and dialogue.

Markers for success 2• Clinical involvement - within and across

organisations, integrated into planning processes.

• Clinical leadership - indispensable in promoting and driving practice change. Precious commodity, often uncomfortable for individuals,can be very fragile. MUST be supported and nurtured.

• Primary care involvement - professionally and organisationally. Proactive and positive.

Markers for success 3• Nurturing relationships - a network has no direct

authority. Networks require a facilitative, empowering and involving leadership style.

• Neither overly bureaucratic nor too informal - network must be characterised by action and innovation, able to demonstrate real progress.

• A forum for identifying and dealing with problems and obstacles - demands candid exchange of views and perspectives focused on resolution of problems, not re-running old debates.

Markers for success 4• Balance of power and engagement - not dominated

by any one organisation, sector, professional group or interest.

• Stakeholder support, engagement and participation - encouraged and reciprocated, real influence, perspectives valued, interests acknowledged.

• Demonstrable progress, generation and maintenance of momentum - evidence that the approach delivers.

Emergency care networks - can be part of the solution if they:

• Ensure a focus on processes and pathways

• Act as a mechanism for systems, cultural, organisational and role change

• Are centred on development of collaborative, integrated models

• Do not retreat into organisational ghettos

Emergency care networks - can be part of the solution only if they:

• Ignite, develop and maintain passion and commitment to improving the patient experience

• Tap into strong, determined and visionary clinical leadership

• Develop and maintain a supportive and inclusive management style

• Deliver the broader engagement of frontline professionals into future planning and development

The reality on the ground

East Kent Hospitals TrustTypical Week Typical Week Week

ending

January 2002 January 2003 27 April 2002

Trolley Waits >12 hours 27 0 0

Trolley Waits >4 hours 83 9 0

Medical Outliers 98 38 33

Cancelled Operations 9 47 4

Delayed Discharges 88 73 26

WEST’s later findings on the emerging network...

• “.. [it] includes representation from all Health and Social Care Agencies helping to delivery emergency care and has rapidly developed a structure to enable future planning and investment to be properly integrated”

• “We see the development of the East Kent Emergency Care Network and the adoption of a similar model to discuss elective and out patient access across the health economy [now being implemented] as an innovative and pioneering way to translate the NHS plan into a truly integrated local strategy”

….and CHI’s view

• “.. The trust (EKHT) and staff members of the local health economy have worked to achieve major changes in how emergency care patients are treated and cared for within East Kent”

• “The East Kent emergency care network was established in January 2002 and brought together all health and social care organisations in East Kent…….Stakeholders repeatedly cited that the network has had a positive impact on encouraging the health economy to work together to resolve common healthcare issues”