The College of Emergency Medicine and Candesic delved into data on A&E attendances and found discrepancies that should be viewed an opportunity to design services fit for the future. By Clifford Mann and Michelle Tempest

Clifford Mann

And so it was decreed: 40 per cent of people who attend accident and emergency could be treated closer to home.

As a result of this statement, sways of policy documents and even a new blueprint for urgent and emergency care across England were published.

These well intentioned reports aimed to encourage extensive services outside the hospital, making services more personalised and expanding the roll of pharmacies.

There is little doubt that community care needs to increase and improve, and the NHS needs to evolve to reflect demographic needs.

‘Community care needs to increase and improve, and the NHS heeds to evolve to reflect demographic needs’

However, new healthcare systems must be built on solid foundations and accurate data.

Delving into the data

NHS England’s medical director Sir Bruce Keogh’s review of urgent and emergency care, revealed in November, said “40 per cent of patients who attend A&E departments are discharged requiring no treatment”. 

Reviewing 2012-13 hospital episode statistics data, 43 per cent of people did not have any investigations and 37 per cent had no treatment within A&E. To test these figures the College of Emergency Medicine decided to go back to the shop floor and establish the facts for themselves.

On 20 March the college collected clinician-based analysis of the records of 3,053 patients who visited twelve A&E across the country over 24 hours. The A&Es were representative in terms of geography, age and case mix. The result gave a starkly different picture to the one painted with broad brush strokes from the HES.

‘Some 85 per cent of people who visited A&E were there appropriately’

Candesic, an independent strategy healthcare consultancy, analysed the data and found that 85 per cent of people who visited A&E were there appropriately. Only 15 per cent of attendees could be seen by a GP in the community without the need for emergency department assessment.

The difference between 15 per cent and 40 per cent is stark – around 3.5 million patients per year – and should prompt NHS policymakers to reconsider some of their current assumptions.

Of the 15 per cent of people who could be seen by a GP the following day, the largest subgroup were young children presenting with symptoms of minor illness.

The group redirection was least probable for was the elderly. The data went on to show that 22 per cent of people could be appropriately managed by a GP working in the emergency department with access to A&E resources. A further 63 per cent needed the skills of a specialist emergency medicine doctor and 28 per cent were admitted to hospital.

Ignore at your own peril

The group who were admitted to hospital may give rise to further policy questioning. 

The current policy trend is that too many people, especially older people, are admitted to hospital and should be treated elsewhere

The data bore out the fact that the elderly were five times more likely to be admitted to hospital than children and almost three times as likely to be admitted as the 16-65 age group.

‘The current trend is that too many people are admitted to hospital and should be treated elsewhere’

Integrating health and social care systems intuitively makes sense; encouraging the treatment of people closer to home and preventing social isolation from being a cause for hospital admission.

However, of the elderly who were admitted to hospital, 97 per cent had undergone at least one diagnostic test and 68 per cent had treatment within the emergency department. So although the momentum to keep elderly people out of hospital must be maintained, the data reminds policymakers to ignore at their peril the group who most need specialist emergency provision.

Tricky target

There is no doubt that A&Es have found it increasingly difficult to meet the four-hour waiting time standard. The cause of this is multifactorial. 

First, demographic changes mean that A&Es have to cope with more elderly people who increasingly have more long term conditions. 

Second, economic pressures within the NHS, alongside the “Nicholson challenge”, mean that A&Es have become low priority for investment among acute trusts as the current tariff system ensures all type 1 A&Es are a financial drain on these organisations.

Third, an acute and chronic shortage of experienced emergency medicine doctors resulted in less efficient departments and in some cases insufficient senior cover for seven day working.

‘The data discrepancy should be viewed as an opportunity to design services fit for the future’

Fourth, the A&E brand is so strong it can be a victim of its own success, being seen by many as the first port of call before an out of hours GP service or a minor injury units.

So what can be done? Far from being downbeat about A&E, this data discrepancy should be viewed as an opportunity to design services fit for the future.

The College of Emergency Medicine is at the vanguard of the drive for efficient, effective and sustainable urgent and emergency care, and this data reinforces its campaign both for tariff reform and contract changes to ensure neither hospitals nor clinicians are disadvantaged by delivering/choosing emergency medicine.

The message is clear that triage emergency departments should be optimally configured with access to:

  • urgent care centres. These should be co-located and where safe should be able to book next day GP appointments;
  • GPs to work within the emergency department and use A&E facilities; and
  • early access to specialist emergency medicine doctors.

Urban myth revealed

Although the redirection figure of 15 per cent is substantially less than the urban myth of 40 per cent, it equates to 2.1 million attendances – more than enough to justify the establishment of co-located urgent care centres and in doing so, decongest A&Es – very few of which were built to cope with such numbers as what present now.

The Keogh review strongly supports the notion of co-located urgent care centres alongside every emergency department.

This symbiotic arrangement has clear advantages as not everyone can be expected to determine whether their symptoms represent a time critical illness.

Similarly, co-location offers economies of scale, common governance arrangements and the reassurance that any triage errors can be quickly and reliably corrected.

‘Simon Stevens is well placed to ensure A&Es are optimally configured and appropriately resourced’

It is with a sense of urgency that the college wants to highlight that attendances to A&E are unlikely to diminish, with only 15 per cent – not 40 per cent – attending A&E inappropriately. 

The trend for better “sign posting” and “self-care” education and apps are likely to have only marginal effects.

With Simon Stevens at the helm of the NHS, the opportunity could not be greater. 

He has indicated he is keen to hand over more power to clinical commissioning groups and armed with this data from the “front line” they are well placed to ensure A&Es are optimally configured and appropriately resourced.

Dr Clifford Mann is president of the College of Emergency Medicine and emergency medicine consultant at Taunton and Somerset Hospital, and Dr Michelle Tempest is a partner at Candesic, a healthcare consultancy, and locum liaison psychiatrist

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