The annual headlines on A&E pressures are becoming almost a winter tradition. Solving this deep-rooted problem extends far beyond the front door of local emergency departments.
A&E and ambulance services are the 24-hour frontline part of this system – and get this scrutiny as the most recognisable “brand”, but we ignore at our peril the role that community nurses, pharmacists, walk-in centres and GPs can play in delivering a sustainable and consistent urgent care service.
I chaired a recent commission looking at GP urgent out-of-hours care funded by Care UK and featuring contributions from clinicians, policymakers and both private and not-for-profit providers. Our objective was to make practical recommendations for how this single and currently undervalued service might work better and more efficiently with, and for the good of, the whole urgent care system.
Out-of-hours care services have been subject to a series of well-intended policy false starts over the past 15 years. New services offered patients little clarity as to where best to access urgent care, out-of-hours. The introduction of the NHS 111 triaging service was designed to signpost patients, ensuring a seamless pathway of care. In reality, only 50% of out-of-hours services currently use NHS 111 as their front-end, and the strength of the A&E brand means patients are still drawn to its doors in an emergency. Recently, however, numbers of patients attending A&E have fallen slightly and since the advent of the 111 service, there has been a significant drop in numbers contacting GP out-of-hours services.
Through our deliberations it became clear that the NHS GP out-of-hours service has plenty of scope for improvement. It is measured by different standards, often commissioned as “add-on” services; disconnected in many respects from the medical education system; facing a recruitment crisis and with poor referral links.
How then do we enable the system to work better together?
Current quality measurements and payments incentives are poorly aligned across the organisations involved in urgent and emergency care – helping create poor integration and patient experience. For example, in many places it is impossible to refer from out-of-hours directly to hospital departments – sending patients through an unnecessary spell in A&E to explain their problem from scratch.
Those commissioning out-of-hours services can have a limited understanding of how the service needs to work as part of a whole system of care, with growing financial pressures resulting in a “race to the bottom” to the detriment of quality and patient experience.
A possible mechanism for achieving greater consistency across the urgent care pathway would be to establish the role of a system integrator – providing strong clinical leadership; ensuring that the patient journey through the system is seamless; and that the system itself is held to account for the care it delivers.
The urgent care sector is perhaps where the prospect of real-time data sharing within the NHS could demonstrate once and for all its value to patients. It has never been more technically within our grasp. National IT solutions would be doomed to technical failure and would never deliver a system that worked for everyone on the ground. However, an agreed national standard of data collected and shared between NHS services would be desirable.
The NHS has started planning for seven-day services in hospitals – it is time to look at delivering 24-hour healthcare in the community. With imaginative workforce planning, integrated systems and removal of perverse financial incentives and contracts, many more people could get cost-effective, high quality medical help in or close to their homes. The NHS Five Year Forward View calls for ideas for new, locally-led NHS organisations that are more flexible. There has never been a more important and opportune moment to make progress.
Prof David Colin-Thomé is an independent healthcare consultant and was national clinical director for primary care at the Department of Health from 2001 to 2007.
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