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.

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Urgent Care

Organisation
http://www.icareclinic.com/urgent-care-service.php
Comment date
22 April 2014
I am very glad to know about importance of urgent care centers and emergency services.

Jo Bayley

Position
GP,
Comment date
10 May 2013
"Until patients can gain access to see a doctor within 4 hours, then ED attendances will continue to increase. Worried patients need immediate access."

Access to services must be based on actual clinical need, not perceived need. Very few patients actually need to see a doctor within 4 hours (barring emergencies that we would all agree should be seen in an ED).

The ED 4 hour wait target certainly drives patients into the ED and increases strain on the system but the answer is not to replicate those problems elsewhere. Much of what primary care does is invisible to secondary care consultants (I say this as a former emergency medicine SpR myself), particularly preventative medicine and management of long-term conditions. Diverting GP time from that work to see any patient who is "worried" within 4 hours would be an utter disaster. Primary care would immediately fall over and the demand on EDs would be greater than ever.

ED attendances are rising but so are GP attendances - the average patient now sees a GP/practice nurse 5.8 times per year, up from 3 times less than a decade ago. This is a whole-system problem and the answer is not to shift counter-productive targets from the ED to primary care.

dr alice findlay

Position
consultnat emergency medicine,
Organisation
dartford and gravesham trust
Comment date
07 May 2013
Until patients can gain access to see a doctor within 4 hours, then ED attendances will continue to increase. Worried patients need immediate access, and will go to the place that can provide This is currently only the EDs.As each part of the NHS becomes more inaccessible to the patient, the ED is becoming the only place they can seek advice and treatment in a timely way without appointment , especially out of hours.

stephen black

Position
management consultant,
Organisation
pa consulting
Comment date
03 May 2013
The first thing many people suggest when the A&E departments are busy and slow is that they are being swamped by demand or other external factors. There has been an orgy of such suggestions in the last few weeks as performance plumbs depths not seen since the early days of the 4hr target.

Most of this commentary is based on plausible stories about why things go wrong. These stories appear to be substantially more powerful that the actual evidence and data which directly contradicts most of them.

For example, Jeremy Hunt and many others have alleged that changes in the GP contract leaving them free to not provide out of hours coverage has led to A&Es being swamped by demand. Nice story, but not remotely consistent with the actual statistics (as John Appleby, almost uniquely among commentators, pointed out here http://www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing ). I added some other stats supporting this on the HSJ twitter discussion on thursday may 2 (look for the #HSJEmergency hashtag).

Nigel's report claims early on that the data don't explain the current situation. This reminded me of a controversial piece of analysis done by the Audit Commission a year or two before the A&E target was introduced and refreshed by the Healthcare Commission in 2005. This concluded that none of the obvious factors explained the differences in A&E performance (and they included analysis of staffing levels and other hard-to-get internal stats).

I said the following in a BMJ article (http://www.bmj.com/content/333/7563/358) at the time:

"...there is no relation at all between staffing levels and performance. Nor does any relation exist between changes in staffing and performance. None of the intuitively “obvious” factors that might be thought to influence performance seem to matter much.

... the way a department is organised has more influence on its performance than even major changes in staffing. In other words, management matters. And just increasing resources is a poor way to fix performance problems."

This incited much incredulity despite being an accurate summary of the regulator's work.

We seem to have arrived at the same point again. We are identifying problems and proposing solutions neither of which are consistent with the evidence while ignoring known practices that work (Nigel's report also points this out).

In seeking external causes and eschewing known solutions because they are related to "management" ideas not resources, we make the quality of care worse and hurt patients.

Michael Paul

Position
Physician,
Organisation
Independent
Comment date
03 May 2013
I started and ran a group of urgent care centre based on the US model such as you describe, for fifteen years in the City of London, and they were highly effective and very popular. Despite having streams of politicians in the early days, and even a sec of state visit once, never managed to interest the NHS, nor been asked for details of how we did it. I am now trying to interest individual trust A&E depts to consider my proposals without any success. Uphill battle.

Peter Devlin

Position
GP, Clinical Director, Primary Care Adviser,
Organisation
Brighton & Hove Integrated Care Services Ltd, Brighton & Sussex University Hospitals
Comment date
28 April 2013
A really interesting discussion. In primary care it is a mistake to separate long term condition care from unscheduled care - most acute admissions arise form the unscheduled care needs of the population with ltc. We need to optimise our proactive care of the these patients, and we need to respond to their urgent needs. Our urgent care response needs to be sensitive and proportionate to underlying risk stratification. Fit young men with sore throats do not need a GP.
There has been very little attention paid to unacceptable variation in internal care pathways within hospitals, variation in use of diagnostics, medications, complication rates, waste and duplication - which leads to huge variation in length of stay. There is still a pervading culture of a need to "fix everything while they are here", what some colleagues refer to as the "acute medicine factory" and a general lack of awareness around the risks that accumulate around each additional day spent in a hospital bed.
Two additional short to medium term solutions:-
1. Primary care needs to be incentivised to move towards stretch targets for appropriately adjusted acute admission rates.
2. Hospitals need to performance manage individual consultant teams around length of stay.

Matthew Miller

Position
Consultant General and Colorectal Surgeon,
Organisation
East Sussex Healthcare Trust
Comment date
28 April 2013
Systems of care are usually set up by reasonable people trying to do their best with the resources available. These systems persist until either superceded, or evolve driven by external pressures. Often the underlying assumptions on which these systems are based were not explicitly recognised at the time of setting them up. This makes it even harder later to work out if they still hold true, and to either rectify or adapt to the current situation.
Unfortunately there is a tendency when faced with a clinical decision in a pressured A&E dept to want it made as quickly as possible and with the best chance of managing the patient without unnecessary admission to a scarce acute bed. This has led to the call for more and more senior clinicians to be involved, and to be present for more hours in the day. From personal experience the cases that I was managing as a surgical house officer in the early 90's were the same ones I ended up having to manage as a senior specialist registrar in the 2000's. By then the effect of reduced hours of experience,and more importantly reduced expectations, had resulted in the inability of the Foundation year and Core Trainee doctors to manage these cases. The situation now is where we routinely have newly appointed surgical specialty registrars unable to perform an appendicectomy unaided. Whilst that is an issue mainly for the general surgical dept - the general lack of knowledge in younger doctors about routine matters general surgical has now spread beyond the hospital and pervades all disciplines. This includes many younger GPs. The situation is not helped by many medical schools reducing anatomical teaching and trying to make surgery a postgraduate subject.
Combine the above lack of experience with heightened patient expectations and a litigious culture, then it is unsurprising that problems once dealt with by primary care and junior doctors are now routinely being referred and admitted to hospital.
Likewise a patient with for instance three medical problems will be sent to see three different specialists- as opposed to the old style general physician who was happy to manage the entire situation- and had the advantage of a holistic approach.
The "demand" for specialist care has increased above and beyond the simple number of patients- let alone the increased life expectancy with multiple comorbidities.
One of the unrecognised assumptions in this current situation may be that doctors are getting the same clinical experience and training as in the past, and are able to perform to the same workload. And that performing a 4 month attachment to A&E or General Surgery equips them with the same experience as in the past.
I do not believe that this is the case based on my experience of trainees over the last five years as a Consultant, and discussion with colleagues across specialities.
The overall situation is of course multifactorial - and I do not for one moment believe that there is one magic bullet which will solve it- however we either have to factor in the very real lack of general surgical experience for doctors over the last 5 years and its implications- or we have to address the training enviroment and program for them.
I expect much of this to be mirrored in similar ways in general medicine and its subspecialities.
Should we now be training the next generation of doctors as generalists?

Marion lynch

Position
Associate Dean,
Organisation
NHS England Health Education
Comment date
27 April 2013
Dear Toby The shifts of workload to other colleagues, ED to GP, GP to Practice Nurse requires skills development and career development. Your comments on PracticeNurse development are welcome and we have programmes in place. The challenge is now to support Practices to see themselves as training organisations for whole primary care workforce. Current payment processes do not help. Your involvement and insights will be welcome. Please contact me. Dr Marion Lynch Oxford Deanery

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