What I learned on my shift in A&E
GP Dr David McMaster spent a shift in A&E to find out first hand what the priorities were for reshaping urgent care services.
Why I decided to do a shift in A&E
I am clinical director for urgent care in Oldham. Urgent care costs the area around £60m each year – a huge chunk of Oldham CCG's overall budget of around £275m. Clinical commissioning groups all over the country will also count emergency care as a priority because of the huge costs involved.
The A&E department at the Royal Oldham Hospital had 91,889 new attendances from 1 April 2011 to 27 March 2012 and 2,427 clinic attendances, of which the ambulance teams dealt with 28,236 cases. The department is staffed by 10 consultants, 26 other doctors and 74 nurses.
A King's Fund report from 2011 found emergency admissions grew by around 12% in England between 2004/5 to 2008/9 – resulting in around 1.35 million extra admissions across the country.1 It found little evidence walk-in centres had reduced the burden on A&E or reduced waiting times in GP surgeries, and that urgent care in England was frequently fragmented and confusing for patients.
NHS Oldham has continued to experience increased costs for non-elective activity – in April 2011, emergency admissions were 5% higher than April 2010 and 17% higher than April 2009.
There has been a particular increase in admissions with a zero to one-day stay in hospital. The Greater Manchester Utilisation Management Team reviewed a cohort of 200 patients with a zero-day length of stay in September 2010, and concluded that a large number of these admissions were avoidable and that patients could be better served by alternative pathways.
I decided to pick up some pointers to help the CCG reshape urgent care by spending a shift at the A&E department of Royal Oldham Hospital. I had never worked in A&E before – not even as a junior doctor – and my only experience of the current system was through my patients, friends and family, so it was a privilege to visit the department. What I learned during my visit came down to seven priorities – which I felt could easily be addressed by clinicians improving service design and considering care from the patient's perspective.
1 Reduce repeat assessments
Patients can often be asked the same questions by several members of staff – for example, if they are able to climb stairs. Asking these questions is an essential part of the patient's care, but I would like to see one member of staff asking the questions and at the right time. In addition, patient assessments can be duplicated – for example, if a patient sees a district nurse and then a physiotherapist.
I would like to see a system where one overall assessment is carried out and the results then shared with other services involved in the patient's care. For this, staff would need an understanding of the other areas of healthcare. There are no cost projections for introducing this yet – IT system changes may be the solution in the medium to long term, but in the short term data-sharing agreements can be put in place.
2 Extend staff skills
I would like to see all staff equipped with a wider range of skills. So for instance, a prescribing nurse is more than able to treat a patient with cystitis, but currently the patient would need to see a doctor. Setting up a triage system in A&E has its benefits, but nursing staff have indicated that they would like to have more training in order to reduce the burden on doctors.
There may also be ways to involve volunteers and the third sector in urgent care – for example, to deal with the increasing volumes of patients with dementia. Where patients have chronic conditions, I think using volunteers could reduce stress and the sense of isolation in our communities. Sometimes when these patients are hospitalised it's because they live alone and are afraid their symptoms are more serious than they really are – I wonder if integrated care might be able to reduce the A&E visits from this group of patients.
3 Improve service access
In some urgent care services, not all services are available all the time. This problem became apparent when I talked to the ambulance services about difficulties with protocol. When they pick up a patient, if their condition meets certain criteria they go to hospital – but if it doesn't, the patient can often be treated at a walk-in centre. However, if the ambulance crew delivers the patient to a walk-in centre and the service advertised – for instance, suturing – isn't available at that time (perhaps because the staff member trained to offer the service is not working), the ambulance crew has had a wasted journey and must go to A&E. I would like to make sure that the right services are provided all the time, or not offered at all, in order to reduce wasted time like this.
4 Manage patient expectations
Often I, and other GPs, will refer a patient on to a named member of staff within A&E, which makes patients feel they're being treated by a joined-up service. However, the patient must still wait their turn to see the named doctor – and not every patient expects a delay, which I discovered from one hospital receptionist. I will now make sure I fully explain the process to patients and will share the information with colleagues. In this case, it would be easy to run some posters informing patients of the possible delay, managing their expectations and reducing dissatisfaction.
5 Reduce paperwork
Psychiatric nurses can spend around an hour completing paperwork after seeing a patient. Without a doubt, there is a good reason for this – but I plan to work with the mental healthcare clinical director to see if there is a way of cutting down the time it takes, while continuing to safeguard the health and safety of patients. Talking to the head of A&E at Royal Oldham, Dr Nick Gilly, we felt that our long-term strategy should be to create a universal IT system across primary and secondary care in order to reduce duplication and improve the opportunities to offer screening.
6 Collect data on A&E attendances
The current computer system tells staff how many times a patient has attended A&E, but the time period of these visits isn't immediately obvious. For example, six attendances in a patient's lifetime would be acceptable, but this many in a month could be cause for concern. It's important staff are immediately aware of this information so they can look more closely at any common themes in the patient's visits. We're developing a new model to manage data, the Urgent Care Clinical Dashboard (UCCD), which we hope will enable GPs to get a live feed on a daily basis of patients' urgent care attendance.2 This year all local GP practices are signed up to implement both the UCCD and the QIPP programme for long-term conditions, and we anticipate they will reduce emergency admissions in line with the new QOF indicators.
7 Stagger GP clinics and visits
GPs across Oldham tend to run clinics and visit patients on similar schedules, which can mean several patients need to go into hospital at the same time. This sudden demand for an ambulance can cause a back-log, meaning patients may not get to hospital until the late afternoon. But many routine hospital services such as X-ray and ultrasound are closing around this time. Patients may then have to stay in hospital overnight.
I plan to work with my GP colleagues to better co-ordinate our clinics and visits. Our new local enhanced service for supporting access in primary care provides an incentive for practices. It is widely acknowledged that primary care access cannot be measured solely in relation to face-to-face appointments, but also in terms of high-quality, responsive clinical care delivered in a timely manner.
The LES uses winter monies from A&E budgets to set up phone triage and provide extra phone lines to practices. The scheme also recommends local practices reserve two appointments a day so patients with non-urgent health problems can get a same-day appointment with their GP, which reduces the burden on A&E.
In future I plan to spend time in other local urgent care services, including Oldham's walk-in service, the out-of-hours GP service, an intermediate care facility and a medical assessment unit, and with a team of paramedics to find out more about the changes that NHS workers want to see under clinical commissioning.
Dr David McMaster is a GP in Oldham and the Oldham CCG clinical director for non-elective care
1 King's Fund. Ten priorities for commissioners. 2011. tinyurl.com/66jx9eg
2 Department of Health. QIPP national urgent care clinical dashboard – invitations for expressions of interest from pioneer sites. 2011. tinyurl.com/5umuo6r