AHP Unscheduled Care Event 2019 (Morning Session)

Attend Anywhere –
Video Presentation
https://youtu.be/R_0cDigr8_4
https://nhsforthvalley.com/
health-services/near-me-
video-consultations/

Impact is Key – AHPUSC19!
1 Essential Group Supporting 6 Essential Actions!
10th October 2019
#AHPUSC19 #AHPsday2019 #AHPsDAYSCOT

10th October 2019
Claire Ritchie
AHP Director NHS Greater Glasgow & Clyde
AHP Unscheduled Care Group Chair
Event Chair

10th October 2019
Making a Difference in Unscheduled Care – The Vital Role of AHP’s
Professor Derek Bell
Professor of Acute Medicine Imperial College London

Need the right amount of the right data at the right time
Right staff right place right time
Making a Difference in Unscheduled Care;
The vital role of AHP’s
Improving the patient journey
www.menti.com enter 901595

Mind the Gap – AHP’s at every step
Ambulance
Service

Acute (unscheduled) care
the context
Definition
(of an unpleasant or unwelcome
situation or phenomenon) present or
experienced to a severe or intense
degree

The AHP team
• Dieticians
• Occupational Therapists
• Paramedics
• Physiotherapists
• Radiographers
• Speech and language therapists
Plus pharmacists and others even Doctors!

International Journal for Quality in Health Care 2009;
Volume 21, Number 6: pp. 397

Responsibility
Research
High quality audit or improvement

Extended roles for allied
health professionals: an
updated systematic review
of the evidence
Saxon et al
J Multidiscip Healthc. 2014; 7: 479–488.
Initial SEARCH – 1000 Papers
21 met search criteria
19 – Physiotherapy
1 – Occupational Therapy
1 – Speech and language therapy
No randomised control trials
Only one study reported
pre and post outcomes

Extended roles for allied health professionals: an updated
systematic review of the evidence
‘There remains limited evidence as to the true impact in terms of overall patient
waiting times. In fact, the majority of the literature describes these comparisons
in terms of a retrospective audit or as a simultaneous clinical pathway. This
appears to be the “groundwork” to convince health care professionals and
managers that roles can be substituted’

Case study – St Elsewhere’s

Day of Care survey – London + Scotland Overview
16
1. Three hospital sites were excluded as had less than 100 beds
2. Total number of patients surveyed on the day of DOCS at site
3 Boarders are patients who are in a ward bed not related to their main specialty needs. This is the % of boarders out of the number of patients surveyed
4 Excludes patients for discharge
45 sites across London & Scotland1 Medians & Ranges
Number of beds surveyed 19274 Range: 112 - 1523
Number of patients surveyed2 18450 Range: 95-1430
Bed occupancy (%) 96%
Median: 96%
Range: 75% - 131%
Boarders (%)2 6% (1045 patients)
Median: 5%
Range: 0% - 18%
Day of Care – criteria met (%)3 78% (13097 patients)
Median: 77%
Range: 55% - 90%
Day of Care – criteria not met (%)4 22% (3718 patients)
Median: 23%
Range: 10% - 45%
Of those not met – within hospital control (%) 34%
Median: 32%
Range: 5% - 70%
Of those not met – whole system issue (%) 62%
Median: 64%
Range: 27% - 90%
Of those not met – Home designated as most appropriate alternative place (%) 48%
Median 50%
Range: 8% - 72%

17
• Reasons are split equally: 3 acute specific, 3 system issues
Top 6 reasons
account for
63% of delays
Day of care survey – London + Scotland Key findings 2
217
287
295
484
511
545
0 100 200 300 400 500 600
Awaiting final multi-disciplinary team decision
Awaiting community hospital bed
Awaiting consultant decision/review
Home care support availability/funding
Awaiting social work allocation/assessment/completion of assessment
Waiting for AHP assessment/treatment
Number of patients
Reasonnotdischarged
Top 6 reasons not discharged

18
191
193
217
287
295
484
511
545
0 100 200 300 400 500 600
Awaiting procedure/investigation/results and not meeting criteria for acute care
Making choices/awaiting place in care home
Waiting for AHP assessment/treatment
Number of patients
Reasonnotdischarged
Top 8 reasons not discharged
Day of care survey – London + Scotland Key findings 2
Top 8 reasons
account for
73% of delays

Do we need to reframe for system
redesign?

Facilitating the patient journey – 4 principles

Physiotherapy and Occupational Therapy in the Acute Medical Unit: Guidelines for Practice
2015
Competencies for Acute and Emergency Medicine 2017
Society for Acute Medicine
Allied Health professionals guidance documents

Emergency Readmissions
120,000 per year 75% relate to recent emergency admission
• 15% readmission rate for emergencies
• 5 % for previous elective procedure
• 1:12 for < 65yrs and 1:8 for > 65yrs
• 30% within 7 days
Impact
• Equivalent to
• 1 months ED attendances in Scotland
• 3-4 months of emergency admission to Scottish Hospitals

Readmissions with
Board Emergency readmissions within 7
days
Emergency readmissions within 30
days
General Medicine within 30 days
A 6-14% 9.8-27% 21.8
B 4-11% 13-22% 16.3
C 6-10% 8-20% 17.6
D 5.5-15% 9-21% 14.5
E 5-10% 8- 21% 16.4
F 4-13% 9-24% 16.5
G 5-16% 9-28% 16.2

What are the key research questions for
the unscheduled care pathway for
AHP’s

What are the key service delivery
questions in the unscheduled care
pathway for AHPs?

Flu
Vaccination
Dr Deepack
Dwarakanthan

Whole system challenge
 Hospital – Macro
 Directorate or Departmental level – Meso
 Individual(s) - Micro

AHP’s are vital
• Need a louder and coordinated voice
• Leading the system change – based on needs
• You are vital – for patients and the system
34

Community
35
Healthcaresystem…
Volumeofpatients
ED
Avoid
multiple
moves in
ED
Manage
the non
admitted
workstream
more
effectively
AMU/ASU
Twice daily
ward
rounds7/7
All patients
reviewed
7/7 AHP
and
pharmacy
input
Ward
Embed
EDD
Daily Senior
decision
making
Weekend
Consultant
input
Rehabilitatio
n or other
acute beds
Develop pull
systems from
acute beds
Returnto
communit
y
Direct
admissions to
AAU/ASU
Rapid Access
Clinics
Returnto
community
Returnto
community
Returnto
community
Streamlinetransfer
BroadenAAUcriteria
Fasttrackprotocols
Simplifybedmanagement
Streamlinetransfer
ImprovetimelySpecialtyopinion
Improvetimelysupportinpute.g.Echo
Avoidinliersandoutliersandsimplifybedmanagement
Mind the gap – Streamline Transfers
Streamlinetransfer
Agreedrepatriationprotocols
Accesstorealtimebedstate

Wrong place wrong time and clinical outcomes
Publication in preparation

Tests/ Review
Downstream Ward
Labs
Community Care
Care PlanPatient in Admission Clerk Examined
Analyse results
Junior Doctor Consultant MDT MDTNurse
Results back
Invisible decisions
Iterative
Investigation

Essential building blocks for effective
flow
Prescribing the treatment
Location Staff team
Processes and
infrastructure

Visual representation
of the journey

Acute Medical Decision algorithm needs based
Patient
Assessment
24 HR
24 - 48 HRS
Specialty Ward Transfer
ASAP if LOS > 48-72hrs
Multi-
disciplinary
Team
Stay
Diagnostic
uncertainty
Mobilisation
Care package

Systematic Approach
Supports success at organisational and team/project level
• Anticipating potential barriers to sustainability will help you
plan and set priorities at an early stage
Acting scientifically and pragmatically
• Take action to improve the prospects of your improvement
within healthcare where a range of factors can influence
sustainability
Embrace complexity
• Understanding factors affecting sustainability supports
engaging stakeholders, discussing barriers and management
of risks
Engage and empower

The Emergency Floor and
Hospital
Specialty
bed base

Some musings and ‘facts’
• What does your local data tell you ?
– Qualitative or quantitative
– Admitted and non-admitted data ?
• In day early discharges improve ‘flow’
• Improve continuity v improved handover
• Capacity in the system (beds) closest to front door on Monday make the week easier.
• Although demand is often down at weekends – they are rarely quiet.
– Do we have the right team in place at weekends
– Can we augment team over winter – time in lieu v ££
• Wrong bed wrong time = poorer outcomes
• Right bed right time

COMPLEX NEEDS PROCESS
GP/A+E
40% Home33
36%
RIE
24%
O/S
LOS ~ 48hrs
OT PCP PT NursePharm

Managing length of stay
0
50
100
150
200
250
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)
Numberofpatients
Take ½ day off clinically unnecessary LoS
and it has a dramatic impact
Alternatives to admission
These patients may have more
complex support needs
Left shift

Duration in system, time
Numberofpatients,volume
4 days - weeks2-3days8 hours
ED Acute Downstream Ward
4 hours
Schematic of ‘flow’ characteristics across hospital system
Transition
Transition
10
5
2
Needs related =
benefit

Understand Practices
and Processes
Understand Variation
Identify Systemic
Issues
Strategic, Political and
Financial Alignment
Active Engagement of
those responsible for
and affected by
change
Facilitate Dialogue
Willingness to Learn
and Freedom to Act
Provision of
Headroom,
Resources, Training
and Support
Capture and Share
New Knowledge
Combine Existing
Evidence with Local
Knowledge
Iterative Development
Invest in Continuous
Improvement
Achieving Sustainable Healthcare Improvements From Translating
Evidence-Based Medicine into practice (SHIFT-EBM)
Act Scientifically
&
Pragmatically
Engage and
Empower
Embrace
Complexity
Improving
Quality of Care
Safe
Effective
Patient Centred
Efficient
Equitable
Timely
QualityDimensions
A framework for practice and research

Sir Charles Gairdner Hospital
High level system overview and balance measures (8 weeks ending 16 Feb 2014)
March 2014 50Sir Charles Gairdner Hospital Emergency Flow Report - UK Visit
These figures highlight the problem with outliers throughout most clinical areas.
Representations and re-admissions may be an important area to review.

The table shows a set of measures and balance measures that capture aspects of flow through the emergency
department.
Emergency department measure - weekly average (8 weeks ending 16 Feb 2014)
Attendances* 1,302
Re-presentation within 48 hours 5.2%
Re-presentation within 7 days 9.2%
Average length of time in department 3h28m
NEAT compliance 79%
Outliers in ED (not under care of ED team for greater than
90mins)
19%
Mortality in ED 0.1%
Did not wait to be seen* 1.2%
NEAT compliance for SSU admissions* 81.3
Ambulance ramping* 28.7h
* Denotes data for 1 Mar 2013 – 28 Feb 2014
Emergency Department Summary Statistics
The measures shown in red are the measures and balance measures that may be areas for improvement or require greater
understanding. The average time in the department is long, consistent with overcrowding. The re-presentation data should be
monitored and understood.

Acute Medicine needs to deal with complexity not age

Admitted Patients Discharged before 10:00am
Interpretation
The percentage of discharges achieved before 10.00am has varied over the period
appears to be declining.
Reviewing this in relation to cumulative % discharge by midday may be helpful and
quantifying role of the discharge lounge in this process may be beneficial
Description
This chart shows the percentage of discharges of admitted patients achieved before
10.00am. Such discharges provide an early release of beds for patients requiring
admission that day. The data is presented monthly between Jul 2011 and Feb 2014.
Months are on the x axis. The percentage of patients discharged before 10.00am is on
the y axis.
Statistical Process Control (SPC) has been applied to the data: the average is drawn
as a solid line and the upper and lower control limits as dashed lines.

Current Journey
DAY 1 DAY 2 DAY 3

ADMISSION
Current Journey
DAY 1 DAY 2 DAY 3

Total of 4 hours to be admitted and clerked.
Nurse called-off during admission, leaving it incomplete. No
knowledge of home circumstances.
Current Journey
DAY 1 DAY 2 DAY 3

Junior Doctor forgets to prescribe fluids.
No doctor checks tests results before handover.
Lucy is not seen by a consultant on the first day.v
Current Journey
DAY 1 DAY 2 DAY 3

INVESTIGATION
Current Journey
DAY 1 DAY 2 DAY 3

Consultant sees patient 13 hours after admission.
Diagnosis Pneumonia.
Query home with Hospital at Home support.
Current Journey
DAY 1 DAY 2 DAY 3

Blood tests are just taken in the afternoon.
Doctors just check results after 4pm.
Potassium is low but no time to stabilise it.
Current Journey
DAY 1 DAY 2 DAY 3

New consultant starts review from scratch.
Unaware of previous decisions.
Orders more investigation tests.
Current Journey
DAY 1 DAY 2 DAY 3

Bloods are back normal.
Staff nurse needs to chase discharge letter, medicine, hospital at
home referral and book transport in 45 minutes.
Current Journey
DAY 1 DAY 2 DAY 3

PATIENTPARTICIPATION?
Current Journey
DAY 1 DAY 2 DAY 3

FOLLOW-UP?
Current Journey
DAY 1 DAY 2 DAY 3

Patient in
MDTMDT
Current journey
from hospital admission
Admission Discharge
Investigation Treatment
Care plan
& Follow-up
Community
care
Relatives

Discharge
Patient in
MDT
Ideal journey
from hospital admission
Admission Investigation Treatment
Care plan
& Follow-up
Community
care
Relatives

MDT
Patient Information
Visibility
Improving the discharge
process

Information
Downstream Ward
Community Care
Shareable
MDT
Patient Information
process

Patient &Relatives
Information
Downstream Ward
Community Care
MDT
Patient Information
Empowerment
process

process
Patient &Relatives
Information
Downstream Ward
Community Care
MDT
Patient Information
Follow-up

process
Follow-up
Visibility
EmpowermentShareable

DAY 1 DAY 2
Visibility
Doctors team can see notification of results
back.
Consultant sees Lucy before doctors handover.

DAY 1 DAY 2
Visibility
Visibility of care plan in place to discharge the next day.
Opportunity to proactively test bloods before round.
Time to stabilise the patient on time for discharge.

DAY 1 DAY 2
Shareable
Dietitian receives referal timely and sees the
patient while this is waiting for second blood test.

DAY 1 DAY 2
Improved journey
Visibility of care plan in place and home query.
Teams can coordinate to have all elements in place at time of
oficial discharge.

DAY 1 DAY 2
Patient empowerment
Lucy has the opportunity to understand the care she will receive, as
well as tell the ward her current circumstances early on.

DAY 1 DAY 2
Follow-up
All teams are aware of Lucy’s
developments and reassured that she is
safe.

Current JourneyDAY 1 DAY 2 DAY 3
DAY 1 DAY 2
Improved journey

30 years ago:
Concern about the quality of care must be as old as medicine itself. But honest
concern, however genuine, is not the same as methodical assessment based on
reliable evidence.
RJ Maxwell. BMJ 1984
Derek Bell Imperial College80

Overcrowding / boarding is unsafe
Exit block

10th October 2019
National USC Team
Improvement – What has Worked? What is Next March 2020?
Helen Maitland, Director National USC Team, 6 Essential
Actions, Scottish Government

6 Essential Actions Improvement Approach
• Delivery of 95% target for all patients to be admitted,
discharged or transferred within 4 hours.
• Aiming towards a standard of 98%
• Monitor 8 and 12 hour waits.
• Developed in partnership with the Academy of Royal Colleges
• Safe, person centred, effective care delivered to every
patient, every time without unnecessary waits, delays
and duplication
• It requires a whole system response to ensure capacity meets
demand - by hour of the day and day of the week
• Performance Improvement Collaborative approach
Safety, mortality, person centred

4 hour Emergency Access Performance

Scotland core weekly Over 12hr trends
Data relating to the period between the week ending of 12-October-2014 and 29-September-2019
Source: ISD weekly A&E publications. Data relating to the week ending 29-September-2019 (the most recent week) is
Scottish Government Weekly Management Information and is not for onwards release
85

Scotland Core sites - Weekly Attendances
86

System Challenges
• Winter
• Influenza – Southern Hemisphere
• Challenging Elective Strategy
• Medical Workforce
• Vacancies and pension changes
• Recruitment and retention
• Nursing and AHP
• Across 7 day services
• Brexit – no deal

Clinically Focussed Empowered Leadership
Responsive Operational Management
Whole System Escalation
Triumvirate Leadership Team
- Site Director,
- Chief Nurse,
- Chief Doctor
Capacity and Patient Flow Realignment
Determining and utilising
appropriate information and trend
data for performance improvement
to ensure correct resources are
applied to meet demand and
system need
Patient Rather Than Bed Management
Daily Dynamic Discharge
Shifting the discharge curve left
Developing a coordinated,
multidisciplinary approach to
discharge planning encompassing
acute and community resources
Medical and Surgical Processes
Aligned for Optimal Care
Designed to
pull patients from ED
through assessment and
diagnostics process to be
seen at right time, by right person
in right place
7 Day Services
To reduce variation in access
to all services across
weekend and out of hours.
Includes clinical assessment,
diagnostics, and access to
Senior Decision Makers. Also
support services such as
porters, cleaning and
transport
Ensuring Patients Care for at Home
Pathways to reduce
attendance, avoid admission
and if admission necessary
ensure home when ready
Basic Building Blocks
Improve rate of early in
day and weekends
Signposting and redirection to
appropriate community services
6
Essential
Actions

EA1.
Clinically Focused and Empowered Management
• Triumvirate Management
• Clinical Leadership
• Escalation
• Responsive Operational Management
• Safety, Flow Huddles
• Morning - waking the hospital up
• Afternoon – prediction and plans
• TRUST the system
Eliminate silo working

EA2. Capacity and Patient Flow Realignment
• Basic Building Blocks
• Understanding what we manage across Community, PC ,
Acute unscheduled & scheduled
• Flow Analysis
• Balancing measures
• Capacity Realignment
• Admitted and Non-Admitted Pathways
resources applied at right place and right time
combined elective & emergency capacity plan

EA3. Patient Rather than Bed Management
Daily Dynamic Discharge
• Daily ward management -
Electronic Whiteboards
• Multi-disciplinary Team
• Focussed ward round routine
• Estimated Date of Discharge
• Criteria Led Discharge
• Discharge to Assess
• Use of Discharge Lounge
• Afternoon huddles - focus on
prediction
• Day of Care Surveys
Outcomes:
Shifting the curve ……every day
 coordinated planning & implementation of appropriate discharge with no delays
Eliminate Exit Block and Crowding
 ELIMINATE BOARDING
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of Day
Cumulative % Discharges by Hour of Day
Dec-18 Jan-19 Feb-19 Mar-19

EA4. Medical and Surgical Processes
Timely assessment in most appropriate place to get early
specialist clinical interventions will prevent/radically reduce
boarding
• Manage Patient Journey through Assessment Areas
• early management plan
• Specialty receiving – In / Out Balance
• Redirection to appropriate care provider
• early, value-added triage
• Assess for discharge – even after dark!
improve patient flow through the unscheduled care pathway

EA5. Seven Day Services
• Weekend discharges
• Rates monitored
• Evening capacity & demand
• workforce
• Length of Stay variability
• Diagnostics
• Pharmacy
• AHP
appropriately targeted to reduce variation in weekend and out of
hours support for discharge

EA6: Patients Cared for at Home
• People are supported to live well at home
or in the community for as much time as
they can
• Reduce attendances
• Reduce admission
• Home when fit and ready
• They have a positive experience of health
and social care when they need it
There is no ward like home

Health & Social Care
6 National Indicators
1. Acute unplanned bed days
• The number of acute unplanned bed days has reduced
2. Emergency admissions
• The number of emergency admission has risen
3. A&E attendances
• The number of emergency attendances is rising - 4% this year
4. Achievement of 4 hour Emergency Access Target
• Still working to achieve this
5. Delayed discharge bed days
• Seasonal variation
6. End of life spent at home or in the community
• gradually increasing

Delivery of Health & Social Care
for Unscheduled Care
Whole System Working
• Common vision with patient care at the heart
• Whole System Measures
• working to achieve the same outcome
• Whole System Respect
• Improved understanding of services
• Whole System Trust
#6EAScot UnscheduledCareTeam@gov.scot
 Next steps

10th October 2019
Improving crisis management in the community – the Distress
Intervention Group
Mr Jacques Kerr, Senior Medical Officer, The Scottish
Government

Distress Intervention Group
J Kerr
Senior Medical Officer
Scottish Government

MH Attendances
Financial Year
ED Attendances
(All Sites)
ED Attendances
(Episode Level
Data1
)
MH Attendances1
Proportion of
Attendances with
MH Diagnosis1
2014/15 1,639,991 1,535,934 37,944 2.5%
2015/16 1,606,682 1,505,042 42,089 2.8%
2016/17 1,622,272 1,522,477 45,878 3.0%
2017/18 1,645,849 1,551,190 55,456 3.6%
2018/19 1,691,952 1,598,651 63,891 4.0%

0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
Q1
2014
Q2
2014
Q3
2014
Q4
2014
Q1
2015
Q2
2015
Q3
2015
Q4
2015
Q1
2016
Q2
2016
Q3
2016
Q4
2016
Q1
2017
Q2
2017
Q3
2017
Q4
2017
Q1
2018
Q2
2018
Q3
2018
Q4
2018
Q1
2019
CAMHS seen PT seen CAMHS seen <18wks PT seen <18wks

Continuous Unscheduled Care Pathway (CUP)
•N NHS24
•O OOH Primary Care
•S SAS
•E Emergency Department
•A Acute Medicine I/P
•M Mental Health I/P

More likely to live in the most deprived areas in Scotland at 42%
(compare to non-MH-related attendances at 29% in most deprived areas)

• Half of the pathways for people
attending ED with MH problem
involve an ambulance (28%
attending for other reasons)
• For those pathways that involve an
ambulance, 12% involve a police
officer on scene

Attendance numbers & 4 hour standard
ED
Attendances
(Episode
level data)
Breaches
(Episode
level data)
Breaches
(%)
MH
Attendances
Breaches
(number)
Breaches
(%)
1,598,651 147,977 9.3% 63,891 12,473 19.5%
Financial Year 2018/19

MH Unscheduled Care Performance
• MH presentations are approx. twice
as likely to breach the standard as
any other patient
• MH presentations are more likely to
breach overnight, irrespective of the
lower numbers of attendances OOH
• MH presentations breach waiting for
specialty assessment or for first (ED)
assessment rather than waiting for a
bed (the most frequent breach reason
for all other conditions)

Severe and Multiple Disadvantage

Distress ≠ Mental ill-health

Right patient individual, right place, right time, every time

What will success look like?
• Improved patient & staff
experience
• Improved MH metrics
• Reduced ED/front door
attendances
• Reduced police presence in
secondary care systems
• Reduced unnecessary ambulance
conveyance
• MH Quality Indicators
• Reduced variation

Individual
in
CRISIS Police
Ambulance
Access to Mental Health Services
People and Places of Safety
ED
Fire and Rescue
MH Unit InpatientPolice—Custody
Suite
OOH Primary Care
Acute Care
Triage
111
101
NHS
24
Crisis Prevention
Community
Services
Rescue
Community
Services
Rescue
Home
Relapse Prevention

Individual
in
CRISIS
Police
Ambulance
Access to Mental Health Services
People and Places of Safety
ED
Fire and Rescue
MH Unit InpatientPolice—Custody
Suite
OOH Primary Care
Acute Care
Triage
111
101
NHS
24
Crisis Prevention
Community
Services
Rescue
Community
Services
Rescue
Home
Relapse Prevention
Community
Hub

Key Outcomes
This is Lanarkshire
Mental
Health
97
Physical
Health
70
For GPs
• Reduced patient reliance on their GP and others in the Primary Care Team
• High levels of GP satisfaction with service and patient care
• Increased support/options for patients
GP Quote- “the more we’ve seen, the broader the range of people we feel OT can benefit”
For Patients
•High levels of patient satisfaction, improved health and well-being and quality of life
•Improved functional outcomes , via proactive therapeutic interventions, improved
management strategies and supports , to enable people to continue with their daily lives,
return to work/education, improved social inclusion
Patient Quote “now my thought process has changed a bit...I can build myself up to it and actually
go out”
Leading to reductions in
•the need for social care
•medications for some individuals with LTC
•sickness absence, benefits bill
•referrals to secondary care specialist services
Established a workable Occupational Therapy Service model
within Primary Care - that maximises the distinctive
contribution and impact of occupational therapy for adults
who are experiencing barriers to occupational performance
as a result of
mental well-being and/or physical health issues
right person, right place right time
Occupational Therapy referrals -
function affected by mental/physical health or both
For patients who completed their occupational therapy
episode of care-,their paired data available

Role of AHPs
• OTs -> CBT
• Drama, music, art therapies
• SALT
• Pharmacy
• SAS
• Primary & Secondary Care
• Integration
• Third sector

10th October 2019
Leadership for Challenging Times – Project Lift
Dave Caesar, Head of Leadership & Talent Management ,
Scottish Government & Head of Project Lift

Putting People at the Heart of
Leadership
Dave Caesar
Head of Leadership & Talent Management
NHS Scotland

Are we looking for the right stuff?
• Formal authority
• Positional influence
• Hierarchal
• Social authority
• Connectivity
• Engagement
• Networks
• Sense-making

• Purpose
• Values
• Ambition
“Economies of co-operation as
well as economies of scale.”
(H.Cottam, Radical Help 2018)

“In a democracy, the State can never lead. You need
leadership of a different kind, listening with antennae.”
“I feel a bit like Sisyphus pushing the boulder up the hill. There
are a lot of seething people. We’re trying to work with them,
and there’s a lot of noise. Collaboration is hard.”

Thank you
“Compassionate leadership creates the necessary
conditions for innovation among individuals, in teams, in
the process of inter-team working, at the level of
organisation functioning as a whole, and in cross-boundary
or systems working”.
Michael West et al (May 2017)

System Leadership – Myron’s Maxims
• People own what they help create
• Real change happens in real work
• Those who do the work, do the change
• Connect the system to more of itself
• Start anywhere, follow everywhere
• The process you use to get to the future is the future you get.

Our Ambition
• Be game-changing
• Make NHS Scotland an
international leader in
developing talent
• Design a longitudinal
accredited end-to-end
career approach

What is Project Lift all about?
• People – our humanness, the relationships between us, both the
rational and the emotional;
• Purpose & connections - connecting across the system on the shared
ambition and aspiration of the National Performance Framework;
• Kindness & compassion - in all of our interactions, behaviours,
policies, and cultures.
• Humility & curiosity - being open to other knowledge, to
vulnerability, to growth, to courage, to the power of “we”;

What is Project Lift also about?
• Inclusivity - seeking leadership at all levels and in all professions,
valuing the strengths of people wherever they are, and working
alongside each other in our communities;
• Diversity - respecting and valuing different backgrounds, skills,
perspectives, and contributions;
• Choice & responsibility – encouraging people to exercise individual
agency and take responsibility for personal and collective
development;
• Collaborative & collective approaches - looking and working across
boundaries in pursuit of common purpose and outcomes; and being
adaptive to navigate complexity, volatility and uncertainty.

• What motivates you?
• How do you respond to
difficulties?
• How do you seek out the
unknown?
• How do you see your future, and
that of your team, your
organisation, and of Scotland?
• How do you feel about your
place in the system?
• What is your purpose &
potential?
• What makes you do what
you do?
• Are you willing to learn?
• Do you know what others
think about you?
• How do you respond to
those views?
• Do you understand the
wider system?
• Can you demonstrate
empathy?
• Do you inspire others?
• Can you maintain a positive
outlook?
• Do you demonstrate
exemplary teamwork?
• Can you engage people
from all backgrounds?

Leadership
Development
Talent
Management
Performance
Appraisal
Values Based
Recruitment

self
Reflective practice on
learning in real time
Personal resilience, health & well-being
Personal leadership
profile & PDP
system
team
Collaborative leadership project
Learning in real time
(“heat experience”)
Take learning into
own team / live
work
Group
learning
events
Team work on
collaborative
leadership
project.
Undertake
“team journey”
(supported by
team coach)

It’s a different and exciting way of working around Leadership,
transformative, hard and challenging, and with active listening –
a good way to learn from others in how they handle those
challenges. Its such an important way of learning and changing
our leadership because it’s been very unconventional and quite
soul searching in some places. Understanding that involving
people at every level, empowering people, breaking down
barriers, flattening hierarchies and structures, giving ownership
to people (this will) bring change.
(Cohort 1, Leadership3)

Project Lift
Community
• Inclusive
• Humble
• Curious
• Courageous
• Compassionate
• Boundaryless

“There may be no greater leadership challenge in 2019 than to help
people under pressure to feel valued and for everyone to appreciate
the benefits which come from rebuilding strong relationships,
bringing out the best in each other and enabling everyone to be
more effective in every way.”
John Sturrock, QC and mediator. May 2019.
Scottish Government (April 2019) Report to the Cabinet Secretary for Health and Sport into
Cultural Issues related to allegations of Bullying and Harassment in NHS Highland

Thank you
projectlift.scot
@projectliftscot
projectlift@gov.scot

10th October 2019
Impact/Learning from DOC National Surveys
Gerard Mooney, USC Improvement Advisor, National Team

Using Day-of-Care Surveys (DoCS) for improvement
across acute and community hospitals
Impact/Learning from DOC National Surveys
Gerard Mooney

Session agenda
1. Background to the DoCS
2. How we use it for analysis and improvement
3. Pan-Scotland DoCS results
4.Review National DoCS AHP criteria
5. Using the DoCS for Improvement

The Day-of-Care Survey (DoCS): What is it?
Methodology published : Identifying reasons for delays in acute hospitals using the day of care survey method.
Clinical Medicine. 2015; 15(2) 117-120 Reid, E., King, A., Mathieson, A., Woodcock, T & Watkin, S 11
http://www.qihub.scot.nhs.uk/quality-and-efficiency/whole-system-patient-flow/day-of-care-survey.aspx
• The purpose of the survey is to provide a “snapshot in time of the inpatients present
within your hospital using a tool based on the Appropriateness Evaluation Protocol
(AEP)”
• Provides a Scotland wide picture to understand capacity issues
• Provides opportunities for improvement to reduce delays in discharge - that can be
supported by the 6EA programme
• Provides platform for improved collaboration between primary and secondary
healthcare professional to work together and finding joint solutions to eradicate them

Scotland DoCS – how it was done
• Since April 2018, X3 National DoCS across Scotland,
approx. 30,000 patients
• Survey has been used nationally & internationally
• All adult inpatient beds excluding
ITU/HDU/Obstetrics/Mental Health
• Patients deemed inpatients if waiting more than 4
hours in ED
• Unfunded/surge capacity beds included in survey

DoCS Inclusion Criteria
1 Acute or ongoing deterioration in conscious level
2 Acute or ongoing new confusion
3 Acute neurological deficit, including stroke within 72 hours
4 Acute coronary syndrome confirmed or suspected
5 Acute dysrhythmia with haemodynamic disturbance
6 Pule rate <50 or >100
7 BP systolic <90
8 Phase IV hypertension
9 Active bleeding
1
0
Transfusion due to blood loss
1
1
Temperature <35* or >38*
1
2
Arterial pH <7.3 or pH >7.45
1
3
Na <123 or >150
1
4
K <2.5 or >6.0
1
5
Acute kidney injury
1
6
Post-operative ileus
1 Therapy Requires IV, IM or subcutaneous medication (that
cannot be delivered at home/in the community)
2 Therapy Receiving treatment or new/experimental treatment
requiring frequent dose adjustments or medical
monitoring under direct medical supervision
3 Therapy AHP treatment ongoing – can only be provided within
acute setting
4 Procedure Surgical procedure today that is not suitable for day case
5 Procedure Invasive procedure not suitable for day case (e.g. some
interventional radiology, some guided biopsies, etc)
6 Monitoring Vital sign monitoring every hour or more frequently
7 Monitoring Chemotherapy requiring constant supervision
8 Monitoring Requires accurate input/output fluid balance
9 Respiratory Requires continuous oxygen, non-invasive ventilation or
intensive nebuliser therapy that cannot be delivered at
home
10 Fluid/
Nutrition
To establish complex nutritional support, including enteral
feeding
11 Fluid/
Nutrition
Requires intravenous fluids (that cannot be delivered at
home/in the community)
12 Recovery Immediate post-operative recovery phase from
therapy/procedure covered in 2 and 3 (above), including
need for complex dressings/would drainage (that cannot
be delivered in the community/at home)
13 Investigation Requires multiple investigations for urgent diagnosis

DoCS Reason not Discharged, Alternative place of
care & Boarders
A Awaiting social work allocation/assessment/completion of
assessment (11A/11B)
B Alteration to/equipment for home/re-housing (25E/25F)
C Home care support availability/funding (25D/25F)
D Making choices/awaiting place in care home
(24A/24B/24C/24DX/24EX/24F/71/71X)
E Awaiting vacancy in home of choice/funding available/discharge
planning in progress (25A)
F Awaiting final multi-disciplinary team decision
G Waiting funding for placement, vacancy in care home (23C)
H Awaiting consultant decision/review
I Delay due to relatives (73/74)
J Delay due to transport (44)
K Health care assessment arrangements (41/41A/41B)
L Legal/Financial (51/51X/52)
M Disagreement between family/patients/NHS/local authority
(61/62/63/67/81/82)
N Ward/care home/facility closed - patient well but cannot be
discharged (46X/26X)
O Awaiting community hospital bed (42)
P Awaiting/planned repatriation to other board (42/42X)
Q Awaiting tertiary care (is within own board area?)
R Awaiting procedure/investigation/results and not meeting
criteria for acute care
S
W
Waiting for AHP assessment
S
C
AHP treatment ongoing – could be provided out of current
setting if alternative place of care available
T Other
U Awaiting hospice bed/ palliative care services community
A At home
B Hospice
C Non-acute area of care – Community team
D Non-acute area of care - Community
hospital
E Non-acute area of care - Intermediate care
bed
F Non-acute area of care – Sheltered Housing
G Outpatients follow up
H Other - Please specify
M Medical
O Orthopaedic
S Surgical
A Other - please specify

168
Day of Care Survey: Pan-Scotland Acute (29 Sites) Overview
1. Total number of patients surveyed on the days of DOCS.
2. Boarders are patients who are in a ward bed not related to their main specialty needs. This is the % of boarders out of the number of patients surveyed.
3. Excludes patients for discharge.
4. Weekly census data
BENCHMARKED DATA
Pan-Scotland
Acute (29
Sites) May
2019
Pan-Scotland
Acute (29
sites)
October 2018
Pan-Scotland
Acute (27
sites) April
2018
Medians & Ranges
Number of beds surveyed 10,485 10,483 10679 Range: 23 - 1436
Number of patients surveyed1 9,983 9,524 9935 Range: 20 - 1389
Bed Occupancy % 95% 91% 93% Median: 93% ------ Range: 45% - 106%
Boarders %2
4% (445
patients)
3% (254
patients)
4% Median: 3% ------ Range: 0% - 13%
Day of Care - criteria met %3 79% 79% 80% Median: 77% ------ Range: 30% - 88%
Day of Care - criteria not met %3 21% 21% 20% Median: 23% ------ Range: 12% - 70%
Of those not met - within hospital
control (%)
17% 29% 33% Median: 12% ------ Range: 0% - 32%
Of those not met - whole system issue
(%)
79% 59% 65% Median: 83% ------ Range: 61% - 100%
Of those not met - Home designated
as most appropiate alternative place
(%)
33% 44% 40% Median: 36% ------ Range: 0% - 60%
ED performance on the week of the
survey
88% 92% N/A N/A
Delayed Discharges4 1,514 1,507 N/A Median: 109 ------ Range: 4 - 276

Pan-Scotland Acute (29 Sites)
Day of Care Survey results (May 2019)
72
1508
333
0 500 1000 1500
Other
Outwith
Within
Number of Patients
HospitalControl
Groups
Acute specific
System issue
Other
Reason not discharged within/outwith hospital control
Excludes patients being discharged today

Pan-Scotland Acute (29 Sites)
Day of Care Survey results (May 2019) Can I
amalgamate both acute and community for AHP
reasons???
103
102
71
57
282
262
230
223
119
62
57
54
53
39
32
28
27
22
9
8
1
72
0 100 200 300
Waiting for AHP assessment
Awaiting procedure / investigation / results and
not meeting criteria for acute care
AHP treatment ongoing – could be provided out of
hospital if alternative place of care available
Home care support availability / funding
Awaiting social work allocation / assessment /
completion of assessment
Alteration to/or equipment for home / re-housing
Vacancy in home of choice/funding
available/discharge planning in progress
Waiting funding for placement, vacancy in care
home
Legal / financial
Awaiting hospice bed / palliative care services
community
Delay due to relatives
Awaiting / planned repatriation to other board
Disagreement between family / patient / NHS / LA
Awaiting tertiary care (is within own board
area?)
Health care assessment arrangements
Delay due to transport
Ward / care home / facility closed – patient well
but cannot be discharged
Other
Number of Patients
Reasonnotdischarged
Reason not discharged

DoCS – reasons for discharge delays Highlight
AHP reasons
Wider system issuesAcute
specific
• Awaiting final
multi-
disciplinary
team decision
• Awaiting
consultant
decision/review
• Waiting for AHP
assessment
• Awaiting
procedure/inves
tigation/results
and not meeting
criteria for acute
care
• AHP treatment ongoing – could be provided out of
hospital if alternative place of care available
• Home care support availability/funding
• Awaiting social work allocation/assessment/completion of
assessment
• Awaiting community hospital bed
• Making choices/awaiting place in care home
• Alteration to/equipment for home/re-housing
1 2 Other
• Unspecified
3

172
Day of Care Survey- Pan-Scotland Community Overview
1) Total number of patients surveyed on the day of DOCS at site
2) Excludes patients for discharge
3) Weekly census data
4) NHS GGC and NHS Shetland have no community sites
BENCHMARKED DATA
Pan-Scotland
Community
(12 Health
Boards- May
2019)
Pan-Scotland
Community
(12 Health
Boards-
October
2018)
Pan-Scotland
Community
(11 Health
Boards- April
2018)
Scotland comparator (12 Health
Boards)
Number of beds surveyed 2,512 2,548 2031 Range: 14 - 494
Number of patients surveyed1 2,142 2,154 1789 Range: 13 - 418
Bed Occupancy % 85% 85% 86% Median: 87% - Range: 76% - 99%
Day of Care - criteria met %2 61% 61% 62% Median: 59% - Range: 43% - 76%
Day of Care - criteria not met %2 39% 39% 38% Median: 41% - Range: 24% - 57%
Of those not met - within hospital
control (%)
5% 9% 6% Median: 2% - Range: 0% - 20%
Of those not met - whole system issue
(%)
94% 89% 89% Median: 97% - Range: 80% - 100%
Of those not met - Home designated as
most appropiate alternative place (%)
42% 45% 52% Median: 47% - Range: 12% - 80%
Delayed Discharges-Scotland3 1,514 1,507 N/A Median: 109 ------ Range: 4 - 276

173
Pan-Scotland Community (91 Sites)
Day of Care Survey results
9
764
38
0 250 500 750
Other
Outwith
Within
Number of Patients
HospitalControl
Groups
Hospital specific
System issue
Other
Reason not discharged within/outwith hospital control

174
Pan-Scotland Community (91 Sites)
Day of Care Survey results
30
8
218
138
124
65
59
48
40
24
18
17
8
5
9
0 100 200
Awaiting GP/Consultant decision/review
Legal/financial
Alteration to/equipment for home/re-housing
Vacancy in home of choice/funding
available/discharge planning in progress
Waiting funding for placement, vacancy in care home
Ward/care home/facility closed – patient well but
cannot be discharged
Disagreement between family/patient/NHS/Local Authority
Delay due to relatives
Ongoing AHP assessment/treatment
Health care assessment arrangements
Other – please specify
Number of Patients
Reasonnotdischarged
Groups
Hospital specific
System issue
Other
Reason not discharged

DoCS – reasons for delayed discharge
Wider system issuesAcute
specific
• Awaiting
consultant
decision/review
• Awaiting final
multi-
disciplinary
team decision
• Home care support availability/funding
• Awaiting social work allocation/assessment/completion of
assessment
• Making choices/awaiting place in care home
• Legal/financial
• Alteration to/equipment for home/re-housing
• Vacancy in home of choice/funding available/discharge
planning in progress
1 2 Other
• Unspecified
3

Development of AHP questions
Signed of by
AHP USC
Group
AHP USC
National Lead
group review
& redraft
Feedback
from AHP
services &
national
working group

AHP Criteria
Original Day of Care Criteria: Reason not discharged
S Waiting for AHP assessment/treatment – please specify which AHP
service
• Following the first DoCS in May 2018, AHP leads felt original narrative for
delay was too ambiguous and didn’t allow for proper analysis of their service.
• Results were not clear if delay was due to awaiting assessment or completion
of treatment.
• AHP had traditionally been within the top 3 reasons behind delay from
hospital.
• Unable to return in national tool which service of AHP
• AHP service didn’t feel this was a true reflection on the service they provided.
• AHP reason for delay was expanded and piloted in October 2018 DoCS

AHP Criteria
First iteration – October 2018: Reason not discharged
SW Waiting for AHP assessment/treatment – please specify which AHP
service
SC Waiting for completion of AHP treatment – please specify which AHP
service
• Following the October survey, AHP leads felt narrative was still too ambiguous
and still did not reflect the service they provided.
• It was unclear from the October survey – and May’s – if delay was due to
ongoing treatment that could only be provided in hospital or if it could be
provided elsewhere e.g. community setting.
• AHP criteria was changed and piloted in May 2019 survey.
• The guidance document was updated to reflect the new criteria.

AHP Criteria
Second iteration – May 2019: Reason not discharged
SW Waiting for AHP assessment
SC AHP treatment ongoing – could be provided out of hospital if alternative
place of care available
• Following the May survey, AHP leads and national working group felt narrative
was still unclear and still did not fully reflect the service.
• It remained unclear if delay was for ongoing treatment and medically fit for
discharge or had to remain in current setting for therapy.
• AHP criteria was changed and will be piloted in October 2019 survey.

AHP Criteria
Third iteration – October 2019: Reason not discharged
SW Waiting for AHP assessment
SC AHP treatment ongoing – could be provided out of current setting if
alternative place of care available
New Criterion Added:
Service Intensity that requires access to acute hospital inpatient facilities
3 Therapy AHP treatment ongoing – can only be provided within
acute setting.

367
332
230
164
113
108
0 50 100 150 200 250 300 350 400
HOME CARE SUPPORT
AVAILABILITY/FUNDING
WAITING FOR AHP
ASSESSMENT/TREATMENT
AWAITING SOCIAL WORK
ALLOCATION/ASSESSMENT/COMPLETIO…
AWAITING COMMUNITY HOSPITAL BED
AWAITING CONSULTANT
DECISION/REVIEW
AWAITING FINAL MDT DECISION
Top 6 May-18
339
212
177
176
175
129
0 50 100 150 200 250 300 350 400
HOME CARE SUPPORT
OTHER
WAITING FOR COMPLETION OF AHP
TREATMENT
ALLOCATION/ASSESSMENT/COMPLETION…
MAKING CHOICES/AWAITING PLACE OF
AVAILABILITY IN CARE HOME
Top 6 October 2018
282
262
230
223
119
103
0 50 100 150 200 250 300
AHP TREATMENT OPNGOING - COULD BE
PROVIDED OUT OF HOSPITAL IF…
ALLOCATION/ASSESSMENT/COMPLETION…
HOME CARE SUPPORT
MAKING CHOICES/AWAITING PLACE OF
AVAILABILITY IN CARE HOME
Top 6 May 2019
Docs Top 6 Results Nationally

Docs Top 6 Results Nationally
43
87
109
122
177
0 50 100 150 200
AWAITING
PROCEDURE/INVESTIGATION/RESULTS
AND NOT MEETING CRITERIA FOR ACUTE
CARE
WAITING FOR AHP
ASSESSMENT/TREATMENT
AWAITING CONSULTANT
DECISION/REVIEW
WAITING FOR COMPLETION OF AHP
TREATMENT
October 2018
57
71
102
103
0 20 40 60 80 100 120
AWAITING
PROCEDURE/INVESTIGATION/RESULTS
AND NOT MEETING CRITERIA FOR ACUTE
CARE
WAITING FOR AHP ASSESSMENT
AWAITING CONSULTANT
DECISION/REVIEW
May 2019

184
• The national survey shows 21% of patients do not meet criteria for ongoing acute care. This is similar
to previous surveys.
• Requires an agreed integrated Health and Social Care response
• Develop an action plan to address the top 6 cause of delay and systematically reduce aim to reduce this
• Action plans will be monitored through PMAP and should be on agenda of monthly local partnership/UC meeting
• The balance of cause of delay has shifted from acute based cause of delay to wider whole system
• Complete footprint of capacity to include community services that support discharge, reduce attendances and admission
• Develop whole system approach to delay reasons through a clearer understanding of provision of community referral criteria
• Review national and local acute and community report as benchmark – engage with colleagues with similar issues
• Align provision of community bed against demand supported by Basic Building Blocks
• Delays are greatest in older age groups
• Review current, and agree appropriate, referral criteria for community/PC services
• Engage in activity to reduce effects of deconditioning – e.g. Move it campaign, #endPJparalysis
• Over half (57%) of patients not meeting criteria have a Length of Stay >14 days - Acute
• 77% of patients not meeting criteria have Length of stay > 30 days - Community
• Aim to reduce length of stay through early discharge planning – utilise Daily Dynamic Discharge process
Recommendations: Pan-Scotland Acute & Community (May 2019)
The following recommendations are designed to prioritise areas of potential need to expedite the patient
journey for the specific patient(s), but also to focus on themes which could improve overall system flow by
shifting the discharge time curve to the left and reducing overall LOS
Day of Care Survey May 2019 Recommendations

Repeat DOCS
regularly
Results
Design change
Monitor
Change
Drive
improvement
DayofCare@gov.scot
185
Day of Care Survey: Next steps
• Develop Whole System Actions plans
agreed across Health and Social Care
Partnerships
• Incorporate findings into 6EA UC
Improvement plans monitored through
PMAP and Local meetings
• Examine individual themes and agree
recommendations to systematically
reduce delays
• Iterative DoCS have been shown to
lead to improvement
• Explore DoCS for mental health +
paediatrics.
• Repeat NHSScotland DoCS across all
Acute and community beds

Next Steps AHP’s
• Join local DoCS teams
• Invite community AHP colleagues to participate in
acute survey – vice versa
• Use DoCS review chart in your area
• Link/liaise with local AHP USC lead

Learning from AHP related delays and moving away from blame :
AHP review chart

Bibliography
1. Bell, D., Lambourne, A., Percival, F., Laverty, A. A. & Ward, D. K. Consultant input in acute medical
admissions and patient outcomes in hospitals in England: a multivariate analysis. PloS One 8, e61476
(2013).
2. O’Brien, L. et al. What makes weekend allied health services effective and cost-effective (or not) in
acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers. BMC
Health Serv. Res. 17, 345 (2017).
3. Gertman, P. M. & Restuccia, J. D. The appropriateness evaluation protocol: a technique for assessing
unnecessary days of hospital care. Med. Care 19, 855–871 (1981).
4. Bai, A. D. et al. Mortality of hospitalised internal medicine patients bedspaced to non-internal
medicine inpatient units: retrospective cohort study. BMJ Qual. Saf. 27, 11–20 (2018).
5. St Noble, V. J., Davies, G. & Bell, D. Improving continuity of care in an acute medical unit: initial
outcomes. QJM Mon. J. Assoc. Physicians 101, 529–533 (2008).
6. Scott, I., Vaughan, L. & Bell, D. Effectiveness of acute medical units in hospitals: a systematic review.
Int. J. Qual. Health Care 21, 397–407 (2009).
7. McCoy, D., Godden, S., Pollock, A. M. & Bianchessi, C. Carrot and sticks? The Community Care Act
(2003) and the effect of financial incentives on delays in discharge from hospitals in England. J. Public
Health Oxf. Engl. 29, 281–287 (2007).
8. Fontaine, P. et al. Assessing the causes inducing lengthening of hospital stays by means of the
Appropriateness Evaluation Protocol. Health Policy Amst. Neth. 99, 66–71 (2011).
9. d’Alché-Gautier, M.-J., Maïza, D. & Chastang, F. Assessing the appropriateness of hospitalisation days
in a French university hospital. Int. J. Health Care Qual. Assur. Inc. Leadersh. Health Serv. 17, 87–91
(2004).
10. Donald, I. P., Jay, T., Linsell, J. & Foy, C. Defining the appropriate use of community hospital beds. Br. J.
Gen. Pract. J. R. Coll. Gen. Pract. 51, 95–100 (2001).
11. Reid, E., King, A., Mathieson, A., Woodcock, T & Watkin, S. Identifying reasons for delays in acute
hospitals using the day of care survey method. Clinical Medicine. 2015; 15(2) 117-120

10th October 2019
Ask the panel
Derek Bell
Helen Maitland
Jacques Kerr
Dave Caesar
Gerrard Mooney
#AHPUSC19 #AHPsday2019 #AHPDAYSCOT

10th October 2019
Reflections on the event – What comes next
Claire Ritchie – Event Chair

10th October 2019
Close

AHP Unscheduled Care Event 2019 (Morning Session)

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