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State of emergency

State of emergency
4 September 2013

Emergency admissions are on the rise and it’s up to GP commissioners to try and manage that demand

Emergency admissions are on the rise and it’s up to GP commissioners to try and manage that demand
Emergency admissions have been rising above the rate of population growth for many of the last 20 years, placing an increasing financial strain on the system, and on hospitals which have been reducing their beds at the same time. Commissioners have been targeting this area for some time but with limited evidence of success. A review of urgent and emergency care in the South of England undertaken by The King’s Fund suggests some approaches used by commissioners may be more effective than others.
Stop doing ineffective things
There are a number of approaches that we know are ineffective. General public education to divert patients to alternative settings is still a surprisingly popular approach, in spite of the fact that it does not appear to work. Similarly, efforts to divert less serious emergency cases to smaller units such as walk-in centres and minor injury units show no sign of making an impact on the workload of A&E departments or on admissions. In fact, the evidence suggests these schemes have the effect of increasing overall demand. This has led some commissioning groups to look hard at the future role of units situated away from the main hospital sites. 
Rethink and redesign
There is a need for community services to be rethought and simplified. The evidence for what works is much more limited than it is for hospital care, but what evidence there is seems to point to a need for more integrated services with flexible capacity and linked to a hospital footprint or localities. Services need to have very close links to primary and social care, and be active in ‘pulling’ medically fit patients out of hospital. To achieve this, the standard block contract needs to change and provide incentives to flex capacity and create better flow through the system. The responsiveness of community services has to significantly improve to allow a response within hours rather than days.
There has been a proliferation of small community-based schemes with a very narrow focus on a particular patient group or problem. This can lead to unhelpful complexity which uses up time and resources. Some schemes seem to be based on exploiting (probably unreliable) price differences between hospital and community settings that may bear little relationship to the true cost. They have often been too small to make an impact and evaluation seems to be patchy at best. 
There is now a good understanding of the operational practices that hospitals need to implement to ensure an effective response to emergency pressures. These are often quite difficult to implement. Rapid access to senior general physicians and geriatricians as early as possible in the patient’s journey, combined with continuity of care after admission, are crucial components. Focusing on the discharge processes in hospitals is also likely to produce improvements in performance. Geriatricians working closely with community services can make a big difference in both these areas.
While funding cuts are increasingly causing difficulties, social care must work with primary care and community services in a more integrated way. This must include accelerated response to speed up hospital discharge. Joint commissioning at a local level and a pooled budget for adults looks like an important part of the solution.
In spite of the fact that primary care sees the vast majority of patients in any health system, it is the area where we have the least information about its ability to respond to demand for emergency treatment. There seems to be some anecdotal evidence that the difficulty in obtaining a same-day appointment and confusion about the out-of-hours service leads to increased A&E attendance, but there is no hard evidence to support claims that changes to the GP contract in 2004 have increased A&E waiting times or attendances. Other areas of primary care that might impact A&E attendance include:
 – Allocating more time and resources to the management of older people with frailties and complex needs.
 – A focus on nursing and residential homes including ward rounds, care planning, advanced directives, medicines management and where necessary staff training and the involvement of specialists.
 – Improving the availability of same-day appointments – this does not necessarily need to be in person – with many practices having had success with systems in which GPs provide advice over the telephone.
 – Allowing home visits much earlier in the day, combined with changes in the ambulance service’s approach to avoid going back to the GP in urgent cases. At present many home visits have to wait until after surgery, and then patients that require hospitalisation have to wait for an ambulance. These are often arranged in batches so that the patients all arrive en masse in A&E hours after the first call.
In all cases the system’s ability to make services more flexible to balance capacity and demand is crucial.
All parts of the system should collaborate effectively to improve the flow of patients through the system. Performance will be affected by adversarial or strained relationships, unnecessary resistance between departments, or commissioners and providers attempting to exploit the payment system for their own purposes. It is not clear which way the causality runs – poor performance leads to poor relationships, but the opposite may also be true.
Too much stress may have been put on incentives, governance, contracts and the machinery of management to the detriment of the effective operation of the urgent care system – shared leadership model is needed.
The model for commissioning emergency care has some significant problems. The introduction of clinical commissioning groups (CCGs) offers an opportunity for rethinking this, with providers given a stronger leadership role, accountability for delivering outcomes and more responsibility for determining the best methods for doing this. Commissioners’ focus should be much more on outcomes, setting clear objectives and bringing the system together. Commissioning emergency care should shift from an adversarial approach, with significant micro-management by commissioners, to one based on oversight, scrutiny and challenge.
There needs to be a much better understanding of the capacity of different parts of the system and how patients flow through it. The data currently used to manage the system is not fit for purpose. It is entirely retrospective, does not provide a comprehensive view of the capacity of the system, and fails to capture a number of important aspects of how it is performing for patients. Commissioners need to do more to capture broader indicators of the performance, including:
 – Proportion of patients with a length of stay greater than seven days.
 – Emergency readmissions to hospital.
 – Proportion of people dying in their usual place of residence.
 – Proportion of high-risk patients with a care plan.
 – Patient perceptions of the system.
 – Proportion of admissions for ambulatory care sensitive conditions.
These need to be combined with more forward-looking indicators used on a day-to-day basis, to map and manage the capacity of the system. It might be assumed that locally there is a shared understanding of this, but we frequently found there was nobody with a real time view of the whole system. Individual services made some predictions of where they need to prepare for spikes in demand but this was poorly co-ordinated. For example, there may not even be a common approach to how services escalate their responses to high levels of pressure.
It will be important to remember the fact that schemes to fix parts of a complex system may have a limited impact on flow through the whole system. Commissioners should tackle obstacles to the effective operation of the system and should promote the adoption of best practice. But, despite the pressure from above, it is not their job to dictate the detail of how to run services or attempt to micro-manage them. We have tried that – it doesn’t work. 

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