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Six Goals for Urgent and Emergency Care

In Fe­­bruary 2022, Welsh Government published the Six Goals for Urgent and Emergency Care Policy Handbook, setting out the priorities for urgent and emergency care to ensure that patients get the right care, in the right place, first time.

The handbook contains a series of quality statements for each of the six goals, to describe in detail the outcomes and standards individuals should expect when they may need urgent or emergency care.

In April 2022, the Minister for Health and Social Services launched the Six Goals for Urgent and Emergency Care Programme at an event attended by over 300 representatives of health and social services, third sector and other organisations.

A Six Goals for Urgent and Emergency Care Programme Management Office (PMO) has been established to deliver the NHS-led programme. The PMO will work closely with Health Boards and partners to maintain pace, resolve issues, remove barriers and manage key relationships.

Key contacts for the PMO are:

The two priorities for the Six Goals for Urgent and Emergency Care Programme for 2022/2023 are:

  1. Increase capacity in urgent primary care through development of, and enhancements to, Urgent Primary Care Centres. This should enable more people with urgent but not emergency care needs to be treated closer to home and away from Emergency Departments, improving experience and outcomes as well as value.
  2. Delivering twelve hours a day, seven days a week Same Day Emergency Care (SDEC) services. This should improve experience, outcomes and value for money by safely supporting the right patients to return home to sleep in their own beds without need for admission.

To help prevent future urgent or emergency care presentations, populations at greater risk of needing to access them should expect to receive proactive support through enhanced planning and coordination of their health and social care needs. This should support better outcomes, experience and value.

Quality Statement:

  • Parents or guardians of children in ‘Early Years’ settings will be supported to anticipate risks of childhood accidents in the home.
  • People eligible to access the Welsh Government’s Nest Warm Homes scheme are offered support to improve their resilience and well-being, through improving the health of their homes.
  • People living with multiple long-term conditions are offered an opportunity to participate in regular holistic reviews and to co-produce a personalised care plan. This should include an offer of involvement to carers in conversations about care plans. This should cover the carer’s own needs to help prevent admission to hospital for the person for whom they have caring responsibilities for non-clinical reasons, in the event of sudden illness for the carer.
  • People with frailty syndromes, including those with dementia, are proactively identified by health and social care teams to ensure they receive care by a team of professionals competent to assess and manage individual needs at, or closer to, home.
  • Community teams support individuals who are lonely, socially isolated or excluded through social prescribing schemes, awareness of them and encouragement and support for their use.
  • People with mental health issues will be supported through early identification and intervention in primary care. They will be empowered to access self-help and community support.
  • People with substance misuse issues receive support to reduce their risk of harm through access to advice from the right professional. They can access rehabilitation, recovery services and psychologically informed care.
  • Residents of care homes and people known to be at greater risk of falling, are offered proactive support through home safety checks, home adaptations and advice on adoption of healthy behaviours appropriate to their needs.
  • To read more about Goal 1 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.
  • People with a progressive life-shortening illness have the offer of agreeing an advance care plan through close collaboration between the person, their families and carers; and the professionals involved in their care to enable them to die in the place of their choice.

Goal 1 lead: Shane Mills, Clinical Director National Collaborative Commissioning Unit - shane.mills2@wales.nhs.uk

When people need to access urgent care they can access a 24/7 urgent care service, accessible via NHS 111 Wales, providing advice online or over the telephone and where necessary are signposted or referred to the right community or hospital-based service, first time.

Service users are involved in shared-decision making and experience coordinated care with clear and accurate exchange of patient level information between relevant health and social care professionals.
 

Quality Statement:

  • People who require urgent care are supported to understand the value of seeking advice through the NHS 111 Wales online platform or telephony service, receiving a highly responsive service that delivers care as close to home as possible, minimising disruption and inconvenience.
     
  • Those who have an urgent health and wellbeing issue that may result in significant or permanent harm if not assessed or treated within the next eight hours, are supported to achieve optimal experience and outcome through urgent primary care services. This will include:

- an initial phone consultation through 111

- signposting to a same day or out-of-hours primary care appointment; or pharmacy, dental or optometry advice

- direct connection to mental health advice

- signposting / referral to an urgent primary care centre; and/or

- signposting / scheduling to an arrival time slot at a minor injuries unit or Emergency Department
 

  • Health and care staff have access to a ‘directory of services’ holding comprehensive, accurate and contemporaneous information to signpost or refer people to the right place, first time based on their individual need.

To read more about Goal 2 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 2 Lead: Richard Bowen, National Programme Director for Six Goals for Urgent and Emergency Care / NHS 111 Wales - richard.bowen@wales.nhs.uk

People with urgent or emergency care needs can access appropriate and safe care close to home, and with as much continuity of care, as possible. Admission for ongoing care to an acute hospital bed should only occur if clinically necessary.

Linked to Goals 1 and 2, and the establishment of an integrated 24/7 urgent care service, Health Board and partners will work together to achieve this goal.

Quality Statement

  • People with urgent or emergency care needs can access appropriate and safe care close to home, and with as much continuity of care, as possible. Admission for ongoing care to an acute hospital bed should only occur if clinically necessary. Community based nurses, allied health professionals and GPs should have timely access to GP and / or specialty advice and guidance to support safe decisions about a person’s urgent or emergency care needs. This includes helping them to remain at home; receive timely follow-up care after accessing the ambulance service or accessing the right hospital setting, first time.
     
  • People who are assessed for bed-based intermediate ‘step-up’ care are given clear advice about the support the service will be able to provide and, if accepted for intermediate care, start the service within two hours of referral in line with NICE guidance.
     
  • People who have a clinical need for a hospital-based urgent or emergency face-to-face assessment, diagnostics and/or treatment are always considered for management on an (ambulatory) same day emergency care pathway.
     
  • Older/frail people, and people nearing the end of their lives, will be assessed quickly at the front door or adjacent to the Emergency Department with decisions on their care acted upon by a multi-agency team. This should include a system that is able to respond to peoples’ specific needs to prevent unwanted or unnecessary admission to hospital, focus on maintaining nutrition and hydration, mobility, communication and control.
     
  • Individuals will have available, outside of normal working hours, crisis cafés or sanctuaries in their local communities which will provide compassionate safe support for those in mental health crisis.

To read more about Goal 3 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 3 Lead: Sue Morgan, National Director and Strategic Programme Lead for Primary and Community Care - sue.morgan22@wales.nhs.uk and, Adele Gittoes, Deputy COO NHS Wales Delivery Unit - adele.gittoes@wales.nhs.uk

The fastest and best response provided for people who are in imminent danger of loss of life; are seriously ill or injured; or in mental health crisis.

Quality Statement

  • People with mental health and emotional distress will receive a coordinated response from services across the urgent and emergency care pathway. This should seamlessly link:

- In-hours and out-of-hours primary care
- Emergency ambulance services
- Emergency Departments
- Police
- Mental health liaison
- NHS crisis services; and
- Crisis cafes and sanctuaries.

  • People dialling 999 with non-time critical presentations are referred to alternative community, mental health single points of access or direct access hospital pathways, or safely discharged over the telephone following a secondary clinical assessment.
     
  • People who have dialled 999 for an emergency ambulance and are in imminent danger of loss of life or limb, have a time sensitive injury or illness or require palliative care receive the fastest and best type of response commensurate with their clinical need. They are transported/referred to the best direct access pathway based on clinical need, as quickly as possible.
     
  • Defibrillators are readily available and accessible to the public who are aware defibrillators are easy to use and can do no harm.
     
  • Those arriving by ambulance at a hospital facility should be transferred safely from ambulance clinicians to the care of hospital clinicians in order of clinical priority and always in a timely manner (an hour at most).
     
  • People who have accessed care in an Emergency Department (and the wider hospital) will find suitable environments and proactive processes to greet them. On arrival, there will be quick identification of whom the patient is, why they have attended and, following triage, what the next step in their care should be. Wherever possible, this will occur within 15 minutes of arrival, with an assessment by a senior decision maker complete within an hour.
     
  • People suffering with acute complications of cancer or its treatment are able to bypass the Emergency Department, where appropriate, and quickly access an acute oncology service for appropriate specialist input to facilitate urgent assessment and rapid initial management.
     
  • Ambulance clinicians will develop necessary end of life assessment and support skills to deal with difficult conversations, administer appropriate medications and support family/carer concerns.
     
  • When people are ready to leave the Emergency Department, there will be effective arrangements in place to provide continuity of care with the minimum of delay, including returning home with support and timely admission to a hospital bed, when that is the right next stage in the person’s care.

To read more about Goal 4 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 4 Lead: Stephen Harrhy, Board Director/Chief Ambulance Service Commissioner - stephen.harrhy@wales.nhs.uk

Optimal hospital-based care is provided for people who need short term, or ongoing, assessment or treatment for as long as it adds benefit to outcome, with a relentless focus on good discharge practice.

Quality Statement

  • People admitted to hospital should be treated consistently and reliably in line with the expectations of health, social care, third and independent sector partners in Wales as described in Welsh Government Hospital Discharge Requirements guidance.
     
  • People admitted as an emergency to a hospital setting should:
    - Be reviewed by an appropriate consultant as soon as possible after admission. This should be no later than 14 hours from the time they were admitted to hospital. Frailty assessments should be completed where required on admission.
    - Should have a reconciled list of their medications within 24 hours of their admission.
    - Be fully involved in and informed of plans for their treatment, recovery and discharge from hospital. They should have answers to four key questions on a daily basis: what is the matter with me? What is going to happen to me today? When am I going home? What is needed to get me home?
    - Have a structured patient handover during transitions of care, with a focus throughout on return to home as soon as they are clinically fit to leave.
    - Have a patient care plan that includes active intervention to avoid deconditioning, maximise recovery and support independence throughout their hospital stay.
    - Have access to rehabilitation regardless of condition and ward to which they are admitted; available immediately upon admission, or as soon as the person is medically able to participate to accelerate recovery and reductions in side effects.
     
  • Frail and vulnerable people, including those with disabilities and mental health problems of all ages, should be managed assertively but holistically (to cover medical, psychological, social and functional domains) and their care transferred back into the community as soon as they are medically fit, to avoid loss of ability to self-care.
     
  • The person’s consultant is responsible for deciding when they are clinically ready to move on from an acute phase of their care, and agrees an ‘individual clinical criteria for discharge’ to enable return home even if the consultant is not present.
     
  • People who are eligible for discharge through Non-Emergency Patient Transport Services will receive safe, timely and comfortable transport to and from their destination, without detriment to their health. They are treated with dignity and have their religious and cultural beliefs respected. Where people are at a hospital ward or department, the Health Board will ensure they are ready to leave at the time they notify the transport provider of readiness to travel.

To read more about Goal 5 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 5 Lead: Adele Gittoes, Deputy COO NHS Wales Delivery Unit - adele.gittoes@wales.nhs.uk

People will return home following a hospital stay – or to their local community with additional support if required – at the earliest and safest opportunity to improve their outcomes and experience, and to avoid deconditioning.

Quality Statement

  • People who require additional support on discharge should be transferred from hospital onto the appropriate ‘discharge to recover then assess pathway’ (usually back to their normal place of residence) within 48 hours of the treatment of their acute problem being completed.
     
  • Integrated health and social care teams should respond in a timely manner to ensure support systems are safely in place to respond to a person’s needs on discharge. Effective care coordination must be in place to ensure that, once recovery and assessment is complete, transfer to onward care arrangements is timely and seamless.
     
  • Programmes are in place to help people develop the knowledge, skills and confidence to manage their physical and mental health, access the support they need, make any necessary changes and be better prepared for any deterioration or crisis.
     
  • All patients on mental health or learning disability wards with admissions longer than 90 days must have a clear discharge plan in place. All patients cared for in specialist services outside of NHS Wales will have a repatriation plan in place.

To read more about Goal 6 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 6 Lead: Adele Gittoes, Deputy COO NHS Wales Delivery Unit - adele.gittoes@wales.nhs.uk