Executive summary

A case for change

Providing the medical help needed in an urgent or emergency situation is a core function of the NHS. But our urgent and emergency health care services are under extreme pressure and busier than they have ever been. People are waiting longer for ambulances to arrive, more people are being admitted to hospital in an emergency, the numbers of people attending our emergency departments (ED) continue to rise and since Covid-19 more people are accessing urgent appointments with their GP or NHS 111.

We urgently need to improve access to high quality urgent and emergency care services to meet this unprecedented demand and to support our staff in making the safest decisions for all patients across the system.

Our health and care teams work hard to manage the challenges of busy urgent and emergency care services every day, and while we deliver excellent care, the system remains under extreme and continued pressure and retaining and recruiting staff is difficult.  Growing the workforce is not enough, we need to develop the skills and expand our capacity to deliver care closer to home whilst supporting people living well for longer.

Purpose of this strategy

This strategy sets out how the health and care system in Hertfordshire and west Essex will transform over the next five years to deliver safe and sustainable urgent and emergency care for all who need it.

This recovery and transformation can only be successful if the whole system works together in a different way to meet our changing population demands, improve performance in waiting times and ensure when our residents have urgent and emergency care needs that they get the right care, in the right place, the first time they try to access it.

What is the strategy?

In five years, our ambition is that people in Hertfordshire and west Essex will experience urgent care as close to home as possible to avoid harm of hospital stays and minimise disruption to their lives. The care they receive will be consistently high quality and safe and they will have confidence that they will receive the right care, first time and be supported in managing their health.

Our vision is:

For everyone in Hertfordshire and west Essex to be able to understand and rapidly access safe, tailored, high quality, and sustainable urgent and emergency care which is received at the right place and time for them to remain well and independent.

Why this matters

How and when people use urgent and emergency care services are not the same within our population. People living in our more deprived neighbourhoods are far more likely to attend the emergency department, be admitted to hospital as an emergency, and have worse health outcomes.

There are disparities in access to, and experience of, our services, and variations in health outcomes across different geographies and groups of our population.

Through an iterative assessment of our population urgent and emergency care needs we can better understand and start to address this unwarranted variation and reduce health inequalities.

It is important to focus not only on services providing urgent and emergency care, but to understand the factors contributing to this uneven distribution. 

A small segment of our population uses emergency care frequently. Often these individuals face multiple health issues and challenging circumstances such as financial hardship, housing instability, social isolation, and substance misuse.

To tackle these inequalities and prevent unnecessary emergency care we must engage with population groups facing inequality and tailor our approaches to address the wider determinants of health.

Predicting those at risk of deteriorating ill health and future unplanned care will allow us to mitigate this risk through proactive support and targeted interventions.

What our population can expect

• The health and care system uses data tools to understand and predict people’s urgent medical and care needs. 
• Local teams use data to identify people whose condition might get worse and need hospital treatment, so proactive care can be put in place to stop them needing hospital admission.
• To have access to a variety of urgent care services that are shaped by successful models elsewhere and adapted to fit local needs.
• The health and care system adjusts and improves its services to make sure everyone has equal access and good health outcomes.

We will:

• Use population health management approaches to study our communities’ urgent healthcare needs, embed a Core20Plus5 lens in our reporting.
• Engage and learn from our communities, especially those facing health inequalities.
• Use predictive models and techniques to identify those at greatest risk, or rising risk, of deterioration and unplanned care, and use this to develop proactive care models and flag at-risk patients for faster management.
• Proactively use remote monitoring and health technology to target community services and prevent deterioration.
• Understand the profiles of high intensity users to evaluate different interventions and optimise their care.
• Use data to find health disparities and gaps in care and apply our collective preventative resource and tailored evidence-based care to specific communities and cohorts.
• Follow patient journeys to better link different services together.
• Evaluate our services and interventions to see how they impact different groups of people, and how we can improve them.

Why this matters 

Our hospitals are operating at over 90% bed occupancy. Helping people to leave hospital as soon as they are ready and then receive the care they need at home is preferred by patients and aids quicker recovery. Despite this, a proportion of hospital beds are taken up by patients who no longer need to be in hospital. Assessing someone’s long-term care needs in their own home, rather than in hospital, can reduce hospital stays and improve patient and family satisfaction.

High bed occupancy rates also lead to long delays in emergency departments which adds to stress for staff and patients. EDs are often inappropriately designed to meet the needs of people in a mental health crisis, evidenced by long waits in noisy environments resulting in increased reports of violence and aggression towards staff. Ambulances are often unable to handover patients promptly at our busy EDs meaning delays and a clinical risk to patients who are waiting for ambulances in the community.

Prolonged waits in ED, and subsequent long inpatient stays can harm patients, particularly frail older people who are at risk of very quickly losing muscle strength and, psychological and functional decline (deconditioning syndrome).

Merely increasing the numbers of beds will not solve the issue. We must organise ourselves and co-ordinate our health and care system with close working between hospitals, mental health, community care, primary care, social support, and the voluntary sector. We need to use all our capacity, enabling access to the right care, at the earliest opportunity and to provide safe and effective discharge and step-down from services. We need to improve visibility of operational pressures and align this view with clinical risks to support operational and clinical leaders in dynamic decision-making to minimise system clinical risk. To improve our responsiveness, we aim to forecast and predict changes in demand.

What our population can expect:

• Shorter waits for ambulances and in emergency departments.
• To access the right care, at the right time, with connected teams and information.
• Seamless, safe hospital discharge to get people home as soon as they are ready.
• Shorter hospital stays to reduce harm and the ability to make decisions about long-term care needs in their own surroundings when out of crisis.
• That hospital beds, including mental health inpatient beds, are available for those in need.

We will:

• Ensure optimal discharge planning, consistent 7 days a week starting on admission with daily reviews and a discharge-to-assess model that promotes home-based care and prompt access to therapy, integrated with virtual ward/hospital at home to facilitate early supported discharge.
• Provide digitally-enabled care transfer hubs with the right staff, leadership, and processes to manage daily flow, co-ordination of care, and facilitate safe discharge and access to intermediate care and wraparound VCFSE services.
• Ensure sufficient intermediate care capacity that is both timely and appropriate to reduce hospital admissions and maximise independent living.
• Provide a 24/7 System Co-ordination Centre (SCC) to improve visibility of system pressures, understanding of system clinical risk, and manage patient flow redirecting patients away from pressure points to services with better capacity.
• Foster a positive culture with an understanding of clinical risk across providers, in the community and acute hospitals, with dynamic, collective decision making to mitigate this system clinical risk to improve patient safety and support the SCC with clear clinical escalation to agree mitigations.
• Carry out modelling to forecast pressures and predict risks to pre-empt planning and enable proactive co-ordination by the SCC. As well as understand where to invest to achieve the best outcomes.
  

Why this matters

We need to take a long-term approach to urgent and emergency care, going beyond just dealing with emergencies in hospitals towards helping people keep physically and mentally well through use of our public health programmes and primary prevention measures. Working in partnership across health, local authorities and voluntary and community services we need to provide personalised support to address the wider determinants of health (for example housing, employment, and social isolation) for those facing health inequalities and who are at high risk of emergency department attendance and emergency admissions.

We can identify those at risk of ill health, through screening programmes and initiatives to enable early identification of disease and low-level mental health needs. We can use data-driven approaches in primary care to deliver prevention activity and proactive care to target those with greatest need. We know frailty increases the risk of future hospitalisation and ‘frailty crises’ (such as sudden mobility loss, delirium or falls) are the most common reason for older people needing emergency services. Early identification of frailty can slow its progression and keep people independent for longer.

Too many older people in HWE are admitted to hospital in an emergency due to a fall.  A major risk factor for falls is the cumulative effect of medications with anticholinergic effects, termed the ‘anticholinergic burden’. In HWE, a higher proportion of individuals aged over 85 have a high anticholinergic burden compared to nationally. We need a whole-system approach to prevention.

Many emergency admissions are entirely preventable if we better managed peoples’ long-term conditions such as COPD, heart failure, and atrial fibrillation in primary and community care. Early identification of issues, deterioration, and timely treatment can prevent emergency admissions. We can empower people with the skills, knowledge, and confidence to manage their health condition and healthcare effectively.

Embedding advanced care planning to start conversations with people before they are ill and frail, so patients’ preferences and wishes are taken into account in an emergency.

What our population can expect:

• To feel empowered to manage minor illnesses and some minor injuries on their own.
• All parts of the health and care system support them to lead longer, healthier lives through adopting healthier habits, earlier identification and proactive management of disease, mental health needs, and frailty.
• To have the knowledge, skills, and confidence to recognise the signs and symptoms of deterioration in their health and seek timely help to stay well at home.
• To be given the opportunity to plan their future care so that it is focused on what’s most important to them and that they die in their place of choice.

We will:

• Create consistent public awareness campaigns so people know which services to use and when, using resources like Healthier Together
• Develop mental health initiatives for suicide prevention, and early intervention for low-level mental health need (e.g., NHS Talking Therapies).
• Increase uptake of health checks (and appropriate action plans developed) for those with severe mental illness, learning disabilities and early identification of those at risk of frailty.
• Strengthen referrals to ‘person-centred’ social prescribing and VCFSE support to tackle practical, social, and emotional needs for those at risk of frequent urgent and emergency care use.
• Ensure pathways into drug and alcohol services are accessible across all our urgent and emergency care services.
• Focus on falls and fracture prevention, strengthening links with voluntary sector, systematic medication reviews, and development of fracture liaison service.
• Support Integrated Neighbourhood Teams (INTs) to design proactive care models to support people with complex needs.
• Pilot use of real-time data to pinpoint patients with COPD, heart failure and frailty who will benefit most from proactive case management and explore learning models to identify patients in the days before crisis to reduce risk of admission.
• Embed advanced care planning to set out patient preferences and prioritise for clinical care.

Why this matters

Many individuals seek care in emergency departments when their needs could be addressed elsewhere. One third of ED visits result in no investigation or treatment and surveys found that few patients attempted to use a GP or pharmacy before visiting. We need to support patients to access the right care, the first time and ensure we free capacity within our EDs to respond rapidly to serious or life-threatening emergency needs.

In public surveys, people suggest better primary care access would improve their urgent care experience. Simplifying and enhancing access to urgent primary care is a key priority in Hertfordshire and west Essex, this includes investment and expansion of community pharmacy capabilities to manage minor illness and offers patients convenient care close to home. Local patient networks consider effective triage as key to supporting people to access the right care by the most appropriate service. National research indicates patients want a simplified, joined up, (so they don’t have to repeat their medical information) and easier to understand system with equal access regardless of where they live, together with clear and up-to-date information about services available. 

Our local analysis shows that the top 5% of patients with the most frequent emergency admissions were often admitted with conditions such as urinary tract infections, pneumonia, or cellulitis that could be managed by our same day emergency care (SDEC) services.

Older individuals account for the largest volume of emergency admissions for conditions suitable for SDEC and are at greatest risk of harm from an inpatient admission. This highlights the need to ensure greater same day emergency care for these patients.

What our population can expect:

• A less confusing urgent care system with clear, consolidated access points to empower individuals to make informed decisions about their urgent health needs and be guided seamlessly to the right care first time.
• Access to same-day care that is most appropriate for their needs and is convenient and available 24/7.
• Reduced waiting times for assessment and treatment, avoiding unnecessary ED and hospital visits.
• Greater capacity for GPs to provide relationship-based care to support people dealing with complex long-term conditions, frailty, or social and psychological needs.

We will:

• Optimise same day emergency care (SDEC) provision with streamlined digital access and expanded pathways to see, treat, and discharge people on the same day to avoid emergency admission.
• Review urgent treatment centre models and share learning across the system.
• Evaluate and learn from the mental health urgent care centre offering targeted crisis response as an alternative to ED.
• Provide a highly responsive integrated urgent care service so people understand the value of seeking advice through NHS111 rather than emergency services.Scope new models supported by digital triage tools that are data-driven and testing of artificial intelligence to effectively prioritise and navigate patients to the most appropriate local service 24/7 365 days a year.
• Ensure 24/7 integrated urgent care provision with primary care central. Explore potential for all UEC access points to be integrated into a single assessment service, using consistent initial assessment, signposting, and streamlined referrals.  Virtual networking of services to enable consistent diagnostics and expert advice regardless of entry point in the system.
• Develop and evaluate locally-led models of same day access, integrated with other UEC services to improve resilience, particularly in areas of high need e.g., Harlow, Stevenage and Hertsmere.
• Effectively integrate community pharmacy into urgent care pathways to support system resilience, redirecting people for treatment of minor ailments.

Why this matters

Patients want a more ‘joined up’ urgent and emergency care system meaning they don’t have to repeat their medical information.

Many 999 calls could be safely dealt with through community services, without the need to send an ambulance. Identifying these calls would help protect capacity within the ambulance service to respond to more critical emergency cases. When ambulances are dispatched, crews often lack information on alternative, safe, and appropriate care options and resort to conveying people to hospital.

Older people with frailty, dementia, and complex conditions, and also those at the end of their life face long waits in  EDs and account for the greatest volume of emergency hospital admissions. These individuals are also the most vulnerable to the harms of stays in hospital, including deconditioning, delirium, and rapid decline. We need to ensure that we are only sending people to hospital if it’s absolutely necessary and if we can’t provide the care they need closer to home.

Our urgent and emergency care pathways are not supporting patients at the end-of-life well either. People in their last year of life experience a high number of emergency and urgent care episodes and many people are not supported to die or be cared for in their preferred place. 

What our population can expect:

• If they call 999 with a life or limb-threatening illness or accident which requires immediate, intensive treatment, an ambulance is reliably dispatched within minutes, and they will be seen rapidly in ED.
• If they do not have an immediate, life-threatening need, they will be safely navigated to alternative out of hospital care that is comprehensive, co-ordinated, and effective to manage their urgent needs and provide acute-level care at home.
• People will no longer need to repeat information to multiple different health and care professionals.
• Older people and those with complex health needs can expect to live independently for longer in their own homes and experience better health outcomes.

We will:

• Create a single point of access with a team of decision-makers for timely clinical advice, helping patients stay at home, receive follow-up care, or access the right setting the first time.
• Ensure efficient management of emergency cases by ambulance services, using ‘C2 segmentation’ of emergency calls to identify cases that could be dealt with by alternative services and automated redirection of calls to community services to provide alternatives to conveyance for non-critical cases.
• Provide the unscheduled care hub with a live system to proactively identify ambulance calls suitable for an alternative service and for ambulance crew to ‘call before convey’ and find the most appropriate care.
• Establish direct referral pathways between ambulance services and hospitals e.g., SDEC and fractured hips.
• Expand urgent community response services, maximising referrals from all sources through a single point of access.
• Develop and evaluate our virtual ward/hospital at home services to continue acute-level care provision at home, extending the capabilities of the service based on population needs and effectiveness.
• Increase the number of appropriate referrals into our virtual ward/hospital at home, giving clinicians and managers clear information about the capacity and capability of services

Why this matters

A one size fits all doesn’t work for urgent and emergency care services. Our analysis recommended we focus on:

Children and young people

Many children attend emergency departments when they could be treated elsewhere. Research suggests some of the reasons for this are that parents and carers want greater reassurance when their child is ill and perceive paediatric ED to be the right place for their child’s care.

We need to enhance our same-day urgent care pathways so parents have confidence and trust in them and empower families to self-care. Pathways of care outside of hospital need strengthening to support young, wheezy children who were found to be at highest risk of a future ED attendance. A child in hospital causes a significant burden of travel for families, with virtual wards being able to provide hospital-level care at home, safely and in familiar surroundings.

Mental health crisis response

For patients in mental health crisis, there is a need for better join up between the services and greater collaboration between emergency services, community teams and mental health. EDs are often inappropriately designed to meet the needs of people in mental health crisis as the estate does not lend itself to enable reasonable adjustments to be made to ensure that patients can deescalate their mental health crisis safely. Mental health services can provide a core component of the service offer required to meet the needs of individuals with drug and alcohol presentations at ED once their physical health needs have been met and on discharge. However, there is current fragmentation of the system which calls for better join up between mental health, drug and alcohol services, social services, and primary care.

Frailty and end-of-life

We need to boost our ability to respond rapidly to urgent needs such as falls, reduced mobility, or palliative support in the community. Uncertainty in end-of-life care pathways often mean patients are admitted to hospital more frequently and die in hospital.

Evidence demonstrates that identifying frailty, and assessing needs in ED ensures multidisciplinary teams can provide integrated and coordinated care in a timely manner and avoid unnecessary admissions.

What our population can expect:

• Families of children and young children feel empowered to self-care and know when and how to seek the most appropriate care.
• Clear routes to responsive services in primary care and community settings so that families no longer perceive ED to always be their best option.
• Appropriate specialist support when they experience a mental health crisis, and that crisis cafes or sanctuaries are available in all communities to those who need it.
• Older frail people are assessed quickly by a team of professionals on arrival at ED who can respond to their specific needs and prevent unwanted or unnecessary admission to hospital.
• We will identify people approaching the end of their life and support them to receive the care and treatment they choose, in the settings they wish to be in, to improve quality of life and patient and family experience.

For children and young people we will:

• Empower families to self-care and to know when and how to seek the most appropriate help, using evidence-based technologies. We will work with health visitors, schools and early years settings to educate on managing minor illness and preventing childhood accidents. We will run campaigns for families facing inequalities, making the most of community connections through VCFSE partners.
• Enhance paediatric expertise in NHS 111, ensure clear routes to same-day access, and redirect low-acuity cases from ED to the most appropriate community or primary care setting. 
• Continue to strengthen out-of-hospital care for wheezy children including access to paediatric pulse oximetry and explore virtual wards for children and young people, driven by population need.

For mental health crisis response we will:

• Ensure comprehensive, timely and reliable crisis advice, supported by multiple routes of direct access to urgent mental health support, including mental health expertise in NHS111 and the unscheduled care hub, crisis cafes and sanctuaries, and 24/7 all-age crisis support in ED and acute wards.
• Review out of hours mental health crisis interventions, e.g., mental health ambulance, together as system partners.
• Monitor, evaluate and learn from a new mental health urgent care centre to provide an appropriate alternative to ED.
• Provide a training and development programme for ED staff to ensure they are appropriately mental health trained and equipped to deliver trauma-informed practice.
• Develop supported discharge from ED for people with co-occurring mental health and substance misuse and ensure collaboration between VCFSE, secondary mental health, and drug and alcohol services.

For frailty and end of life care we will:

• Monitor and develop early intervention vehicles or falls cars responding to falls where there is no injury.
• Develop alternative falls pathways providing acute care or support in the community for those who fallen so they do not need to be transferred to hospital.
• Provide out of hours clinical support for care homes, targeting our urgent care response.
• Implement an integrated acute frailty service supporting staff to identify alternatives to bringing someone to hospital, rapid identification of frailty at the front door, swift comprehensive assessment, and a review by frailty experts to treat promptly and discharge home.
• Implement a culture change programme for clinicians to support adoption of alternative urgent and emergency care pathways.
• Strengthen out of hospital care for end-of-life patients, embedding skills in our workforce so they are confident in assessing end-of-life and develop clear pathways to access specialist palliative care when needed.
• Evaluate and share learning from a west Essex pilot of an end-of-life discharge facilitator post.
• Plan for intermediate and long-term care capacity to ensure services will meet care needs and that they are fit for our future, ageing, population.

Key enablers

To enable the system to deliver the six core strategic priorities we will:

Our focus is on understanding and meeting the needs of our UEC workforce. We will undertake system-wide modelling of a skills-based workforce which operates flexibly across the system, and collaborate with the voluntary sector for workforce growth. We will provide training and development opportunities and support operational managers and clinicians in adopting new and alternative pathways of care.

We aim to achieve seamless digital patient streaming, allowing direct appointment bookings across the UEC system. Enhanced shared access to records (including care plans, GP records, pharmacy data etc.) across the UEC pathway to prevent duplication and ensure staff deliver care which remains aligned to patient wishes. We will use technologies to enable self-care through apps and websites and partner with tech companies for use of remote monitoring and incorporate machine learning to proactively identify risk, deterioration in health, and support decision-making tools.

We will simplify the UEC system and make it easier for patients, carers and clinicians to find the right care, in the most appropriate setting, first time. We will ensure information and support are readily available to enable people to make informed choices about health and care, consistent messaging around when and how to access urgent and emergency care, and professional stakeholder support. We will carry out targeted engagement work to address inequalities and ensure the voices of underserved communities are heard

We aim to excel as a care system, focusing on quality and continuous improvement. Our clinical and professional leaders will foster a positive culture with an understanding of clinical risk across providers, and one that embraces innovation and research. We will horizon scan and learn from neighbouring institutions, establish a quality improvement infrastructure, learning from and supporting implementation of successful pilots. We will support localities to interrogate outcomes for their population and lead enquiries to enhance care quality.

How we will deliver the strategy

This strategy sets out the intentions for urgent and emergency care recovery and transformation across Hertfordshire and West Essex Integrated Care System over the next five years. Each year a prioritised delivery plan will progressively implement the intent of this strategy. A UEC strategy implementation group consisting of diverse membership will be empowered to review whether we are delivering work to meet our ambition. The strategy will be updated and reviewed regularly.