Coping with winter pressures

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As trusts begin to prepare for accident and emergency departments’ busy season, a concerted move towards co-located urgent and primary care services to take the pressure off is gathering pace, writes Alison Moore

As we move towards the autumn, many trusts will be focusing on how to ensure their accident and emergency services meet performance targets and cope with the winter rush.

But doing that will require the involvement of other parts of the NHS to ensure patients with more minor illnesses and injuries are treated in the most appropriate setting, leaving A&E to concentrate on the seriously unwell or injured.

Service integration

In May, the College of Emergency Medicine suggested that co-located primary care services could take between 15 and 30 per cent of the A&E workload but that service integration was vital.

And during the summer, the Commons health select committee called for co-located urgent care centres to be considered where they do not already exist - but it also warned of the need to communicate what they could and could not do.

Jim Chase, managing director of Advanced Health & Care, says that the trend towards alternative easily available primary care services started several years ago, with walk-in clinics. More recently interest has focused on co-located services which can take some of the strain off A&E.

Increased demand

These changes play into the debate about how to manage the increased demand that results from a desire to make access to care easier, he adds. “Perhaps we the public have changed? It could be that we are presenting where and when we want to present rather than how the NHS wants us to present,” he says.

If this is the case, the NHS may have to respond to this by providing appropriate care where people present - and a number of his customers have already started to do this by putting primary care-led services alongside A&E.

‘The operational model drives the IT solution rather than the other way round’

The experience of these has been encouraging, suggesting a significant proportion of patients can be seen and treated in a primary care setting. For example, in Blackpool the primary care unscheduled care service is run by Fylde Coast Medical Services and paid for under a block contract by the CCG. It takes between 18 and 20 per cent of the patients who present, which significantly reduces the burden on the A&E department.

Rapid response team

In Medway around 25 per cent of people who present at A&E are diverted into a primary care-led service which also provides a rapid response team for people discharged from A&E or the acute medical unit. Many patients who come into these services will also be treated more quickly than if they were in A&E - they won’t be bumped down the waiting list if an urgent trauma case comes in, for example. And, by seeing an experienced primary care professional, they may have fewer tests than if they entered a full-blown A&E and be less likely to be admitted while tests are run.

Case study: Medway On Call Care

Streaming patients so that those who can be are treated safely and appropriately by a community healthcare team is key to supporting Medway Foundation Trust’s A&E service.

Around 25 per cent of the patients turning up at A&E are diverted to the Medway On Call Care (MedOCC) service after being triaged by a senior acute trust nurse.

Such patients are flagged up in the A&E department’s computer system and their information is shared with MedOCC - although at times of pressure the GP and nurse-led service will proactively seek out other minor cases which it can treat safely.

MedOCC works with the rapid response team, which supports both A&E and the acute medical unit in getting patients home or into a community rehabilitation bed rather than admitting them unnecessarily. Another MCH community navigation team supports early discharge from the acute sector.

The glue binding these services together is shared information. Rob Howard, assistant director for business intelligence and IT at Medway Community Healthcare, the social enterprise which runs MedOCC and the rapid response team, says: “It is vital.”

The Adastra and Advanced Community systems used allows for electronic referral between the services, he says, which saves staff time in phone calls. And it will allow them to communicate with different systems so, for example, electronic discharge notifications will soon be sent to GPs.

Many of the community nurses are already using tablet computers to access information close to the patient - so, for example, the rapid response team can find out whether a patient is already known to community health services and may have a care package in place. Mr Howard says it was the way Adastra was already used in mobile devices for out of hours services which influenced the organisation to choose it for the rest of its community services.

And operations director Oena Windibank says: “Our staff have been involved in choosing the right device for them: giving them technology they can easily use and value and so making their lives easier.”

Patient records

But those who run these units stress that information flow is important, not just between A&E and co-located services - which assists the easy movement of patients between the two, if necessary, and limits the number of times patients have to give their details - but also out into other primary care and community services.

‘The ability to share information and pass it between different providers helps us achieve excellent clinical results’

NHS medical director Sir Bruce Keogh’s review of urgent and emergency care made this clear, stressing information critical to a patient’s care should be available to all those treating them.

Mr Chase says: “You need safe, quick prioritisation and routing of patients, access to patient records such as the summary care record, auditability and safe onward referral and messaging to GP patient records. Add the ability to pass cases to and from A&E systems and you have the basis of IT pre-requisites for urgent care centres. The benefit to the NHS is a quicker, cheaper and more appropriate consultation that is joined up with the wider NHS.”

Excellent results

David Archer, director of service and IM&T at London Central and West Unscheduled Care Collaborative - which runs several urgent care centres, as well as GP out of hours services and two NHS 111 services - says access to key information can prevent inappropriate hospital admissions.

Suzy Layton, chief executive of Fylde Coast Medical Services, says this information transfer helps continuity of care. “Wherever a patient appears in our unscheduled care systems this makes sure that we have their unscheduled care record in front of us,” she says.

Systems which work best tend to be ones which are driven by clinical needs and ways of working, rather than by staff having to change working practices to suit the IT system. Mr Archer says this is one of the advantages of the system his organisation uses - Adastra, produced by Advanced Health & Care.

“The operational model drives the IT solution rather than the other way round,” he says. “And the ability to share information and pass it between different providers helps us achieve excellent clinical results.”

Co-located services and better information flow will not solve all of the NHS’s problems this winter but they could help A&E departments cope with increased demand.

Smart triage is the answer

However much NHS managers want to steer non-critical patient care away from accident and emergency, they may be fighting a losing battle against patient choice. A pragmatic alternative is to manage patients more effectively once they’ve walked through the door.

Patient choice is becoming as much of a driver for healthcare initiatives as government targets and budget challenges. In hospital A&E departments this is increasingly the case. Even with the raft of admission avoidance schemes designed to alleviate the pressure on these critical health services, the volume of patients who present themselves continues to rise.

Despite access to services like NHS Direct, NHS 111 and out of hours GPs, some patients are voting with their feet and choosing to queue for appointment-free consultations at their nearest hospital.

Given that existing attempts to intercept and divert non-urgent cases to alternative services have failed to stem the flow of patients presenting at A&E, trusts need to adopt new strategies to keep emergency services clear so that they can devote their resources to life-threatening cases. Failure to manage rising patient numbers means high risk to patients who really need urgent attention; it is also highly inefficient and costly.

The answer, as a number of trusts have now realised, is to develop more effective triage facilities, where presenting patients can be intercepted and channelled towards appropriate services within the hospital’s premises. At trusts where this strategy has already evolved, there have been associated efforts to make primary care provision on site, in the form of co-located “urgent care centres”, staffed by GPs and nurses. Having primary care clinicians on site who can handle non-life threatening cases is a pragmatic solution for hospitals that still find themselves with severe A&E bottlenecks.

The challenge then is to manage the triage process. It is here that technology comes in. Where patients are directed away from urgent care towards a nurse and then GP, it is important that relevant case and patient histories can be accessed in the consultation so that decisions are fully informed.

For now, on-site urgent care centres are still at the trailblazing stage. Adopting this model requires vision and joined-up thinking. But it is an effective solution to a problem that won’t go away. In time, as trusts realise they cannot stop patients from turning up at A&E with a whole range of conditions, co-located emergency/primary care services will become more common. Providing an on-premise primary care alternative is cheaper and quicker than allocating A&E resources indiscriminately, and it ringfences frontline emergency care for those who really need it.

Jim Chase is managing director of Advanced Health and Care