With accident and emergency departments in crisis Anna Garner and colleagues look at a relatively simple way to reduce the pressures now and in the future
The number of patients attending accident and emergency departments across the country is increasing, although there is dispute over how much and the cause.
Various initiatives have been tried, in both primary and secondary care, with limited evidence so far of successfully reducing attendance rates.
City and Hackney Clinical Commissioning Group has higher rates of A&E attendances than the average across all London CCGs, with about 10,000 patients going to an A&E department every month. Of these attendances, 70 per cent are at Homerton University Hospital Foundation Trust’s A&E department.
‘It is expected that A&E attendances might reduce over time, as patients consider more appropriate services’
The hospital has a primary urgent care centre within the department, to which 30-40 per cent of primary care cases are diverted after seeing the assessment nurse. These patients are the most obvious cases that could have been seen elsewhere, primarily by GPs.
A significant number are not registered, however, and there are no walk-in centres elsewhere in City and Hackney.
The idea of employing non-clinical patient navigators, working within Homerton University Hospital’s A&E, to educate patients about sources of healthcare and encourage GP registration, was developed by the CCG’s urgent care programme board.
The board looks at what measures are required across the whole system to support effective urgent care services for Hackney and the City of London.
Essential input is received from representatives from all health and social care organisations - the hospital’s A&E medical, nursing and managerial staff, London Ambulance Service, GP out of hours services and the London Borough of Hackney - alongside patient representation.
The board has high levels of attendance and engagement from members, and all participate in clinical debate of ideas on the best way to deliver urgent care to the local population.
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Observations of the effects of clinical streamers and non-clinical navigators at other local hospitals was fed back to the board. The hospital was clear it needed a model that did not risk diverting patients from A&E who did actually need clinical help.
The CCG agreed funding for four navigators, covering two whole time equivalent posts, starting in February 2013. Their role was to approach patients in A&E waiting areas to:
- educate and inform patients who had been triaged by the assessment nurse as only needing non-urgent appointments/referrals about local services available, including GP and out of hours services, pharmacies, sexual health services, improving access to psychological therapies services and self-care;
- show unregistered patients how to register with a GP, including informing patients which practices in their area are taking new patients and liaising with GP practices about the enrolment process needed; and
- work with frequent attenders to help identify recurrent problems and signpost them to other services.
The navigators interacted with approximately 8 per cent of patients attending Homerton A&E each month; this number increased over time as the service became embedded in the department and pathways became established.
A&E staff felt the main benefit of the navigators was that they could offer more time to patients to talk them through registering with a local GP and their role, and felt this was a more effective service than just offering patients a leaflet.
‘Assisting patients register with a GP amounted to a quarter of all navigator interactions’
Assisting patients register with a GP amounted to a quarter of all navigator interactions. After this, 40 per cent of patients registered with a GP - this was checked via NHS Spine, indicating a much higher success rate than other known interventions designed to encourage GP registration.
As well as discussing possible alternative sources of healthcare with patients - navigators have become a valuable source of information about local clinics and services for which clinicians did not know specific details - A&E staff also felt they helped manage patient expectations about waiting times in A&E.
While only 6 per cent of patients left A&E to access alternative sources of healthcare after interacting with a navigator, there was a 30 per cent increase in people leaving the primary and urgent care centre without being seen between 2012 (pre-navigators) and 2013 (post-navigators).
It is expected that A&E attendances might reduce over time, as a bigger proportion of patients who have had interactions with navigators may consider more appropriate alternative services in the future. The number of City and Hackney CCG patients attending A&E did not increase significantly between 2012-13 and 2013-14, compared with rising attendances elsewhere in the country - this could be linked with the introduction and impact of navigators.
‘Navigators have the resources and time, which doctors don’t have, to give patients the information they need’
They also provide an unexpected benefit: for a large number of patients, the interaction was to correct details on the A&E electronic patient record, including adding GP details where missing - this led to a 20 per cent reduction in the number of patients attending A&E who were then discharged with missing GP details.
By correcting a patient’s records, the chances of the patient’s discharge summary being sent to the wrong GP practice are reduced. In addition, it ensures medical information is up to date, which can result in better treatment and, as a result, better patient outcomes.
Information collected by navigators showed there is an ongoing need for education about different sources of healthcare.
It was found that:
- 46 per cent of patients had not accessed other healthcare services about their symptoms before attending A&E;
- difficultly accessing primary care was raised as a key factor in the use of A&E - more than 50 per cent of patients were not registered with a GP; and
- a significant number mentioned that getting an urgent appointment was too difficult, or impossible.
In terms of what patients wanted as an outcome of their visit to A&E, 31 per cent sought a diagnosis, 55 per cent wanted treatment, 19 per cent a prescription and 15 per cent a referral to a specialist or further investigation.
Adding up the benefits
The service provided by navigators has evolved over time and they now also work alongside the assessment nurse in A&E, enabling advice and information to be offered to patients expediently during assessment. By working with the assessment nurse also makes navigators more visible in the department, and thus more approachable for patients.
An economic model was developed by the North and East London Commissioning Support Unit to evaluate the economic benefits of the role. It looked at:
- cost savings arising from averted A&E attendances;
- the benefit of GP registration in reducing the probability of future attendances for those registered;
- the reduction in costs to the trust associated with improved patient records; and
- the economic benefit for the CCG and the GP practice as a result of the increased number of previously unregistered patients registering with a local GP.
It was shown that as a result of all the above components, there was an average net monetary benefit of over £160,000 per year for each whole time equivalent navigator.
The service has provided a bridge between patients and staff. They are uniquely positioned to have the time and resources, which nurses and doctors do not often have, to give patients the information they need to make informed choices about their healthcare. It is a valuable role that serves both patients and staff, with further benefits for the future of the health service.
Considering this, City and Hackney has extended funding to increase the number of navigators to cover five whole time equivalent posts. This will give greater coverage of the shifts in A&E and allow more staff to be on duty at any one time to increase the number of patients they can help.
‘By working alongside an assessment nurse makes navigators more visible in A&E’
The CCG is also working with the London Borough of Hackney to place one navigator in the Hackney Service Centre to work with people accessing council services there.
Increasing GP registration, improving patient experience of A&E services, and raising awareness of community and voluntary sector services have been long term strategic objectives of both local commissioners and the
The introduction of non-clinical navigators has gone some way towards achieving these goals.
Anna Garner is strategic outcomes manager, and May Cahill is chair of the urgent care programme board, both at City and Hackney CCG; Victoria Holt is GP lead for the Primary and Urgent Care Centre, Elisa Johnson is a non-clinical navigator, Jean Lyon is a emergency services senior nurse, all at Homerton University Hospital; and Georgios Ketsetzis is health economist at North and East London Commissioning Support Unit