Transforming Urgent and Emergency Care Services
in England
Improving referral pathways between urgent
and emergency services in England
Advice for Urgent and Emergency Care Networks
NHS England INFORMATION READER BOX
Directorate
Medical
Nursing
Finance
Commissioning Operations
Trans. & Corp. Ops.
Publications Gateway Reference:
Patients and Information
Commissioning Strategy
04075
Document Purpose
Guidance
Document Name
Improving referral pathways between urgent and emergency services in
England
Author
Urgent and Emergency Care Review Programme Team
Publication Date
November 2015.
Target Audience
CCG Clinical Leaders, CCG Accountable Officers, Care Trust CEs,
Foundation Trust CEs , NHS England Regional Directors, NHS England
Directors of Commissioning Operations, Emergency Care Leads,
Directors of Children's Services, NHS Trust CEs, System Resilience
Groups; Urgent and Emergency Care Networks
Additional Circulation
List
CSU Managing Directors, Medical Directors, Directors of Nursing,
Local Authority CEs, Directors of Adult SSs, NHS Trust Board Chairs,
Directors of Finance, GPs, Special HA CEs
Description
This document is designed to help Urgent and Emergency Care (UEC)
Networks and System Resilience Groups (SRGs) to improve the flow of
patients and information within the urgent and emergency care system
by supporting an enhanced and consistent approach to the referral of
patients between healthcare professionals and providers.
Cross Reference
Superseded Docs
(if applicable)
Action Required
Timing / Deadlines
(if applicable)
Contact Details for
further information
Revised planning guidance for 2015/16; Five Year Forward View
N/A
Best practice
N/A
england.urgentcarereview@nhs.net
0
0
Document Status
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the intranet is the controlled copy. Any printed copies of this document are not controlled. As a
controlled document, this document should not be saved onto local or network drives but should
always be accessed from the intranet.
2
Document Title: Improving referral pathways between
urgent and emergency services in England
Subtitle: Advice for Urgent and Emergency Care Networks
Version number: FINAL 1
First published: November 2015
Updated: (only if this is applicable)
Prepared by: UEC Review Team
The National Health Service Commissioning Board was established on 1 October
2012 as an executive non-departmental public body. Since 1 April 2013, the National
Health Service Commissioning Board has used the name NHS England for
operational purposes.
Equality and Health Inequalities
Promoting equality and addressing health inequalities are at the heart of NHS
England’s values. Throughout the development of the policies and processes cited in
this document, we have:

Given due regard to the need to eliminate discrimination, harassment and
victimisation, to advance equality of opportunity, and to foster good relations
between people who share a relevant protected characteristic (as cited under the
Equality Act 2010) and those who do not share it; and

Given regard to the need to reduce inequalities between patients in access to,
and outcomes from healthcare services and to ensure services are provided in an
integrated way where this might reduce health inequalities.
Urgent and Emergency Care Networks are reminded to pay due regard to the two
duties above when this guidance is implemented locally.
Information Governance
Safe and efficient patient care requires effective, timely and appropriate transfer of
key information that follows the patient through the healthcare system. This is
particularly important in the urgent and emergency care system where, by definition,
the patient is accessing care from outside of their routine care providers.
The informed consent of patients should normally be sought and obtained before
accessing or sharing information about them. This informed consent needs to ensure
that the patient understand who will access their data and for what purposes. If they
are adults and lack the capacity to make these decisions, those decisions should be
3
made in their best interests in accordance with the Mental Capacity Act 2005 and its
Code of Practice.
If they are children aged under 16, those decisions should be made by someone with
parental responsibility for them, unless they are Gillick competent and, after applying
the Fraser Guidelines it is best interests to respect their decision. If they are children
aged 16 or 17, the principles set out in paragraph 12.13 of the Mental Capacity Act
Code of Practice should be followed.
The wishes of children (and those with parental responsibility for them) can/should be
overridden in their best interests to save them from significant harm; the wishes of
adults with capacity cannot be overridden unless overriding their wishes may prevent
serious crime Significant abuse or neglect are/may be crimes.
All of the above is subject to what might happen in an emergency when people
cannot make, or cannot properly be expected to make, decisions. When that is so, all
decisions to do with their immediate care and welfare should be made in their best
interests in accordance with chapter 5 of the Mental Capacity Act Code of Practice.
4
Contents
1
Document summary ............................................................................................ 6
1.1
1.2
1.3
1.4
1.5
1.6
Transforming urgent and emergency care services in England ..................... 6
Purpose ......................................................................................................... 7
Audience ....................................................................................................... 7
Structure ........................................................................................................ 7
How it will be used ......................................................................................... 8
Clinical governance ....................................................................................... 8
2
Introduction.......................................................................................................... 9
3
Description of the proposed changes ................................................................ 10
3.1
4
How this works in practice: ................................................................................ 11
4.1
4.2
4.3
4.4
5
HealthPathways .......................................................................................... 11
The Initial Response Service ....................................................................... 12
Paramedic Pathfinder .................................................................................. 13
Direct referral to a diabetic specialist nurse team ........................................ 14
Implementation .................................................................................................. 15
5.1
6
Guidance on referrals across the UEC system ............................................ 10
Principles of enhanced referral .................................................................... 15
Benefits ............................................................................................................. 16
6.1
6.2
Benefits to the system ................................................................................. 16
Benefits to the patient .................................................................................. 16
7
Summary and Conclusion ................................................................................. 17
8
Appendix 1: Case illustrations ........................................................................... 18
Case 1................................................................................................................... 18
Case 2................................................................................................................... 18
Case 3................................................................................................................... 19
5
1 Document summary
1.1 Transforming urgent and emergency care services in England
The NHS Five Year Forward View (5YFV) explains the need to redesign urgent and
emergency care services in England for people of all ages with physical and mental
health problems, and sets out the new models of care needed to do so. The urgent
and emergency care review (the review) details how these models of care can be
achieved through a fundamental shift in the way urgent and emergency care services
are provided to all ages, improving out-of-hospital services so that we deliver more
care closer to home and reduce unnecessary hospital attendances and admissions.
We need a system that is safe, sustainable and that provides high quality care
consistently. The vision of the review is simple:

For adults and children with urgent care needs, we should provide a highly
responsive service that delivers care as close to home as possible, minimising
disruption and inconvenience for patients, carers and families.

For those people with more serious or life-threatening emergency care needs, we
should ensure they are treated in centres with the right expertise, processes and
facilities to maximise the prospects of survival and a good recovery.
As part of the review, a number of products are being developed to help create the
conditions for new ways of working to take root and when combined, deliver an
improved system of urgent and emergency services. The review proposes that five
key changes need to take place in order for this to be achieved. These are:

Providing better support for people and their families to self-care or care for their
dependants.

Helping people who need urgent care to get the right advice in the right place, first
time.

Providing responsive, urgent physical and mental health services outside of
hospital every day of the week, so people no longer choose to queue in hospital
emergency departments.

Ensuring that adults and children with more serious or life threatening emergency
needs receive treatment in centres with the right facilities, processes and
expertise in order to maximise their chances of survival and a good recovery.

Connecting all urgent and emergency care services together so the overall
physical and mental health and social care system becomes more than just the
sum of its parts.
NHS England is collaborating with patients and partners from across the system to
develop a suite of guidance documents and tools to promote best practice and
6
support commissioners and providers in achieving a fundamental shift towards new
ways of working and models of care. These guidance documents are being
developed as a suite entitled ‘Transforming Urgent and Emergency Care Services in
England’ and are designed to be read together. The suite comprises the following
components:

Role and establishment of Urgent and Emergency Care Networks (UECNs),
published June 2015.

Clinical models for ambulance services.

Improving referral pathways between urgent and emergency services in England.
(This document.)

Safer, faster, better: good practice in delivering urgent and emergency care’,
published August 2015. This good practice guide focuses on the safe and
effective care of people with urgent and emergency health problems who may
seek or need specialist hospital based services.

Urgent and emergency care: financial modelling methodology.
Other products to support include a Directory of Services (DoS) – a tool to include all
available services that can be referred to, and Commissioning Standards for
Integrated Urgent Care (that includes the NHS 111 contact number), which has been
published, as well as its supporting documents, to be published. These will include
the Integrated Urgent Care Payment annex; Integrated Urgent Care Contract
Alignment Plan; NHS England Integrated Urgent Care (NHS 111 Telephony) National
Business Continuity Policy; Procurement Guidance and Integrated Urgent Care
Model (Financial Model Tool).
1.2 Purpose
This document is designed to help UECNs to improve the flow of patients and
information within the urgent and emergency care system by supporting an enhanced
and consistent approach to the referral of patients between healthcare professionals
and providers.
1.3 Audience
This document is intended to be used by UECNs. It provides advice for
commissioners on the benefits of enhancing referrals within the urgent and
emergency care system, and advice for providers on good practice and how this
might be implemented, understanding that this will also be determined by local need.
Membership of UECNs is outlined in the Role and Establishment of Urgent and
Emergency Care Networks.
1.4 Structure
The document begins with an introduction explaining why the move to a more
cohesive and integrated approach to the delivery of care is desirable, and how
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different parts of the health service can collaborate to deliver this. It goes on to
describe the proposed changes in patient referral across the urgent and emergency
care system, and the benefits of implementing these changes.
1.5 How it will be used
The 5YFV emphasised the importance of how we will increasingly need to manage
health care systems through networks of care; not just by, or through, individual
organisations. UECNs are expected to define consistent pathways with equitable
access across urgent and emergency care. Commissioners should utilise the
principles outlined in this document, tailoring them to meet local need as identified by
the networks across England.
1.6 Clinical governance
At an operational level, the patient pathways described under each service
specification will define clinical accountability according to the patient’s needs and
their referral pathway.
8
2 Introduction
The demand for urgent and emergency care has increased significantly over the last
decade. Patient attendance at hospital Emergency Departments (EDs) has increased
by more than two million, to 16 million annually, and emergency admissions to
hospitals have increased by 31%. Attendance at walk-in centres and minor injury
units has increased 12% annually, and the number of 999 calls to the ambulance
service has increased from 4.9 to 9 million calls per year. As the population is living
longer, and has increasingly complex medical needs, this demand is only predicted
to increase.
The annual cost to the NHS of admissions for conditions that are appropriate for
ambulatory care was estimated to be £1.42 billion in 2009/10, and accounted for
15.9% of all emergency admissions to hospital.1 Many patients who seek emergency
input from the NHS111 and ambulance services with ambulatory care sensitive
(ACS) conditions would benefit from referral to more appropriate care pathways
without admission to hospital.2 There is emerging evidence that the 999 activity of
patients on clinical registers is predictable, and access to data and appropriate and
expedient care can reduce conveyance by over 20%. In 2010, in the North West
alone, more than 18,000 chronic obstructory pulmonary disease (COPD) patients
who accessed urgent and emergency care were admitted to hospitals, of which
11,000 could have been treated in their community via primary and community
services. 3
Additionally, mental illness is estimated to be the primary cause of around 5% of ED
attendances, and alcohol-misuse a further 10%. 4
It is estimated that there are around 150,000 hospital attendances for self-harm each
year. Approximately 90% of these patients have a diagnosable mental health
condition.4 Often, the physical symptoms are treated without managing the underlying
mental health problem resulting in future multiple attendances.
At present ambulance and other urgent care professionals are not uniformly
empowered to refer patients to community or specialist services. Urgent Care
Centres (UCCs) frequently do not permit paramedics to refer patients to them on the
assumption that the ambulance service does not deal with minor injuries,3 and
hospitals, in turn, may not accept referrals from non-medical healthcare professionals
working in UCCs.
Paramedics report that an absence of appropriate referral pathways can lead to
duplicated and unnecessary activities which consume time and resources, reduce
1
Tian, Y, Dixon A, Gao H. Emergency hospital admissions for ambulatory care-sensitive conditions. Data briefing. Kings Fund. 2012. Available at
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/data-briefing-emergency-hospital-admissions-for-ambulatory-care-sensitive-conditions-apr-2012.pdf
2 Paramedic Pathfinder and Community Care Pathways, North West Ambulance Service NHS Trust. Last accessed 30/7/15. Available at
https://www.nwas.nhs.uk/DownloadFile.ashx?id=286&page=16586
3 Health Committee. Written evidence from the College of Paramedics (ES 17). May 2013. Last accessed 30/7/15. Available at
http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/171/171vw13.htm
4 Liaison Psychiatry in the Modern NHS, Centre for Medical Health (2012) Available at:
http://www.centreformentalhealth.org.uk/publications/liaison_psychiatry.aspx?ID=665
9
efficiency and almost certainly affects patient perceptions of a joined-up NHS.3
3 Description of the proposed changes
3.1 Guidance on referrals across the UEC system
In order to facilitate an improved flow of patients and information within the UEC
system, all registered health and social care professionals within physical and mental
health (referred to in this document using the general term ‘practitioner’), following
telephone consultation or face-to-face contact with a patient, should be empowered,
based on protocols developed and agreed locally, to make direct referrals and/or
appointments for patients with:
 The patient’s registered general practice or corresponding out of hours
(OOH) service;
 Urgent Care Centres;
 Emergency Departments in Emergency Centres and in Emergency Centres
with Specialist Services;
 Mental health crisis services and community mental health teams;
 Specialist clinicians, if the patient is under the active care of that specialist
service for the condition which has led to them accessing the urgent and
emergency care system.
UECNs are encouraged to define the exact referral pathways available to each
professional working within their network. The underpinning documentation to
support this proposed change is described further in Commissioning Standards
Integrated Urgent Care (for NHS 111 services).
The diagram below illustrates what a functionally integrated urgent care service
including an urgent care clinical hub might look like:
10
This integrated care model is also described in more detail in Commissioning
Standards - Integrated Urgent Care (for NHS111 services).
4 How this works in practice:
4.1 HealthPathways
Developed in 2008 in Canterbury, New Zealand, HealthPathways is described as the
‘most innovative and most effective’ change to the health and social care system.5
Essentially, HealthPathways are local agreements on best practice whereby hospital
doctors, GPs, nurses and allied health professionals have designed patient pathways
and treatment plans in cohesion. These are managed within the community and
incorporate guidelines on referrals, available resources for GPs to avoid unnecessary
referrals and indicate suitable tests to be conducted before making a referral either in
the community or to a hospital.
5 The quest for integrated health and social care - A case study in Canterbury New Zealand. Timmins, N & Ham, C (2013) Available at:
http://www.kingsfund.org.uk/blog/2013/09/right-track-how-healthpathways-are-improving-care-canterbury-new-zealand
11
Canterbury has more than 480 pathways which are routinely reviewed every year
and regularly audited. Referrals are directed through an Electronic Shared
Management System which is used to request tests as an outpatient, to make
community assessments and to request specialist advice.
An Acute Demand Management System (ADMS) has been implemented which
provides general practice with a support structure for patients who may need medical
support but otherwise do not need to be referred to a hospital. It also offers support
for the hospital to refer patients from the emergency department to more appropriate
settings, thereby benefiting patients who require tests or observation but do not
require admission to hospital. As a result patients can be managed close to home
where it is safe and appropriate to do so.
How the ADMS works in practice – an example
A specific programme for COPD was introduced after analysis showed that once
patients reached the emergency department they had very high admission rates.
Patients are given care plans and something as simple as a fridge magnet which has
their normal oxygen saturation and exercise tolerance on it. This allows the
ambulance service to know what is ‘normal’ for the patient, so that – supported by
telephone access to a respiratory physician – paramedics can decide whether the
patient needs to go to the emergency department or can be managed in the
community by the GP or by acute demand management. In the winter of 2012,
Canterbury estimates that some 40 per cent of COPD patients who would previously
have been taken to the emergency department were diverted to other forms of care’.6
Other innovative changes include an Electronic Shared Care Record View (eSCRV),
a 24 hour General Practice service where GPs responsible for out of hours care work
alongside a nurse triage system, and a number of centers that have extended
opening hours. A falls management system has been implemented, as has a
pharmacy-linked medication management system which conducts a review of
patients prescribed multiple drugs.
Results
Canterbury demonstrates low rates for acute medical admissions compared to other
health boards in New Zealand. Its average length of stay is low, and its acute
readmission rate is also low.
These innovations have led to a demonstrably reduced demand on hospital
resources and a flattening and reduction of the demand curve across health and
social care, due to improved integration between hospital, primary care and
community services.
Overall this has resulted in better and more integrated care for patients, resulting in
‘the right care in the right place at the right time’.
4.2 The Initial Response Service
12
Northumberland Tyne and Wear NHS Foundation Trust have implemented an
assessment response team providing a single entry point for patients with mental
health issues via a 24/7 telephone line. The service provides advice for patients on
their current presentation and allows referral into other services so that patients can
access the right care for their needs, without the need to default to Accident and
Emergency Departments. The service also provides advice to General Practice on
presenting patients, so GPs feel better supported in managing patients with mental
health issues.6
Nurses triage through telephone consultation. This results in a clinical decision,
identifying the most appropriate intervention for the individual which could be:




Referral to rapid response for face to face triage; home visits undertaken within
one hour;
Referral to GP services to manage presenting symptoms;
Referral to existing Crisis Resolution and Home Treatment Teams for crisis
management;
Simply providing telephone advice on managing the current situation.
Staff meet daily to discuss patient referrals, which enables the large proportion of
referrals that are not urgent or in mental health crisis to be booked into the most
appropriate outpatient service or proceed with an agreed management plan.
Results
Following implementation of the assessment response team, the Trust report:




100% of service users surveyed reported satisfaction with the response and
would recommend the service to a friend;
A reduction in the number of urgent calls to the ambulance service, improved
response times from the Crisis Team and a reduction in four-hour breaches;
Reduced avoidable harm due to reduced referrals ‘bouncing’ around the system;
100 per cent of GPs said their calls were answered quickly and the team met their
needs.
4.3 Paramedic Pathfinder
The North West Ambulance Service (NWAS) implemented Paramedic Pathfinder in
2012. Based on the Manchester Triage System, Pathfinder is a consistent and
clinically safe triage system to enable accurate face-toface assessment of individual
patient needs on scene, identifying the most appropriate care pathway for that
patient. This initiative has been adopted by several UK Ambulance Trusts and has
enabled NWAS to increase safe care closer to home by over 10% in 3 years. 7
Pathfinder will generate one of four key outcomes which stream and direct patients
based on their care needs, including:
6 The Initial Response Service, Northumberland Tyne and Wear NHS Foundation Trust. Available at: www.nhsiq.nhs.uk/media/2422305/northumberlandtyne_cs_final.pdf
7
Paramedic pathfinder and community care pathways. Available at http://www.nwas.nhs.uk/DownloadFile.ashx?id=286&page=16586 and
http://www.nwas.nhs.uk/professionals/paramedic-pathfinder/#.Vegi8aHTU-I
13




Emergency department;
Urgent care centre;
Community or primary care pathways;
Self-care.
Community Care Pathways (CCPs) are one of the clinical outcomes linked to the
Paramedic Pathfinder. Each individual care plan will enable ambulance paramedics
to access the most effective referral and treatment option for known patients. The
community care plans are prepared by the patient’s ‘case worker’ or lead clinician
and are an effective alternative pathway of care for patients with long term conditions
that enables paramedics to identify when referral to expert community teams may be
a better option for the patient.
GP Referral Scheme in Paramedic Pathfinder
In 32 of the 33 Clinical Commissioning Groups (CCGs) across the North West,
ambulance crews have access to a GP via a GP Referral Scheme, with patient
consent, to establish if the patient is safe to be left at home, requires a GP visit or
should be transported to the ED. Over the past 12 months this has greatly increased
the proportion of patients successfully managed using a “See and Treat” model of
care.
The GPs have been funded by the local CCG, as an ED avoidance scheme. The
results show that in little over a year, almost 30,000 ED attendances have been
avoided, with financial savings noted in both ED attendances and acute admission
costs.
4.4 Direct referral to a diabetic specialist nurse team
A direct referral pathway for acute hypoglycaemic events, where patients are referred
directly to a diabetic specialist nurse (DSN) by the ambulance service, has been
trialled in West Yorkshire.8
Patients with acute hypoglycaemia for whom an ambulance has been called are
assessed and treated on scene by the ambulance service, rather than being
transported to an ED or UCC.
Patients are referred directly by ambulance staff to the DSN team, who contact the
patient via telephone within 7 days.
Results
The DSNs arranged for 76% of referred patients to be reviewed in clinic; all were
provided with patient education regarding hypoglycaemia and over half had their
medications altered.
Following contact and review by the DSN team:
8 Walker A, James C, Bannister M, Jobes E. Evaluation of a diabetes referral pathway for the management of hypoglycaemia following emergency contact with the
ambulance service to a diabetes specialist nurse team. Emerg Med J 2006;23:449-451
14


88% of patients reported in a post-treatment survey that their understanding of
hypoglycaemia had improved;
73% of patients felt more able to self-manage any future hypoglycaemic
episodes.
Overall patient satisfaction with the care pathway and the care they had received was
high.
5 Implementation
Successful implementation of this guidance should be supported by the local
development of direct community and acute specialist referral pathways to enable
safe and effective onward care to be reliably achieved as an alternative to ED
presentation and emergency hospital admission.
Appropriate clinical and information governance arrangements will need to be
established, and it is suggested that governance and responsibility rests with the
referring practitioner until the referral has been accepted by the receiving practitioner,
at which point governance and responsibility transfers.
Successful implementation is also dependent on the development of a trusting,
reciprocal arrangement between composite parts of the UEC system. Practitioners
will need to be able to trust the referrals from other health and social care
professionals without the need to re-triage.
To facilitate a process of continuous quality improvement, and to provide education
for those who refer, an enhanced feedback loop should be established. This will
provide the practitioners who receive referrals with access to a method of feeding
back to a named practitioner in the referring service.
To achieve this, a senior member of clinical staff with clinical governance
responsibilities should be nominated in each referring service (e.g. ambulance trust,
NHS 111 provider, etc.) to act as an accessible point of contact for collating and
responding to this feedback, and introducing any education and system changes that
are required in response to the feedback received.
In some instances a “trusted assessor” model may be implemented that, by pathway,
provides senior clinical expertise and authority to support practitioners operating
within that care pathway and also offers expert clinical assurance for practitioners,
patients and relatives.
This will help to build confidence in the enhanced referral pathway, and ensure it can
be subject to regular audit and review.
5.1 Principles of enhanced referral
Nothing in this guideline is intended to replace the primacy of general practice in
coordinating care and referral to specialist services.
15
The referring practitioner must assess the patient either over the phone or in person
prior to initiating any onward referral.
Patients can only be referred to hospital specialists when they are under the active
care of that specialist team for the condition that has led them to contact the urgent
and emergency care system.
The timing of any referral should be proportionate to clinical urgency. In many cases
the utilisation of the expertise within an urgent care clinical hub may help to assess
and prioritise referrals, thereby preventing system overload.
6 Benefits
6.1 Benefits to the system
The benefits to the system of adopting an enhanced and consistent approach to the
referral of patients include:







Enabling health and social care professionals to enact previously agreed care
plans, by removing potential referral barriers in the system. This reduces pressure
on EDs and acute hospital beds by offering access to alternative services and
pathways of care. It also reduces the use of ED as a “default service” or “safety
net” when other services prove inaccessible.
Management of patients within community care settings enables emergency
resources to be more available and responsive to life threatening emergencies.
Enabling patients with presenting mental health issues to be seen by mental
health services at an earlier point, which can significantly improve chances of
recovery.
Financial savings may be significant, and a direct result of a reduction in ED
attendance and emergency admissions, particularly for patients with care plans.
Examples of this can be seen in Kirklees and Warrington where admissions for
patients with a current care plan are 50% lower than pre-care plan9.
Up to 40% reduction in conveyance to the ED as a result of paramedic pathfinder.
60% reduction in 999 calls for those patients with an active care plan.
Avoiding ‘duplication of effort’; for example when the patient is assessed by
multiple services before reaching a point of definitive care.
NHS England will be releasing in the later part of the year an Urgent and Emergency
Care Review financial modelling methodology document – this document will provide
further guidance for localities on how they can model and understand the potential
financial implications of improving referral pathways.
6.2 Benefits to the patient
The benefits to the patient include:


9
Avoiding unnecessary and inappropriate delays to the appropriate care;
Avoiding duplication of assessment and additional steps in the urgent care
https://www.nwas.nhs.uk/DownloadFile.ashx?id=286&page=16586
16



pathway that add no value to the patient;
The patient can be guided towards the most appropriate care destination
directly, by overcoming unnecessary referral restrictions and integrating
elements of the urgent and emergency care system;
Where the patient requires follow-up with a specialist service to which they are
already known, this can be arranged directly in a timely way;
Access to community care for patients who require it, such as district nursing
care, community physiotherapy or review by a falls team.
7 Summary and Conclusion
This guideline describes the principles underpinning a system of enhanced referral
and improved patient pathways achieved by removing unnecessary blockages and
reducing duplication in the urgent and emergency care system.
Clear and consistent feedback mechanisms are required to support this
recommended service development and ensure a process of continuous quality
improvement supported by education and audit.
17
8 Appendix 1: Case illustrations
Case 1
ST is a nine year old child who has brittle asthma. He has previously been
hospitalised on a number of occasions due to his severe and recurrent attacks. ST
has regular review appointments at his local hospital in a specialist paediatric
asthma clinic.
It is Monday morning, and ST’s mother has observed deterioration in his condition,
which has worsened further over the weekend. She dials 111 and is connected to a
children’s nurse, working in an urgent care clinical hub. The nurse is able to assess
ST’s condition over the telephone and assess the acuity of his attack. The nurse and
ST’s mother agree that he does not need immediate hospital admission, but further
specialist input is required.
The nurse is able to refer ST directly to the inpatient specialist team, who arrange to
see ST at the hospital outpatient clinic that afternoon.
ST is seen within four hours of the 111 call by a consultant paediatric respiratory
physician who prescribes a high dose of oral steroids and modifications to ST’s
inhalers that rapidly improve his breathing. ST’s condition settles, and he is able to
return to school the next day, avoiding a hospital admission.
Case 2
JN is an 80 year old lady who lives in sheltered accommodation; she uses her
emergency call bell after falling at home. When the paramedics arrive they find her
on the floor, shaky and upset, with some bruising to her right shoulder. The
paramedics help JN to her feet, and are able to assess the need for hospitalisation
based on the injuries sustained and agree that clinically, admission to hospital is not
required. The paramedics treat JNs physical injuries in her home, avoiding the need
for transfer to hospital.
The paramedics note that JN is taking medication to lower her blood pressure, and
with her consent refer her to her GP for follow up. The referral includes a request for
a review of her current medication
The paramedics recognise JN’s anxiety regarding her fall, and that she is at risk of
further falls. With JN’s consent they refer her to the local falls team who arrange to
visit JN at home in two days’ time. The community falls team develop a personalised
treatment plan with JN, which includes an exercise programme and advice on how
to complete everyday tasks more safely. JN reports that her confidence has
increased, and that her independence is improved as a result.
JN has avoided a hospital visit and her risk of further falls; injury and hospital
admission are substantially reduced as a result of these referrals.
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Case 3
KR is a 47 year old man with schizophrenia who moved to new accommodation
several months ago. He was unable to find a practice that would register him and
lost contact with his community psychiatric nurse (CPN), and was unable to access
his antipsychotic medication. Since then he has become progressively more
withdrawn, and has been seen by his new neighbours to be muttering to himself.
KR calls NHS111 with a sore throat, which he feels has been caused by poisons
that his neighbours are concealing in his food. His call is transferred to a mental
health nurse, who establishes KR’s mental capacity and with his consent is able to
access his electronic summary care record and confirm his history of schizophrenia
and usual medication list. The nurse also establishes that KR has not been to a GP
for a prescription of his medication for some time, and has lost contact with
specialist mental health services.
The nurse provides advice to KR regarding his presenting minor illness, and with
his consent is able to refer him directly to the local mental health crisis home
treatment team. He is seen by the crisis team that afternoon, and is restarted on his
medication, which has been dispensed by his GP pharmacy. The crisis home
treatment team see him daily for 2 weeks, help him register with a practice and
allocate a new accountable care coordinator. This CPN arranges to review him
regularly, and his symptoms improve over the next few weeks.
The prompt involvement of mental health services through a direct referral pathway
means that KR’s mental health issues are addressed swiftly, and this prevents him
from deteriorating to a point where an acute mental hospital admission is required.
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