It’s time to act so A&E is treated as an integral part of the wider system rather than a misused backstop, says Rick Stern
Patients are confused about where and how to access urgent care − general practices, accident and emergency departments, the ambulance service; as well as a host of new facilities including urgent care centres and community services seeking to prevent hospital admissions.
‘We too often design care around myths − such as that patients misuse urgent care services − rather than the evidence’
Access matters. If it is hard to access care, there is less interest in the quality of care once you are treated. As Ben Page, chief executive of Ipsos Mori, has pointed out, patients judge services on speed of access rather than quality of care.
Benchmarking out-of-hours services across England has shown that patients perceive rapid care as good care. But a system purely driven by time targets may lose sight of delivering good care − “hitting the target but missing the point”, as Sir David Nicholson might say − but we should never forget that time matters, both clinically and in terms of our experience as patients.
Many GP practices now understand that identifying the few individuals deteriorating who need rapid intervention, supported by screening all requests for home visits within minutes rather than hours, can have a significant impact on the wider system, reducing avoidable emergency admissions to hospital.
We must also trust patients more. Too often we see patients as the problem, seeking care they don’t really need at the wrong place in the system. In reality, our behaviour as patients is shaped by the systems we face. The more barriers to getting care when we feel we need it, the more we will do what it takes to get seen.
If we face a complicated systems at a time of personal crisis, going straight to the easiest point to access care, often perceived to be A&E, is just common sense. Rather than blaming the wrong sort of patients we would do better looking at unhelpful systems.
Designing care around myths
Put another way, we too often design care around myths − such as that patients misuse urgent care services − rather than the evidence.
So what do we know? Systems are complicated and frequently don’t work together. Continuity of care coordinated by one person is important, especially in the absence of effective systems for sharing patient information. Public education tends to have little impact, in large part because patients don’t use urgent and emergency services very often (1).
‘It is time to be bold and trust clinicians to design better systems and behaviours’
In reality, there is no “magic bullet” shortcut to providing effective urgent care. Our systems are complex (often unnecessarily so), and the answer is to make each part work effectively, and then join it all together.
So general practice, in and out of hours, must ensure patients can get appointments more easily and spot the few cases that need to be seen quickly. Community services must be better at identifying patients who, with the right support, can stay at home. Ambulances must ensure more patients are treated away from hospital.
Urgent care centres need greater clarity about how they work and link with the rest of the system. A&E must be seen as an integral part of the wider system, rather than the backstop when all else fails. Hospitals need a constant focus on doing everything they can to get patients out quickly.
To support our urgent care system to work together, we need a way of understanding how the system as a whole performs as well as the individual parts. Matthew Cooke, as urgent care “tsar” until October 2012, rightly emphasised the importance of indicators that work across the system.
Developing an urgent care benchmark may help develop a sense that we will all succeed or fail together (2).
This requires consistent hard work within services and a shared commitment to keep improving care for patients as the overriding priority, rather than protecting organisational or professional interests. At a time when everyone is focused on making financial savings this requires a profound change in the way we work together.
The one benefit of austerity and financial challenge on an unprecedented scale is that tinkering at the edges just will not be enough − it is time to be bold and trust clinicians to design better systems and behaviours that have the potential to save money and improve care.
And if nothing else, the last few years has re-established primary care as the front line for managing urgent care. Small changes in 8,200 practices will have a much more profound effect than focusing on keeping patients out of A&E. Improving care may be challenging but it is within our control.
1) Breaking the Mould without Breaking the System: New Ideas and Resources for Clinical Commissioners on the Journey towards Integrated 24/7 Urgent Care. NHS Alliance and Primary Care Foundation, 2011.
See also Getting to grips with integrated 24/7 emergency and urgent care, October 2012, NHS Alliance. A new approach to 111: Re-establishing general practice as the main route in to urgent care, May 2011, and NHS 111: getting lost in translation? January 2012.
2) Reforming urgent and emergency care performance management, Department of Health, 18 July 2011
Rick Stern is chief executive of NHS Alliance and a director of the Primary Care Foundation