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Introduction to tackling unscheduled care

With A&E attendance and admissions rising, practice-based commissioners are increasingly looking for ways to improve primary and community care and keep patients out of hospital. Below, Rebecca Norris explores the issues and challenges commissioning GPs face

With A&E attendance and admissions rising, practice-based commissioners are increasingly looking for ways to improve primary and community care and keep patients out of hospital. Below, Rebecca Norris explores the issues and challenges commissioning GPs face

Unscheduled care – or urgent care – covers unplanned care ranging from patient attendance at A&E, walk-in centres, or minor injuries units; urgent telephone advice sought in and out of hours; emergency hospital admissions; paramedic services; and emergency mental health or social care provision.

There is a strong financial and clinical imperative for practice-based commissioners to prevent inappropriate patient use of urgent care services and improve primary and community care of complex patients to avoid admissions.

An A&E attendance costs up to £102, regardless of whether the patient needs to be admitted, whereas the cost of admitting an elderly patient ranges from about £1,800 to £4,000 depending on which ‘complex elderly' tariff is used.

Both A&E attendances and admissions are rising, according to the latest Department of Health figures. From October to December last year, 4,625,426 people turned up at casualty – more than 66,000 more than in same period in 2006. Emergency admissions also rose by nearly 20,000 to 774,142 over the same time frame.

No GP wants a patient to be admitted as an emergency if it can be avoided through better patient case management and co-ordination of community services – such as the community matron model described in Dr Alex Williams' article.

And although patients' inappropriate use of urgent care services, such as A&E, may feel outside many GPs' control, that does not prevent them from trialling new ways of working, such as the A&E diversion scheme just launched by South Liverpool PBC consortium.

In other cases, alternatives to acute admissions already exist under the noses of GPs – they just need help finding them, as Dr Russell Muirhead explains.

These three examples are just a taste of the various solutions to the conundrum of unscheduled care. Minor injuries units, urgent care centres, emergency practitioners, and unique care case management are others.

So is there any national evidence to help commissioners decide how to design new pathways and services?

The latest research was carried out by the University of Southampton for the Department of Health and published last year (A review of the urgent care literature published 2001-2006). It was based on 133 papers selected from 16,618 potentially relevant studies.

The researchers warn that despite the growth of new ways of working, evidence of their impact remains limited and studies are often evaluations of single services. Key conclusions from the review for commissioners to consider are:

• multidisciplinary models that include social care show promise in identifying older people at risk of admissions and also preventing admissions

• nurses can safely substitute doctors and deliver equal care for the relevant subset of conditions in out-of-hours services, walk-in centres, minor injuries units, and general practice, and should be given authority to treat patients at home, refer or admit them

• some first contact services are attended more by white middle-class people and may have increased health inequalities

• patients need good information about the way local urgent care services operate

• there is insufficient evidence of the effectiveness of computerised decision support systems for triage, assessment and management compared with traditional clinical assessment and diagnosis.

Commissioners may also use section 75 of the NHS Act 2006, to integrate services and pool budgets to tackle unscheduled care.

If GPs are starting from scratch, a best practice toolkit on commissioning patient-centred urgent care services can be found under the Practical Advice section at www.dh.gov.uk.en/healthcare/primarycare/urgentcare/index.htm.

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