Urgent and emergency services - Health Committee Contents

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.


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.


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


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.


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

previous page contents next page

© Parliamentary copyright 2013
Prepared 24 July 2013