Stopping Demand – The Purpose of an Unplanned Care System

I recently had the pleasure of coaching a team of urgent integrated care commissioners and clinicians in helping help them to review their strategic plan to refocus upon their purpose. We started to map the current state system, brought transparency to the multiple commissioned service lines (or microsystems) and the interdependencies between those services. In order to understand by patient need which of those services worked, which required optimisation and where there were gaps.  I introduced them to the 3+1 model of unplanned care, a simple yet powerful tool which presents unplanned care in its natural form; horizontal end to end pathways (processes), surrounded by vertical microsystems (the functional units that form the front line of all health systems), which cut across multiple sovereign providers. 

I asked the team to describe their purpose and most answered with noble statements of intent; right care, right place, right time. For others it was the official response; the ‘Out of Hospital’ strategy, a bold if not an ambiguous set of aims and aspirations. I then described what I believed is their purpose: to stop people going to A&E, to stop people becoming a non-elective admission.

Purpose of an Unplanned Care System;

Current State

We began to populate the system map with the current services, examples included;

The reflections made by the participants in discovering a system that had evolved over many years, were understandably varied. However, three key themes emerged;

·      Complexity of service delivery  

·      Ambiguity about the services available

·      Lack of a strategic plan

Measuring the impact 

I asked; how do you know what impact these services are having in the unplanned system, in other words, is the unplanned care system delivering the triple aim of: 

·      Improving the quality of patient care

·      Achieving performance of the 4-hr target

·      An efficient & productive service. 

Is the investment in the infrastructure assets (Medical & Care professionals, Bricks and Mortar, Digital, Processes, Structure, etc) of the sovereign providers delivering what was expected? Are we getting the return (quality, performance, productivity) on the investments we commissioned? 

The current challenges faced by many unplanned care systems is the inability to answer that question. The current measure of success is a binary outcome measure; the 4-hour target of the A&E department. As for process we measure ‘non-elective length of stay’ and more recently ‘delayed transfer of care’. For those patients admitted we count the number of non-elective admissions (hospital system input measure). 

The focus is on the performance of the hospital centric system of care and as evidence suggests problems with A&E performance are a symptom of a problem, failure and/or a gap across the wider system. Commissioners with good intent lay claim that every new out of hospital investment will reduce demand. Unfortunately, as consequence of the poor design or limited investment in data capture mechanisms, it’s difficult to tell which one of the multiple commissioned services actually works, as I commented to an Informatics colleague; “everybody is fishing in the same pond!” 

Patient need v Service design 

My final question; how do you know which of these services work for the different types of patients you have? Have you profiled your patients based on clinical and experiential need and want? A scatter gun approach, a one size fits all or a piecemeal approach to plug gaps or respond to service failure (poor design, unstable micro/meso systems) often fail to deliver sustainable, equitable and quality care. 

Right care, Right time, Right place 

Unplanned care is about the potential risk of illness or injury of the local population. How you mitigate that risk is through the design and investment of the appropriate interventions which either proactively prevent demand, actively de-escalates demand or meets that demand. This risk and thus the appropriate intervention(s) are dependent upon the profile of the population. A one size fits all service solution will not achieve that, a more tactical approach is to cluster the population based upon a number of factors or measures. Primary care uses the frailty score (Severe, Moderate, Mild, Working Age & Kids) to stratify patient risk, complimented more and more by the Patient Activation Measurement (PAM). Data and analytics companies provide more complex methods of risk stratification.

In NHS Ashford and NHS Canterbury and Coastal CCG’s they analysed their population to try to identify the areas of greatest opportunity for reducing emergency admissions and expenditure, those at the greatest risk of emergency admission had the highest frailty score.

Seasonal Surge 

The variation in unplanned care demand is as predictable as winter, yet year on year many unplanned care systems become unstable because of system wide mis-matched capacity and capability. Whilst winter may see the greatest variation, demand fluctuates throughout the year. The planning, monitoring and management of system wide demand and capacity should and needs to be a continuous ‘live’ activity. A frenzied and short-term ‘winter’ only planning cycle, often based on incomplete data and hastily designed service ‘add-ons’ not only consumes a disproportionate amount of leadership capacity but can also distort and de-stabilise the existing system, thus exacerbating the problem.

Capacity Management Centre

Multi-partner capacity management centres bring together the systems sovereign organisations to manage the day-to-day pathways centrally through real time data. Linking historical and live demand profiling, variation to the system wide capacity profile is visible. Seasonal short, medium and long-term co-ordination and resource direction actions are taken, whilst system stability is constantly monitored and management time is freed up to support a proactive not reactive approach to system wide capacity management. System sustainability is achieved and independent organisation sovereignty is maintained, whilst system capacity management becomes the collective responsibility of all of the system partners.

3+1 

The 3+1 conceptual model of unplanned care supports integrating care systems (commissioners and providers) to identify interdependencies, duplication and gaps by patient categorisation type, informing strategic commissioning intent, tactical system optimisation and QIPP opportunities.