Last reviewed 28 June 2013
Across the UK, the demand for urgent and emergency care has been increasing over the past year. For example, hospitals in the South of England have experienced an 8–9% growth in emergency admissions between June 2008 and June 2012, as highlighted in a recent report by the King’s Fund. Hospitals across England have reported that they have been facing great challenges to manage the increase in emergency admissions, which are often in excess of the rate that can be explained by population changes. Thoreya Swage reports.
The result that ensues from this increase is that patients have to wait longer in accident and emergency (A) departments and extra beds have to be provided to meet the extra demand. Although the relatively severe winter was a factor, a number of other issues have had an impact on these services, such as the urgent care telephone service and discharging patients to social care.
Review of access to routine services by NHS England
This issue of access to routine services has been recognised as a priority area for examination this year by NHS England in its Planning Guidance for Clinical Commissioning Groups. Sir Bruce Keogh, the NHS Medical Director for England, has been charged with the responsibility of leading this review.
A forum, established by Sir Bruce Keogh and comprising national and local commissioners, and providers and regulators of health and social care, will identify how access to routine services could be improved.
The first stage of the review will focus on improving emergency and urgent care, and diagnostics. A key aspect of the exercise will be to assess the non-availability of clinical services throughout the seven-day week. NHS England is clear that emergency care should not be used when patients would benefit from care in other settings. A report on the findings of the forum will be published in the autumn of 2013.
Options for urgent and emergency care
There are many reasons as to why patients do not use urgent and emergency care appropriately. In the first instance, there are a number of options a patient could use when seeking medical advice or treatment. These include local pharmacies, general practice, general practitioners (GP) out of hours, telephone advice lines such as NHS 111, walk-in centres, urgent care centres, or A
With such a range of options, patients will take the route that is easiest to follow and to access. This will mostly be services such as walk-in centres, urgent care centres or A, as these are open and permit patients to enter and wait to be seen.
This is further compounded by the lack of information or understanding about how to access local healthcare services, particularly if patients do not come from the UK and are used to other healthcare systems where such services tend to be available in the local hospital.
One solution that has been implemented is to place a GP in A to see the patients that could have been dealt with in primary care, and to prevent a possible hospital admission. However, this does raise the question of how easy was it for the patient to access his or her local GP services in the first place?
Getting an appointment quickly to see a GP at the local surgery can vary from practice to practice. Various solutions have been developed in primary care, including diverting patients to the practice nurse or nurse practitioner, having extended hours, and offering online appointments.
What can primary care do?
The obvious response to increasing demand for care is to consider increasing the capacity of the service, ie to add more GP sessions or expand minor injury or urgent care centres. However, in the current climate of the NHS achieving efficiencies and savings, together with the decreasing budget for social care services, this is no longer a viable option.
Another way of addressing the problem is to look at managing demand rather than increasing the capacity of the service; or in primary care, redesigning the method by which patients can access their GP and improving the efficiency of the system.
A typical surgery
The traditional way in which patients access their GP services is to wait outside the surgery before it opens first thing in the morning. The queue grows and patients are seen in order of arrival, if there are appointments available for the session. In addition, there is another queue of patients who hope to receive an appointment for the same day waiting in a telephone queue to get through to the surgery, again first thing in the morning.
For the patients telephoning the surgery, there is the added factor of not being able to get through, particularly if the telephone lines become fully engaged. These patients then have the option of either going to the surgery in person and waiting their turn or contacting the surgery the next day, or going elsewhere if the problem by that time has become acute.
Examining this situation from the surgery perspective, the traditional model works in the following manner.
Telephone calls into the surgery are answered by the receptionist, who allocates the patients to the appointments that are available. These appointments generally get filled up quickly so callers are then advised to “call back tomorrow”.
The lack of immediate appointments on the day these patients contact the surgery means that they have to book in advance, often up to two to three weeks ahead. This then leads to some patients not attending the appointment, meaning a spare appointment slot that could have been used by another patient.
While some patients may not re-book as their problem was resolved during the waiting time for a GP appointment, others will still require an appointment and will contact the surgery to arrange this.
During this time, patients may find that their problem becomes acute and/or they become desperate to see the GP. In these situations, patient pressure will turn a routine request into an “urgent” one, requiring the patient to be seen by any GP or locum, and not necessarily by his or her own doctor. This can be unsatisfactory for the patient as he or she may not receive the outcome he or she requires. This fragmented continuity then results in a repeat booking for another appointment in an attempt to see their own GP.
All of these actions add to the pressure for appointments, with the end result being that patients have to wait a number of days to see their own GP.
It also means that there is a significant inefficiency in the system as patients have to make more than one telephone call and more than one appointment is required to solve a problem.
Appointments in primary care
A face-to-face appointment with a GP is typically 10 minutes in length. This is recognised in the General Medical Services contract as an indicator of quality. However, it is recognised by the Royal College of General Practitioners in its document Leading the Way: High Quality Care for all through General Practice that longer appointment times may be necessary due to chronic and complex conditions, a growing older population, health promotion targets, and the need to bring care closer to home.
While appointment times may be fixed at 10-minute intervals, the actual length of time that patients need to consult their GP may vary from a few minutes to much longer than 10 minutes. It is this inflexibility that gives rise to bottlenecks in the system.
Telephone consultations have been used in different areas of medicine, eg follow-up of breast cancer patients who have a low to moderate risk of recurrence, or of respiratory out-patients. They are increasingly being used in primary care and have shown to be efficient in use of GP time. For example, work undertaken by Patient Access has shown that, by the GP’s own assessment of consultations, between 50% and 70% of those patients could have been dealt with by a telephone consultation. In addition, these telephone consultations typically take between 3 and 4 minutes to conduct, with a satisfactory conclusion, instead of the usual 10 minutes.
The main concern of telephone consultations is the potential for unlimited availability of the GP, together with the risk of increasing demand by patients. There are many ways in which GPs and practices offer telephone consultations, and the key to the success of the method is to recognise that access and continuity of care is a major concern to patients.
Managing patient demand using telephone access in general practice
Previous methods of implementing telephone consultations in general practice have included open lines for patients to use at any time, often interrupting face-to-face consultations, at the end of a very busy surgery, or during specific times of the day. This work is in addition to the usual face-to-face consultations that are scheduled during morning and afternoon surgeries. This can result in extra stress on the GPs and reception staff rather than the desired reduction.
So how can this situation be overcome?
The main change is to reconnect the GP directly with the patient. This is the system redesign that has been developed by different practices over time and which has been refined by Patient Access. The process is as follows.
The patient calls the practice and requests to see their own GP. This request is placed on a list for that specific GP.
The GP works through the list, ringing back the patient to discuss the request.
In that telephone conversation, the problem is addressed, resulting in one of the following outcomes: advice; referral to the practice nurse or nurse practitioner who could deal with the problem; or a face-to-face appointment with the GP.
If a face-to-face appointment is required, this is offered by the GP to the patient for that day. The receptionist is not needed for this action.
The other key change is to ensure that the appointment schedule for each day is clear so that each doctor is able to book patients into those slots on a daily basis.
The immediate effects of this new way of working are as follows.
The waiting time for an appointment to see a GP falls from a few days in advance to the same day.
Although the number of calls to patients rises, the GP’s time is saved as only one in three of these patients will need to be seen face to face.
The pattern of telephone calls that are made to the surgery change from a peak in the first hour of the morning to being more spread out during the day.
The response time by GPs to returning their patients’ calls decreases to as low as 30 minutes.
Reception staff do not have to make clinical decisions as to the urgency of a patient’s condition, as the GP will contact the patient within that clinical session time.
GPs are able to manage their appointments with their own patients and are well prepared to deal with each problem face to face as they will already have had a telephone conversation with that patient.
A significant improvement in patient satisfaction with GP access and continuity.
This system allows for better planning and timing of specific clinics where booking is required, eg postnatal clinics, without the doctor running over time on their normal surgery.
In the longer term, patient continuity is improved and has been shown to be up to 80%, with the use of A services being 20% lower. By addressing access to health services at the primary care level this can begin to tackle the issue of increased demand for urgent and emergency care.
Everyone Counts: Planning for Patients 2013/14 (2013), NHS Commissioning Board
Urgent and Emergency Care, a Review for NHS South of England (2013), The King’s Fund
Leading the Way: High Quality Care for all through General Practice (2010), Royal College of General Practitioners
For more information see the Patient Access website.