What is the specialist paramedic role and what can they achieve?

Specialist paramedic roles are used in a variety of ways across the UK. A review of the profession undertaken in 2013 looked at the roles and educational frameworks required. The review found that the role of the paramedic has altered from a focus on first aid and transportation to greater emphasis on decision-making, treatment and where appropriate, referral. This increase in clinical capability has led to the realisation that paramedics can make a fundamental contribution to unscheduled and urgent care.Many paramedics have now undertaken additional training and moved into specialist practitioner roles, combining extended nursing and paramedic skills and supporting first contact needs of patients in unscheduled care. Specialist practitioners are primarily employed by ambulance trusts and undertake a range of activities, including carrying out and interpreting diagnostic tests, undertaking basic procedures and assessments of patients with long-term conditions in their homes, and prescribing a wider range of medications. Some hospitals e.g. Heartlands have developed well established extended roles for paramedics and other staff within their ED. There is research evidence that specialist practitioners have a positive impact on the workloads of the emergency services leading to fewer referrals for other healthcare professions. Further information can be found contained in the review here.

How can we identify frail patients in primary care consistently? How do you maximise the primary care response?

Frailty is a complex and fluctuating syndrome so identification and assessment of severity can be a challenge. Whilst experienced clinicians can instinctively recognise a frail person, there is a need to support identification using case-finding tool and techniques.
Examples of some tools and approaches can be found here alongside other information for commissioners, providers and nursing, medical and allied healthcare professionals to maximise the community and primary care response.
See also the work undertaken by the National Institute for Health Research here on the development of a an electronic frailty index that uses existing electronic health record data to identify and grade frailty by severity, to improve primary care pathways.

How do we solve the late arrival of GP expected patients (at teatime) at the ED/Acute Medical Units (AMUs)?

The first step is to monitor and report the arrival time and pattern in ED/AMU of GP patients by practice. If data from the acute trust is not readily available, this information, or at least time of request for an ambulance and time of response, should be available from the local ambulance service.
If arrivals are being batched into the afternoon/early evening, then this data, by GP practice, should be shared with local GP practices. Late arrivals to ED/AMU reduce the likelihood that an alternative, such as AEC, can be used to avoid unnecessary admission. It is therefore imperative to identify and reduce any unnecessary delays to the late arrival of GP expected patients into the trust. 
It is important to note that time of arrival in ED has an impact upon length of stay (LoS), with patients admitted during the evening more likely to have an increased LoS than those admitted in the morning. This effect is even more significant for older people.

What is the most effective Ambulatory Emergency Care (AEC) model?

The most effective model for Ambulatory Emergency Care (AEC) is a process model. This is where AEC is the default approach and the majority of patients are considered for an AEC process before any decision to admit is made. This approach works well with GP referrals where clinical teams have set up processes so that patients are automatically sent into AEC for their first assessment unless they are clinically unstable. In this scenario sites have reported 50% of GP referrals discharged on the same day.
Another process that works very well to maximise AEC is when a senior clinician responds to all the GP referrals for admission and diverts all appropriate patients to an AEC service. Using this approach clinical teams have reported between 10-20% of the medical 'take' being directed to an alternative AEC offer and up to 30% being discharged on the same day. For more information on AEC models go to the AEC Network website here.

How do we work with our consultant teams to change their practice to prevent unnecessary admissions, and only admit when truly required?

The basic principle around hospital admissions is of ‘decision to admit’, not ‘admit to decide’. In order to achieve this, it is important to ensure that senior decision makers are located at the ‘front door’ to enable early decision making concerning the need for admission. This can be achieved through Rapid Assessment & Treatment (RAT) within A&E departments.
It is important that suitable alternatives to admission are available which operate consistently and effectively for patients to be directed to. Monitoring of admission rates can help to understand variation in clinical practice which need addressing.

What is the right workforce model to properly deliver better Acute Frailty?

An effective acute frailty model requires the skills of a range of healthcare professionals to deliver comprehensive geriatric assessment (CGA). This should include geriatricians, nurses, ‘primary care coordinators’, and therapists working collaboratively with emergency and acute physicians. In community hospital settings, advanced nurse practitioners or general practitioners should be supported by geriatricians to deliver CGA. For more information see here. Also, access the Acute Frailty Network website here.

There is a shortage of elderly medicine consultants; what innovative ways are there to manage the front of house workload?

Multi-disciplinary teams can provide effective Comprehensive Geriatric Assessment (CGA) which will help to address the shortage of geriatricians. Redesign of clinical support to ED and assessment areas can help. The introduction of an assessment area, with a clear process for frail and vulnerable people provides a focus of nursing and therapy expertise. Ambulatory Emergency Care (AEC) principles can be applied to support patient management.
Front-loading ED & AMU with therapists and integrated discharge teams that can identify patients at risk of deconditioning alongside processes that improve discharge for patients, can help the front of house to operate effectively. For more information and direction to a range of guidance see here. The are many centres where there are good examples of advanced nurse practitioners supporting management of frail patients across the country such as Heartlands, Kings College London, and Leicester and in community hospital settings, as well as at the front door.

Does anyone have an inpatient boarding policy that works?

ECIP recommends that the priority is not to have an effective boarding policy but to have an effective escalation system which minimises boarding. Trust boards should be made aware that there is an increasing body of evidence that boarding is not just associated with poorer patient and staff experience but is also associated with increased mortality, increased length of stay, increased risk of emergency readmission and increased likelihood of missed medication whilst in hospital. Find out more here.
However, if inpatient boarding is required, it is imperative that principles for best practice are followed. An example of a robust boarding approach is attached here.

Explain the 'deconditioning' issue and impact on flow. How can we change the story so that this is our focus?

The term deconditioning describes a range of physiological responses to bed rest that harm patients, particularly frail patients. There is a correlation between the length of time on bed rest and functional decline in the activities of daily living, mobility, physical and social activities. One study showed that 10 days of bed rest resulted in the equivalent of 10 years muscle-ageing (Gill et al., 2004). The consequence of this is that patients will have a prolonged hospital stay including referral for rehabilitation or for placement in a care home. While this is a poor outcome for patients it increases the demand for beds and drives up costs to the system. Better outcomes for patients will occur where every day adds value. Some sites now identify this using Red (no value added) or Green (value added) days to identify unnecessary patient waits for treatment, highlight key themes and focus energy to address these. The Ipswich case study provides further detail - see here.

How do we speed up the frailty pathway?

We know that frail older people are at greater risk of experiencing significant harm if they have an unnecessarily prolonged admission to hospital. A care pathway for frail older people reorganises services around the patient and provides care at all stages of the patient journey from healthy, active ageing through to end-of-life care. When a frail older person requires admission to hospital, best practice models should be adopted systematically. All staff should be able to undertake initial assessment, with an interdisciplinary team to undertake a more detailed assessment, proportionate to the needs of the individual. The initial assessment should be summarised as a stratified problem list, with the most urgent and important issues documented first, with other important but less urgent issues flagged for on-going management. More information on use of MDTs is available here. Speeding up the pathway also includes ‘discharge to assess’ where patients are discharged once they are medically fit to have an assessment with the appropriate members of the social care and community intermediate care teams in their own home. For information and case studies on frailty pathways see here.

How do we understand what safe means for the patient and what risk means at each stage?

Choice involves a dialogue between the person, their family, social network and us. What people want needs to be balanced with what can be offered to come to a joint understanding of the implications of any decision made by an individual. Consideration of risk is a part of that process. When we try to understand what risk means to people, it is worth asking them directly. What you consider risky might be very different to others, and what risk you are prepared to tolerate might be very different from the another persons perspective. Anyone with capacity will need to have the issue of risk discussed so that a plan of care can be agreed. The persons needs and desires must be understood. The full range of options for care must be explained including what efforts can be made to eliminate and reduce risk, but also where care agents can’t fully eliminate these gaps, does the person still wish to proceed with the planned care.

What is the most commonly used method of Discharge to Assess (D2A); where can I access guidance?

Discharge to Assess (D2A) or Home First is an approach that facilitates early and safe discharge home from hospital where the functional and social care assessment will occur. South Warwickshire NHS Foundation Trust has a well established D2A model the operating principles are:
1. Patients should always be cared for in the lowest level pathway that can meet their needs to improve or maintain independence
2. Trusted assessment should be in place between partner agencies
3. No adults should be excluded from accessing the process: consent will be formally obtained
Find out more here.

How are trusts recording discharge to assess patients on PAS and what are implications on PbR/tariff?

We are not aware that any trusts are doing this - usually patients are transferred to services in the community so acute trusts are no longer responsible. For Hospital at Home, quite often the acute trust provides consultant cover for these patients and continues to be paid either through tariff or excess bed days. Many systems are moving off-tariff altogether and developing an alliance contract, prime vendor or completely new way of contracting or way of managing the money across the system. Local tariffs may be agreed on occasion. The vanguard sites (not just urgent and emergency care trusts), are looking at new payment mechanisms.

How do we achieve rapid assessment of patients waiting for a care home?

We need to move away from an expectation of assessment in hospital, to a Home First or Discharge to Assess model so that patients stay in hospital for the shortest time possible. We need to stop making assumptions and judgements about how a person will manage when they return to their usual place of residence, based on what we see in hospital when people are still recovering from the effects of their time in hospital. We should not assess patients in environments that are alien and confusing. A single point of access for primary and secondary care would enable rapid, hassle-free, joined up assessments at home, that add value to the place of care decision. Find out more here.

How do we support patients to stay at home?

There are many services that are available to help people to stay in their own home. These range from self-funded care through private care agencies, to services provided by local authorities, the NHS and voluntary sector organisations. Help is available to people for personal care, such as washing and dressing; provision of housekeeping or domestic work; cooking or preparing meals; nursing and health care; and companionship. There is also a growing use of re-ablement services and assistive technologies to aid safe care at home. For more detailed information about the care services at home, care providers and sources of funding see here.

How do we balance elective and non-elective care demand?

In our experience systems can’t gain and sustain control of the elective flow unless they have already gained and sustained control of the non-elective flow. Non-elective demand is relatively predictable. Trusts can use the rolling 6 week tool to predict and plan for likely levels of emergency admissions. It is also worth considering the impact of seasonal changes, in particular the impact of weather, whilst planning for demand. Follow this link to find relevant papers on the impact of weather upon hospital admissions. Predictable events such as Christmas and Easter should also be appropriately planned for, with a recognition that holiday periods usually result in extended periods of absence of senior decision-makers both within the acute trust and across the system.
Elective capacity should be planned around day surgery, bed base, critical care capacity in addition to theatre capacity.

What is the best measure of flow through the system?

The short answer is that there isn’t one. The slightly longer answer is that you need not one but several measures, as described in this supporting paper.

How do you change the workforce structure (recruitment and training) to deliver the changes that are needed?

The workforce plan should mirror the design of clinical services. A clinical workforce strategy should be developed with support from HEE, local universities etc. It should detail the skills, competencies, roles and responsibilities of the planned workforce. From these, job descriptions can be produced using the skills and knowledge framework and a training needs analysis for any existing workforce can be produced. You can either recruit directly into post or appoint on the basis that training will be given to develop a skilled workforce. A useful guide to NHS strategic workforce planning can be found here.

How do we bring a challenged social care system (which is going to become more challenged) on this journey (frail elderly particularly)?

The challenge is to make the right decisions with patients, with the aim of maximising independence at home. This is a shared objective between health and social care. Getting these decisions right will be in the best interests of patients and reduce costs for both health and social care. There is an imperative for whole systems to work together to address the problem. Closer integration across organisations to share the burden of change is key to meeting this challenge.

How have other organisations been able to embed this change within their health economies so everyone understands the need to change?

Organisations that successfully embed change and achieve good buy in recognise the following key points:
- UEC improvement programmes are organisational development initiatives not just service redesign projects. They need CEO leadership, with HR, OD, comms, information and finance support.
- Time spent on planning – momentum is more important than pace.
- Case for change based on links between poor emergency flow and patient safety,  to engage clinicians. Avoid attaching a productivity label to the initiative. 
- Because of links to safety, this type of improvement is too important to be attached to the ‘day job’. It needs proper resource, ideally by releasing internal staff to do the work and back-filling time.
- Changes in clinical practice are key to delivering improvements. Clinicians need to lead the programme with support from management colleagues. The Medical and Nursing Directors can set the tone as a clinically led initiative by acting as SRO for the programme or specific parts of it.
- Project terminology should be avoided - emphasis should be on continuous improvement and developing a new ‘business as usual’.
- Need for clarity about the planned end state as well as the standards and behaviours that underpin this.
- It is important to focus on a core of 3 or 4 priorities rather than spreading effort too thinly. Issues that the organisation has control over should be higher priority than those where the locus of control is external.
- There should be SMART (specific, measurable, attainable, relevant and time-bound) statements that set out clearly how to measure success. However, qualitative feedback from patients and staff is just as important.
- ‘What gets rewarded gets repeated’ - recognise and reward the effort staff make to help deliver the changes. Make that recognition public, personal and frequent.
- A clear improvement methodology should include appreciative inquiry (i.e. applying the principles of a previously successful initiative, a pathway or process which works well).
- Differentiate between communication and engagement. Organisations may be able to rely on hard copy or electronic mechanisms for communication, but engagement is a two-way process of listening as well as telling. It needs to be face-to-face. Don’t forget to target staff at more junior grades and in less visible roles. 
An example of this approach is given here

Once we have all the assessment units, investment etc. how do we make it work efficiently?

It is important that the components of the system operate effectively. This requires ongoing leadership, tests of change & monitoring of effectiveness. Teams need to come together on a regular basis to review key information related to patient outcomes so they can discuss further improvement. This is a continuous process and does not stop once the components are in place.
To ensure efficient working, it is also imperative that there is a robust, governance structure in place, not just within the local acute trust and primary care, but across the whole health and social care system which receives reports on quality of care, risks, incidents and proposed developments.