The 7 Myths of Urgent Care
We have identified seven urgent care myths; it’s time to challenge them and do some myth-busting.
MYTH 1. MUCH OF THE CARE BEING DELIVERED IN A&E IS PRIMARY CARE
The reality: when we used a consistent definition of primary care (cases regularly seen by GPs in general practice) and a consistent denominator of all emergency department cases, we found the proportion of A&E cases that could be classified as primary care was between 10 and 30 per cent. Whilst it is undoubtedly true that primary care clinicians can relearn the skills needed to deal with the minor injuries that were excluded from the definition of primary care cases, there seems little value in this when A&E nurses already do this work well.
MYTH 2. THERE IS ALWAYS TOO MUCH DEMAND FOR SERVICES TO COPE WITH
The reality: Our analysis reveals it is rare for the footfall per hour to vary more than 50 per cent from the average per hour on any given day. This means it should be possible to staff for, and consistently deliver, a timely one-stage response; we are familiar with services which deliver this model consistently and reliably both in urgent care centres and emergency departments.
Inserting a triage or assessment stage in a bid to dispel queues and delays is wasteful of resources (see Myth 5); the aim must be to match capacity to demand. The reasons for queues developing can often be traced back to an under-staffed unit due to absence, or clinicians working at different rates.
MYTH 3. PATIENTS MISUSE URGENT CARE SERVICES – THE MYTH OF INAPPROPRIATE ATTENDERS
The reality: There is a small group of users who will consistently use the system in a different way from most and many service plans are built around this minority group. However, the operational and academic evidence shows the majority of patients use the services appropriately, given the patients’ perceived urgency at the time of use. We feel there is a tendency for services that do not have an effective operating model to blame the users, rather than looking at their performance.
MYTH 4. IT IS IMPORTANT FOR COMMISSIONERS TO EDUCATE THE PUBLIC ABOUT SERVICES
The reality: There is good evidence that initiatives, such as the expert patient programme, and providing condition-specific information for patients is beneficial. In contrast, there is no evidence that general education about how to use a system has any impact.
For most people, using the urgent care system is a rare occurrence: once every six years for out-of-hours, on average every three years for A&E. Giving information at the time of use, will have an impact over time, and we recommend this approach be adopted. For the message about how to use health services to get across, it needs reiterating consistently as a routine part of the consultation in all urgent care services over many years.
MYTH 5. IT IS SAFER FOR PATIENTS AND BETTER FOR SERVICES TO ASSESS AND TRIAGE EVERYONE
The reality: There is good evidence that a rapid see and treat process is safer than a system involving multiple assessments and delays. Triage is most often used to compensate for delays caused by poor capacity planning; there is no evidence that an assessment and triage service can improve utilisation and outcomes.
There is a real danger that an assumption is made that the assessed patient is safe to wait when, in reality the condition of some patients can change rapidly. There is also a view that if everyone is assessed, patients can be directed to the most appropriate endpoint. However, the evidence suggests most patients will make the right choice themselves and if the service is available they will use it.
In addition, evidence shows the feature patients value most is rapid access with minimal steps: they do not want multiple phone calls, ring back and delays, nor do they like to be assessed and then put to the back of a long queue in the waiting room.
MYTH 6. THERE IS A DIRECT LINK BETWEEN A&E ATTENDANCE AND HOSPITAL ADMISSIONS
The reality: There is some evidence that when A&E departments become overwhelmed junior staff will admit more people – the primary failure is in the A&E system not the volume presenting.
There are a number of key factors driving hospital admission numbers. These are: the number of individuals referred by GPs, 999, 111 and NHS Direct staff and out-of-hours services (which are all influenced by access to GP urgent care), and the efficiency of the process in A&E and acute medicine, including the availability of senior staff. There is little or no evidence for the effectiveness of diversion schemes on admissions; some have had serious safety questions raised; while diversion schemes tend to focus on people who were never likely to be admitted because all they needed was advice or more basic care.
Good acute care by GPs in the community, combined with early assessment of the severity of an episode by the GP, has been shown to reduce admissions; this is because there is time to arrange alternatives keeping the patient away from hospital. Out-of-hours providers should also focus on the clinical activity of their staff to ensure unnecessary referrals to hospital are avoided. Targeted approaches, looking at each area where the decision to admit is made such as improvements in ambulatory emergency care, are likely to be much more effective at reducing admissions.
MYTH 7. COMMISSIONERS SHOULD TENDER OUT-OF-HOURS SERVICES FREQUENTLY
The reality: there are the same expectations about out-of-hours services as every other commissioned NHS service, yet for some reason, out-of-hours services are put out to tender frequently, apparently with the view that this guarantees value for money.
Commissioners are required to procure services in a way that is transparent and non-discriminatory. Contestability, or the knowledge that if all else fails, services can be market tested, is important, but it is far from clear that the full range of traditional performance management processes have been deployed to raise the performance of the service during the contract. If a provider is to invest in a service their time horizon needs to be long enough to make it worthwhile – or at least five years - short contracts and short-term extensions will discourage investment in training, equipment, staff and systems.
Tendering is expensive (estimated as at least £100,000 for the commissioner and for each provider involved) and disruptive and in some cases may lead to too much focus on the tender price rather than quality, patient safety and the overall cost to the wider healthcare system.
There are times when commissioners will want to tender services, but this should happen far less frequently. A much more effective way of improving care for patients and driving cost-effectiveness is to work consistently with providers looking for one incremental improvement after another.