More hospital admissions could be avoided if people needing emergency and urgent care were managed differently rather than just being taken to A&E
One issue dominates discussions about the NHS. In the corridors of Whitehall, at trust board meetings and in the political party conferences, the question is the same: how can the NHS make up to £20bn of savings over five years? Think tanks, politicians and commentators propose seemingly easy solutions: “Cut bureaucracy and waste. Freeze pay and pensions. Ration services.”
Managers and clinicians could be forgiven for rolling their eyes
But more sensible voices urge a different approach. They point to evidence which shows better quality healthcare is also more efficient, and that instead of seeing the financial climate as an excuse to “take on” public sector pay or reduce the role of the state, it should be seized as an opportunity to genuinely transform patient care.
There’s no shortage of options for reform. The danger is rather that the NHS lacks focus on which services should be a priority. One clear candidate is emergency and urgent care. Despite considerable improvements in recent years, there are still too many hospital admissions that could be avoided if services were organised in a different way.
Managers and clinicians could be forgiven for rolling their eyes at this suggestion. There have been numerous attempts at reforming urgent care which have not simplified the system or reduced demand or costs - in fact, just the opposite.
There are three reasons why things could be different this time round. First, we know much more about what’s driving increasing demand. Take 999 calls. This is a particular problem, increasing by an average of 6.5 per cent each year. Spending on ambulance services is around 1.5 per cent of the NHS budget, but the decisions taken by ambulance staff can lead to around 20 per cent of total healthcare costs. The number of ambulance journeys to hospital is coming down, but taking patients to A&E is still too often the only option, especially when the main measure of ambulance performance is response times, rather than the overall quality of care.
New research from the Department of Health shows that four problems account for three quarters of the increase in ambulance calls since 2000-01: falls (one in 10 calls to 999 are for an older person who has fallen), breathing problems, chest pain and people who are unconscious or have passed out (which is often alcohol related).
Many of these patients could be cared for better in the community or at home, or prevented from requiring help in the first place through better management of their condition.
The second reason why reforming emergency and urgent care could be different this time is that we have learnt from past experience. Adding new services without linking them to existing provision makes things more complicated and confusing for patients and staff, not less. We now need “whole system” change so that patients get the right care, in the right place at the right time, however they access the system.
We finally have the tools to make this happen. NHS Pathways is a new telephone assessment system that can triage 999, NHS Direct and GP out of hours calls consistently and appropriately. It is owned by the NHS and backed by the royal colleges and British Medical Association, who are leading its clinical development. Once assessed, patients need to get the most appropriate care for their needs.
A big problem in the past has been the lack of information about local urgent and emergency care services, including GPs, minor injury and walk in centres, community nurses, mental health and social care, as well as emergency departments and ambulance services. But the NHS now has the technology to create a “real time” directory of local services.
Crucially, the technology matches patients’ needs with the skills of staff in each service. This not only means patients will get the best available care but that commissioners will be able to identify gaps in services that need to be addressed.
The final reason why a new focus on emergency and urgent care could be different is the emerging consensus for change. Patients and the public consistently say they want simpler, easier access to care. The next stage review recognised this, and every region has proposed options for change. Labour and Conservative policy is also remarkably similar in this area. Both want a single point of access for emergency and urgent care and both support the development of a new three digit number - probably 111 - to sit alongside 999. So whichever party is in government, the direction of travel will remain the same.
None of this means change will be easy. But with leadership and focus, the NHS can deliver better care and value for money. We should seize this opportunity with relish.