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Lord Darzi's recent report summarises the challenges for the National Health Service (NHS) in the 21st century: rising expectations, demand driven by demographics, continuing development of the “information society”, advances in treatments, the changing nature of disease, and changing expectations of the workforce.1 These challenges are all relevant to the provision and development of emergency and urgent care services in the future. Perhaps, most acutely, as demand for emergency care in the UK rises, with an increasing proportion of callers with underlying chronic conditions, the challenges become those of meeting demands in a patient-centred way while managing changes to enhance the effectiveness and efficiency of the delivery of services across the spectrum of care. Meeting these challenges requires an increased level of understanding and cooperation among different healthcare professionals, provider organisations and patients. The changes mean reconsidering traditional roles and areas of responsibility and renegotiating the boundaries between acute and community care and between health and social care.
Despite the introduction of Minor Injury Units (MIUs), Walk-in Centres (WIC) and NHS Direct, attendances at emergency departments (EDs) continue to rise each year, as can be seen in figure 1, and calls to ambulance services have risen at an even faster rate.2
As well as in response to rising demand, change in the UK has been driven by external factors such as the General Medical Services (GMS) contract introduced in April 2004 and the introduction of the European Working Time Directive. These mean that physicians are less available than in the past to provide 24-h cover for emergency care. Several national UK policy documents—the “NHS Plan”,3 “Reforming Emergency Care”,4 “Taking Healthcare to the Patient”,5 “Choosing Health: Making Healthy Choices Easier”,6 and, most recently, the Darzi report “High Quality for All”1—have emphasised the problems encountered by people using the present emergency services and indicated that new initiatives need to be developed to improve access and quality. These policy documents have stressed the importance of initial assessment and care or referral of patients so that needs are met in an optimal way.
Limitations and inconsistency in first contact assessment and triage or signposting of patients have been identified as barriers to the development of coordinated systems of urgent healthcare delivery that are both appropriate to the needs of patients and efficient.7 There are several routes that patients can take in order to access emergency or urgent healthcare, advice or information. Factors influencing patient behaviours are not well understood, but with greater emphasis on the need to provide patient-centred care, evidence is needed to provide an understanding of patterns of demand and presentation and design services that meet an existing need rather than create a new one.
Computerised triage systems are in use in ambulance service, NHS Direct and out-of-hours settings, but outcomes are not consistent between systems, and although these systems have low levels of both sensitivity and specificity for cases at each end of the spectrum of urgency, overall, they are all risk-averse systems that result in inefficiencies in resource usage. Research and evaluation are urgently required to develop these systems if progress is to be made towards improving allocation of responses.
Evolution of prehospital care services
It has been acknowledged that ambulance services need to develop a wider range of responses and clinical roles for staff in order to provide appropriate care pathways for patients. Different ways of handling 999 calls have been tested involving triage of nonurgent calls by nurses and paramedics.8 However, recent UK trials have found that only a small proportion of calls could be diverted away from the service in this way, largely because of difficulties in identifying appropriate call categories for alternative management and the lack of nonemergency responses available.9
One example of a service that is aimed at a more patient-centred response from prehospital care services is emergency care practitioners. These practitioners are healthcare professionals with a paramedic or nursing background. They have extended skills to assess and treat nonurgent illness and injuries without necessarily transferring the patient to another facility. They also have the relevant skills and pathways open to them to refer patients to other health and social care professionals when required. A number of studies10 have concluded that paramedics cannot safely or accurately identify patients requiring ambulance transport or ED care. However, evidence from the UK is emerging to the contrary11 and indicates the potential to reduce burden on traditional emergency and acute services while maintaining current levels of patient satisfaction and safety. Change management issues have, however, been raised by these studies, and further evaluation of these types of roles is required.
Alternatives to the ED
For the past 10–15 years, other facilities capable of providing emergency care for patients have evolved. Minor-injury units and walk-in centres (WICs) are mainly nurse-led and treat patients with minor injury and ailments. Previous studies have found that emergency nurse practitioners (ENPs) are as effective as junior physicians in managing minor injury conditions.12 However, it must be remembered that ENPs cannot replace physicians. Their role is not generic, and as such, their scope of practice has limits. In addition, ENP services are less cost-effective.13
It was originally anticipated that WICs would reduce the demand on other emergency services such as EDs and primary care; however, studies have shown this not to be the case.14 There is insufficient evidence that collocation of services such as EDs, minor-injury units, WICs and out-of-hours primary care will have a beneficial impact. Drivers towards this cooperative model are not currently present in the UK, with payment by results providing a disincentive for services to redirect patients to more appropriate facilities. It remains to be seen what effect the new urgent care centres will have on ED activity.
Joined up working: role of networks
Further constraints on efficient and effective delivery of services have been shown to include the lack of available alternatives—for example, urgent social care and falls services (figure 2). The ambulance service and ED have been seen as offering a safety net when other services cannot respond, even when care required is social rather than clinical. National policy advocates working across boundaries, but, in common with other areas of healthcare, factors related to geographical, organisational and role boundaries make this difficult to achieve.15
In order to deliver patient-centred effective and efficient urgent care in the community, system-level thinking is required at policy, practice and research levels. The public cannot be expected to necessarily make the contact that is most appropriate to their needs, especially in the ever-shifting context of primary and emergency care. Those seeking urgent healthcare, advice or information need to be reassured that whichever point of access they use, they will consistently receive a safe, high-quality service most appropriate to their immediate needs, linked to optimum subsequent care or referral.
New models of assessment, triage and healthcare delivery need to be implemented across providers and be evaluated rigorously across sectors to ensure that all effects are picked up and so that lessons can be learned to inform system-level and provider-level care development.
Box 1 Developing efficient alternative responses requires
Assessment processes that are robust, safe and transferable between services
An evidence base to support clinical and cost-effectiveness
Tailoring to local needs
Effective communication and referral processes between services
Development of new community-based alternative services (eg, for falls and mental health crises)
A whole systems approach (eg, through a network with appropriate levels of funding and responsibility)
Competing interests None.
Provenance and peer review Commissioned; not externally peer reviewed.
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