Emergency departments should provide range of out-of-hours services, conference hears

BMJ 2015; 351 doi: (Published 23 September 2015) Cite this as: BMJ 2015;351:h5080
  1. Nigel Hawkes
  1. 1London

Emergency departments should make the most of their strong brand and become the home for out-of-hours primary care and community pharmacy, nursing, and mental health teams, a King’s Fund conference in London on 22 September was told.

Clifford Mann, president of the Royal College of Emergency Medicine, said that emergency departments, universally recognised by the public, should become a hub for a range of services. Then patients attending emergency departments could have immediate access to whatever service was appropriate to their needs.

“People know all about the alternatives but still choose to use A&E [emergency departments],” he said. “The more we say don’t use it, the more it reinforces brand recognition.”

There was now a large mismatch between what emergency departments were set up to do and are commissioned to deliver and the volume and case mix of patients who turn up at the door, he said. They have “become the default facility for any and every out-of-hours care need, with the emergency medicine workforce treating patients who could best be seen by another service. Consequently we believe that other services should be co-located with A&E.”

Some co-location already goes on, he said, with primary care available in 60% of emergency departments. But it was now time to think more ambitiously. He claimed widespread support for the idea, including from Monitor and the Trust Development Authority, NHS England, and the royal colleges of physicians, surgeons, paediatrics, and psychiatrists.

While much has been made of the rising demand for emergency care, it sees far fewer people than does primary care—around 15 million attendances a year compared with more than 300 million for GPs, he said. Rises in emergency care in recent years had been more or less in line with population increases, with the exception of elderly people, for whom attendances have risen more quickly. “But you must remember that a 1% increase in A&E attendances is equivalent to two new A&E departments,” he said.

Co-location would ease the pressure by providing more staff, with the right qualifications, and could help slow the loss of trained emergency medicine doctors who are increasingly emigrating to places such as Australia where the pressures are less. “It’s nonsense to say that we couldn’t afford it,” he said. “The average A&E costs £6.5m [€9m; $10m] a year to run, and currently we’re spending £3m on locum staff in A&E departments in England every week.”

Part of the problem, suggested David Colin-Thomé, who chaired the 2014 Urgent Care Commission, was that people were either unaware of out-of-hours GP services or thought them poor. “Out-of-hours GPs have got a bad name, but reports have shown that many provide good services,” he said. Keith Willett, director for acute episodes of care for NHS England, said surveys had shown that a quarter of patients were unaware that out-of-hours GP services even existed.

Would co-location be a threat to these services? Simon Abrams, a Liverpool GP and chairman of Urgent Health UK, a federation of social enterprise out-of-hours providers, thought not. “The majority of our members do support co-location” he said. “They agree that it’s important and valuable.”

Among those for whom a new role might be found in emergency departments were pharmacists, said Anthony Sinclair, chief pharmacist at Birmingham Children’s Hospital. A programme in the West Midlands had shown that with a modest amount of training pharmacists could deal with about half the patients attending emergency departments—a similar level to that dealt with by advanced nurse practitioners. “Where nurses were 20 years ago, pharmacists are today,” he said.


Cite this as: BMJ 2015;351:h5080

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