Access to Emergency Care across the whole population
73. The indicators currently being collected by Integration Authorities are:
Reduce emergency admissions to hospital ( NPF)
Accident and Emergency Waiting Times ( LDP)
Rate of emergency bed days for adults ( HSCII)
Readmissions to hospital within 28 days of discharge ( HSCII)
Percentage of total health and care spend on hospital stays where the patient was admitted in an emergency ( HSCII)
Number of days people spend in hospital when they are ready to be discharged ( HSCII)
74. Integration Authorities are developing local objectives and plans in relation to the six agreed priorities identified in the Scottish Government's Health and Social Care Delivery Plan  (occupied bed days for unscheduled care; unplanned admissions; A&E performance; delayed discharges; end of life care; balance of care spend). As is appropriate, these plans are being developed taking into account the local context of health and social care services in their area. Some authorities are focussing on the wider journey of care and this is particularly important in dealing with patients presenting to A&E departments.
75. Considerable attention is paid to the performance against the LDP standard that: "95 per cent of patients to wait no longer than 4 hours from arrival to admission, discharge or transfer for A&E treatment. Boards to work towards 98 per cent." This is an important standard and should remain since there is strong evidence of poorer outcome in patients who wait longer than 4 hours to be seen, treated or discharged. However, the A&E episode is one stage in a patient's journey along the unscheduled care pathway. Some Integration Authorities report that they are collecting data on why patients are presenting to A&E and examining whether enhanced community based services, working in association with primary care and social care including care homes might meet some patients' needs more effectively. In addition, data on the outcome for patients admitted is being collected and some Integration Authorities are developing new services with specialist assessment at an early stage for elderly patients to determine the most appropriate level of care for them, thus facilitating early discharge. At present, the evidence points to difficulties in finding beds in hospital for patients requiring admission as the main reason for waiting time breaching.
76. This approach embodies the recommendations for designing targets and objectives advocated by Berry and colleagues in that it is pragmatic, collaborative and iterative. Shared learning across Integration Authorities will allow good practice to spread and this approach to improvement should be supported. Much of the information obtained from these indicators can be collected accurately and timeously. It is suitable for a collaborative improvement approach and it appears that several areas are already working in this way.
a) All these indicators should remain. However, A&E attendances should be seen as part of an unscheduled care journey. Information on the number of attendances at A&E, their referral pathways ( GP or self referred) the length of time they spent in A&E, whether they were admitted, how long they spent in hospital and what their outcome was should be reported on regularly. Information on bed availability in hospital should be reported as a key determinant of long waits in A&E. Such data gives important contextual information on demands on Emergency Departments and the effectiveness of the whole system in managing such patients.
b) Information on the number of patients from each GP practice attending A&E would give insight into opportunities to develop other services such as new, holistic approaches to social support or mental health support in association with primary care. It is recommended that each GP practice receives regularly information on how many of its patients attend A&E and how many self refer. As already indicated, this is already happening in some IJBs. Where numbers are significant, additional support for those practices should be considered.
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