New Opportunities

For Practices to audit their appointments and

For local health systems to shape their integrated urgent care system

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.

About Us

The Primary Care Foundation was established to support the development of best practice in primary and urgent care.  The three Directors bring different skills and perspectives to understanding primary and urgent health care - for more details click below:

David Carson

Rick Stern

Henry Clay

 

 

Latest News

Healthcare Leader Forum

Henry Clay will be speaking at the upcoming Healthcare Leader Forum: Improving urgent and emergency care conferences on 14th September at the Hilton Birmingham Metropole and also in Reading on the 21st September. This interactive conference will give its audience vital insight into the delivery of streamlined, efficient urgent care pathways emerging from regional transformation partnerships and local initiatives. Speakers will explore the necessary steps to ensure the audience know how to guarantee their organisation is fully prepared and that services are properly resourced.

 

Are there any simple lessons for practices looking to improve access?

A new feature article in Management in Practice by Rick Stern reviews what we have learned from working with over 1,500 practices across the UK – you can read the full article HERE  

 

Integrated Urgent Care – how to make NHS 111 work

A lead article for Health Care Leader by Henry Clay describes a financial and capacity model developed for NHS England, the potential benefits and pitfalls, and what we have learned from working with a dozen areas to apply the model. The article is available at HERE and a fuller version with a number of explanatory graphs can be downloaded HERE

 

A new audit of potentially avoidable appointments in general practice – available to all practices at no cost

This audit was developed as part of our research for NHS England with the initial results - suggesting that 27% of GP appointments are potentially avoidable - published in ‘Making Time in General Practice’. NHS England are now committed to extending this work by funding support for practices - so there is no direct cost - of an App you can download on to your computer screen, making it really easy for you to see how many of your appointments might be avoidable and helping you explore how you might be able to do something about it. If you want to know more, download Frequently Asked Questions, the Governance Statement and the Application Form and take a quick look at a virtual tour or email us at This email address is being protected from spambots. You need JavaScript enabled to view it.

  

Integrated Urgent Care – opportunity for support to your locality

We have developed a financial model for the Integrated Urgent Care Team at NHS England that focuses on the NHS 111 and OOH ‘front end’ to an integrated urgent care system (but also looks at the cost of onward referrals to other services). This is proving to be an invaluable tool for both commissioners and providers. It is now available to use and NHS England have also agreed to support some sites to setup and work through the model with PCF’s Henry Clay who developed the model. For further information please contact Henry on This email address is being protected from spambots. You need JavaScript enabled to view it.

 

We are now supporting over 1,500 practices across the UK to manage access and urgent care

Our support for general practices looking to improve access for patients and streamline the management of urgent care continues to expand. Based on a web based tool, developed out of our work commissioned by the Department of Health, we collect practice data for one week and prepare a report for each practice looking at how you compare to others and explore what this means for making practical changes in the way you work. We are regularly improving the format of our reports for practices based on constant feedback. If you would like to see an example report, CLICK HERE.  If you want to know more about how we might work with you please contact Rick Stern on  This email address is being protected from spambots. You need JavaScript enabled to view it.  or call on 07709 746771.