The urgent care challenge – what works?
CCGs must tackle the major commissioning challenges now if they are to succeed. Here, Emma Wilkinson looks at redesigning urgent care
Urgent care – an unplanned, unscheduled or emergency contact with the health service – accounts for a third of NHS activity, but half the cost.
Traditionally, such care has built up in silos with services working fairly independently.
In recent reports, the RCGP,1 the Primary Care Foundation and NHS Alliance2 point out there is duplication, with systems often fragmented and confusing for the patient.
New services such as walk-in centres have failed to cut A&E numbers, with emergency attendances in England increasing by 46% between 2003/04 and 2009/10.
With the national rollout of the 111 single urgent care number, now is the time for commissioners to redesign their urgent care networks.
Urgent care is vitally important for clinical commissioners because of unacceptable variation and the need to improve clinical safety in some areas against a backdrop of increasing demand for certain services.
Dr Agnelo Fernandes, the author of the RCGP report, says we have to get away from the idea that when patients contact the NHS it is ‘inappropriate'.
Rick Stern, urgent care lead for the NHS Alliance, agrees and says the system has been blaming people when the system itself ‘is far from perfect'.
‘If we get the system right, people will go to the right place,' he adds.
Expanding GP access
There is a new emphasis on general practice taking on responsibility for urgent care, with QOF points for reviewing practice access arrangements to relieve pressure on A&E.
Options for changing primary care include rebalancing practice appointment capacity, receptionist training and practices forming federations to share resources and facilities such as diagnostics. There is also the option to set targets for how quickly practices respond to urgent calls.
The Primary Care Foundation, for example, says every practice should ideally have the ability to respond within 10 minutes with telephone assessments for urgent problems and to organise themselves, perhaps in league with other practices, to be with the patient within an hour of the initial call.
• More than 300 practices have now used the Primary Care Foundation's web-based tool to highlight where existing resources could be better used, and in some cases this has led to a 20-40% drop in acute admissions.
• A 1% increase in primary care causes a 20% decrease in secondary care.1
• Good acute GP care and early
assessment reduces admissions because there is time to arrange alternatives to hospital admission.2
Although neither report specifically addressed potential disadvantages of GPs doing more urgent care work, concerns may include:
• GPs may feel they have little control over whether their patients attend A&E.
• Evidence suggests deprivation and proximity to a hospital most accurately predict A&E attendance.
• Simply measuring A&E attendance may not capture ‘success' of general practice strategies to do more urgent care.
• Motivation will be lacking unless resources are redirected.
During 2007/08, there were 19.1 million attendances at A&E departments and urgent care centres, compared with 14 million attendances in 2002/03.1
Many clinical commissioners are keen to explore who sees such patients coming through the A&E doors and where they might be redirected to.
Options here include having trained clinical staff – GPs and nurses – to safely stream patients coming into A&E, or an integrated urgent care service.
Some areas have also started to site mental health and substance misuse services in A&E.
• An integrated, rather than standalone, urgent care service in A&E can help make the best use of a range of skills, including primary care's lower tariff.
• Having a range of skills in A&E may help prevent admissions and will help see and treat patients at the point of contact.
• Matching supply to demand works.
• Primary mental health presentations account for 5% of A&E attendances and mental health problems occur in 30-40% of unscheduled medical and surgical admissions.
• Alcohol-related problems account for 13-30% of attendances.
According to the Primary Care Foundation and NHS Alliance2:
• Only 10-30% of A&E cases can be classified as suitable for primary care.
• The majority of patients use A&E appropriately.
• Multiple triage assessments are not safer and may add to delays.
• There is little or no evidence for the effectiveness of diversion schemes on admissions because they tend to focus on minor problems.
• Placing GPs into A&E or establishing a new service at below tariff cost per case will not on its own lead to savings and may cause costs to rise.
• Urgent care centres and walk-in centres may increase the total burden on the NHS rather than take the pressure off. As they say: ‘Build it and they will come'.
A single 111 urgent number
Over the past decade, a range of services – walk-in centres, minor injury units, urgent care centres – have become available to the public, each with different facilities and staff.
This, in addition to variable quality of out-of-hours care, has left patients confused. By April 2013 a single 111 number for urgent care calls will be rolled out nationally.
• Makes it easier for patients to access the NHS at the right place.
• Directs patients away from inappropriate parts of the system.
The Primary Care Foundation/NHS Alliance warn that 111 alone will not solve the problems of confusion and fragmentation.
• It could undermine the key role of general practice in delivering urgent care.
• Practices will need to improve access or 111 will be swamped with calls that need to be redirected to a GP.
• The urgent care network behind 111must be seamless and integrated.
The RCGP says the GP Urgent Care Dashboard can be used to identify patients who use services frequently or have had multiple contacts with different services.
It also recommends preventing admissions through palliative care teams in the community, better integration with social care and nursing teams and risk stratification of long-term conditions with systematic care planning.
The Primary Care Foundation and NHS Alliance also point to the success of attaching complex care GPs to care homes with high levels of hospital admissions, and a single point of access for all admissions with real-time information about alternatives to acute admission.
There is evidence that some schemes are successful in reducing hospital admissions. In the King's Fund report Avoiding hospital admissions – what does the research evidence say?,3 schemes that had an impact included:
• continuity of care with a GP
• hospital at home as an alternative to admission
• assertive case management in mental health
• multidisciplinary interventions and telemonitoring in heart failure.
A future strategy?
A single urgent care solution won't be right for all areas. The make up of local services will, to a large extent, reflect the needs of your particular population.
But the one strategy that both the RCGP and Primary Care Foundation/NHS Alliance reports agree on is that general practice could and should do much more work in urgent care to take pressure off hospital services.
Dr Fernandes points out: ‘The role of general practice mustn't be to deflect urgent care, it must be to get on and do it. General practice also needs to be much more proactive, changing the mindset of how it works. We need risk stratification both for physical and mental health.'
Mr Stern says the starting point for urgent care must be for general practice to better understand how it can use the resources it has at the moment.
‘I don't think it's about practices having a lot more capacity,' he says. ‘GPs need to look carefully in their locality at the best way of using this resource.'
Emma Wilkinson is a freelance journalist
1 RCGP Centre for Commissioning. Guidance for commissioning integrated urgent and emergency care: a ‘whole system' approach. 2011.
2 Primary Care Foundation/NHS Alliance. Breaking the mould without breaking the system: new ideas and resources for clinical commissioners on the journey towards integrated 24/7 urgent care. 2011.
3 The King's Fund. Avoiding hospital admissions: what does the research evidence say? 2010.
Case study: Single 111 urgent care number
Dr Fiona Sim, cluster medical director, NHS Luton & Bedfordshire
We are one of four pilot sites for the NHS 111 number and in the first year took more than 30,000 calls. An independent evaluation by the University of Sheffield found that 85% of people would use the service again and 66% were ‘very satisfied' in the way their call was handled.
We are averaging around 100 calls a day with nearly half of callers directed to a primary care service – perhaps the out-of-hours service, their own GP or a walk-in centre. And there are always nurses available for telephone consultations.
In all, 7% required an ambulance, which can be activated directly.
Another 4% were advised to visit A&E and just over one in 10 received self-care advice and did not need to see a health professional.
An important message is that people have not been disadvantaged by calling 111 instead of 999 if they need an emergency response.
It is not easy to demonstrate an impact after such a short time, but the data suggests A&E attendances have risen less in Luton than in comparable neighbouring areas.
The CCG is currently in discussions over how it will work in the future, but there has always been input from GP clinical leads, the out-of-hours service, the walk-in centre and the hospital. The scheme is still growing, but it is beginning to prove itself as a valuable tool for the patient, taking out some of the confusion.
Case study: Redesigning A&E
Dr Chris Peterson, GP in Toxteth, Liverpool, and lead primary care clinician, Liverpool A&E diversion scheme
We had noticed a trend for increased admissions at A&E, mainly in minor attendances – for things such as musculoskeletal problems and skin conditions.
We set up a diversion scheme that at first used primary care nurses within the emergency department to identify suitable patients.
But this was not very successful because the emergency department had not bought into the scheme.
So we commissioned a round-the-clock service from our secondary care provider, first using triage nurses and subsequently – more successfully – emergency nurse practitioners.
Patients who can be treated in primary care are offered a prompt appointment in their own surgery or walk-in centre, or with the out-of-hours service, or are given self-care advice. If they refuse they are still seen in the A&E department.
Through EMIS the nurses can see the patient's details, record the consultation and book appointments directly.
The number of patients diverted from the A&E department reached an average of 152 per month in the first quarter of 2010/11.
Our aim is to divert 6% of patients, with a potential saving of £184,000 per year.
We found the numbers varied depending on experience of the nurses.
But we are looking to add it as a CQUIN (see page 33 for more on CQUIN) from next year to make the scheme more consistent.
We felt there was no evidence that putting a GP in the A&E department would reduce the numbers of patients presenting with primary care problems. What this does is give the nurses a different option.
It is also about primary care facing up to the fact that it has to be accessible enough for these patients.
Case study: Targeting care home patients
David Thorne, chief executive, Newcastle Bridges Clinical Commissioning Group
We were spending £8,000 a day on admissions from patients in care homes, with the peak time being Friday night, and for conditions that were largely preventable. The most distressing thing was that 18% of patients who were admitted died within five days.
Our aim was to reduce admissions from three a day to one a day. First, we have monthly educational events. We also have 43 GPs who go into the 52 care homes to work directly with them. They are rarely involved in individual treatment as patients have their own GPs, but they provide assistance in developing practices in the home – for example, equipment for lifting and handling. We also have a local enhanced service for setting up anticipatory care plans.
In the first year we cut non-elective admissions by 9% against a trend of increased admissions and we have halved the rate of people admitted to die. There have also been incidental benefits such as better procedures for treatment of UTIs. The programme, funded through savings made elsewhere, costs around £250,000 a year. It is difficult for technical informatics reasons to get precise figures, but we have made a five-figure net saving and we expect that to increase.