PEOPLE FIRST: Optimising Pathways

Page last updated: 28 April 2023

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Integrated care systems (ICSs) should create person-centred pathways that support people to live healthier lives.

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Data and knowledge are often siloed in services and unavailable to the wider ICS.

When people cannot access the care they need, their health can quickly deteriorate. Hospital admission can become unavoidable. For some, often those living with frailty, there is a further risk of hospital-acquired deconditioning. Deconditioning means there has been a decline in functional, cognitive or physical health. It is caused by prolonged periods of bed rest and inactivity. Ultimately, it can be unsafe for some people to return home as they now require full-time care. 

We can avoid these situations if we:

  • identify patients who are at risk
  • provide early support through local services
  • create effectively integrated care pathways for frailty and social care
  • provide more senior clinical decision-makers to triage people at an early stage.

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Examples of good practice and innovation

Safely reduce conveyance of older people
South Warwickshire ICS

South Warwickshire ICS wanted to reduce unnecessary transfers of older people to hospital. The trust and ambulance service decided to work together using virtual wards. This meant ambulance crews could contact clinicians on-scene to seek advice. As a result:

  • 48% of cases in people over 80 were managed from their homes 
  • only 25% of those over 80 needed transfer to an emergency department
  • those admitted to hospital had reduced length of stays.

See full NHS confederation case study.

Planning to safely reduce avoidable conveyance, ambulance improvement programme
NHS England and NHS Improvement

This publication aims to safely reduce the number of people conveyed to emergency departments (EDs). It identifies areas for nationwide improvement. For example, ambulance services need on-scene access to consultant advice. Some ICSs already do this. In fact, some are developing ways to share videos and images between teams to support this work further.

See full publication Planning to Safely Reduce Avoidable Conveyance.

Safely reduce avoidable conveyance of children 
Blackburn Royal Hospital

Schemes also exist to avoid child hospital admissions safely. For example, Blackburn Royal Hospital gives GPs direct access to guidance from senior paediatricians or community paediatric outreach teams. 

Use of multidisciplinary teams (MDTs) in end of life care

There is excellent work happening in this pathway. Some MDTs have members from across the ambulance service, primary and secondary care. End of life care needs to be a national priority. It is essential to treat people and their loved ones with dignity, and to support their wishes at this critical moment.

Community diagnostic hubs

Increase the use of community diagnostic hubs that include services such as pharmacy, dental, nursing and diagnostics. This will make it easier for people to access the care they need. It also reduces pressure on emergency departments caused by non-urgent visits. 

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