Can we keep up with the demand for urgent and emergency care?

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The urgent and emergency care system is under severe pressure. Performance on a number of important indicators, including the four-hour wait and ambulance handover targets, is heading in the wrong direction. Demand is growing and calls for work to be shifted out of hospital look oddly out of line with a system that cannot even constrain, let alone reduce, the rate of increase in many places. Our recent study for NHS South of England raises some questions about the management of urgent and emergency care and identifies some important lessons.

The methods for running a hospital in the face of high levels of variable demand are now quite well understood. They are, however, based on an assumption that capacity and demand are in balance – which may not always be the case.  For example, it may be necessary to make major changes to consultants’ job plans to provide 18-24 hour cover, seven days a week. These methods are also hard to implement and need continuous monitoring and maintenance. The key to success is to ensure that patients flow quickly through the hospital and are discharged rapidly. This may have been made more difficult by attempts to improve efficiency and utilisation, and close beds, which have left hospitals running at high levels of occupancy and with reduced ability to respond to fluctuations in demand or to discharge patients.  

If community services and social care were able to respond flexibly and quickly, this would be less of issue. However, it does not often happen in practice. Community services have been commissioned on inflexible block contracts and often measure response time in days rather than the hours required by hospitals. Social care is feeling the impact of very tight finances and often does not respond at the pace required.

There is still much more to do to improve the urgent and emergency care system, including increasing the availability of primary care appointments, ensuring continuity of care for patients, dealing with problems ‘in hours’ where possible, and improving the quality and consistency of ‘out of hours’ services. The big variations in ambulance service practice also need to be addressed – for example, in the percentage of people who are taken to hospital. And we need better metrics that capture more useful information about the experience of patients and the operation of the system – the four-hour target conceals too many differences in practice to be very useful on its own.

There are also major issues around how commissioners have operated. Some have taken adversarial approaches, whilst others have tried to do a detailed redesign of pathways. In our report we found examples of questionable approaches – for example, exploiting the difference between the community tariff and the hospital tariff. We also found a number of schemes aimed at avoiding admissions and A&E attendance. These were generally very poorly evaluated, often based on hunches rather than evidence, too small to make much impact, hard to manage and prone to creating additional demand. This adds to the very high level of complexity that is already present due to layers of previous projects, national initiatives and uncoordinated service developments.  A directory of services will help with this but, rather surprisingly, the commissioners we spoke to did not have a clear map of the system’s capacity or of the flows between the different parts of it.

So how can we overcome the problems around increasing demand? One option is to create extra capacity, although there is the danger that this will lead to increased admissions or other changes in the behaviour of the system as it fills up. The only way to beat this is through a combination of very senior people making clear decisions at the front door and the ability to extend the hospital beyond its traditional walls by using beds in nursing and residential homes, and in the patient’s own home.

Directing patients elsewhere is another option, although treating minor cases in A&E probably costs no more and possibly less than some of the alternatives and in general they do not impact on the four-hour target. General campaigns to persuade people not to go to A&E do not seem to work, but there is scope to target practices and individuals with very high utilisation rates.

To address the problems created by increasing demand on urgent and emergency care we need more strategic approaches that reduce complexity, reshape primary care and chronic disease management, support patients in their own homes, and change the way that nursing and residential care are incorporated into the system. These need to be built around natural communities and involve a new relationship between the different providers. All of this requires leadership across a system rather than attempting to fix each individual component.

This blog is also featured on the British Medical Journal website.

Comments

Harry Longman

Position
Chief Executive,
Organisation
Patient Access Ltd
Comment date
24 April 2013
The research I published linking 20% lower A&E rates with access to GPs, very rapidly at first by phone, is now over two years old. We have more and more case studies, more and more CCGs are interested and playing around with it, but no one has picked it up with any kind of urgency. You complain above about schemes to divert demand which have no evidence behind them. This one does. Just tell me, what more am I supposed to do to get this on the agenda?

Angus Murray-Brown

Position
GP,
Organisation
NHS
Comment date
24 April 2013
100% GP phone triage isn't the way to save ED and Urgent Care resources - anecdotally a lot of practices are now dropping it as it is generally shunting risk to the GP's side via many more patient contacts as well as increasing expectations in healthcare access - which may stoke the fire more in future. Since the time of Erlang, Queue Theory always allows for balking and reneging.

What would I do? Offer a central prize to the Universities/Academics to come up with the most effective mathematical solution to best resource utilisation. Set 3 problem groups 1) ED efficiency etc 2) GP resource allocation etc 3) Overall design of Urgent Care.

Model the entrants solutions into thousands of simulations to select a winner.

I suspect the results could be stellar as well as being very cost effective. But there is no easy solution to this problem.

Harry Longman

Position
Chief Executive,
Organisation
Patient Access Ltd
Comment date
24 April 2013
Angus, we don't say it's easy, we do say it works. To say "anecdotally a lot of practices are dropping it" will not do. We have around 90% success rate, I wish it were 100%, but it is sustainable because it is putting GPs back in control of their time, who they see, when and for how long. GPs invented it for that reason. To make it work in high demand practices requires fine tuning and perseverance, but look at what some of them are achieving, eg The Elms Liverpool, another case study from inner Salford about to go public.

Sure we should work on ED efficiency, and again start with demand, and with better allocation of GP resources, and with overall design. But I wouldn't look to mathematical modelling. I'd look for real world practice, probably already happening somewhere, which is how I found GPs on the phone. The first ones showed up by having low A&E, unconsciously.

Dr Daniel Albert

Position
GP; A&E doctor; CCG non-exec,
Organisation
NHS
Comment date
24 April 2013
You are right to identify this as one of the most important issues facing the NHS. The current shortage of emergency medicine middle-grade doctors will translate into a consultant shortage that will haunt us for decades -- if we continue with the same model.

Attempts to replace high-tech hospital care with low-tech community care have broadly failed because the diseases did not down-grade to suit. A large proportion of the work that now goes to A+E is too simple to need hospital care, but too complex for general practice. A gap in medium-severity care has developed, that is widening with the increase in patients with long-term conditions, with older patients and particularly with older patients with long-term conditions.

The solution is to develop high-tech medium-severity urgent care facilities close to where people live. Similar to what might be meant by "Urgent Care Center" in the USA, but nothing like what we use (misuse) the term for over here.

I will talk about this at the "Improving Urgent and Emergency Care Conference" in London on 26th June 2013. Please see http://bit.ly/16WGp6u You would be welcome to attend.

Andy's Proctor

Position
West Midlands Council Member,
Organisation
College of Paramedics
Comment date
25 April 2013
More can also be done Pre-hospitally with improved training and investment. Paramedics are in an ideal position to reduce patients requiring treatment at A & E and this can be done further with the push for some Paramedics being able to Prescribe drugs.

Dillo Sykes

Position
Director,
Organisation
Productive Primary Care
Comment date
25 April 2013
A decent article as usual from Nigel. It is an age old problem he addresses one which has seen me in a personal capacity work with General Practice for more years than I care to remember on improving access systems and patient outcomes.
A key success is levelled on increasing primary care access, and for me balanced with increasing patient confidence that on the day they feel un well they can speak with their GP.

We have many successes of this through our Doctor First system (over 50 practices we have worked directly with) which is rightly documented in the Digital First initiative as an option for General Practice to reduce unnecessary face-to-face appointments.

We don't look to get this on any ones agenda the key is to make sure you are there to help those that need it. There are many big system changes happening at the moment in the NHS and success will come working with those that 'have left home' on the journey to improvement. Without them leaving home in the first place we will make little progress. Let's focus on those key people making the journey before telling them what the answer is or how many evidenced based papers are out there...trust me and I'm not a doctor!

David Carson

Position
Director,
Organisation
Primary Care Foundation
Comment date
25 April 2013
There is not a good relationship between A&E attendances and Admission Rates. Many trusts have high attendances and lower admission rates. Much depends on the process within the trust, those with senior early assessment and decision making tending to do better. We have some way to go to have effective acute ambulatory systems in many trusts. General practice can contribute significantly with good solid evidence linking good access and continuity of care to lower acute referral rates and better QOF outcomes. The key issue is continuity which can be delivered in practices in many ways. We should learn from the past that one size fits all (do it this way and all will be ok) changes to general practice processes tend to benefit a few but degrade performance and response in many. Each practice needs to have confidence in its own system. The operational links between community services and GPs need to be improved and re-establish a proper local team. In too many places this link has been broken. Much can be done by the Ambulance Service however moving beyond high profile interventions transporting the elderly at risk of admission who have been seen quickly by GPs in substantially less than 4 hours to hospital if they do need assessment would be life changing for many.

Ruth Rankine

Position
Director of Strategy & Business Development,
Organisation
NHS Direct
Comment date
25 April 2013
Nigel, I'd be interested to know if your study looks at the impact of 111 on urgent and emergency care - in a good or bad way?

Phil Sanmuganathan

Position
Consultant Physician,
Organisation
Acute Trust
Comment date
25 April 2013
Telephone triage by GPs with hot-lines for specialist advice and access to specialist clinics will reduce ED access pressures. This will be similar to having specialists seeing first and getting a management plan done on in-patients who stay for 0-3 days done in an OP clinic setting. This needs co-ordination and co-operation, with community support to prop these patients up at home.

jay banerjee

Position
Health Foundation QIF/Consultant in Emergency Medicine,
Organisation
IHI, Cambridge, MA/UHL NHS Trust, Leicester
Comment date
25 April 2013
Identification of the populations at risk and tailoring services to their needs should be the way to start. Traditionally we have developed services to respond to defective processes. We need to respond through changes in how we learn, deliver and create cross-bridges to address seamlessness in providing and commissioning. This needs to be done with special emphasis on vulnerable groups - especially frail older people.
Quantifiable solutions through scientific analysis would be a boon. Flow and capacity cannot be addressed reliably without mathematical modeling. It is not very appealing, needs capability and should proceed simultaneously with other tests of change.
We in healthcare have the uncanny ability to look at everything through our eyes only. It is time to do this through the eyes of the people in society and engage in honest discussions to address the wellbeing of the individual, contribute towards population wellbeing and at a price that society is willing to pay.
No single solution will solve a whole systems problem. The issues may be more around a lack of will to move towards integrated working rather than a lack of ideas and potential solutions. Competition needs to be on delivering quality through sharing of knowledge and expertise. We need to stop thinking in silos although it is easier said than done. Many of us are still trying to think our way out of silos rather than acting our way out of it. At the same time, we cannot expect anyone to behave differently unless each one of us does so first. Leadership is crucial – but this needs to be everybody’s problem. No single person, service or institution can get us out of this.

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