by GK Strategy 4th February, 2014

Reflections on the urgent and emergency care debate

The political and policy battleground over urgent and emergency healthcare services in the NHS has been significant throughout the autumn and winter months. It has been used by both the Government and Opposition as a means to both drive policy and system change or to score political points. This looks set to continue through to the General Election in an area of policy that is usually favourable to Labour.

Figures released this week by the Health and Social Care Information Centre (HSCIC) on the sharp increase in elderly patients attending Accident and Emergency (A&E) were jumped on by the College of Emergency Medicine as an indictment of GP out of hours care. Andy Burnham blamed cuts to local authority social care budgets and Jeremy Hunt blamed the 2004 GP contract which allowed GPs to opt out of out-of-hours service provision.

As one of the doyens of public services in the UK, the NHS, and especially A&E, holds a particular place in the political and media debate. In policy terms it raises very interesting questions as to how such a large and complex system can operate in a joined-up and integrated way for both patients and NHS service providers at all levels of the system.

The former are motivated by a desire to be seen quickly and efficiently by the right healthcare professional. The latter by the need to deliver the right service or treatment in the most appropriate healthcare setting for that person’s needs, and within the funding constraints of the system.

From a personal perspective I experienced firsthand the need for unplanned and urgent care over the Christmas and New Year period due to a chronic condition I have. To boot, I was visiting family so away from the usual services I use in London. While a relative ‘expert’ in the machinations of the NHS the process was far from perfect to ensure I received the care I needed in a timely and effective manner.

I feel I did all the right things to escalate though the system. I rang my GP, consulted my specialist team and spoke to the GP my parents use locally to ensure I was taking the correct course of action. Despite the local GP calling ahead to the hospital in question’s acute medical team it took more than four hours of waiting (and politely questioning staff) in the A&E to be assessed by a doctor and admitted, a decision which had effectively been taken before I even arrived at the hospital.

What this showed me, both in A&E and on the wards where I was treated, is that the level of demand placed on hospitals is severe, but that the system outside the walls of the hospital itself equally prevents, or at least makes it harder, for people to be treated closer to home or discharged to a setting which is appropriate to their clinical or social care needs. The knock-on impact on staff in hospitals is clear to see.

But are GPs, out-of-hours providers, NHS 111 (beset with its own problems) and social care providers under any less pressure? The Royal College of General Practitioners claim that GPs see in excess of 1 million patients in their surgeries every day. And what can they do to prevent the general public from fetching up at A&E if that is what a worried family member thinks is in the best interest of their loved one?

Equally, anyone who has tried to secure a GP appointment on Monday morning in the face of overwhelming demand or spent time waiting for an out of hours visit will understand the frustrations people feel.

Demand pressures are clearly a factor across the system. The answer surely lies in better communication and interaction within the system as well as a relentless focus on ensuring the clinical outcomes of patients are front of mind greater and a greater alignment of financial incentives to back this. The realities of achieving this are however far from simple in a system which has traditionally been one of many silos.

Integration and prevention of unnecessary hospital admissions are the watch words of the policy debate but what more can be done to make this a reality which patients can rely on to prevent unnecessary trips to hospital or to care for them effectively when they are well enough to leave?

Jeremy Hunt’s recent speech at Guy’s and St Thomas’ had some interesting ideas from the perspective of someone that was recently receiving treatment in hospital. Continuity of consultant team, improving information sharing and access to records, truly 7-day services and improved discharge practices and procedures. These all impact on ensuring patients move through the system effectively but will it cure the illness?

Embedding the rhetoric of integration into reality on the ground is vital. Innovative ways of delivering services and new capitation-based models of care that incentivise primary care and community providers to work more effectively with their hospital colleagues need to be given the space to flourish and innovate.

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