On the right pathway

Dr Kevin McKenna

In the latest column from NHS Connecting for Health, Dr Kevin McKenna, clinical director of NHS Pathways, talk about its work. NHS Pathways set out to deliver an evidence-based assessment tool to improve the response made to calls to both emergency and out-of-hours care.

The tool has been piloted in three areas, serving a total population of over 4m people, and has demonstrated significant benefits for care integration. A wider national roll out is planned. NHS Pathways has won several industry awards for its work, including IM&T Team of the Year at last year’s BT e-Health Insider Awards.

In almost every setting in which patients can call for urgent and emergency care, the first person they speak to is a call handler. Thereafter every access point – such as NHS Direct, GP out-of-hours services or the Ambulance Service – has a different approach to clinical assessment.

Some refer straight to a GP on the telephone, some direct to nurses. Some use locally developed protocols and others decision support tools. Often, such tools are imported from other countries, where they have been developed to support a litigious, financially driven health care model – quite different to the NHS.

One thing is striking. The UK has no access to any single system capable of assessing calls and determining the clinical skills required for definitive care that covers the entire spectrum of urgent and emergency care outcomes.

Emergency 999 calls are assessed using ambulance specific software that cannot identify clinical need other than how fast the ambulance needs to get there. To do so requires a second assessment, using a different triage system. Equally, there is no system at all to support the identification of primary care calls that are true emergencies and to trigger immediate dispatch of an emergency ambulance.

Attempts to bolt together variants of both types of system have resulted in varying degrees of repetitive questioning, multiple calls to close the encounter and delays to the delivery of emergency care. Message transfer between bolted together systems, using staff with different skills, also carries an increased risk of miscommunication of the patient story and key clinical data.

A comprehensive, clinical assessment tool

NHS Pathways set out to deliver an innovative, UK focused, evidence-based clinical assessment tool that would enable the rapid, effective assessment of calls to both urgent and emergency care. In addition it sought to establish whether, for both types of call, the initial assessment could be safely and consistently delivered by a call handler using a single clinical tool. Such an approach would enable the call to be directed to an appropriate service on the first telephone contact.

A further aim was to link the details of the clinical assessment with a dynamic service directory during the call. By doing this, it would be possible to create a direct match between the clinical skills required by the patient and their local availability. This would mean that for people not needing an emergency response, a direct referral to a very appropriate local service would be possible on the first patient contact – regardless of where the call was received.

The outcome has been the development, by UK doctors and nurses, of a comprehensive clinical assessment tool known as NHS Pathways, in which every part of the assessment is supported by at least three pieces of clinical evidence, dated from the past five years and of UK origin where possible.

National pilots and evaluations

An initial pilot was conducted at West Hampshire Out of Hours Service. This was followed by a main pilot at North East Ambulance Service, which tested the principle, proved the concept and confirmed the safety of the clinical assessment tool.

For obvious reasons, the greatest clinical risks come in high volume emergency calls. Prior to live use, and during the pilot, performance was under close scrutiny to ensure patient safety and the accurate transmission of patient data.

An academic evaluation report into the national pilot was completed in 2008. The clinical assessment was found to be both very safe and effective in determining the clinical requirement and then enabling the delivery of that service by the ambulance or out-of-hours provider.

With over 1m calls to 999 and out-of-hours safely assessed, the pilot at North East Ambulance Service, which covers 3m people, is enabling the avoidance of 700 inappropriate ambulance journeys per month.

NHS Pathways has been found to safely identify the highest level emergencies at least as well as any equivalent process, while at the same time enabling a significant number of emergency callers to be referred to and safely managed in primary care.

What next?

Approval for wider use by UK ambulance services and other providers is expected shortly. So, for the first time, a genuine UK common front-end to urgent and emergency care telephone access is possible. What next?

A basic but fundamental capability of NHS Pathways is the transmission of the assessment to ambulances, out-of-hours vehicles, GP practices and so on. This clinical message is transmitted as the call closes and is available for verification during any subsequent face to face encounter.

In 2009, an application to enable paramedics to continue the assessment face to face will be delivered. This will support paramedics in deciding the next step for an individual patient, including referral to local primary care services, instead of transfer to A&E.

It will also be possible for a return message to be generated by the paramedic. Comparing the original transmitted message relating to the call assessment with the return message generated by the on-scene, face to face assessment, will allow a virtuous circle to be set up, enabling the continuous improvement of the software and progressively improved referral patterns.

Clinical practice is always a “work in progress.” NHS Pathways will need to constantly reshape to reflect this. The close relationship between clinicians, IT development and project management, using a rapid development cycle, has put it in a unique position to support any point of telephone access and possibly underpin national policy on the integration of urgent and emergency care.

However, urgent and emergency care referral patterns in areas where it is used will be strongly influenced by NHS pathways, so it is clear that the wider clinical community must also continuously shape its content to maintain safety and improve effectiveness. The governance arrangements for NHS Pathways have been drawn up with that in mind.

The work of NHS Pathways has been recognised by a number of recent awards.

BT e-Health Insider Awards 2008
Winner: IM&T Team of the Year

The CUBE Awards 08
Filemaker Developers of Excellence
The Innovation Award and Winner of Winners

Computing Awards 2008
Finalist: Public Sector IT Project of the Year