Themes:
- Partnership working
- Admission avoidance
- Leadership and culture
Background
The Mid Yorkshire Hospitals NHS Trust (MYHT) is a large acute provider, working across three hospital sites. They also provide community services within the West Yorkshire Health and Care Partnership integrated care system footprint.
Pinderfields Hospital is the largest of the trust’s three hospitals, providing a broad range of specialist, emergency and critical care services. It is also the site of the trust’s same day emergency care (SDEC) service.
Same day emergency care: an evolving national policy
The central principle of an SDEC service is that a substantial proportion of adults who require ambulatory emergency care can be cared for safely and appropriately on the same day without an admission to hospital.
While MYHTs SDEC had been in place for some time, at a national level more focus is being put on this model and more trusts are looking to develop their own SDEC. NHS England’s (NHSE’s) plan to recover performance standards in urgent and emergency care highlights the use of SDEC as a key enabler.
There are significant benefits associated with SDEC, including shorter waiting times, reduced unplanned admissions as well as a reduced average length of stay. It also means patients can receive the care they need without the associated risks of an acute hospital admission. For some patients a risk of deconditioning and a detrimental impact to their overall health is therefore avoided.
Since April 2022, MYHTs SDEC service has worked across its surgical and medical divisions. It is overseen by two clinical leads; they have focused on building a multi-disciplinary workforce and developing their advanced clinical practitioner’s role to offer an extended range of services.
The medical SDEC team had struggled to find a permanent location for their service. It became clear that what was needed was a facility, outside the emergency department (ED) without beds – this effectively safeguards against the possibility of the SDEC becoming overspill capacity at times of very high demand. This was secured in the summer of 2022 and has proved invaluable in supporting the developments of the service.
Working across the system: communicating the value of SDEC
Jo Halliwell, the trust’s deputy chief operating officer, explained one of the key challenges and enablers of running a successful SDEC was in how the service offer is communicated, not just to patients and the public, but also to partners within the trust and across the local health and care system.
Jo told us: “Making it easy to refer to the SDEC was essential; de-formalising the process and creating a culture of clinical respect, where we didn’t criticise primary care for making referrals that weren’t right for SDEC – but instead explained what kind of referrals we’re best placed to manage.”
Working with colleagues in other departments, as well as community and primary care organisations, to drive appropriate referrals and raise awareness of the service has been vital. Taking time to build these relationships has highlighted the value of the SDEC service and means it is able to pull in a high level of referrals, thereby reducing pressure on other parts of the system as well as improving patient outcomes.
The permanent location and the continued development of the pathways has meant there has been a 17% increase in SDEC activity compared to 2020/21 activity levels. Increases are evident month on month with March 2023 seeing the highest number of patients accessing SDEC on record.
Reducing pressure across urgent and emergency care pathway
The MYHT is one of the busiest type one A&E departments of any trust in its region. Given the volume of activity it manages and pressure on resources in recent years, the SDEC has been vital in helping to manage demand effectively.
The team currently work to a principle of offering SDEC pathways for all suitable patients – so more people avoid admissions, freeing up capacity for those that need it. The trust regularly sees over 100 patients per day through the SDEC facilities, and while like all acute trusts, MYHT saw very high demand during the winter of 2022/23 which led to a deterioration in operational performance, it did better than many comparable organisations.
In short, a high-functioning SDEC service has been effective in reducing demand elsewhere in the trust which has contributed to the resilience of the wider urgent and emergency care system during a very challenging winter.
Leadership and culture are key
Jo and the team at MYHT were keen to stress the importance of empowering, trusting leadership.
The senior leadership team at MYHT have, as Jo explained, taken ‘a supportive and enabling approach, rather than a punitive approach to monitoring activity and targets’. There is space for the clinical leadership to focus on delivering patient care while operational colleagues support by ensuring all the elements needed are secured, working together to drive and embed change.
In this culture, clinicians’ principal concerns are delivering care and ensuring good outcomes for patients, using the national performance standards as a framework to evidence improvement.
Next steps
Sustaining and building the SDEC service is a key priority for the trust and for its ICB. National policy is clearly aligned to this ambition.
As trusts across the country look to develop and grow their SDEC services, to support efforts to achieve the core performance standards set out in NHSE’s urgent and emergency care recovery plan, MYHT will be starting from a strong point of having a well-developed service.
The service has an established location, is well understood and known across their system and also supports the development of the local health and care workforce.