Urgent Care

The shift in emphasis

The National Health Service (NHS) in England has benefited from an unprecedented growth in funding over the last ten years. It is now bracing itself for an end to consistent growth in budgets of 8-9 per cent a year as the full effect of the global financial crisis begins to bite. Increasingly, managers and policy makers will be looking for improvements in care fuelled by greater productivity rather than more funding, or for opportunities to improve patient care in ways that also reduce overall costs to the healthcare system.

As a reliance on national targets is relaxed, it is becoming more possible to focus on areas that have tended to be overlooked. Media attention has focussed on key targets involving 24 or 48 hour access in general practice, the speed of ambulances to emergency calls, and reducing waits at A&E departments. While all of these targets are important in their own right, they have distracted attention away from all other important aspects of the system. The Primary Care Foundation, an independent organisation committed to developing best practice in primary and urgent care, were commissioned by the Department of Health in England to look at two important areas of the NHS—the management of urgent care in general practice and the performance of out of hours medical services—and the results suggest that a greater focus on these and other areas could do more to improve the quality and safety of patient care and offer better value for money.

What do we mean by urgent care and how is it managed?

Urgent and emergency care is being used to describe all unplanned care; a need for a rapid response to an immediate health problem rather than a developing complaint that can be managed in a planned way. Within unplanned care, emergencies cover care for conditions that are, or could be, immediately life threatening. Urgent care is more difficult to define and is likely to be differently understood by the patient rather than the clinician. In the end, the Department of Health has avoided a technical definition and prefers to give priority to the patient’s perspective, so whatever that patient thinks is urgent, is presumed to be so until they have been properly assessed by a clinician.

The patient is also faced by a confusing array of choices in accessing care when they have an urgent health problem. The table below shows that after considering self care, they can contact a range of services that vary depending on developments within their local healthcare system. They can contact, their GP surgery, or potentially a series of community based nursing or therapy services, which may now be based at a new Walk In Centre, if it is out of normal practice hours they can call their ‘GP out of hours service’, they can dial 999 to call an ambulance, or go direct to a hospital Accident & Emergency (A&E) Service. Recent studies have shown that while patients understand the role of their GP surgery and of A&E, everything else is far from clear. This has led to new ideas to pilot a national 111 number for urgent care, to sit alongside the 999 number for genuine emergencies.

A whole system perspective: An urgent & emergency care pathway

There has been increasing attention given to developing ‘urgent and emergency care networks’ to ensure that all the different agencies co-operate together and ensure that patients do not slip between the different care systems. Our focus, at the Primary Care Foundation, has been to ensure that we have a better understanding of each part of the chain of urgent care. Below we describe our work looking at two key parts of this whole system.

Improving the management of urgent care in general practice

An estimated 300 million primary care consultations take place in some 9,000 practices throughout England each year. Practices vary considerably in their size, staff mix and way of operating. The cities, towns, villages and populations they serve vary too. In a diverse and complex system for providing primary care, it is clear that one size does not fit all.

Urgent care in general practice is important from a number of perspectives. It matters to patients, who may be harmed or distressed if diagnosis and treatment is delayed. It matters to the NHS as a whole, because urgent care arrangements which have not kept pace with other operational changes within the NHS place pressure on the rest of the system, driving people towards A&E and avoidable hospital admissions. It matters to general practices, where workloads can become unmanageable if urgent care is not handled well. It also affects the reputation of the service – unhappy patients tell their family, friends and colleagues about their experience.

In April 2009, a report funded by the Department of Health ‘Urgent care: a practical guide to transforming same-day care in general practice’ was distributed to all practices in England.

It describes our work with practices across five very different communities, including a survey of how 150 practices currently manage same day urgent care, as well as supporting eight practices to make rapid improvements. It focused on three simple questions concerning care for patients who contact their practice with an urgent need:

• Will they get through?
• Will they be identified?
• Will they be seen rapidly?

The report asked practices to apply the principles we outline to their own practice and system (see table below). The decisions on what solution to put in place must rest with the practice and its team rather than imposed centrally.

Our findings highlighted a number of potential barriers to accessing services. This included difficulties in booking appointments on the telephone, with over a third of practices within the study having insufficient lines or reception staff to manage calls at peak times. We also found a large variation in the number of appointments available over a working week, suggesting that many practices simply did not have enough capacity to meet demand. In other practices, it was less an issue of the overall number of appointments, but rather trying to ensure a better match between when people were seeking appointments and scheduling appointments. The clearest example of this is that while there is between 20-30 per cent more demand in almost every practice for appointments on a Monday morning, few practices schedule extra appointments at this time. Simple changes to the way patients access care and the practice manages its appointments can have a big impact on whether patients are seen rapidly when they have an urgent need.

It also highlighted the importance of non-clinical reception staff in spotting potentially urgent cases. While there was a high level of consistency in identifying and responding to potentially life threatening cases, there was greater variability in other cases that were potentially urgent, so that patients might wait longer than necessary for an appointment with a clinician. In a similar way, request for a home visit were often left until the end of the morning, even though they are more likely to require an urgent response. We found one example of a number of small practices working together to employ a doctor who would pick up all urgent home visits as soon as possible, following an initial call from the practices to check if an urgent response was needed. This prompt response to urgent requests for home visits led to a 30 per cent reduction in emergency hospital admissions, freeing up resources for the practices to use in better ways.

The report highlights five key areas that all general practices should address:

1. Address urgent needs of a patient, whether they choose to access the service by phone or in person.
2. Match capacity to demand—both in responding to patients initial call and recognising the different demand patterns for same day and advance appointments.
3. Ensure that the full range of cases that might need urgent attention will reliably be recognised by staff when the patient rings or presents in person and that the process is understood
4. Set deadlines for assessment and intervention and measure performance against these, paying particular attention to the needs of those requesting home visits where the chances are that the case may be more acute or complex
5. Review and audit the processes to refine the way that they operate

An example of how one innovative practice developed their service will help to illustrate these issues.

The Birchwood practice, a medium-sized rural practice in Norfolk, is a pioneer in urgent care and has developed a comprehensive urgent care service. GP Paul Everden led a national project to give ‘appropriate care at point of need’ (ACAPON). Its aim is to take away barriers to care.

The practice has established a genuinely integrated team, working across primary care, based on clear patient pathways. It includes an experienced GP, a nurse practitioner, emergency care practitioner and a healthcare assistant. The aim is to assess patients as early as possible and to make sure that they are seen by the right person, best able to provide timely care.
When a patient presents with an immediate need a message goes to a team leader who makes an immediate telephone assessment. The patient is directed to the most appropriate clinician, who makes a full assessment, rapidly discusses what to do with the wider team and implements an agreed pathway.

The results have been impressive. Lives have been saved that might well have been lost; there is better use of other services such as ambulances and paramedics; patients are being treated quicker and with better results. This has led to 16 per cent fewer hospital admissions than other local practices, saving money across the system. It offers a good example of how general practice can change the way it manages urgent care.

Driving up standards through a national benchmark in out of hours care

The national out of hours benchmark is a new initiative to drive up the quality of care and improve value for money across England. The first round of the benchmark was completed in March 2009 by the Primary Care Foundation and involved 63 different services measured on a wide range of performance indicators, ranging from cost, to quality, outcomes, productivity and patient experience. The benchmark is rigorous being based on a sample data extract typically of several thousand cases, supplemented by web based questionnaires, as well as a specially commissioned patient experience survey. All of this ensures that we are genuinely comparing ‘like with like’.

Although the benchmark, initiated by the Department of Health, has been up and running for less than a year, more than half the PCTs across England have made separate decisions to buy into this service for three years. Commissioners understand that this type of information is the currency for world class commissioning of urgent care. There is already evidence that the benchmark is a powerful catalyst for action and there are good examples of how it has led to changes in the way services are delivered and significant improvements in patient care.

The benchmark marks a new approach, driven by data extracts supplied by out of hours providers for four separate weeks over a six month period. This is supplemented by web based questionnaires for both commissioners and providers. Reports were sent to each commissioner and service provider identifying their performance, but providers currently retain their anonymity. We also ran a series of half-day workshops with both commissioners and providers to help them understand the different measures and how they can be used to improve performance locally. We have now further refined the benchmark, with a second round underway, with reports due on up to 100 services in September 2009. This includes a number of improvements suggested by users as well as results from the first patient experience survey.

The first round of the benchmark has identified striking difference across services. These include:

• Wide variations in cost per head (from £3.69 to £12.76 per head) and cost per case (from £31.41 to £119.91)
• Extremely wide variations in the way providers identify callers as ‘urgent on receipt’ ranging from 1.3 per cent to 60.3 per cent
• Substantial differences in the balance between offering telephone advice (21.2 per cent to 67.4 per cent), seeing patients at a base (19 per cent to 69.2 per cent), or carrying out home visits (3.3 per cent to 23.6 per cent)
• Striking differences in productivity of clinicians at peak times ranging from 0.91 to 4.60 cases per hour
• Large differences in the percentage of cases referred towards hospital (a key indicator of the effectiveness of an out of hours service), although we have asked providers to focus on the way clinicians records this informational outcome on their systems.

It is now clear that the benchmark is encouraging greater consistency so that like for like comparisons can be made in all areas. As membership increases, the strength and credibility of the benchmark is enhanced. It has also provided a more positive story in the media in a sector that only tends to attract media attention following a catastrophic service failure.

In the end, the value of a benchmark is to drive improvements in care. One example helps to illustrate the potential for driving change, in this case, by understanding why their productivity was low, leading to improvements in both quality of care and value for money.

Urgent Care 24, providing out of hours services to about 600,000 people in the North-West of England, were involved in an early pilot were broadly pleased with the overall pattern of performance, but were concerned by their comparatively low level of productivity. This led them to dig deeper in this area. They carried out a further review of productivity by each clinician (doctors and nurses) and found an even greater variation across the wide range of clinicians covering shifts in their out of hours service. They then fed back this information to all clinicians and met with all clinical staff to discuss the results and reflect on what this might mean for an individual’s practice.

They also looked at other aspects of clinical behaviour. They found out that some GPs were logging onto the system late for shifts, others in remote Centres were not picking up telephone advice calls and were often inactive, while their colleagues undertaking triage at the main base were over-stretched. By addressing these and other issues they were able to improve performance, patient care and promote a culture of fairness for all staff.

The overall result was that productivity at peak times more than doubled, clinicians were happier that workload was more evenly spread and patient care improved. Their Clinical Director commented that “by making clinicians more productive—supporting them as necessary, sorting out the problems that they face and addressing one or two poor performers—it has improved care for patients because clinicians can focus on the job that they are there to do”.

What are the lessons from these new initiatives in the NHS for improving urgent care?
There are a number of key learning points for the NHS which may also apply to other healthcare systems.

• General practice has a crucial role to play in managing urgent care, but up until recently, little was known about their role and it has tended to be overlooked
• The crucial factor driving the quality of care and the nearly all cost in the NHS is clinical decision making. We have begun to understand some of the variations across organisations but underneath this is an even greater variation between individual clinicians. Understanding this variation, feeding it back to clinicians and reducing unnecessary variation is a key route to improving quality of care at the same time as reducing costs
• The UK has relied heavily on a few key central targets which have tended to distract attention away from other potential improvements. In primary care we have focussed exclusively on 24 hour and 48 hours targets to see a doctor or a nurse, rather than potentially more important focus on seeing urgent patients much more rapidly
• There is an understandable desire to try and develop a set of metrics across the whole of the urgent and emergency care system, but it is proving difficult to identify suitable measures and even harder to monitor them effectively and consistently. It may be better to start in a less ambitious way, by finding an effective way of monitoring performance in each part of the system, as described in the out of hours benchmark, before then trying to join them up
• Politicians tend to push policy makers towards simple solutions in systems that are too complex to respond to a ‘quick fix’. The reality is that rather than seeking to improve urgent care by tackling the way patients are admitted at the front of about 300 hospitals across England, there are probably better solutions to be found by improving the management of urgent care across 9,000 general practices. A series of small, sustainable improvements are likely to have a greater impact to the system as a whole
• A key challenge is integrating urgent care within local care systems. Increasingly patients have more choices for accessing care, including Walk-In Centres, Out of Hours Care, Urgent Care Centres and now ‘Darzi’ Centres (named after the Health Minister, Lord Darzi), but they are far from clear where to go when they need rapid help. Introducing a new national three digit number (such as 111) for urgent care may offer a new way in, but will only help if the services available locally are properly joined up
• There is a strong case to be made to trust patients to make sensible decisions about how to access care and how urgently they need to be seen, rather than trying to educate them into using a complex and confusing service in the ‘right’ way.

Author bio

Rick Stern was previously a Chief Executive of a Primary Care Trust, responsible for commissioning NHS services for a community on the South Coast of England. He is also leads the NHS Alliance Urgent Care Network and is part of the Department of Health’s governing board for urgent and emergency care.

David Carson was a GP in Scotland before working in an Inner London Health Authority leading primary care policy and performance. He is also author of a key report, known as the Carson Report, for the Department of Health in 2000 that defined the way ahead and set the standard for unscheduled care in the healthcare community in the UK.

Henry Clay has spent over 15 years as a consultant to organisations in both the private and public sector. He has worked with many Out of Hours providers and has a particular expertise in benchmarking their performance.