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As the NHS restores and resets following phase one of the response to COVID-19, it has the chance to look at lessons learnt from March and April 2020 to see if they hold the key to the future shape of urgent care.
A seminar hosted by KSS AHSN on 26 May gave colleagues from Surrey Heartlands a chance to hear how Denmark has changed access to urgent care in ways which provide timely care, manage demand and retain the support of the public.
“We have longstanding links with Denmark who have a population with similar challenges. Nationally their approach has been very similar to the NHS: integration, collaboration, and the increased use of technology.” – Guy Boersma, MD of KSS AHSN.
The rise of digital
COVID-19 has seen both citizens and health and care services adapt rapidly to new circumstances. Some of the most visible and striking changes have been in access to care. Digital solutions have enabled primary care to switch to online and video consultations – changes which seem to have been accepted by patients. Equally significant, citizen behaviour has also changed, with far fewer people accessing care by attending an A&E department.
Claire Fuller, Senior Responsible Officer, Surrey Heartlands Health and Care Partnership, summarises the change:
“COVID has meant that we have approached healthcare in a very different way in the UK, moving to Digital First and phone triage in primary care. We are very determined in Surrey Heartlands to explore how we can use the momentum of recent change to build a system that’s even better adapted to people’s needs, reaches everyone who needs our support, and empowers people to be more in control of their own health and well-being.”
We do not yet know what impact this has had on people’s health. Although some people will have self-treated or got the care they needed elsewhere, there may be others who simply did not access care when they needed it. It also remains to be seen if the changes in public behaviour and expectations will continue.
Now is the time to focus on how the health and care sector can work with staff, patients and the public to sustain the best of COVID-19-related innovations and initiatives into everyday practice that improves care and citizen experiences.
How can we avoid going back to the old ways? The Danish approach may offer some clues.
April A&E attendances lowest on record
A&E attendances and emergency admissions to hospitals in England have fallen to their lowest figure on record in the face of coronavirus. Data published in May by NHS England shows 0.92 million A&E attendances were recorded in April 2020, down 57% from 2.11 million in April 2019. The number is the lowest for any calendar month since current records began in August 2010.
Delivering healthcare in a different way
One of the biggest differences between the NHS and the Danish health system is how people access urgent care.
Denmark used to experience the same difficulties as we see here in terms of increasing A&E attendances, long waiting times in A&E and a rising number of unplanned admissions. The decision was taken to reduce the number of hospitals with A&E departments and to centralise specialist care on a small number of acute sites.
The reduction in the number of hospitals with emergency departments is part of a much wider project that involves new hospital builds, completely re-designing the urgent care pathway and working with citizens to change the way they access the emergency department.
Hans Erik Henriksen, CEO at Healthcare DENMARK, believes that for both Denmark and the NHS, there are five predominant forces influencing healthcare:
▒ The population growing older
▒ More patients with chronic disease
▒ Patients who are better informed
▒ The drive for innovation, and
▒ New technology.
Within this context, and as part of a major overhaul of healthcare provision, Denmark began a hospital construction programme in 2012 that’s not due to complete until 2025. Although having the right hospitals is crucial, solving the healthcare challenges is much more than just being about buildings. Hans summaries the Danish approach: “The problem cannot be solved just by building new hospitals. We need to deliver healthcare in a different way, we need to rely more on primary care and outpatient clinics, because that’s the only sustainable way to handle the increase in demand.”
So what does that different way look like?
Nationwide system transformation
Denmark is on a radical journey to re-structure its healthcare. The number of hospital sites will reduce from 79 in 2007 to 53 by 2025 as services become concentrated in larger units. The number of hospitals with emergency departments has already reduced from 45 in 2005 to 21 in 2018.
Making these changes work, so that patients can access the care they need when they need it, has required significant system change within the new hospital landscape. It has also needed government backing and investment of over £6bn to fund the new hospital building programme.
The ‘joint emergency department’ model
As the number of acute care hospitals reduces from 45 to 21, a “joint emergency department” has been created at each one. The joint emergency department manages patient flow promptly by putting the emergency care specialist at the front door, backed by new technology and implementing a “flowmaster” role.
The flowmaster uses real-time capacity management information to manage the work of the whole joint emergency department. Options open to the flowmaster include providing patients with:
▒ GP appointment
▒ Next day hospital outpatient appointment
▒ Community outreach service
▒ A&E appointment.
Citizens who present at A&E are redirected to the triage telephone system. If they need face to face secondary care treatment, they are offered an appointment. There are video links for remote consultations.
Prof. Mikkel Brabrand, A&E consultant in Southern Denmark’s university hospital, says that the joint emergency department works by bringing together experts in Emergency Medicine, Orthopaedics, Neurology, General Surgery and Urology, with separate assessment units for Cardiology, Obstetrics, Oncology, Haematology and Paediatrics. There is active bed and patient management, with senior staff ‘at the front door’. Capacity conferences happen twice per day.
According to Mikkel, there are a number of factors which contribute to the success of this model on the frontline:
▒ The importance of close collaboration with GPs
▒ The need to empower ambulances to navigate to the best destination for patients
▒ The need for relentless focus on bed management and escalation/de-escalation, and
▒ Recognition that the IT systems and the ‘flowmaster’ role are key.
The seamless flow of patient information is a crucial component that underpins the whole model.
The eight hour window
Technology plays a vital part in enabling this to work. The Danish model includes point of care testing in ambulances, electronic health records available in ambulances and A&E departments, real-time waiting times information on the citizen app, and real-time capacity management information for managers.
Mikkel Jacob is CEO of health technology company Systematic who provide some of the technology in the joint emergency department. He describes the aim when an admission is needed as being to put “the right patient, in the right bed, at the right time, and with the right care team.”
He sees the role of the technology at any given point as focusing on the next eight hours, so that staff can make “sensible decisions on things that will happen in the near future”.
The Danish story shows how planned change, with the right technology, and supported by citizens, can result in transformational change at system-wide scale.
Is now the moment for a new approach to urgent care for the NHS?
The acceleration of digital adoption
The NHS Long Term Plan signalled the intention to move towards digital first primary care and progress has accelerated rapidly during the pandemic.
Since March, as part of the response to the COVID-19 outbreak, KSS AHSN has supported an increase in access to online consultation (OC) and video consultation (VC) in primary care across the region. Between April 2 and June 28, OC availability increased from 281 practices (58%) to 796 practices (91%), and VC availability increased from to 418 practices (86%) to 862 practices (99%).
The new reality
COVID-19 has forced the health and care system in the UK to accelerate its adoption of digital enablers. It has also ignited thinking about the relationship between statutory bodies and their communities, with wider acceptance of the reality that the NHS and social care can’t do everything.
This brings two of the building blocks in the Danish model much closer. It means that the NHS can look again at urgent care from a very different place to just a few months ago. There is momentum for change, is now the moment to make it happen?
▒ For further information on system change in Denmark, read Healthcare DENMARK’s White Paper on emergency medical services.
▒ Pre-hospital treatment is an important part of the Danish healthcare system and combining technology with a patient-centred focus for treatment during the ambulance journey to hospital: watch the video
▒ Read more about the spread of Digital First in primary care in Kent, Surrey and Sussex
▒ Or speak to Guy Boersma, Healthcare DENMARK’s UK Ambassador and Managing Director, Kent Surrey Sussex Academic Health Science Network