Ambulance waiting times as well as the impact of COVID-19 on Emergency Departments (EDs) across the whole country have created concern among healthcare leadership and patients. The increasing demand and need for timely quality care for patients has made it necessary for healthcare innovations to design care pathways more efficient for both patients and providers.

During ‘The Big Conversation’, which was a public engagement programme held in the autumn of 2019 across Cambridgeshire and Peterborough by the Urgent and Emergency Care (UEC) Collaborative comprising of HUC, Cambridge University Hospital (CUHFT), Northwest Anglia Foundation Trust (NWAFT) and local the CCG as well as a range of other providers, 6,000 people submitted their views on healthcare. Even pre-pandemic, this showed that:

• 79% of people wanted to access healthcare faster, through technology
• 88% of people believed that individuals should be re-directed to other NHS services, if they went to an Emergency Department (ED) and did not have serious injuries or illnesses
• 73% wanted advice about treatment, and the ability to book an appointment within a short timespan

Driven by this feedback as well as taking advantage of a general openness to doing things differently due to COVID-19 and infection prevention protocols, the Urgent and Emergency Care (UEC) Collaborative worked together to take Think 111 First one step further to improve access to urgent and emergency care services and reduce footfall in the Emergency Department (ED). Think 111 First is a national programme that encourages patients who may need urgent emergency care to call NHS 111 first with a view to booking an Emergency Department (ED) appointment for them if necessary, trying to manage busy waiting rooms.

According to NHS England:
1) 20%+ of patients presenting with minor injuries could be diverted to either an alternative, less acute setting (Urgent Treatment Centre (UTC)) or self-care, if they were able to be fully assessed via video consultation by a clinician with a special interest in the management of minor injuries, or
2) 20%+ of patients could be diverted from the Emergency Department (ED) if they were similarly fully assessed by an experienced Emergency Department Consultant or Specialist Doctor
(Transformation of urgent and emergency care: models of care and measurement: NHSE December 2020.)

Although many patients who call NHS 111 have acute dispositions that need referral to the Emergency Department (ED), through HUC’s revalidation process approximately 1700 calls per month that come into our Cambridgeshire and Peterborough call centre are reviewed and assessed. After patients who received an initial Emergency Department (ED) disposition during the first assessment have been revalidated by a senior Clinician over the phone through our Clinical Assessment Service (CAS), approximately 73% of patients can be diverted to primary care, self-care or other services which are more appropriate for their healthcare needs. This reduces the number of patients who arrive at an Emergency Department (ED). This confirms the necessity for the Urgent and Emergency Care (UEC) Collaborative and its commissioners, acute trusts and NHS 111 partner organisations to discover alternative pathways that would help with diverting some of the activity away from Emergency Departments. In Cambridgeshire & Peterborough this resulted in the development of a Virtual Waiting Room. This initiative had two pathways:

– one for patients who had been assessed by the Clinical Assessment Service (CAS) as needing an Emergency Department (ED) disposition,
– and one for patients who had incurred a minor injury and had also received an Emergency Department (ED) disposition.

In both scenarios, a Healthcare Professional, i.e., an Emergency Department Consultant for those who received an Emergency Department (ED) disposition, or an Urgent Care Practitioner (UCP) with experience with minor injuries for the Minor Injuries patients, would consult with the patient via video as the first step in their Emergency Department journey. The use of Video Consultation has made it possible for patients to have the first part of their consultation at home. Often this can result in an alternate disposition e.g., a patient with a possible fractured wrist could be sent for an x-ray before attending an Urgent Treatment Centre rather than the Emergency Department (ED), and the mum of a toddler who has swallowed a foreign body reassured that there is no need to attend the Emergency Department (ED) but to let nature take its course. Other alternatives to the Emergency Department (ED) have been to, GP Practices, Minor Injury Units, dental care, even self-care or pharmacies.

For patients who are assessed as requiring an Emergency Department attendance, the Consultant can often arrange for diagnostic tests e.g., scans or x-rays to be taken before the patient attends the department, saving the patient waiting time and congestion in the waiting room, they can also arrange for immediate referral to a speciality e.g., Surgical Assessment, completely bypassing the Emergency Department.

In order to evaluate the effectiveness and impact of a Virtual Waiting Room on Emergency Departments in Cambridgeshire and Peterborough, over three months, there was a series of testing. For the pilot to be successful, the Urgent and Emergency Care (UEC) Collaborative assessed what internal or joint processes needed to be implemented to connect the various partners to each other to provide the best care to patients, including the removal of initial roadblocks such as how to allow Clinicians who assessed patients virtually to have access to patient information.

Breaking through the boundaries that separated the various members of the Urgent and Emergency Care (UEC) Collaborative was pivotal to the success or failure of the initiative. This has also been a crucial element in the programme’s expansion. Emergency Department Consultants could potentially stop patients from unnecessary visits to Emergency Departments. Utilising members of HUC’s Transformation team and Clinician ambassadors, HUC will continue champion for expansion of the Virtual Waiting Room to convince potential partners and Clinicians to join the project.

When a patient has been identified for a virtual consultation by one of our Health Advisors, patients will need access to a smart phone –– and/or a computer. If they do not have ready access, a loved one or carer would be able to connect to our service them. Or, a traditional call could be held. Either way, by the very fact that technology will make access easier to some extent, this could potentially also help balance out inequities in healthcare.

HUC’s Leadership team embraces change and moves forward quickly. During the trial, the Virtual Waiting Room downgraded an average of 66% of Emergency Department dispositions.
The service was initially funded for three months, then extended to six and will now continue until March 2022. Even better, the Urgent and Emergency Care (UEC) Collaborative has received funding from NHS England to roll out the Virtual Waiting Room across the whole East of England Region. This is a recognition that the Virtual Waiting Room is the first step for many patients in their Emergency Department (ED) pathway, which can streamline their journey and create a smooth experience for them, as well as ultimately improve healthcare efficiency.

The vision of how technology can enable healthcare to be more efficient and to reach more people has been quite impactful for the Virtual Waiting Room. The very fact that a patient can have that first consultation without having to worry about transport will aid those who are less mobile, or less financially able to make their way to a hospital. Because of this pilot, there is now evidence that shows the Virtual Waiting Room can indeed avoid unnecessary Emergency Department attendances.
We are proud that HUC won in the ‘Driving Efficiency Through Technology Award’ category at the HSJ Awards on 18 November for this project. Read more.

We were also co-nominated for The Palliative Care Hub, which can be reached via option 3 when calling 111 and is run collaboratively by the Cambridgeshire and Peterborough CCG, HUC, the East of England Ambulance Service Trust (EEAST) and Arthur Rank Hospice Charity won in the ‘Primary Care Innovation of the Year’ category. Read more.

We are appreciative of the collaborative partnerships we have fostered that have allowed us to recognize advances in technology that support our patients. We look forward to what comes next.