The interim report of Sir Bruce Keogh’s urgent and emergency care review, published yesterday, is brave and visionary.
It is brave because it acknowledges that many acute hospitals cannot deliver the best care for a range of serious conditions. It is visionary because it proposes initiatives to reverse our growing cultural dependence on acute hospitals and their A&E departments to provide same-day care to all comers.
The hypothesis is that demand on A&E departments and hospitals can be reduced if viable alternatives can be created. This is not a new idea but it has been difficult to develop evidence based initiatives that really work and can be scaled up.
A very real problem is that new services designed to reduce A&E demand may create new demand (or address unmet need) without affecting A&E attendances. This is not a counsel of despair but a warning about unexpected consequences and the need to pilot and evaluate new schemes.
Another real issue is whether to focus on A&E attendances in general or to concentrate on those that tend to result in admission. The report discusses attendances and admissions with equal emphasis, but it is generally patients waiting for beds that cause A&E departments to become crowded, unsafe and to miss the 4-hour standard.
Decongesting an A&E department is really about moving patients promptly to wards, rather than managing less serious cases elsewhere. That said, an A&E crowded with patients waiting for beds may find it difficult to manage its ‘walk-up’ patients. Less serious cases may be admitted inappropriately as staff get stretched and the quality of decision making suffers. This is particularly the case where consultant supervision is thin or absent and less experienced doctors struggle with large workloads.
The Review’s terms of reference restricted it to urgent and emergency care in A&E and outside of hospital. This may be a weakness, as A&E crowding is as much to do with in-hospital processes and the management of patient discharge as it is to do with demand for admission. Consideration of hospital inpatients and discharge is being done by others, including the Seven Day Services Forum set up by NHS England, so it is not being ignored. It will be essential to join up work to modernise pathways, through and out of acute hospitals, with the wider urgent and emergency care review if it is to have the hoped for benefits.
Sir Bruce is clear on the need to reduce hospital admissions, arguing that 20% may be avoidable. The argument that frail older people may deteriorate rapidly if admitted unnecessarily and managed poorly in hospital is well made.
Several research papers have suggested that up to 25% of admissions of people over the age of 75 could be avoided had alternatives, coupled with expert medical assessment, been available. The recent National Audit of Intermediate Care identified a huge gap in the availability of resources needed to avoid admissions of frail older people and facilitate discharges.
Phase two of the Review will consider resource implications. Bridging the current major gap in intermediate care provision will need to be a priority.
It is likely that GPs will baulk at some of the suggestions in the report. Primary care is under considerable strain and practice income has fallen. Asking them to do more with less may be unwelcome. The suggestion that more consultations are conducted by phone is sensible, but may not produce enough headroom for GPs to create the time to become leaders of integrated teams.
Opening more urgent care centres may reduce pressure on practices, but could equally siphon off resources while creating new demand in the same way as Walk-in Centres. Great caution is needed to avoid creating services that may later be hard to close. A more promising approach may be to commission pharmacies to manage a much greater array of minor illnesses and provide health care advice as a way to relieve pressure on GPs and release their time.
Newspapers have latched on to the report’s discussion of two types of A&E department. The logic that A&Es should network and that a smaller number should provide highly specialist care, 24/7 is compelling. The NHS has not served the population well by colluding in the illusion that all A&Es provide the same service.
It is certainly time for honesty about what can and cannot be provided by all A&Es and why it is safer to arrive at an A&E that can treat a time-dependent condition such as a major vascular emergency, rather than one that cannot.
Russell Emeny is Director of the NHS Emergency Care Intensive Support Team, which is part of NHS Interim Management and Support and is hosted by NHS Improving Quality. Russell trained and worked in London as a nurse before taking further training as a hospital manager. His views in this blog are personal.