The challenge
According to an analysis carried out by the Health Foundation, 30.0% of attendances at a major A&E led to an emergency admission in December 2017. This compares to 11% at North Middlesex University Hospital NHS Trust as outlined in a recent research from Healthwatch Enfield, supported by data held by North Middlesex University Hospital NHS Trust.

Across the country, several initiatives, aiming at reducing inflow to A&E departments, such as ‘GP led triage and redirection’, ‘Non-clinical navigators’ and ‘Consultant led redirection’ have been trialled. However, all of these have been delivered at a point where an individual patient already made a decision to attend A&E.

Our idea
Our idea seeks to test a new approach of placing non-clinical navigators within the community to improve the ‘enablement’ aspects of A&E attendance (and aftercare) including keeping people well in the community whilst also helping them easily understand where to go for help, effectively signposting individuals away from A&E.

With almost 90% of patients choosing A&E at North Middlesex University Hospital NHS Trust to seek help for their everyday healthcare needs, between January and April 2018 inclusive, the department saw approximately 39,182 patients with primary or non-life-threatening conditions at a cost of £4.4m to the local health economy.

Public Health England and NHS England invest significant resources in mainstream communications campaigns, such as ‘Stay well this winter’ which aims to persuade people, where possible, to go to the pharmacy first before going to A&E or to their GP. Despite this, only 4% of participants in Healthwatch Enfield’s research reported using alternatives to A&E. Furthermore, having conducted an evaluation of the winter communications campaign across North Central London, we know that 37% of people do not keep up to date with health-related information. By deploying non-clinical community navigators and co-designing approaches and resources that bring information ‘to’ local communities, we seek to test an idea that aims to:

1. reduce the number of people using Urgent and Emergency Care services to access low-level healthcare needs improving experience for patients with life threatening conditions
2. improve compliance with 4-hour waiting time standard
3. save money for the local health economy i.e. based on the NHS reference cost, £148 will be accumulated each time a patient does not present in A&E

Based on research from Healthwatch Enfield, we propose to recruit and deploy up to 20 non-clinical community navigators, recruited through our existing links with local communities, to work with people across Enfield and Haringey to co-design:

1. ways to raise awareness amongst local communities of appropriate ways to seek support for primary, secondary and mental health care needs as only 4% of patients sought different ways of accessing support prior to presenting at A&E
2. accessible information resources about services available as 1 in 3 patients would have made a different choice of a healthcare setting, if they had appropriate information prior to presenting at A&E

Throughout the project, the non-clinical community navigators will host up to 20 co-design events and will utilise community outreach to refine the approaches and resources based on the PDSA model for improvement. To ensure the navigators have the necessary credibility to ensure community engagement and influence behavioural change, the navigators will be identified from a pool of established community leaders.

Once co-designed, resources and approaches will be used by our partners, including: North Middlesex University Hospital NHS Trust, Barnet Enfield and Haringey Mental Health NHS Trust, Chase Farm Hospital (part of Royal Free London NHS Foundation Trust), Enfield and Haringey Clinical Commissioning Group and the voluntary and community sector in Enfield and Haringey. The non-clinical community navigators will also ‘train’ their communities to mobilise existing assets so that key information can be shared by ‘word of mouth’.

To track the impact of our intervention, we will utilise evidence base of the Healthwatch Enfield report as a baseline and we will work closely with our partners to assess the effectiveness of the co-designed approaches and information through:

• evaluating awareness of local health and care services
• monitoring, compared to a corresponding time period in the previous years,

1. overall number of people presenting in A&E
2. number of people from specific backgrounds presenting in A&E
3. uptake in alternatives to A&E

Learning and resources developed as part of the project will be shared widely with the Q community through: social media, establishing a Special Interest Group, offering Q talks and hosting Q visits. We will also work with the networks of our NHS partners to disseminate information across the healthcare sector, outside the Q network. If widespread, our project could help address a national problem.