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Urgent need in primary care

Urgent need in primary care
4 September 2013

Rising demand in emergency departments needs to be tackled to make better use of the money available
You could have been forgiven for thinking the summer season had started early this year as the row about crowded NHS emergency departments spilt over into threats to make GPs take back 24-hour responsibility for patients. 

Rising demand in emergency departments needs to be tackled to make better use of the money available
You could have been forgiven for thinking the summer season had started early this year as the row about crowded NHS emergency departments spilt over into threats to make GPs take back 24-hour responsibility for patients. 
As the brouhaha dies down, the NHS is still left with the problem of how to manage rising demand for urgent care. Behind the scenes lobbying is underway to find a political and practical solution not just on how to manage out of hours GP care and re-write the GP contract but also what to do about the failing NHS 111 service and the impact of the four hour target. 
Meanwhile, Sir Bruce Keogh, the NHS medical director, continues with his review of emergency and urgent care, examining whether some emergency departments (EDs) should be shut down so that others can provide a higher level of service for the more seriously ill patient.
Urgent care is a top priority for clinical commissioning groups (CCGs) and many are developing integrated plans that bring together their local acute hospitals, urgent care providers, local authority partners, ambulance services and others. 
But, as Harry Longman, director of the social enterprise Patient Access points out: “Commissioning needs to be based on evidence.”
There is a wealth of evidence out there and it seems to highlight a number of common themes.

 – The figures on urgent care attendance are not what they have been presented as.

 – The quality of urgent care services such as minor injury units and walk in centres is very variable.

 – The quality of GP access is a key determinant of demand on EDs.

 – High quality, rapid clinical advice is key to managing demand.

 – Commissioning integrated pathways for patients reduces demand on EDs and results in better care for patients.
So, starting with the figures. Health think tank, The King’s Fund recently analysed the data and asked: Are accident and emergency attendances increasing? The numbers tell one story; the facts behind how they were collected tell quite another. 
The top-line figures show a rapid increase in the number of people using urgent care services from 2003/4 onwards. But this masks both a change in urgent care services –  minor injury units (MIUs) and walk in centres (WICs) opened around 2003/04 – and new data sets that not only collected but also differentiated the type of centre attended.
The King’s Fund analysis shows that it was attendances at the MIUs and WICs that increased while the number of people attending EDs remained more or less unchanged. 
“That’s not to say that there is not mounting pressure on EDs,” says Rick Stern, chief executive of the NHS Alliance and director of the Primary Care Foundation. “Like primary care, EDs are dealing with more complex cases, more frail elderly people and more vulnerable people.”
There is also evidence that MIUs and WICs can increase the demand on EDs. Russell Emeny, director of the Emergency and Urgent Care Intensive Support Team based at NHS Improving Quality, says: “There has been quite a lot of scrutiny of MIUs and walk in centres and quite a lot of them have closed. What we have found in our work is that they can have high conversion rates, (ie, sending patients on to the ED), particularly for children.
“The result is that the NHS pays three times for those patients. Once to have GP access, once for the MIU attendance and then again for the ED in the acute hospital.”
Work by the Primary Care Foundation (PCF) similarly found that there is little evidence that urgent care centres such as WICs and MIUs reduce attendance at EDs and some evidence that they may increase ED attendance. Certainly, they varied widely in what they provided and for what hours of the week, and many were doing essentially the same job as primary care. 
So do patients go to the “wrong” place? “I think people in general are fairly sensible about where they go,” says Emeny. “It’s logical for a mum to take her children to a walk in centre if there are problems with access.”
There is now mounting evidence that access in general practice is a key driver of urgent care demand. 
Recent research from Imperial College London  for the first time made this link on a national scale, showing that where patients can get an appointment within two days of their first call to a GP, there are fewer visits to the local ED.
According to the analysis, 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.
Emeny admits that the whole debate around GP access is in danger of becoming toxic. “There is a lot of heat around about this, with the Keogh review and people suggesting that the GP should be the senior named person responsible for everybody in the world 24 hours a day,” he says. “But actually, there are a number of really sensible things that any practice can do to improve access.”
They include carrying out domiciliary visits in the morning rather than the afternoon as well as the telephone consultation models such as Doctor First and Patient Access.
At the other end of the pipeline, though, is the pressure on acute hospital beds and Emeny argues that CCGs need to consider new models of care in which GPs and geriatricians work together to keep frail elderly people out of hospital and out of the ED.
Simon Conroy, an author of the British Geriatric Society’s Silver Book , published in 2012 to recommend ways in which emergency admissions of older people can be reduced and the experience of those admitted improved, says this requires close work between primary, secondary and social care to develop patient pathways. 
Dr Conroy, who is also a consultant geriatrician at Leicester Royal Infirmary, says: “We have developed virtual integrated pathways with primary care and they are effective in reducing admissions of frail elderly people, especially where they use our complementary skills properly.” 
“But with the best will in the world, people will still land in the ED so they need a clinical service involving physios, occupational therapists, nurses and geriatricians to provide a friendly response and a single point of access.” 
The service at his hospital, which admittedly operates only from 8am to 6pm seven days a week rather than round the clock, has seen the conversion rate for over 80-year-olds drop by 20% in a year. 
“It’s about having confidence in your hand off,” says Dr Conroy. “I need to know that when I hand off a patient to the community that the right services will be there.”
A key ingredient of the success is rapid access to the high quality clinical advice. Both Emeny and Stern emphasise just how important this is in reducing the ED workload. 
“Early senior review has the potential to reduce admissions,” says Emeny. 
The experience is mirrored in mental health where the RAID model started in Birmingham is now being taken up widely across the country. Essentially, it is a generic, multidisciplinary mental health rapid response team based in secondary care providing a single point of contact for all mental health needs among patients over 16 years old. 
It means that when a patient with mental health needs – regardless of the precise nature of that need – can be seen rapidly by someone who can help rather than face a long wait for a specialist referral.
An economic evaluation in 2011 by the London School of Economics and the Centre for Mental Health showed that it reduces admissions from the ED and reduces length of stay, delivering savings of around £6.4m compared to the £1.4m it cost to run.
Kerry Webb, RAID’s operational director and a mental health nurse, says: “We are at the front door to do quick triage as well as the back door making sure discharges are not delayed.”
A new economic evaluation has been commissioned to try to understand where the savings are made. “We think it is around 80% to the acute trust and 20% to primary care,” says Webb. 
Stern says this is one example of how commissioners need to work across the whole system in order to reduce pressure on the ED – and to deliver the kinds of services that patients want. Elsewhere GPs are working with the ambulance service to reduce pressure there – a challenge given that an ambulance service patch will typically contain 1,000 GP practices.
“The key thing we all need to do is break down the boundaries between primary and secondary care,” he says. “There is a place for networks and yes, for the kind of urgent care review that many CCGs are now carrying out. I think there is something in the idea that we should give patients what they want. If you give people what they want, they like it and it makes the service more efficient.” 

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