Urgent care: we need a shared sense of scale

The debate about emergency care pressures in the NHS has been engulfed by the sound of many voices, all speaking from different perspectives and shouting for attention.

This is understandable in the current climate, and it is perfectly legitimate for your world view to be defined by where you sit.

The isolated patient with multiple chronic diseases will have a particular world view when feeling ill on a Friday night.

So will the district nurse providing palliative care and support at home in the early hours; the paramedic dealing with issues at the scene on a cold morning; and the accident and emergency consultant in the unit where the lights are always on.

Whisper it, but dare I say it, in an election year, the health secretary has an interest too.

‘Scale is poorly understood and the paucity of data dogs our understanding and reporting of the issues we face’

Each player in the system will have a legitimate view about how and why they act in the way they do. Each will have a sense of what needs to change.

My argument is that, to paraphrase the author Will Self, we need to understand these different perspectives, but we must also never lose our sense of scale.

The issue of scale is a problem. It is poorly understood in the debate and the paucity of data dogs our understanding and reporting of the issues we face.

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Scale in numbers

Recent efforts by Keith Willett to describe the whole system and the huge volumes of care that take place each day, and mostly away from hospitals, are commendable.

There are 428 million visits to community pharmacies and 340 million general practice consultations in England each year. Community and mental health teams have about 100 million contacts a year. Not all of these contacts will be urgent, though many will be.

‘The data does not exist in real time and consistent community services data is even more elusive’

About 22 million attendances go through A&E or equivalents. This means that a 0.3 per cent shift in GP attendances towards hospitals would put 1 million attendances into emergency departments.

So, very small changes in one sector could engulf another, or lots of very small, positive steps in one sector could mean a big step in the system overall.

When you understand scale, it puts recent headlines about GPs into perspective.

Unfortunately, our understanding is hampered as we don’t know whether general practice is generating any pressure at all or sucking up even more itself.

The data does not exist in real time and consistent community services data is even more elusive. Social care data - so important to flow - is patchy.

Fuzzy information

Overall, while there has been significant public debate, and some suggested theories regarding the causes of pressures on urgent and emergency care, there is widespread acknowledgment of the lack of clear, detailed information on whole system demand and a consequent lack of robust alignment between any proposed system responses.

This is important because we also know a lot of big change in one sector could mean big change in another.

Graham Phillips, a community pharmacy proprietor from Wheathampstead in Hertfordshire, says that about 57 million GP attendances could be dealt with in pharmacy with the appropriate approach, design and staffing.

‘Physios and occupational therapists are lobbying to get involved’

That’s nearly a whole day of GP time for every GP in England.

And we have a relative surplus of pharmacists, who also have a role on medication compliance, review and quality.

As well as pharmacists wanting to pick up the burden, I would add physios and occupational therapists as two professions lobbying to get involved.

The scale of their impact could be huge; one in three over 65s will fall, and there are 3 million falls a year, of which up to 25 per cent sustain a serious injury. Plus, falls are significant drivers of premature mortality.

Changing our world view

If we took into account the whole scale of the problem we face and our current activity, we might start to take a different approach and hear different perspectives.

We would:

• genuinely focus on prevention;
• get pharmacists to free up GP time;
• use the GP resource to deal with frailty, supported by multidisciplinary teams including nurses, physios and occupational therapists in a defined population;
• get interface geriatricians into communities to manage their caseload;
• use a bit more of that time to get genuine GP involvement in hospital multidisciplinary teams dealing with acute medicine, as well as the emergency department; and
• properly staff emergency departments and manage flows through hospitals.

These are solutions that support Professor Willett’s view of the future. He argues, rightly, that we need three things to be better:

• an integrated, out of hospital urgent care system, available 24/7;
• well developed emergency centres that are staffed and able to deal with genuine emergencies; and
• an effective interface between the two.

The public might then access care that meets their needs and ours.

‘Dealing with this change will require a vision we can all get behind’

I had a series of discussions with college presidents and representatives recently. I was left understanding that none of these things are in place yet, but a true commitment to get there does exist.

This requires a true understanding of their relative scale and the relationships between them.

Tackling the challenge

So, what else do we need to do to corral multiple perspectives into delivering at scale?

I have a few thoughts that build on the NHS Confederation’s Ripping off the Sticking Plaster and the 2015 Challenge. Dealing with this change will require a vision we can all get behind, the national framework to support delivery, and freedom for local leaders to work in their context. Lincolnshire is not London, Barrow is not Birmingham.

The immediate tasks are:

• getting behind the model described in the urgent and emergency care review, with political and clinical support for its adoption;
• defining the workforce consequences of new approaches and implementing a programme that will deliver significant changes, backed by the colleges;
• sorting out the financial flows, so that risk is managed and invested in so that change is double run using the transformation fund;
• protecting social care budgets; and
• starting to measure system performance across the system in real time.

The issue that remains will be one of defining the “units of planning” for delivery.

The new urgent care networks will be based on system resilience groups, but we should not assume that scientific review groups are consistently established, all inclusive and well coordinated across the country.

‘We need a shared understanding of scale if we are to deliver the change needed’

Indeed, some standardisation work will need to be done and perspectives of patients, professionals and providers will need to be embraced, in order to face the future.

To do so, they will need to operate at the right level; this will be pan-clinical commissioning group and health and wellbeing board, and with impact at scale.

Ah, that word again. We have so many perspectives to accommodate and they need a shared understanding of scale if they are to deliver the change needed.

Rob Webster is chief executive of the NHS Confederation