When health secretary Jeremy Hunt declared that four million additional people were going to A&E because of the ‘disastrous’ 2004 GP contract that removed responsibility from the profession for out-of-hours services, he ignited a debate that has no end in sight.
However, there seems to be a broad consensus that something has to be done about the state of urgent care. And commissioning experts believe there´s plenty they can do – and are in some cases already doing – to tackle the crisis. Here, we look at what practical steps CCGs can take.
1. Establish the facts and understand your own system locally
Dr Agnelo Fernandes, the RCGP’s urgent care lead, advises CCGs to take the headline figures with a pinch of salt and to establish the facts locally for themselves.
’A&E attendances in England haven´t changed substantially either nationally and locally,’ he claims.
’What has actually happened is that there has been an increase in attendances at walk-in centres which are classed in with A&E for the purposes of the statistics. This could represent supply-induced demand as there have been so many more walk-in centres set up.’
Commissioners must also distinguish A&E attendances from admissions, he adds. The increase in attendance is mainly among younger people but actual admissions are among a much smaller number of older people. ‘These represent different problems to the average CCG,’ he says.
For Dr Steve Kell, chair of NHS Bassetlaw CCG and a GP, confronting local A&E data is part of the day-to-day running of the CCG. He says his team monitors updates on A&E performance daily.
’In addition, we have weekly meetings as a CCG with A&E managers and clinicians. A&E clinical directors also come out to talk to GPs to keep them in the picture and CCGs are developing dashboards to better monitor the situation locally. This means we understand the trends locally and can adapt the services we offer.’
2. Analyse local access to primary care
For Rick Stern, director of the Primary Care Foundation and author of a joint report with the NHS Alliance on commissioning urgent care, general practice is the most important part of the urgent care system.
He says: ‘It´s about trying to help practices to reduce pressure on themselves so they can reduce pressure on A&E. We can help CCGs look at a week´s worth of data for practices, looking at telephone calls and use of appointments that can help practices analyse how they manage care.
‘There´s good evidence from the Kings Fund and elsewhere that good continuity of care in general practice affects use of A&E.’
3. Develop a clear vision of what you want from secondary care
Dr Fernandes argues that CCGs can get better service out of hospitals if they fully understand how they work. ‘CCGs need to understand what the issues are in terms of flow/blockages. Hospitals need good operational management – and reduced emergency department workload to improve the flow through A&E.
’For example, if it´s a staffing problem, A&Es may be able to use alternative acute specialists such as geriatricians to help them cope. ‘
He points to the ‘huge shortage’ of A&E consultants. ‘At times there are no senior decision makers available in A&E and departments are having difficulty with staffing rotas.’
Dr Kell´s CCG has already put this approach into practice: ‘Locally, we have actively reviewed staffing resulting in an increase in consultant cover and an increase in nursing cover in A&E.’
4. Adopt a whole-system approach
Dr Kell’s Bassetlaw CCG has found that the actual number of patients admitted to hospital inappropriately was only 11% but that 70% of adults in hospital could have been discharged if there were adequate facilities for them in the community.
He says there is a lot of good work going on nationally looking at the likes of step-down beds as a way of getting people out of hospital until they are well enough to return home.
The whole-system approach applied in Dr Fernandes’s local area of Croydon extends to establishing an urgent care centre on the ‘front end’ of A&E. ‘That alone has cut A&E footfall by nearly 50%. In addition, we changed the out-of-hours contract to an urgent care contract.’
This has saved huge amounts, he adds. ’We´ve invested £3m to save £38m… None of this is rocket science.’
5. Maximise what can be seen outside A&E
The whole-system view means looking at how other local services can be harnessed to provide alternatives to A&E.
’The actual crisis in the NHS is not in A&E but in the increasing workload in general practice couple with a falling GP workforce. And it´s going to get worse,’ says Dr Fernandes.
’About 95% of urgent care actually takes place in primary care so any slippage there can mean a big extra load on hospitals. So CCGs need to integrate the voluntary and the social sector with primary care. CCGs can think much more holistically. We´ve been putting sticking plasters on different parts of the system and have created a culture of dependency among patients.’
For Dr Kell, involving local mental health services in the strategy is key: ‘We know that patients who frequently access urgent care tend to include a majority who have mental health and alcohol-related problems.’
6. Focus on anticipatory care
CCGs can reduce the demand on urgent care services by prioritising the types of patients who are likely to access them. Dr Fernandes says: ‘This can involve using telehealth and the like to get early warning of patients´needs.’
This is also where risk stratification comes in, he adds: ‘In the past, when we used the model of the pyramid of care with the most needy at the top, we focused on the top of the pyramid. It was the traditional logic.’
However, they are the people likely to end up in hospital in any case, he adds.
‘Concentrate on them and the admission rate doesn´t change,’ Dr Fernandes says. ‘CCGs need to be more clever, to concentrate on the next tier down and prevent those patients getting into the top zone. There is a lot of evidence to show this works.’
7. Encourage self-care
For Dr Fernandes, another part of the solution is to encourage self care for those at lower risk. In Croydon, he says, ‘we made prevention, self management and shared decision making one of our QIPP priorities’.
CCGs should work with Health and Wellbeing Boards to promote self care for the 98% of patients who are at lower risk, advises Dr Fernandes.
8. Optimise quality in A&E
Dr Kell – who is also co-chair of NHS Clinical Commissioners leadership group – believes much of the furore around urgent care has been caused by the fact that the four-hour target for A&E isn´t being met: ‘Yes, there are concerns around that but in itself it´s not a crisis.’
Instead, he believes that the existence of the target is itself ‘a sign of stress’ in the system.
’If you meet that target it doesn´t mean that you´ve solved the whole problem. There´s much more that needs to be done than just ticking that particular box and that entails a focus on quality in the system.’
Dr Fernandes agrees: ‘Make quality the focus rather than the four-hour target. If you pursue quality you will meet the target. CCGs should bring quality and safety to the table as a given.’
9. Develop your directory of services
For Dr Fernandes, the widely reported problems with NHS 111 are simply teething problems.
‘It´s just a miscalculation over staffing levels. In our area 111 is already working well. And once 111 is working, the next step is for CCGs is develop their directory of services.’
By developing the directory of services, you can ensure that ‘if a patient has a fall, for example, you don´t send an ambulance, you contact the falls team’.
CCGs can also work with local authorities to develop rapid response teams integrating health and social care, which can respond within two hours at home, Dr Fernandes adds.
10. Streamline the message to patients
According to Dr Fernandes, the public is confused about what to do when they have a medical problem – which increases pressure on the wrong parts of the system.
’CCGs need to change the mantra: It should be: if you have a problem, self manage in the first instance.
’The message to the public should be that you only need to remember three numbers – 999 for emergencies, 111, the single point of access for non-emergencies and lastly your own GP´s number.’
By publicising this widely, it makes it easier for patients to know where to go.
Rick Stern agrees that the introduction of new ways of accessing the NHS – such as walk in centres and minor injury units has confused patients. He adds: ‘Rather than trying to educate patients about a system which is difficult to access, we should make sure the system itself is right.’