This section contains
Aims
Integrated care systems (ICSs) should create person-centred pathways that support people to live healthier lives.
Context
Data and knowledge are often siloed in services and unavailable to the wider ICS.
When people cannot access the care they need, their health can quickly deteriorate. Hospital admission can become unavoidable. For some, often those living with frailty, there is a further risk of hospital-acquired deconditioning. Deconditioning means there has been a decline in functional, cognitive or physical health. It is caused by prolonged periods of bed rest and inactivity. Ultimately, it can be unsafe for some people to return home as they now require full-time care.
We can avoid these situations if we:
- identify patients who are at risk
- provide early support through local services
- create effectively integrated care pathways for frailty and social care
- provide more senior clinical decision-makers to triage people at an early stage.
Key suggestions
- Provide consistent same day emergency care (SDEC) with clear routes for referrals from other providers. For example, GPs, community response teams, NHS 111, ambulances, or via emergency departments (EDs)
- Give direct access to GP and community service booking systems for acute and social care providers.
- Create urgent community response teams (UCRs) to manage minor injuries in the community. They should include representatives from:
- GP practices
- social services
- community therapy
- pharmacy
- senior emergency department decision makers.
- Provide rapid access to support packages 'wrapped around' a person's care. This can help people stay independent and stop a rapid decline in their health.
- Keep an updated directory of services (DOS) for NHS 111 and 999 services. This gives all teams a list of referral options available in primary and community care.
- Implement the new NHS booking and referral standard (BaRS). This standard:
- allows people to book direct appointments with services in a time slot that works for them.
- helps healthcare workers triage more efficiently.
Examples of good practice and innovation
Safely reduce conveyance of older people
South Warwickshire ICS
South Warwickshire ICS wanted to reduce unnecessary transfers of older people to hospital. The trust and ambulance service decided to work together using virtual wards. This meant ambulance crews could contact clinicians on-scene to seek advice. As a result:
- 48% of cases in people over 80 were managed from their homes
- only 25% of those over 80 needed transfer to an emergency department
- those admitted to hospital had reduced length of stays.
See full NHS confederation case study.
Planning to safely reduce avoidable conveyance, ambulance improvement programme
NHS England and NHS Improvement
This publication aims to safely reduce the number of people conveyed to emergency departments (EDs). It identifies areas for nationwide improvement. For example, ambulance services need on-scene access to consultant advice. Some ICSs already do this. In fact, some are developing ways to share videos and images between teams to support this work further.
See full publication Planning to Safely Reduce Avoidable Conveyance.
Safely reduce avoidable conveyance of children
Blackburn Royal Hospital
Schemes also exist to avoid child hospital admissions safely. For example, Blackburn Royal Hospital gives GPs direct access to guidance from senior paediatricians or community paediatric outreach teams.
Use of multidisciplinary teams (MDTs) in end of life care
There is excellent work happening in this pathway. Some MDTs have members from across the ambulance service, primary and secondary care. End of life care needs to be a national priority. It is essential to treat people and their loved ones with dignity, and to support their wishes at this critical moment.
Community diagnostic hubs
Increase the use of community diagnostic hubs that include services such as pharmacy, dental, nursing and diagnostics. This will make it easier for people to access the care they need. It also reduces pressure on emergency departments caused by non-urgent visits.