Abstract
Background: North West London Integrated Care System supports a diverse population of 2.1m. The System includes place based partnerships in eight municipal boroughs, and involves collaboration between commissioners, primary care and secondary care NHS Trusts representing acute hospitals, community and mental health providers.
The providers in the Community Collaborative together are responsible for six urgent community response (UCR) teams which provide care at home across North West London's geography, aiming to avoiding unnecessary hospitalisations, particularly for older people with frailty.
Prior to this initiative, the providers already collaborated to deliver consistent core minimum UCR, overseen by a working group with expert patient involvement. The Group identified each team had a separate referral route which faces place-based referrers in primary care and hospitals. Feedback from the Ambulance Trust told us that our referral pathways didn't align with the needs of emergency services working across the capital.
Having to navigate different UCR teams resulted in unacceptable waiting times, and frustrated referrers were less likely to take up opportunities to avoid ambulance dispatch or conveyance to hospital.
Aim: In October 2019 the Collaborative was awarded a small winter grant of £100k and chose to use this to establish a single shared referral route for emergency services (111 and 999 callers and London Ambulance Service staff). The aim was to simplify pathways, improve referrer experience and consistency of response and to support reduced demand on urgent and emergency care pathways and increase access to community based care.
Method: West London NHS Trust rapidly mobilised the single number embedded in their existing 24/7 referral hub with dedicated clinical triage staffing, bypassing queues and initial administrative triage processes. All teams across providers agreed a 'trusted assessment' approach and used digital tools to share live capacity information so suitable referrals could be accepted without delay.
Results: Early data from the 4 month pilot suggested positive improvements, and the Trust continued this for a full 12 month period.
* Over the year, 1522 referrals were received through the dedicated pathway (approximately 10% of all referrals), with 66% accepted for home based crisis support within 2 hours.
* Referrals from 111 (universal self-referral emergency line) doubled from a baseline of 54 per month pre-pilot to mean of 96 per month (max 123 per month), avoiding Ambulance dispatch.
* Referrals from 999 Ambulance clinical hub (avoiding dispatch) increased from 0 to 23 per month.
* Referrals from Ambulance crews on scene (avoiding conveyance to hospital) increased from 50 per month to 86 per month.
* Average referrer telephone contact time reduced from >25 minutes to call answer time 54 seconds, and clinical discussion time <10 minutes.
Conclusions: This approach was successful and funding has been further extended, and other areas of London are now exploring replicating the model.
The joint working to integrate our pathways had additional benefits in building trust between teams and reducing unwarranted variation.
There is transferrable learning for other places and partnerships seeking to enhance intermediate care pathways and the interfaces with urgent and emergency care services.