Testing out new services to cut hospital attendances

Ensuring that people receive the right type of urgent care when they need it has been a difficult issue for the NHS, and the problem is growing as emergency departments (EDs) struggle to cope with rising demand for their services

Ensuring that people receive the right type of urgent care when they need it has been a difficult issue for the NHS, and the problem is growing as emergency departments (EDs) struggle to cope with rising demand for their services.

To reduce waits in EDs, eight pilot projects are trialling new models of emergency and urgent care across England (see map below). These ‘vanguard’ projects are part of the NHS England New Models of Care programme.

Nurse Caroline Rooney and paramedic Paul Davies undertake home visits as part of Cambridgeshire and Peterborough’s urgent and emergency care vanguard  Picture credit: Tim George



The eight pilots have been joined by 42 other vanguard sites that are investigating a variety of changes to how NHS services are delivered. These include integrating primary, secondary and specialist care, and moving more specialist care into the community.

They are an essential part of the NHS chief executive Simon Stevens’s Five Year Forward View, which calls for new ways of delivering care that break down traditional boundaries.

Not just in hospitals

NHS England, when announcing the urgent and emergency care vanguards in July last year, said care will be delivered not just in hospitals but also by GPs, pharmacists, community teams, ambulance services, NHS 111, social care providers and others. Patients will also be supported and educated to manage their own conditions.

The vanguards are also expected to break down boundaries between physical and mental health to improve care.

Two vanguards, in the north east of England and West Yorkshire, are focusing on large-scale change for large populations. The other six are looking at smaller local systems that involve hospitals, general practices and social care.

A case study describing Cambridgeshire and Peterborough’s urgent and emergency care vanguard is set out below.

Reducing unnecessary visits to emergency departments (EDs) and admissions to hospital is the focus of Cambridgeshire and Peterborough’s urgent and emergency care vanguard. Joint Emergency Teams (JETs) have been created, run by Cambridgeshire and Peterborough NHS Foundation Trust. The teams comprise two people, usually a nurse and a paramedic, and aim to visit people in their homes within two hours of being called to prevent them entering hospital unnecessarily.

The team members, who have advanced assessment skills, decide whether the patient requires hospital care; if not, the team makes a referral to the district nursing team or other services needed to support the patient at home, and informs the person’s GP.

Six teams work across the two counties, providing the service seven days a week from 8am to 10.30pm for patients over the age of 65. Peterborough and Ely JET paramedic and operation lead Paul Davies, pictured above with nurse Caroline Rooney on a house visit, says that referrals have so far come mostly from GPs but are starting to increase as more people find out about the service. In January, the Peterborough team received 260 referrals.

‘It is about trying to keep older patients at home and away from hospital,’ says Mr Davies. ‘About 60% to 70% of our patients don’t end up going to EDs. Most people over 65 want to stay at home and, if they have complicated medical histories and have recently been discharged, they are even keener to do so.’

Models under consideration include the development of new urgent care sites, improving education on self-management for patients, and enhancing access to mental health staff.

Change is needed to relieve pressure on EDs. Data from more than 40 trusts in the UK, published by the Royal College of Emergency Medicine last November, showed that only 88% of emergency patients were being treated or admitted within four hours, well below the 95% target.

NHS England’s director of the New Models of Care Programme Samantha Jones told Emergency Nurse: ‘The vanguard sites are redesigning the NHS in real time. It is important to ensure that the population we serve is receiving the most up-to-date care fit for the future.’

Improving people’s knowledge of where to go for out-of-hours care is crucial, says Ms Jones. Currently, patients have a choice of minor injury clinics, ambulance services, EDs, NHS 111 or GP out-of-hours services.

‘A myriad services are available for the public to access, and it is sometimes confusing,’ she adds.

A total of £200 million in funding has been shared by the vanguards. NHS England has also been working with Monitor and the Care Quality Commission to remove regulatory barriers to change, and has published support and advice for people leading the vanguard sites.

Many of the urgent and emergency care vanguards are still in the planning phase and are finalising what models they will be using. South Devon and Torbay is one site that is scoping out the project. It is developing two urgent care centres, as well as developing ways to promote self-care and improve access to NHS 111, mental health support and shared medical records.

A spokesperson for NHS South Devon and Torbay Clinical Commissioning Group (CCG) says the options will be evaluated and the best locations for urgent care centres in NHS facilities identified.

The largest of the vanguards is in West Yorkshire, and comprises 11 CCGs, six acute trusts, three mental health trusts, 366 general practices, community providers and the Yorkshire Ambulance Service NHS Trust.

Leeds North CCG chief officer Nigel Gray says the group is developing a clinical service to provide specialist advice to NHS 111 and 999 services, and to help front line healthcare professionals manage care closer to home.

The service will also include care co-ordination to avoid hospital transfers and to book patients into primary care, community pathways, mental health facilities and alternative health and social care options.

‘We are on track to implement the Leeds Care Record with Yorkshire Ambulance Service so that clinical advisers have access to it, which will enable appropriate decision making regarding treatment and care options,’ says Mr Gray.

RCN professional lead for acute, emergency and critical care Anna Crossley explains why the vanguards are important: ‘If patients are admitted who don’t need hospital care, not only is it detrimental to them and their family, it is also more costly for the NHS.

‘The vanguards are promoting more collaboration between primary, secondary, community and social care services to achieve collective ownership of emergency care and improve the flow of patients.

‘We need to look at new ways to take care away from hospitals and keep patients in their own environment.’

However, University of Wolverhampton nurse practitioner and senior lecturer emergency care Jim Bethel questions the vanguard initiative. He says the project sounds worryingly similar to past ones that have attempted to integrate primary and secondary care and reduce pressure on emergency services.

‘Huge amounts of time and effort went into such initiatives before, and they have largely failed,’ he says. ‘Patient demand for services is rising relentlessly and people are understandably confused about how and where to access care, and will default to the ED. We should follow patients rather than try to make them follow us, and put out-of-hours services – including GPs, nurses, case managers, physiotherapists and pharmacists – next to or in EDs. In the short term, with financial constraints and an ageing population, I do not see things changing quickly.’


For more on NHS England’s new models of care programme, see






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