How can we better align Urgent and Emergency Care services to patient demands?
Prior to the arrival of Coronavirus, it was very difficult to escape the headlines regarding pressures in the emergency departments (EDs):-
The winter months are always a challenging time for the NHS. The cold wet weather brings with it increases in falls, respiratory conditions and other various colourful bugs affecting anyone and everyone. While EDs are busy all year around, the winter sees increases in older sicker people arriving by ambulance and increases in the number of people requiring a hospital bed. Sustained demand of this type eventually leads to hospitals full to capacity. The result of this is then felt across the NHS with an overloaded urgent and emergency care system.
Demand for urgent and emergency care has increased significantly over the past two decades partly due to an ageing population but also due to people attending services which are not necessarily the most appropriate for their health needs.4,5 To try to help with this demand, alternative services have been introduced including co-locating primary care services in EDs, walk-in centres and telephone triage systems (NHS111). All great ideas but unfortunately evidence has shown these services have not decreased demand, and in fact have introduced further confusion about where patients should go for their health needs.6,7
A survey undertaken in ED waiting rooms in the Yorkshire and Humber region asked patients about their awareness of alternative urgent care services and found awareness ranged between 29% for urgent care centres to 89% for NHS111, with over half of the patients reporting that a health professional had advised them to attend the ED.8 When asked a series of questions about satisfaction with services in the ED, the majority of patients reported they were fairly or very satisfied. But this should not be surprising; The ‘ED’ brand is strong. It fulfils the 7 characteristics of a successful brand9:-
The lights are always on, the doors always open in the ED, and although the headlines might shout about missing 4 hour targets, the performance for those patients that attend with low acuity reasons is pretty good too (median time 110 minutes). In comparison, patients attending with urgent reasons are in the ED for longer (not-admitted: 149 minutes; admitted: 230 minutes) (Figure 1).10
Additionally a patient can more or less attend the ED for any reason and not be turned away. The same cannot be said for walk-in centres and Minor Injury Units which have opening times and lists of what they can and cannot help with. Who wants to risk arriving at a Minor Injuries Unit with a sprained wrist, waiting an hour to be seen only to be told it’s broken and you now have to transport yourself to the ED and wait for 2 hours to be seen again!
This confusion and worry about self-diagnosis was highlighted by patients in a recent study where patients were asked what their ideal urgent and emergency care (UEC) system might look like.11 Based on their previous experiences within various UEC services, patients did not mind lengthy wait times as long as they were kept informed about what was happening and why. Reassurance was key, along with a more 'joined up' UEC system i.e. linked medical records so that patients do not have to keep repeating medical information - a common finding in studies exploring public attitudes to data sharing.12-14 However most important to patients was a simplified UEC system that is easier to understand and access; clear and up-to-date information about local services and equal access irrespective of where the patient lives. Patients recognised that some health conditions did not warrant the services of the ED but due to the multitude of obstacles and lack of knowledge about alternative services, they did not feel confident about making the correct of choice of where to go.
The NHS Long Term Plan emphasised the importance of putting patients and the public at the heart of decision making.15 For any reduction in demand to occur, patients and the public need to be more involved in the discussion and development of system design to ensure any changes introduced meet the needs of the people who will be accessing them.
This blog was written by Maxine Kuczawski, Theme Researcher, Urgent and Emergency Care theme, Y&H ARC.23 March 2020
References1. The Guardian, Jan 2020. Available from: https://www.theguardian.com/society/2020/jan/09/ae-staff-despair-as-nhs-delays-are-at-their-worst-ever-level.2. BBC News Online, Jan 2020. Available from: https://www.bbc.co.uk/news/health-51046616.3. The Independent, Jan 2020. Available from: https://www.independent.co.uk/news/health/nhs-waiting-time-patient-delay-emergency-department-a9276366.html.4. Barker C. Accident and emergency statistics: demand, performance and pressure. House of Commons library. Briefing Paper 6964. 2017. Available from: https://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN06964 (accessed 4 Mar 2020).5. Durand A, Gentile S, Devictor B, et al. ED patients: how nonurgent are they? Systematic review of the emergency medicine literature. Am J Emerg Med 2011;299:333-345. https://doi.org/10.1016/j.ajem.2010.01.0036. Tan S, Mays N. Impact of initiatives to improve access to, and choice of, primary and urgent care in England: A systematic review. Health Policy 2014;118:304-315. https://doi.org/10.1016/j.healthpol.2014.07.0117. Pope C, McKenna G, Turnbull J, et al. Navigating and making sense of urgent and emergency care processes and provision. Health Expectations 2019;22:435-443. https://doi.org/10.1111/hex.128668. Mason S, O’Keeffe C, Jacques R, et al. Perspectives on the reasons for Emergency Department attendances across Yorkshire and the Humber: Final Report. 2017. Available from: https://www.sheffield.ac.uk/polopoly_fs/1.730630!/file/CLAHRC_BMA_Final_Report.pdf (accessed 5 Mar 2020).9. Top 7 Characteristics of a Successful Brand. Available from: www.8ways.ch › digital-news › top-7-characteristics-successful-brand (accessed 5 Mar 2020).10. Mason S, Simpson R. ‘Using data to understand demand in urgent & emergency care systems [PowerPoint presentation]. 2019 (accessed 5 Mar 2020).11. Ablard S, Kuczawski M, Sampson F, et al. What does the ideal urgent and emergency care system look like? A qualitative study of service user perspectives. Emerg Med J 2020;0:1-6. http://dx.doi.org/10.1136/emermed-2019-20892112. Mulrine S, Murtagh M, Minion J. Great North Care record public engagement report. 2018. Available from: https://www.greatnorthcarerecord.org.uk/wp-content/uploads/2018/09/GNCR-public-engagement-report-FINAL.pdf (accessed 5 Mar 2020).13. Healthwatch Briefing. How do people feel about their data being shared by the NHS. 2018. Available from: https://www.healthwatch.co.uk/news/2018-05-17/how-do-people-feel-about-their-data-being-shared-nhs (accessed 5 Mar 2020).14. Healthwatch Surrey. If I've told you once: People's views on record sharing between health and social care professionals involved in their care in Surrey. 2015. Available from: https://www.healthwatchsurrey.co.uk/wp-content/uploads/2017/06/If-Ive-told-you-once-Peoples-views-on-record-sharing-between-health-and-social-care-professionals-FULL-REPORT.pdf (accessed 5 Mar 2020).15. NHS. The NHS long term plan. 2019. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf (accessed 5 Mar 2020).