6 Alternatives to A&E
Primary care
100. The King's Fund's evidence represents a broadly
held view that attempts to provide better access to primary care
services via the development of walk-in-centres has resulted in
an overall increase in demand:
There have been many attempts to divert people
from A&E services over many years by providing alternative
primary care type services. These schemes appear mainly to increase
overall demand, particularly for minor injury and illness, and
have also had the effect of creating a highly fragmented system
which generates confusion among GPs and other referrers about
how and where to access care. There is anecdotal evidence that
patients are also confused and turn to A&E services as they
have confidence in them and find them easy to access.[107]
In its evidence to the Committee, the Department
of Health does not challenge this view. They recognise that:
there is evidence that the creation of lower
acuity facilities, categorised as 'Type 3' (Minor Injuries Units,
Walk in Centres; Urgent Care Centres), does not reduce the burden
on neighbouring A&E departments.[108]
101. The RCGP challenge this notion and say that
walk-in centres (with the term used in the general sense) have
managed to relieve pressure on emergency care and GPs. Dr Gerada
said:
We saw 160,000 walk-ins at one of our sites.
We surveyed them and asked, "If we did not exist, where would
you go?" Nearly 40% said they would go to the local A and
E department; 6% said they would go to NHS Direct; 9% said they
would go to the GP co-op; and 20% said they would go to their
own GP—so it is clearly reducing the demand on their own
GP. We then have "other". In essence, what we are picking
up—we know this anecdotally, as we ask them where they would
go—is that they would go to their emergency department.
[...] Increasingly, the GP is being replaced by the walk-in clinic.
Rather than saying that we are creating demand, what we must do
is simplify the system.[109]
The Committee does not contest the suggestion that
type 3 urgent care centres and minor injury units and type 4 walk-in
centres in certain areas limit demand that would otherwise present
elsewhere in the system. Equally, we do not believe this argument
is inconsistent with the King's Fund's analysis, and that of the
Department, that the creation of these centres has induced supply-led
demand.
102. The Department of Health has yet to illustrate
how primary care should be restructured to support A&E, but
they do say that "the need to ensure that there is an integrated
system with clear points of access is fundamental to the objectives
of the Urgent and Emergency Care Review."[110]
As part of the fourth system objective for the future urgent and
emergency care system, NHS England say that possible options to
ensure same day access to primary include:
· Same day, every-day telephone, web or
email contact to a primary care team integrated with patient's
own GP practice
· A same-day, every-day appointment system
for urgent care facilities
· Direct access to community nurse specialists
and hospital specialist teams for patients with long term conditions
· GPs/Out-of-Hours teams to have easy direct
access to same day opinion from hospital specialists 7/7[111]
103. The Department of Health's written evidence
argues that A&E attendances could be reduced if patients understood
better what services were available:
Primary care could more appropriately treat many
of the patients that dial 999 for an ambulance. Until now urgent
and emergency care has been fragmented and disconnected, as patients
often do not know where they should go when they have an urgent
care need that is not life threatening. This has led to inconsistencies
in the responses and treatment patients receive. These include
preventing cross referral, the need to re-triage at each step
using different clinical assessment tools, patients being referred
to services that do not have the skills they require or patients
simply not knowing where and how they can access urgent care -
and as a result dialling 999.[112]
104. In addition, the Department cites evidence which
concludes that emergency departments are undertaking work that
can reasonably be regarded as primary care.
The Primary Care Foundation's report Primary
Care and Emergency Departments (March 2010) found that, when it
used a consistent definition and a consistent denominator of all
emergency department cases, the proportion that could be classified
as primary care cases (types that are regularly seen in general
practice) was between 10% and 30%.[113]
Dr Gerada, however, questioned whether primary care
had the capacity to undertake additional work, pointing out that
excess pressure would always manifest itself and if one part of
the system was squeezed the pressure would appear elsewhere.[114]
105. Dr Cadigan said in evidence that he believed
there to be a relationship between the availability of the GP
appointments and A&E attendances. He added that there was
evidence that continuity of care with a GP is correlated with
reduced referral rates to hospital".[115]
NHS England's review of evidence for the Emergency and Urgent
Care Review found that there were correlations between patient
satisfaction with GP services and their use of other NHS services.
In addition they identified research by the King's Fund which
said that patients who are not satisfied with their GP practice
"resort to urgent and emergency care services for primary
care needs."[116]
106. The School of Public Health at Imperial College
London published research in June 2013 which found a link between
the availability of appointments with GPs and A&E attendance.
The researchers concluded that:
the rate of A&E visits for the fifth of practices
with the best access was 10.2 per cent lower than the fifth of
practices with the worst access. If the bottom fifth had performed
as well as the top fifth, the researchers estimate this would
have resulted in 111,739 fewer A&E visits for the year.[117]
107. In the long term, a transfer of funding from
the acute sector in to primary care is required. Better signposting
for patients is likely to stimulate demand in primary care and
this transfer of resource will be required to provide the necessary
capacity.
108. The Committee strongly believes that primary
care has an important role to play in delivering accessible, high
quality urgent care. However the service structure required to
deliver this objective is different from the structure required
to deliver 'care to patients with complex needs and deal with
uncertainty in acute conditions'. The Committee does not favour
a single blueprint from the Department or NHS England. The Committee
recommends that NHS England (as the commissioner of GP services)
should seek innovative proposals for the development of community-based
urgent care services in each area. These proposals should include
consideration of step-up and step-down care and they should be
properly integrated into the rest of the urgent care system in
that area. NHS England should be open-minded about how such a
service should be provided.
ELDERLY PATIENTS
109. Over the course of this inquiry the Committee
has heard consistently that emergency departments are treating
increasing numbers of older patients, and this is borne out by
the figures referred to in chapter 1. Ambulance providers have
told us that nursing homes are very regular users of the service
and that they are now looking at ways of reducing call outs,[118]
while Dr Cadigan told us that:
it would be naive—and this was said by
the national clinical director for elderly care—to believe
that any time soon there will be a reduction in the rate of acutely
ill elderly patients coming to hospital.[119]
Dr Cadigan observed that some localities did perform
better in avoiding hospital admissions for elderly patients than
others and there were:
health economies that have a large population
of elderly people living in them have better hospital avoidance
rates and lower hospital admission rates than other health economies.[120]
Earl Howe outlined how some GPs work with care homes
to help educate them in caring for people with specific conditions.[121]
The Secretary of State, however, summarised the existing circumstances
succinctly by saying:
one of the issues at the heart of what is creating
the pressure in A and E is vulnerable older people who are going
into A and E departments who could be much better looked after
in the community.[122]
110. The Secretary of State told the Committee that
older patients are the "group of people we let down the most
in the NHS at the moment." We agree.
111. We therefore repeat our recommendation set out
at paragraph 108 that NHS England should seek proposals for new
models of primary care provision which address directly the needs
of this group of patients and which are fully integrated into
the requirement to meet all their care needs. The Committee believes
that that NHS England should be open-minded about potential providers
of these services, but they will need to address at least the
following issues:
a) Clinical responsibility for out of hours care;
b) Relationships with social care (including
carer support), social housing, residential care, hospital services
and ambulance services, and
c) High quality end of life care.
URGENT CARE CENTRES
112. The integration of urgent care centres with
emergency departments is regarded by witnesses as a positive step
in clarifying the organisation of services. The CEM said they
acknowledged "the valuable contribution to out of hours care
made by minor injury units and walk in centres."[123]
They noted, however, that a "lack of consistent opening hours
and resources (e.g. X-ray facilities) ensure they are sub-optimally
used."[124] The
CEM went on to argue that:
where geographically practical these (urgent
care centres) should be co-located with the Emergency Department.
This allows patients to present, confident that they will be seen
by the most appropriate and first available person. In addition
duplication is avoided and cost effectiveness is increased. Staff
can be easily rotated to enhance skill acquisition and retention.[125]
113. Dr Gerada described the benefits of this approach
to the Committee:
Across the country, GP-led walk-in clinics are
working very closely with their foundation trusts [...] to develop
an integrated approach. For example, you might have a front end
of urgent and emergency care [...] that is manned by the same
admin staff. At the next stage, where you get triage, they triage
to the different parts of the service—left, emergency; right,
GP walk-in clinic—with integration between the two, if it
is wrong.[126]
Professor Willett noted that:
It is the most efficient model, as patients who
arrive at a setting can be triaged into the right pathway. There
is also the ability for the general practitioners who are running
the urgent care centre and, perhaps, the emergency nurse practitioners
to work across both—and for patients to move across both.[127]
He warned however that this model could only operate
efficiently in urban areas and that it was often not an appropriate
structure for rural locations.[128]
114. The Committee welcomes the development of
Urgent Care Centres on hospital sites and accepts the evidence
that these units can improve the quality and efficiency of emergency
care. We recommend that UCBs should actively consider the development
of such centres on acute hospital sites where there do not currently
exist, although we accept Professor Willett's warning that they
can be a variety of reasons why the model does not fit every circumstance.
115. The Committee also accepts that the warning
of the College of Emergency Medicine that patients will continue
to find the organisation of urgent care baffling if similar phrases
mean different things in different places. Extensive application
of the principles of Urgent Care Centres need to be backed up
by clear objectives, clearly communicated.
NHS 111
IMPLEMENTATION
116. The requirement for clear objectives, clearly
communicated, is well illustrated by the sorry saga of NHS 111.
Commenting on the implementation of NHS 111 the Secretary of State
described the benefits associated with the basic principles of
the service:
The underlying concept is one that everyone can
agree with: it is a simple number that everyone can remember;
the fact you are connected directly to a clinician, if you need
to speak to one, rather than being called back is something people
like; the idea that you are triaged only once and do not have
to repeat your story lots and lots of times is a good one; and
the fact you can have a service that is broader than the old NHS
Direct
117. NHS Direct submitted evidence to the inquiry
examining the operation of NHS 111 which the department says "will
get patients to the right place, first time".[129]
NHS Direct observed in their evidence that whilst the intention
might be to signpost patients accurately, reducing demand was
not at the heart of NHS 111. They said:
As Professor Matthew Cooke, then National Clinical
Director responsible for NHS 111, made clear "NHS 111 was
not introduced to reduce use of NHS services. It was introduced
to simplify and improve access to urgent care services for the
public and patients". It is therefore not surprising that
in the NHS 111 pilots run by NHS Direct only about 8% of patients
using the service were given advice to look after themselves without
the need for onward referral.[130]
118. NHS Direct also provided evidence which compared
the skills and knowledge of call handlers in 111 with those in
the NHS Direct service. They say:
In the NHS Direct 0845 service, callers are initially
assessed by a trained 'Health Advisor', with approximately 1 in
2 passed on to speak to a nurse to receive a more detailed clinical
assessment. In NHS 111, all patients are assessed by a call handler
using the NHS Pathways system, with about 1 in 5 passed on to
a nurse who 'validates' the outcome reached by the call handler
or assesses patients with more complex needs. The clinical content
of Pathways deals with the emergency cases such as chest pain
and breathing difficulties, but appears less able to support call
handlers to signpost callers to an appropriate level of care.
As a result of less clinical input a far higher proportion of
callers [are] being directed to other NHS services rather than
supported to care for themselves.[131]
Their evidence adds that following the roll-out of
NHS 111 "the most significant issue was that calls took more
than twice as long as expected."[132]
The Medical Care Research Unit at Sheffield University say in
their evidence that a possible explanation for the problems experienced
by NHS 111 in recent months includes "the use of non-clinical
call handlers has meant training a whole new workforce."[133]
119. The Department of Health's evidence says that
it is too early judge what impact NHS 111 has had on A&E admissions.
They refer to the pilot programmes for some evidence but note
that "the small scale of the pilots, along with inconsistent
control sites, and the short time frame that the evaluation was
looking at meant the conclusions were limited."[134]
NHS Direct build on this point, questioning the procurement process
for NHS 111. They say in their written evidence that:
The procurement process for NHS 111 has led to
the imposition of contracts which are contributing to the poor
performance of NHS 111 services around the country. [...] In many
cases, those responsible for procurement had no stake in the sustainability
of the service they were commissioning. Tendering took place in
advance of the publication of the evaluation of the pilots and
with limited meaningful clinical input from the embryonic CCGs.[135]
120. Supplementary evidence from the Department confirms
that in August 2011 Strategic Health Authorities were asked to
submit their firm plans to complete the "rollout of the NHS
111 service by April 2013.[136]
The final report of the first four pilot locations was not published
until over a year later in October 2012.[137]
Earl Howe said that the 111 pilots produced mixed results but
he argued that the high degree of patient satisfaction provided
sufficient evidence to launch the service.[138]
Earl Howe added that issues related to A&E attendance and
the effect on demand for primary care were not deciding factors,
as the department was "clear that it was a good service".[139]
121. In written evidence the Medical Care Research
Unit at the University of Sheffield explained that it was as a
result of a change in Government policy that NHS 111 was rolled
out before they were able to complete their assessment of the
service.[140] They
say that "the decision to roll out the service was taken
by a new ministerial team in 2010 - before the pilot sites had
gone live".[141]
They agree with Earl Howe that the pilots did record a high degree
of patient satisfaction but also point out that "during the
pilot sites NHS Direct was also still operational."[142]
122. The decision to roll out NHS 111 was made
before any evidence had been gathered to assess the strength of
the service it could deliver. The service was shaped on patchy
evidence despite the results from a small number of pilots questioning
the ability of the service to divert demand away from urgent and
emergency care services. The Committee concludes that the national
deployment for NHS 111 was undertaken prematurely and without
a sufficiently sound evidence base.
ASSESSMENT
123. Dr Cadigan told the Committee that the NHS 111
IT system is inherently risk-averse. Dr Cadigan said:
I think experience and judgment can trump an
algorithm. The algorithms are risk-averse because, rightly, we
do not want to get it wrong. It is a big responsibility for the
people who are taking those calls, and that is why it is set in
that way. One of the consequences of having that approach is that
the referral rates, I suspect, will increase. One of the values
of having an experienced clinical judgment at the beginning is
that you can add more to the judgment than an algorithm.[143]
Dr Gerada concurred with this argument, saying:
Whereas NHS Direct was a clinician and very good
nurse able to triage, we have gone to 111, which essentially is
someone trained for six weeks and a computer. The computer says,
"Go to A and E," and that is what happens.[144]
124. NHS England partially acknowledges this criticism
in the design objectives included in the Emergency and Urgent
Care Review. They suggest greater clinical input in 111 telephone
triage in cases "where hospital transfer is recommended or
for complex enquiries."[145]
Dame Barbara Hakin cautioned that what was important was to ensure
clinical input was available "at the right stage in the patients'
journey"[146]
and this did not mean that clinicians should be answering calls.
Professor Willett added that an enormous amount of nursing time
would be wasted if nurses dealt with every call.[147]
Dame Barbara confirmed that the ratio of call handlers to nurses
is 4:1.[148]
125. The Committee is concerned that NHS 111 did
not apply the principle of seeking early engagement by a senior
clinician, with the result that many calls took longer than necessary
and some patients were advised to attend A&E but did not,
in the event, need to be there. We recommend that, as part of
its workstream examining the future strategic direction of NHS
111, NHS England attributes a higher priority to the principle
of early clinical assessment.
126. In its current form, we do not believe that
NHS 111 is in a position to reduce unnecessary A&E attendances.
Whilst this is not one of the core objectives of NHS 111, the
purpose of the service is to direct patients to the most appropriate
care service. Given the number of inappropriate emergency department
attendances, a successful NHS 111 service would, in achieving
its own objective, divert patients away from emergency departments.
However, NHS 111 must always err on the side of caution and present
the patient with the safest option which may compromise attempts
to keep patients out of A&E. We are concerned that patients
will not value a service which relies on a non-clinical call handler
working through an IT-generated script when the alternative option
is to visit the local A&E.
127. The Committee accepts that a recognisable
telephone led non-emergency service is useful but it is not yet
convinced that the balance between "triage" and early
access to a senior clinician is right. The Committee recommends
that this balance should be actively reviewed by NHS England as
part of the ongoing development of NHS 111.
107 ES 28, written evidence from the King's Fund, para
19 Back
108
Ev 69 Back
109
Q 181 Back
110
Ev 69 Back
111
NHS England, June 2012, p 6 Back
112
Ev 68 Back
113
Ev 68 Back
114
Q 170 Back
115
Q 28 Back
116
NHS England, June 2013, p 23 Back
117
http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_12-6-2013-12-2-28 Back
118
Q 113, Q116 Back
119
Q 48 Back
120
Q 26 Back
121
Q 308 Back
122
HC 119-iii, Q 265 Back
123
Ev 93 Back
124
Ev 93 Back
125
Ev 93 Back
126
Q 173 Back
127
Q 313 Back
128
Ibid Back
129
Ev 68 Back
130
ES 31, written evidence from NHS Direct NHS Trust, para 6 Back
131
Ibid, para 7 Back
132
Ibid, para 24 Back
133
ES 25, written evidence from the Medical Care Research Unit, School
of Health & Related Research, University of Sheffield, p 1 Back
134
Ev 72 Back
135
ES 31, written evidence from NHS Direct NHS Trust, para 13 Back
136
Ev 71 Back
137
Ev 80 Back
138
Q 348 Back
139
Q 356 Back
140
ES 25, written evidence from the Medical Care Research Unit, School
of Health & Related Research, University of Sheffield, p 1 Back
141
Ibid Back
142
Ibid Back
143
Q 41 Back
144
Q 185 Back
145
NHS England, June 2013, p 6 Back
146
Q 342 Back
147
Q 344 Back
148
Q 343 Back
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