Annual Report 2014 - Reporting on the Quality and Efficiency Support Team

Part 03: QuEST Portfolio Office

ABOUT THE PROGRAMME

Shona Cowan
t: 0131 244 6911
e: shona.cowan@scotland.gsi.gov.uk

drivers

The QuEST Portfolio Office (QPO) ensures the efficient coordination and focus of a range of projects across QuEST programmes.

aims

The QPO supports improved service delivery in NHSScotland by providing a national overview of quality, efficiency and value across all NHS Boards and programmes.

workstreams

• Design programme and project management resources that can be flexed across our Programmes of work to ensure that priorities are met and resources are standardised and utilised to best effect.
• Developing an approach to delivering improvements based on quality, efficiency and value, including innovative tools and resources. These are shared widely across our stakeholder groups and are made publicly available on the Quality Improvement Hub website.
• Identifying areas with the greatest potential productive opportunity through benchmarking, data analysis and application of health economic approaches to all improvement work.
• Coordinating networks across NHSScotland to encourage sharing of learning, resources and expertise.
• Identifying up to date research, capturing and sharing knowledge and learning, and spreading good practice.
• Participating in strategic partnerships such as the Quality Improvement Hub, the Joint Improvement Team (JIT) and the Quality Unit.

achievements 2014

In March 2014 the QPO delivered two regional QuEST roadshows in Edinburgh and Glasgow. These events provided NHS Boards with an opportunity to showcase their achievements and share their learning in relation to improving quality and efficiency.

The QPO led the refresh of the NHSScotland Efficiency and Productivity Framework through the development of the 2020 Framework for Quality, Efficiency and Value, a dynamic web‑based resource that provides practical tools and guidance to support NHS Boards.

The QPO has supported NHS Boards to develop their capacity and capability for continuous quality improvement through specific allocations ring-fenced for this purpose. NHS Boards are continuing to build their infrastructure for quality improvement through local quality improvement hubs and portfolio offices.

The QPO has contributed significant knowledge management resources to the Quality Improvement Hub website, including over 100 case studies, produced in partnership with NHS Boards. These case studies demonstrate how quality improvements and efficiency savings have been achieved.

The QPO continues to lead QuEST's involvement in the Quality Improvement Hub partnership.

The QPO has supported tests of change where these do not logically fit within one of the larger QuEST programmes, for example using health economics to quantify the benefits of improving diabetes care in Scottish hospitals.

Health economics can inform and improve decision-making about the allocation of scarce healthcare resources. The QPO in partnership with NHS Health Scotland has developed a Health Economics Network to facilitate collaboration between the health economics academic, policy and practice communities across Scotland to encourage the application of health economics evidence.

The QPO held a major event which focused on the use of data and information to drive quality, efficiency and productivity and brought together colleagues working in the fields of quality improvement, efficiency and productivity, health intelligence, health economics, finance, performance management and planning.

The Health Services Journal (HSJ) acknowledged the excellent work undertaken by QuEST and NHS Boards and QuEST was shortlisted for an HSJ Efficiency Award.

priorities 2015

In 2015 the QPO will:

• Identify and publish a range of quality and value case studies from across NHS Boards.
• Host a 'Business Case for Quality' event which will bring together a wide audience to identity priority projects for a pan-Scotland approach.
• Form a key part of the team QI Hub team progressing the NHS Board Quality Improvement Infrastructure visits.
• Support the development of the UK Improvement Alliance, a network of quality improvement organisations across the UK, taking the lead on Quality as a Business Strategy.

http://www.qihub.scot.nhs.uk/quality-and-efficiency/quality-efficiency-and-value.aspx

Programme Case Study

Health Economics Network for Scotland (HENS)

Background and context

Health economics can help to achieve value for money by informing and improving decision-making about the allocation of scarce healthcare resources. Population, preventive and healthcare interventions can all be prioritised through the analysis of their costs and benefits to increase the benefits achieved with the finite resources available.

In the current climate of tight public spending as well as policy emphases on prevention and shifting the balance of health and social care, there has been a renewal of interest in what health economics can offer public health and healthcare policy and practice in Scotland. However, the full potential of health economics to influence policy and practice has not yet been realised due in part to the need for stronger links between the producers and users of health economics evidence and analysis.

Problem

There is substantial health economics capacity in Scotland in academic departments, Scottish Government and NHS Boards. However, policy makers and practitioners often cannot or do not access this capacity when they need it. There are a number of issues that need to be addressed. These include:

• the availability, accessibility and relevance of health economics evidence
• skills and knowledge required to interpret available evidence
• differences in the priorities of academic, public health and health service organisations in relation to health economics.

The Health Economics Network for Scotland (HENS) is providing a forum for debating these issues and identifying solutions, a network for bringing users and producers of evidence together and, with resources from QuEST, funding activities that will address evidence and skills gaps.

Aim

HENS aims to facilitate collaboration between the health economics academic, policy and practice communities across the health and social care with a focus on:

• the shift to prevention and changes in the balance of health and social care
• improving quality, sustainability and effectiveness in healthcare services

Action taken

HENS is undertaking the following activities:

• Increasing existing capability for using health economics concepts, evidence and tools in the health and health care sectors in Scotland by funding training and development opportunities delivered by academic partners with health economics expertise
• Developing and supporting the evidence for, and application of, health economics approaches and tools through undertaking projects to test the collaborative approach and demonstrate how HENS should work
• Organising events to bring together producers and users of health economics evidence to discuss ways of promoting the translation of health economics evidence into practice
• Providing a forum on the Scottish Public Health Network (ScotPHN) for sharing knowledge and skills amongst HENS members.

HENS is led by a Steering Group, chaired by NHS Health Scotland and comprising members from ScotPHN, Scottish Government, NHS Boards (change and innovation, and public health), Glasgow Centre for Population Health and academia.

The network now comprises over 80 members from Scottish Government, NHS Territorial and Special Boards, universities and local government.

Results

It is too early to identify outcomes in the sense of improvements in the efficiency of resource use resulting from HENS. However, the actions taken highlight a number of outputs that have been produced or are currently being organised:

• An inaugural network meeting took place in February 2014 bringing together users and producers of economics evidence/analyses and identifying activities that users wanted HENS to undertake.
• A conference was organised for December 2014 bringing together users and producers of evidence to discuss the translation of economics evidence into practice.
• A forum has been established on a HENS website with papers and reports for discussion.
• Development opportunities for non-economics specialists to understand and apply economics evidence are being set up by the University of Aberdeen and the University of Glasgow.

These outputs have raised the profile of health economics and its potential to help with current resource allocation challenges. The network has increased engagement between academic producers and policy and practice-based users of economics evidence.

Staff experience

HENS has improved staff experience in the following ways:

• HENS has provided a forum for health economists and others to come together, creating a supportive environment for this group of professionals to discuss challenges and share learning
• The existence of HENS means that staff within NHS Boards requiring support in the practical application of health economics tools, techniques and evidence can now access guidance from professionals
• Academic partners have recognized the value of the network, engaging actively in planning and delivery of outputs to date
• Network members are actively engaging with the network

Efficiency savings and productive gains

Whilst it is too soon in the life of HENS to identify quantifiable efficiency gains from changes in work practices or business processes, it is anticipated that the network will help to support the more efficient use of health economics resources.

By sharing resources, knowledge and skills, and health economics evidence and analyses, HENS will help to reduce duplication and will support the 'Once for Scotland' agenda.

Sustainability

The emphases on networking and training are both aimed at sustainability. Health economics expertise is scarce - it is important that the results of health economics analyses are used as widely as possible to maximize their reach and impact in line with the 'Once for Scotland' agenda.

Better networking will help optimise the use of available health economics expertise by better matching demand and supply. Training opportunities will increase capacity to access, understand and use economics evidence.

Longer term, the aim of HENS is to contribute to the financial sustainability of the health and social care system by identifying more efficient approaches to prevention and by encouraging the use of health economics tools to inform shifts in resources into a more preventative health and social care system. By encouraging more consistent use of health economics evidence and tools, the aim is that efficient solutions will be identified and adopted more widely and consistently.

Lessons learned

Producers and users of economic evidence want the same thing - the efficient use of limited resources in health and social care - but they use different language to frame and answer questions about resource use and prioritisation. They also have different expectations regarding the use of economics evidence and tools. A key lesson from the HENS work so far is the importance of dialogue to narrow some of these differences, so that producers of evidence better understand what users want, and users of evidence better understand what producers are able and what they are incentivised to provide. A second lesson is that this takes time.

Next steps

A HENS event was held in December 2014. This event focused on how health economics can help meet current challenges in public health and health policy, including the shift to prevention and the reduction in health inequalities. The event used a number of case studies including economic analysis of public health measures such as smoking ban or minimum unit pricing.

Completion of the two test projects: Economics of Prevention and Programme Budgeting and Marginal Analysis (PBMA). The evidence and learning from these projects will be shared with the network and the broader health economics community.

HENS are working with the Health Economics Research Unit (HERU) at the University of Aberdeen to develop a course for healthcare planners, finance directors and other health care managers working in NHS Boards who have no prior experience in economic evaluation. The course will provide an introduction to the identification, appraisal and application of economic evaluation for policy-making in population health.

HENS are working with the Health Economics and Health Technology Assessment team at the University of Glasgow to design and deliver a professional development opportunity that will help participants identify and use suitable health economics tools for the translation of economic evidence into practice.

NHS Board Case Study

NHS Dumfries and Galloway

Area Clinical Activity Committee

Background and context

The Area Clinical Activity Committee (ACAC) was set up to review clinical effectiveness and possible over-treatment across both primary and secondary care, including mental health.

Problem

There has been increasing concern over recent years that not enough focus is applied to clinical effectiveness. Management traditionally ensures that clinical activity is delivered in a timeous way at the least possible cost - there is insufficient focus on whether the clinical procedures are effectively meeting patients' needs. Early evidence was provided to the Committee of over-treatment in terms of cataract removal, cystoscopy and upper GI (gastrointestinal) endoscopy. It was noted that the rate of cataract extraction was 80 per cent more than the Scottish average (even when weighted for age/sex distribution) and similar 'excess' activity was found in relation to cystoscopy, upper GI endoscopy and colonoscopy. While all of these procedures carry undoubted benefit for patients, they also all carry a degree of risk. Where the procedure is carried out at a low threshold there is a danger that the risk/benefit balance is tipped towards low benefit and the same degree of overall risk.

In addition, while there is evidence of overtreatment of some clinical issues, there is also evidence of under-treatment of other issues: It must be remembered that there is always an opportunity cost attached to any activity. In the case of ophthalmology there was evidence of an 'excess' of cataract extractions co-existing with extreme waits for patients requiring review of glaucoma - a sight-threatening condition.

Aim

The remit of ACAC was to ensure that sensible steps were taken to maximise clinical effectiveness by ensuring that evidence-based interventions were directed at those patients who would derive most benefit. In many cases this involved re-setting the clinical thresholds for the intervention. In addition, ACAC felt it appropriate to challenge various aspects of medical care with particular emphasis on the number of review appointments in secondary care, the number of new outpatient referrals from General Practitioners, and the number of emergency admissions to both medical and surgical specialties.

Action taken

• Reorganisation of minor surgery in General Practice, with elimination of procedures of limited clinical value
• Review of the threshold for removal of cataracts - threshold now 6/12 and agreed with all high street optometrists
• Review of arthroscopic wash-outs of the knee (no evidence of benefit)
• Tonsillectomy and adenoidectomy indications brought in line with SIGN guidelines resulting in significant decrease in activity
• Review of the rate of cystoscopic examinations: indications changed and intervals for review cystoscopy bought in line with best guidance
• Review of the high rates of colonoscopy procedures: review scopes now done in line with best guidance
• Review of the high rate of upper GI endoscopy: agreed referral protocol change so all patients treated for helicobacter prior to endoscopy consideration
• A pilot scheme in which 15 GP Practices agreed to review - by all partners - all referrals before they were sent to Dumfries and Galloway Royal Infirmary

Results

In most cases we have seen a positive result due to the interventions of the ACAC group - bringing performance closer to the Scottish average. This has reduced unwarranted interventions, reduced costs (e.g. extra scope lists at treble time) and helped address under-treatment - e.g. glaucoma.

Patient experience

The remit of ACAC was to ensure that sensible steps were taken to maximise clinical effectiveness by ensuring that evidence-based interventions were directed at those patients who would derive most benefit. The Kings Fund study on patient preferences (2012) indicated that often patients regret having treatments - up to 20+ per cent in some instances.

Staff experience

The main driver to deliver these changes has been to challenge individual clinician behaviour. It is appropriate that a committee composed primarily of clinicians should exert peer pressure to reduce variation amongst individual clinicians as this generally leads to considerable improvement in the quality of care.

Efficiency savings and productive gains

By moving activity to the Scottish average or upper quartile we have freed up capacity in the system. This has avoided costs such as waiting list initiatives which otherwise may have been necessary.

Sustainability

The continuing existence of the ACAC group is key to sustaining these changes as it ensures an ongoing level of monitoring and scrutiny.

Lessons learned

Apart from the formal meetings it is essential to support the work of the group with appropriate levels of health intelligence input.

NHS Board Case Study

NHS Grampian

Leading the Scottish Patient Safety Paediatric Programme

Background and context

QuEST monies were used to fund a 0.6 WTE Patient Safety Co-ordinator 2013-2014 to lead SPSPP within the nursing team across Combined Child Health (CCH) which includes Royal Aberdeen Children's Hospital (RACH).

Problem

CCH nursing management recognised that there was a need for dedicated time to ensure positive progression of the SPSPP across the service. Previously, this role had sat with clinical nurse managers and senior charge nurses who found it difficult to dedicate adequate resources to make significant changes or enable effective learning and/or awareness within their teams of the aims of the programme.

Aim

The Patient Safety Co-ordinator will develop care bundles and a structured approach to measurement and data display.

Action taken

The following care bundles have been developed:

• Combined insertion and maintenance peripheral venous catheter (PVC)
• Indwelling urinary catheter
• Central venous catheter (CVC)
• A daily huddle has been introduced at RACH
• Senior charge nurses have been supported in the delivery of SPSPP within their wards/departments
• Introduction of Lanqip and BOXI reporting of SPSPP measures
• Standardised display of SPSPP data across all areas
• Structured ward rounds being tested

Results

Work is continuing to embed actions taken within practice, ensuring a sustainable ethos of patient safety for children in CCH's care.

Further improvement work has also been being undertaken within CCH, for example, Improvement Tree, Leading Better Care (LBC), Caring Behaviour Assurance System (CBAS) and participation in the Person-Centred Collaborative.

Efficiency savings and productive gains

The daily huddle has contributed to improving patient flow within RACH. The aims of the structured ward round are to:

• Improve eIDL completion times
• Improve multidisciplinary team communication
• Ensure take home medicines are available when a patient is ready for discharge
• Reduce time to discharge
• Improve patient flow and experience

Sustainability

Developing a workforce with improvement skills is the key. This has been achieved by:

• NHS Education for Scotland/Healthcare Improvement Scotland training
• In-house training and workshops
• Attendance at learning sets
• Raising awareness through mandatory training, use of storyboard and having this on meeting agendas
• QuEST monies are being used to fund this post for another 12 months

Lessons learned

Having dedicated time to develop and support the SPSPP has enabled the work to gather pace.

NHS Board Case Study

NHS Forth Valley

Development of a Rapid Access Frailty Service

Background and context

With an ageing population the hospital inpatient service was seeing more and more patients who are frail with complex needs. Although we have a lower rate of hospital admissions for over 65 years in Forth Valley, we also know that there is variation in patient length of stay for a variety of reasons including demand into and flow out of the hospital system. It is well documented that extended lengths of stay can have a significant detrimental effect on long term care needs and patient outcomes. Having undertaken a review of frail elderly inpatients, we believed that there was scope to develop a service to address some patients needs in an ambulatory setting reducing the need for an unnecessary hospital admission. This project sits at the heart of inpatient capacity and flow, health and social care integration and community services, and is part of the whole system working required to provide better outcomes for older people through collaborative working to achieve shared goals.

Problem

Frail elderly patients frequently have period of decline where specialist review and intervention is required. During these periods they are often admitted to hospital either following a fall or for review. Diagnostics and treatment plans can take some time and during this time, in the hospital setting, they may lose further mobility and reduced nutritional intake and are exposed to the risk of hospital associated infections (HAIs).

Built on the back of work undertaken by Dr Tom Downes in Sheffield, we developed a proposal to test the provision of the required assessment and treatment within a specialist, multidisciplinary ambulatory setting.

Aim

The aim of this project is to improve outcomes for frail elderly patients by reducing avoidable hospitalisation and supporting patients to be cared for in their own home/communities with the following key objectives:

• provision of timely comprehensive geriatric assessment - allowing streamlining of patients to an inpatient or ambulatory pathway
• reduce avoidable admissions through rapid access clinic assessment and treatment
• timely discharge from inpatient pathway as soon as possible when acute care no longer adds value
• reduce avoidable disability/harm - with potential associated on-going burden of care and loss of independence
• optimise partnership approach between the NHS, patients, carers, primary care, social care, community service, mental health, other specialties
• improve patient and carer experience

Results

Outcome Measures

• improved timely access by primary care team to specialist review
• reduce avoidable admissions (min of 50 per cent) from rapid access frailty ambulatory care
• improved patient and carer experience
• greater involvement of carers in assessment and pathway
• reduced wait for specialist assessment with associated improvement in quality of care
• rapid access to 'one stop' diagnostics
• improved communication and planning with social work service
• reduce length of stay in inpatient ward
• rapid access to allied healthcare professional assessment and community rehab services

Patient experience

The benefits for patients and carers are numerous:

• Patients can be seen as a day patient allowing them to return home at night.
• Patients are encouraged to come with a family member or carer which gives them support and often means the patient feels more relaxed and better information can be shared with the team.
• Access is timely and a review will be carried out with a plan before the patient leaves.
• Where follow up is required there is continuity of care as the patient is brought back to the clinic area.
• Feedback has been extremely positive and patients and families have embraced the concept.

Staff experience

The staff involved in the service find it very rewarding as the patient is seen quickly, has an excellent quality of review by a multidisciplinary team and leaves with a holistic package to meet their medical, physical and social needs.

Again, staff feedback from the service and from NHS staff referring to the service has been very good.

Efficiency savings and productive gains

The primary benefit for the patient is that their treatment plan and additional support are put in place in a very timely manner. This improved the quality of care and improves the outcomes for that patient. The associated benefits of this are numerous including admission avoidance, potential complications related to a protracted hospital stay and onward support packages or care needs required. On a basic level the service is seeing approximately 40 patients per month with admission avoidance at 87 per cent (average) as seen above.

This benefit can be considered in two ways, either as a reduction in bed costs, or as added resilience to enable flow within the acute setting with increasing demand. We assessed that all patients who avoided admission would have otherwise required admission. If we assume that 50 per cent of patients would have had a length of stay of 50 per cent at 14 days this equates to a bed saving of approximately 14 beds per day. However, our overall admission levels have remained relatively static which suggests that this saving is in effect offsetting the expected demand due to demographic changes as predicted from ISD prediction information below:

Sustainability

Change Fund monies have been used to aid redesign of service, however it is planned to bring this into core funding. It is also planned to develop this from a five day to a seven day a week service.

Lessons learned

Good approach taken with key outcome measures. Used weekly 'Oobeya - Big Room' approach which helped to land team ownership and involved a wide number of stakeholders in the development. Challenges - not to underestimate the need for communication across a whole system.

NHS Board Case Study

Scottish Ambulance Service

Improving Care for Older People who Fall and Present to SAS

Background and context

The Scottish Ambulance Service (SAS) responds to circa 25,000 calls for people aged 65+ who have fallen. SAS clinicians are largely unable to consider an alternative outcome to the emergency department for this group due to a lack of developed pathways and partnerships with local integrated care services.

Problem

Patients often do not receive the care and service which best meets their needs which can result in an unnecessary attendance at the emergency department (increasing the pressure on that area) or, if the patient is well and uninjured, they remain at home without any on-going referral or notification to their primary care team (the risk of future falls is not addressed).

Aim

Across Scotland the SAS aims to develop partnerships/pathways with local integrated care services to enable our clinical staff to offer the patient an outcome which better reflects their need.

Action taken

• SAS operational managers supported by SAS service improvement facilitators have been engaging with local authority based integrated care teams.
• Through a multi-disciplinary task and finish group SAS has produced a toolkit to support our frontline managers to build sustainable partnerships and care pathways ('Making the Right Call for a Fall' booklet).
• Through a collaboration with NHS Education for Scotland (NES) a short film has been produced aimed at raising awareness and supporting a change in practice by Paramedics and Technicians.
• Applying quality improvement methodology, SAS managers and local partners have been undertaking tests of change to develop concepts into business as usual practice.

Results

The SAS has around 25 active partnerships with integrated care service providers. While, for a national service, this provides significant complexity and challenge those partnerships who are undertaking tests of change have evidence which indicates:

• Reduced conveyance to the emergency department from this patient group evidenced nationally by a 10 per cent reduction since April 2012 and further supported by local data. Please refer to graph below.
• Increased instance of referral to falls prevention services evidenced, for example, in Edinburgh by 14 referrals in three months during our PDSA test (please refer to graph below).
• Reduction of repeat calls to SAS.
• Indicative cost benefits from reduced conveyance and emergency department attendance (circa £400 per case).
• Improved identification and management of patients at risk.

Patient experience

Early informal feedback strongly suggests high levels of patient satisfaction with the outcomes provided from these partnerships.

A more formal approach is planned to be undertaken.

Staff experience

Significant cross system engagement, feedback and more formal review has been undertaken prior to and during any test of change. Consequently staff involved in the development of pathways have contributed positively.

Efficiency savings and productive gains

Evidence indicates a reduction in SAS journeys and emergency department attendances. Work is required to understand any associated change in in-patient stays off set against community health and social care costs.

Sustainability

The partnerships and pathways themselves are fairly simple to sustain however the ability of the whole system to move resource from secondary care to community models will be challenging.

Lessons learned

• The models developed are more responsive, safer and more appropriate for this patient group than attendance at the emergency department.
• Developing partnerships across 32 areas is labour intensive and complex.
• Local partner capability and capacity is varied.
• Front line staff have relished the opportunity to develop effective systems and processes.

NHS Board Case Study

NHS Board Scottish Ambulance Service

SAS Paramedic Practitioner in support of Hospital at Home

Background and context

Scottish Ambulance Service (SAS) Practitioners work as part of an integrated team supporting the delivery of NHS Lanarkshire's Age Specialist Service Emergency Team (ASSET) providing care at home to patients aged 75+ who required complex disease management and are of moderate to high acuity.

Problem

An evidence-based recognition of improved outcomes for older patients when managed at home.

Aim

A reduction in attendance and admission at hospital for this patient group when presenting via primary care to the SAS, 999 and NHS 24.

Action taken

Two SAS Paramedic Practitioners are undergoing development which will allow them to operate as ASSET Practitioners. This partnership will improve the resilience and capability of ASSET and will allow patients who present to SAS to be considered for redirection away from the emergency department to ASSET.

Results

A combination of an evidence and reflective study has indicated, for patients within this group, a potential shift in care:

• Reduction in emergency department presentation from SAS to 0 per cent which would represent a shift of 47 per cent from the current practice, with ambulance crews being able to access not only a wider range of outcomes for the patient but also a greater degree of clinical decision support.
• Indications are that outcomes delivered exclusively by an SAS Paramedic Practitioner would occur for 33 per cent of cases. The Practitioner would also be instrumental in a further 25 per cent of cases by facilitating a referral to other services.
• NHS Lanarkshire's ASSET would provide the outcome for 20 per cent of cases which would represent an increase from 6 per cent.
• Primary care would require to accommodate 47 per cent of cases which represents an increase from 9 per cent.

The shift in care indicated by the on-going test of change of this model is substantial. The role of the Paramedic Practitioner is also clearly crucial as it provides:

• A point of support and referral for ambulance crews
• A source of capacity e.g. ASSET at times of demand surge
• A conduit for the patient to access services appropriate to their need following a detailed and clinically informative assessment.

Patient experience

A focused exercise of the patients' experience requires to be undertaken, however, a comparison of service provision for this patient group, when presenting to the NHS via 999, within the North Lanarkshire test area and South Lanarkshire has evidenced a more appropriate, holistic care package is offered to patients in the North Lanarkshire test area. Two example patient stories which describe this experience are below:

Patient A Jan 2014 - supported by integrated services

• Paramedic Practitioner on duty in the Monklands area (SAS/ASSET).
• Referral request from Coatbridge PRU ref elderly male/frequent faller. Seeking advice as patient is uninjured however PRU Paramedic suspects underlying infection and patient remains unsteady on his feet.
• Background: Gentleman does not suffer from any diagnosed LTCs and has no home support package. He has been falling in his home for four weeks approximately with no injury but finds it difficult to get up from the floor (no walking aids). He stays with his elderly wife and they have no home support. He would normally be the main carer for his wife and also dispenses her medication via a blister-pack which gets delivered to them weekly. On-going falls with multiple A&E admissions with discharge same day (x 6 in last 4 weeks).
• Assessment: Recent discoloured, smelly urine. Chesty productive cough / widespread wheeze on right side. Abdomen SNT. Memory test 4/10. FAST test negative. No ankle swelling or calf pain. Temp increased other obs within normal parameters. Low mood.
• Recommendations: Paramedic Practitioner discussion with senior clinicians within ASSET and referral agreed. First ASSET assessment undertaken by Paramedic Practitioner (Obs, ECG and bloods, urine sample and clerk in). Consultant review within one hour of call. Bloods suggest high inflammatory markers. Blood++ and high white cell count in urine. Diagnosed with LRTI and UTI. Antibiotics prescribed by COE Cons.
• Other requirements followed 1 day later to compliment patient centred care:
• On-going ASSET follow up
• CPN review (low mood)
• Physio review (mobility issues / walking aids)
• CXR arranged with transport to and from hospital
• Social work (medication prompts and personal care x 4 daily)
• Patient maintained at home and discharged from ASSET after 4 days.

Patient B Jan 2014 - no service integration in place

• No Paramedic Practitioner on duty in the Hamilton area (SAS/ASSET).
• 999 call attended by Paramedic/Tech ambulance for 82 year old male in distress and fear.
• Background: Gentleman lives with dementia and has alerted police a number of times over two weeks complaining of being 'held hostage' by wife. Wife is single carer, has not involved primary care and believes behaviour is solely due to dementia. Patient requests to be sectioned under Mental Health Act and wife portrays severe levels of 'carer strain'
• Assessment: Obs normal, cough and chest wheeze, polyuria, recent history of falls, memory test 2/10, does not recognise family or surroundings. No homecare in place. Medications taken (dispensed by wife).
• Recommendations: Contact NHS 24 to arrange GP visit. Return call from NHS 24 after 40 minutes to inform GP advice to transport to A&E.
• Outcome: Patient transferred to A&E by SAS (total SAS case time 2.5 hours). Patient waited seven hours in A&E side room diagnosed with delirium related to chest inf. Discharged next morning with Paracetamol and antibiotics.
• No short or long term care package in place on discharge.

Staff experience

The SAS Practitioners have found the experience challenging but extremely positive. The wider SAS clinical group have welcomed the opportunity to offer patients within this group access to care and services which is more consistent with their need.

Efficiency savings and productive gains

This model undoubtedly offers patient-centred care however the efficiency gains are complex to determine and this is currently work in progress. There is however a likely clear shift from institutional to community delivered care and from a single disease management approach to the management of co-morbidities.

Sustainability

The clinical model is consultant led and there may be an opportunity to review and redesign this which would improve its sustainability.

Lessons learned

• Recognising and understanding prior training and education across different services is a challenge.
• Patients are less concerned about the individual clinician who provides their care than we think (as long as it is appropriate and the clinician is competent).
• Conflicting priorities between partners can be a challenge or potential barrier.
• Shifting the balance of care and identifying a cashable benefit is very complex.