Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Do public campaigns relieve pressure on emergency departments?

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6542 (Published 20 November 2019) Cite this as: BMJ 2019;367:l6542
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com
    Follow David on Twitter: @mancunianmedic

For several years the NHS has issued public campaigns urging people to use alternatives to hospital emergency departments. We have a growing problem with overcrowding, in departments that were often built for smaller numbers of patients attending and are struggling with staffing gaps. Performance against national four hour waiting time targets has worsened to the extent that new targets are now being piloted.1 Overall attendance at major emergency departments has grown yearly, reaching 6.2 million patients in 2019.2 In October one in six patients in emergency departments waited more than four hours for assessment or admission, the highest level since the target was introduced in 2004.3 Winter won’t improve things.

Research has shown that many people attending emergency departments could have been assessed and treated appropriately in other settings.4 An excellent example is a 2017 report from the University of Sheffield on departments in the Yorkshire and Humber region,5 which found that the overall rate of “non-urgent attendances” was 23% (of 908 191) in adults and 31% (of 380 664) in children. Patient surveys found that 50% of patients had been advised to attend by a health professional.5 It would be unfair to blame people for making this choice if an NHS worker suggested it.

The same study surveyed 486 adult and child patients who had self presented at eight emergency departments. Many participants were perfectly aware of alternative services. But the patients’ perception was that such services were overstretched or hard to access. In a structured survey of 25 departments, emergency staff shared similar perceptions. Perhaps what seems to be inappropriate or avoidable use is actually an active and semi-informed choice.

This chimes with an earlier survey of 924 emergency department patients by the Royal College of Emergency Medicine,6 which concluded that the definition of emergency was informed by the users’ own perceived needs at the time of their decision, not by retrospective data describing what then happened.

Staff interviewed in the Sheffield study also thought that the greatest increase in demand came from the “frail elderly” and the “worried well.” But older people with frailty, dementia, or multiple life limiting, long term conditions do account for a high percentage of patients who end up needing admission,7 and they are the most likely to cause and be affected by overcrowding—rather than less sick, ambulatory patients who are targeted in public campaigns to stay away and use alternative services.

What of those older people who self present or whose families or care workers trigger attendance? The University of Birmingham’s “Who knows best?” study found that patients and carers in many cases perceived emergency care as the only way of receiving necessary medical attention in crisis.8

Regarding the “worried well,” emergency department staff interviewed in the Yorkshire study thought that younger generations in particular had become more demanding in their expectations of responsiveness and timeliness in the health service.5

Do the campaigns work? Not only has the use of all types of urgent care grown but so has NHS 111.9 And there are no national datasets on the use of consulting pharmacists as an alternative. The population has grown and aged over the past decade, but this hasn’t matched the rise in attendance at emergency departments of all types. NHS Digital’s analysis10 found a strong correlation between social deprivation and attendance rates. We’ve also seen increasing pressure on the GP workforce11 and cuts to social care and community services.12 It’s hard to disentangle cause and effect, with so many confounding variables.

It seems sensible to ensure that the public is informed about alternatives to emergency departments and that the NHS itself doesn’t steer people there inappropriately. But perhaps we need a better understanding—from research on social marketing, public engagement, and behaviour change—about the types of messages that are most likely to work.

Maybe we also need to accept that, in an imperfect system, people will continue to choose to attend hospitals, which are open and staffed 24 hours a day and which they trust.

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