10. Managing emergency activity: urgent care

What is it?

Developing a more integrated approach to urgent care for patients who have an injury or illness that requires immediate attention but is not serious enough to warrant a visit to an accident and emergency department (A&E) through better co-ordination of the range of services available and sharing of clinical information across different agencies.

Why is it important?

• Urgent care services are currently often highly fragmented and generate confusion among patients about how and where to access care (Lattimer et al 2010).
• Poor sharing of information as patients move between different providers of care in an emergency is a cause of many significant failures of care (Gandhi 2005).
• The quality of out-of-hours care is highly variable, particularly in terms of continuity of care, leading to variable patient experiences (NAO 2006).
• The growth of new forms of urgent care has failed to reduce A&E attendances (Cooke et al 2004). Emergency attendances in England rose by 46 per cent between 2003/4 and 2009/10, (Department of Health 2011c).
• Walk-in centres do not appear to have led to shorter waits in general practice or lower admission rates at other health care providers (Salisbury 2003).
• Emergency admissions have also grown rapidly. The number of emergency admissions in England rose by 11.8 per cent between 2004/5 to 2008/9 – resulting in around 1.35 million extra admissions (Blunt et al 2010).

What is the impact?

• Addressing poor practice, improving care continuity, and reducing variation could have a major effect on health outcomes.
• Making the urgent care system easier to navigate would improve patient experiences substantially.
• Integrated urgent care services that manage demand more effectively could be expected to be significantly more cost effective.

How to do it

Although the impact could be highly positive, redesigning the urgent care system is likely to be very challenging.

Specific actions for commissioning bodies could include:

• GPs playing an active role in commissioning primary care out-of-hours services as part of a whole-system urgent care response including community support and ambulance diversion opportunities
• developing a clinical dashboard for GPs to inform strategic changes in urgent care services
• establishing better and more integrated triage systems
• providing effective signposting and access to urgent care services for patients
• building systems to improve co-ordination of care between different providers
• investigating patient flows around the urgent care system to support the development of a locally revised 'whole system' model of care (Boyle and Pratt 2004).

NHS Bolton developed a clinical dashboard for general practice, giving GPs a clearer picture of urgent care activity, so they could ensure patients accessed the appropriate services. The PCT piloted its dashboard in 2009/10 in 56 practices; that year A&E admissions in the area fell 3 per cent amid a regional increase of 9 per cent and unscheduled hospital admissions fell 4 per cent, with one practice showing reductions of 16 per cent.

Useful resources

• Details of the performance indicators used in NHS Bolton's GP urgent care dashboard are available online
• Tackling demand together: a toolkit for improving urgent and emergency care pathways by understanding increases in 999 demand offers practical analysis, worksheets and tools to help all commissioners and providers improve urgent and emergency care services through better understanding of the factors affecting significant rises in 999 demand:

For further information

• Download all ten priorities: Transforming our health care system
• You can also find all the references mentioned here in that version
• Listen to Candace Imison talk through the ten priorites in our audio slideshow