Editorial Friday 19 December 2014: Thoughts on A&E pressure from 2006

In 2006, I wrote up a conference report of an event on urgent and emergency care for my friend Rick Stern, now chief executive of NHS Alliance.

The hog-whimperingly unsurprising current demand pressures on A&E made me think it would possibly be useful to reopublish a couple of sections from that report, which appear below.

Integrating primary and secondary care
‘Cracked it?’ - Rick Strang, head of unscheduled care, Hammersmith and Fulham PCT

What are we trying to crack?
Rick Strang proposed that the real issue is demand management, which should be managed in same way as in elective care – the goal being a completely controlled flow. This involves challenging the concept of immediacy of care.

Mayday NHS Trust in Croydon implemented a front-door nurse to direct patients to appropriate care – who was turning 22,000 people a year away to go to their GP or a Walk-In centre.

Strang posed some key questions of definition. What is primary care? And who’s really providing urgent care? For every one person going to A&E, 260 are going to a GP in primary care.

Equal commitment to cultural change is needed, as well as to process change. While it seems that A&E nurses can’t send people away, GP receptionists are excellent at doing this! However, in A&E, 1-2% of patients sent away might die.

Social marketing has taught Hammersmith and Fulham PCT that 20% of their population want a face-to-face to function and won’t use telephone triage. The PCT have a GP registration scheme (22% of A&E attendees aren’t registered) and also a GP appointment-making scheme in A&E. To ensure effective streaming, they put GPs in to A&E triage, who direct ‘cold’ emergencies (dressings, practice nurse-type stuff) to the local NHS Walk-In centre.

They used a collaborative partnership approach with acute trust, avoiding the galleons’ broadside (Battle of Trafalgar) approach. Harnessing A&E and PCT expertise, they use direct performance management through data collection – which is looked at and used every single week.

They describe the philosophy as a ‘door ajar’ approach: neither open-door, nor slam-door-in-face. Their acute trust’s A&E reception contains both acute and PCT staff: the streaming nurse and emergency nurse practitioners are employed by the acute trust; GPs and nurse practitioners by the PCT, which also employs the ‘primary care advisors’ who register the unregistered with GPs and book GP appointments.

• 45% of A&E attendances streamed through primary care. Total A&E attendances risen by less than 1% in the past year (after 12 and 14% in the previous two).
• Once booked and streamed, approximately 13,5000 ‘A&E’ attendances were seen by either PCT-funded nurse practitioner or GP
• 200 patients per month registered with a GP
• Attendances for unregistered down form 22% to 9%
• Less than 2% of unregistered attenders re-attend at A&E within 6 months of being registered.

Show me the money
Will PbR develop a reliable shared tariff? At present, it works on the inaccurate basis of a single provider. With 35,000 patients going through A&E at a PBR price of 54 pounds each, the PCT’s local A&E provider was doing 3 million pounds’ worth of sore throats, splinters etc.

Around 50% of patients going through medical assessment units (MAU) or emergency assessment units (EAUs) are treated: thus, 50% of patients going this route get no treatment. The MAU or EAU is still paid 500 pounds per patient. It would be cheaper for them to have a consultant home visit! Walk-in attendances cost about 26 pounds, GPs in the community about 75 pounds.

If the PCT saved 1 million, they should give 300,000 of that back to A&E for real emergencies.

As to separating out the front end, Strang wants to leave A&E at the hospital’s front door – they are good at it. His view is that there should be a ‘health mall’ behind that front door and the role for PCT is providing that.

Dr Julian Redhead, lead A&E consultant, St Mary’s Paddington – role of primary care in emergency departments
Julian Redhead pointed out that A&E nationally covers about 15 million attendances. He acknowledged that this figure is insignificant by GP visit standards – public know where GPs are and use them. He noted the improvements in time spent waiting in recent years: 25% waiting over 4 hours coming down to 10% (DH 2005).

Redhead added that delays in emergency care are an international problem 33% of US emergency departments diverted patients in 2001; and New Zealand is currently looking to the UK’s learning.

Citing research, he noted that patients found Walk-In centres acceptable, and could often accurately self-triage. The most given reason for not attending a Walk-In centre for urgent care was a need for radiology. However, they had caused no decrease in A&E attendances.

Furthermore, variable urgent care services (Walk-In, minor injuries, emergency care centres etc) provided variable standards of care. People who had once used out-of-hours centres were likely to use again. However, there was a public perception that they will wait longer at out-of-hours centre. He also noted that patients attending A&E perceive their illness to be more severe.

What is primary care attendance in A&E? Redhead cited the definition of Manchester triage category 5 – but pointed out that some in this category have serious pathology.

Professional opinions vary by 60%-80% on what is classified a primary care attendance in A&E. He added that 33% of attendances at A&E with headache need hospital admissions; a figure not true of primary care attendances. Some studies suggest that 1/3 of A&E attendances may be wrongly triaged out.

He also cited research showing that GPs in A&E are a valuable resource, and can lead to less use of resources – but not sustained over time, as they ‘went native’. There is no evidence of GPs in A&E providing faster service for patients or reduced delays.

Roles for GPs in A&E:
• Volume?
• Concentrating on complex patients?
• Education of patients?

He added that PBR and PBC will only work by breaking down barriers and seeing the local health economy as a whole: otherwise, PCTs will be regarded as cherry-picking. Good urgent care is about putting the right practitioner in the right place at the right time. And it’s about data, data, data!

At his hospital (St Mary’s), the OOH centre is co-located but separate. They have an appointment system and A&E triage on weekdays 08.00 to 19.30, weekends and bank holidays 10 – 4. In future, they will extend the service; register patients who attend A&E with a GP; and have arranged with local practices for a first GP appointment always to be free for a referral from the out-of-hours service.

Primary care at the front door - Dr Chris Britt, medical director of Partnership of East London Co-operativ es and medical director of walk-in centre at Whipps Cross
Chris Britt described how Whipps Cross trust has co-located the access to their walk-in centre with primary care and A&E, setting up a new ‘emergency and urgent care’ front door. They have shut the front door of A&E – their new emergency and urgent care centre will stream all the patients. A&E is accessed through a short corridor from this point.

1997
Whipps Cross casualty had 100,000 attendance with 9 casualty officers; too few cubicles; and patients waited days to be seen.

1998
collaborative working introduced between A&E and the GPs’ co-operative. The co-op got a room in the acute trust off the A&E department, and saw patients whom they classified as primary care attendances there. The supportive PCT paid urgent care fees, so this was a money-spinner under the urgent care tariff.

2003
The primary care service in the hospital was re-nominated as walk-in centre to get funding, but formalised transfer of patients.

2004
SHA found A&E failing, paid large sums to have GPs help in A&E. This demonstrated that GPs can speed people in and out of A&E quickly if they picked the right patients, who would get bogged down with casualty officers, but who are easy for GPs to see.

2006
Introduction of streaming at emergency and urgent care reception.

The service is a partnership with the co-op, the PCT and Whipps Cross – a difficult partnership, costing 1.5 million pounds. It aims to:
• reduce the number of patients being seen in A&E
• navigate patients to most appropriate services (using care navigators)
• unblock A&E
• save money (?)

Patients arriving are first seen by very experienced nurses, who are cheaper than GPs and, Britt suggested, probably just as good at streaming. Their rate-limiting step is getting patients registered on the hospital’s computer system.

Barriers
• Different culture of hospital doctors and A&E departments (litigation and risk)
• The building (and dealing with builders)
• Finance (PCT bankrolled; acute pleaded poor and contributed little)
• Patient expectation of A&E
• Different waiting times
• Nurses – world shortage (!) want more

Britt estimates that 75,867 people will walk in each year: of those, 48,360 are ‘minors’, and 27,507 will be streamed to A&E ‘majors’

Financial considerations
• The old system was saving the PCT up to 1 million pounds a year; the new one will up the saving to to 2 million with other savings potential on staffing in the medium term
• What does it mean for A&E – can they manage with less staff?
• A&E must be accident and emergency, not anything and everything

Other overall effects
• Patient education
• GP contract enforcement
• Quicker, more appropriate care for patients.

Reflections from the floor
• General practice receptionists deal with 90% of unscheduled presentations
• For effective streaming, we will need very experienced streaming nurses
• What does all of this do to funding under Payment By Results? People need to be getting on and trying to integrate care, and not worrying about the money.