NHS medical director proposes two tier emergency serviceBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6828 (Published 13 November 2013) Cite this as: BMJ 2013;347:f6828
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The Keogh Report – Paradigm Shift or more of the same?
It is with interest we note the summary findings of the recent review by the Health Select Committee1, a report duly informed by the findings of NHS England2 and King’s Fund3. Moreover, your article last week further highlights that while it is acknowledged that the patient journey through the Unscheduled Care Pathway lacks significant (& meaningful) signposting, the concept of ‘whole system’ continues to be widely reported as fragmented. Kick-start initiatives such as revision of the ‘98% target’ and ‘quality indicators’, from our empirical observation, would appear to demonstrate process effect but not process efficiency. Similarly implementation of patient flow initiatives such as consultant ‘based’ decision-making and ‘discharge planning’ continue to prove difficult to reinforce.
Populist alternatives have, to date, shown mixed results; NHS 111 continues to make adverse national headlines whilst integrated Urgent Care (Urgent and Emergency Care Centres) would appear to thrive. Given the significant socio-political context set by the Nicholson effect (cf. efficiency savings), pending ‘Winter pressures’ in addition to the reported year-on-year growth in attendances4 to all-type A&E units across the UK, we suggest that the emphasis ought to be placed on interfacing the Unscheduled Care cohort in the community. From the governance and patient flow perspective, the expectation is that the majority of unscheduled attendances (up to 13 million nationally3) could be dealt with satisfactorily in the community4.
A snapshot qualitative ambulatory patient survey of 60 patients was recently carried out in our department. Each case was retrospectively peer reviewed to ascertain the ‘necessity of ‘/ ‘insight into’ their presentation to A&E. 73% were deemed suitable for GP review (40% of the cohort equally felt their needs were suitable for primary care review). Over two-thirds stated ‘inability to access GP’ and ‘quicker and easier to visit A&E’ [44% & 20% respectively] as reasons for their attendance to A&E. We noted with interest that 15% of those surveyed were not registered with a GP. Other free text comments included: ‘GP doesn’t take you seriously,’ ‘GP seems too rushed’ or ‘GP missed my cancer diagnosis’.
Viable ‘community-based’ alternatives, such as revisiting the out-of-hours primary care access, managed care programmes (for chronic conditions) and expanding the ambulatory care remit, need to be revisited. Perhaps CCG outcome-based commissioning and Social Care budgetary refinement need to be considered as the primary incentives to influence care delivery. We wait with interest to see if any benefit actually results from the paradigm shift proposed in the Keogh review5 as the possibility of supply-led demand resulting in hospitals continuing to facilitate the increased growth in A&E attendances3 (with little chance of whole-system, patient-centred cost efficiency) would appear likely. Is this more of the same?
1 – Parliament.uk. 2013-2014: Urgent & Emergency Services (Health Select Committee). Published 10 October 2013. http://www.publications.parliament.uk/pa/ld201314/ldhansrd/text/131010-w.... Accessed 17-10-13
2 – NHS England. Improving A&E Performance (Gateway 00062). Published May 2013. http://www.england.nhs.uk/wp-content/uploads/2013/05/ae-imp-plan.pdf. Accessed 20-10-13
3 – The King’s Fund. Are accident & emergency attendances increasing? Published 29 April 2013. http://www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-atte....
4 – CHKS. Guide to Hospital Data. Published September 2013. http://www.chks.co.uk/userfiles/files/CHKS_Guide_to_Hospital_Data_SINGLE.... Accessed 21-10-13
5 – NHS England News. NHS England - Sir Bruce Keogh proposes new blueprint for urgent and emergency care across England. Published 13 November 2013. http://www.england.nhs.uk/2013/11/13/keogh-urgent-emergency/. Accessed 23-11-2013
Competing interests: No competing interests
The ambulance service, or soon to be “mobile urgent treatment service”, is stretched enough without being asked to relieve pressures on hospital Emergency Departments.
The London Ambulance Service has seen demand rise by 6.4% from 2011 to 2013 (1). In Wales, demand has also increased significantly with a 29.6% increase in "life threatening" calls between 2006 and 2013. This increase in work is taking its toll, the Welsh Ambulance Service has never met its own target of "reaching 52% of patients categorised as suffering from cardiac arrest, with a defibrillator within four minutes" (2).
If the ambulance service is struggling with its core purpose of responding to life threatening medical emergencies, it is hard to see how becoming a 'mobile treatment service' is in the best interests of patients.
The ambulance service needs investment meaning more paramedics and more ambulances. It is, after all, an emergency service.
1. London Ambulance Service (2013). Annual Review [Online]. Available from: http://www.londonambulance.nhs.uk/about_us/idoc.ashx?docid=cf0aabd2-869f... [Accessed 18th November 2013]
2. S McClelland (2013). A Strategic Review of Welsh Ambulance Services [Online] Available from: http://www.ambulance.wales.nhs.uk/assets/documents/f06e69f9-3921-4946-a5... [Accessed 18th November 2013]
Competing interests: No competing interests
The public needs to be reeducated......says Robbie Hughes. Please remember that education is not that easy. With no disrespect to the patients, of whom I am one, the plethora of services is so confusing that a patient, possibly in a state of panic, will not know what number he should dial. Secondly, the services are shut down or relocated or reconfigurated (a new term to me ), the confusion is worse confounded. Thirdly, the early stages of a serious illness may present as a bad attack of flu. Fourthly, the reconfiguration of roads will probably cause such agitation to an expectant father driving his wife-in-labour to the maternity hospital to overshoot the brand new junction and get snarled up in tbe rush hour traffic of a city centre.
Return to the picture of, say, forty years ago. Tiny old hospitals scattered in London within a mile or two of teaching hospitals. If the GP surgery had closed and the GP not available, the mother of half a dozen children ranging in age from six months to twelve years would turn up at the "casualty", talk to the sister or staff nurse, see the casualty officer, be soothed, the nipper given the medicine (no, Not a prescription to be taken to midnight Boots). The family would go home. Happy.
A fractured fore-arm comes in. You reduced it and plastered it.
A fracture neck of femur comes in. You admitted it and next day it was nailed or replaced.
Were the patients dissatisfied? Not as far as I know. Of course the RHBs wanted to shut the small, "uneconomic" units down. They succeeded.
For the greater glory of "management".
Consider patients in the Cambridgeshire Norfolk Fens. An area traditionally served by conscientious GPs. There was once a village called Manea. In the middle of nowhere, prone to flooded roads. Close to a Waterfowl Trust. A few miles from a little hospital at Doddington. A few miles further from North Cambs Hospital at Wisbech. Much further from King's Lynn, Addenbrookes, Peterborough. Educating the poor substinence farmers about the first class (World Class in today's hyperblole) service in the big cities did not cut much ice. Quite understandably.
It may be that times have changed and the GPs of the Fens may even send in a rejoinder suggesting that my memories are ......erroneous?
Competing interests: I have some local knowledge of the environment.
The strategy of relieving pressure on A&E by coordinating services better is clearly the right one and has been highly effective in France where entire mini theatres are often set up in patients' homes to stabilise them before transport to specialist facilities, but the problem is not just one of treatment options. A&E services have been overloaded because patients treat it as the place to go when they're ill, rather than choosing one of the plethora of other choices that are already at their disposal including 111, pharmacies, GP, walk in clinics, their insurer and even their gym. For better or worse, the public need to be completely reeducated about how to 'consume' healthcare.
As healthcare becomes more unaffordable for an ageing population with increasing ills, only disruptive action with proper education will be enough. A fully coordinated community healthcare strategy with well maintained outpatient services close to the patients' homes will make the difference, but the journey to this destination will be difficult as it will involve the closing of hospitals and the reconfiguration of many services. This is a very positive first step, but it must not be undermined by poor education and half hearted delivery.
Competing interests: No competing interests