How to transform urgent and emergency care will be one of the most challenging questions faced by Sustainability and Transformation Plan (STP) footprints.
Against a backdrop of stretched capacity and a system under intense pressure, STPs will want to understand how they can prioritise their local investment to maximise return in terms of activity, system efficiency and the potential for financial savings that can be reinvested in services.
Providers and commissioners will come together with a shared goal of addressing complex challenges and will need the best information to support their decision making.
As part of its Urgent and Emergency Care Review, NHS England aims to connect all UEC services together so the overall system becomes more than just the sum of its parts. This means we need to offer alternatives to A&E that provide access to a clinician closer to people’s homes, whilst making sure that skilled resource in hospitals is focused on the sickest patients.
The current reality is that much UEC activity is not taking place in the setting that is right for the patient and most efficient for the NHS. The interventions the UEC review has set out are intended, when taken collectively, to help shift care to the most appropriate setting.
This is known as channel shift. There is an expectation that channel shift will always improve quality and, in most cases, that it will be more efficient. In some cases, channel shift will also result in savings.
To support this, we have described a range of interventions that STPs should consider prioritising within their plans, such as:
- Supporting local systems to deliver 24/7, clinician-led Integrated Urgent Care Services, accessed through NHS 111;
- Introducing new ways of working for ambulance services that treat more patients in the community so safely reduce conveyance to A&E;
- Introducing or increasing ambulatory emergency care services that manage emergency adult patients safely and effectively on the same day, avoiding admission; and
- Providing education and support for staff in care homes to better respond to events and illnesses.
STP Footprints may have many questions about how to tackle their local pressures, including:
- How will the interventions set out in the UEC review impact in our locality?
- What will be the combined effect of multiple interventions?
- What evidence do we have to support decision making?
- How can we use local data to reach a collective informed decision of whether shifting activity between different providers / services can deliver savings?
To address these issues NHS England developed a stakeholder group comprising local and national organisations including NHS Improvement and led by Professor Keith Willett, NHS England’s Medical Director for Acute Care.
The group commissioned Capita and the North of England Commissioning Support Unit (NECS) to work with us to develop a “Consolidated Channel Shift Model (CCSM)” that will help commissioners and providers to:
- understand the system effects of individual UEC interventions on activity;
- secondly to understand the consolidated system effects of combining different UEC interventions;
- and thirdly to appreciate the financial implications of system activity shift and the thresholds of activity redirection that deliver benefit.
Working with our UEC Vanguards, models were developed, drawing on the existing evidence base to understand the anticipated financial and activity impact using local information. The models were developed with two vanguard sites before validation with two further sites, to ensure the broadest appreciation of the channel shift impact. Each of the fifteen interventions is then brought together as part of an overarching model which calculates the combined effect of introducing the interventions.
The project team engaged with Professor Gwyn Bevan, an expert in health policy and commissioning at the London School of Economics to provide further, external, confidence on the appropriateness of the modelling.
What is particularly innovative in this work is the way it deals with two key concepts, “thresholds” and “local ambition”. The threshold sets the level at which some of the semi-fixed cost can be addressed; local ambition describes how confident local managers are that they will be able to extract savings. The use of these approaches allows STPs and health systems to develop a shared approach to understand the costing and activity challenges of change in the next five years.
The channel shift model is now available to be populated by local footprints using their local data, supported by a comprehensive user guide. We will continue to build the model as we develop the evidence base, whether from international best practice, evaluation of our vanguards or wider evaluation of UEC interventions nationally.
Feedback from those who use the tool will be invaluable – we will collectively learn as commissioners and providers work together to plan strategically and facilitate service design.
Get in touch with us on firstname.lastname@example.org and tell us how you have found using the model – what you’ve learned, what challenges you’ve faced, what you disagree with, any surprises and what you’re going to do locally as a result. We look forward to hearing from you.
Ciaran Sundstrem is the Care Model Lead for the Urgent and Emergency Care Vanguards, and Programme Lead for Urgent and Emergency Care within NHS England.
He has worked in a range of roles within the NHS since starting on the NHS Graduate Management Training Scheme in 2002, with particular experience in urgent and emergency care, health protection, health and justice, and substance misuse.