Last reviewed 10 September 2018
A Care Quality Commission (CQC) report on The State of Care in Urgent Primary Care Services, based on data gleaned from its inspections of urgent care centres, GP out-of-hours and NHS 111 services has been published. Such services deal with minor injuries and illness, and may also be defined as a type 3 A&E, known as urgent treatment centres, minor injuries units and walk-in centres. Most are deemed as “stand-alone” services, ie outside of NHS hospital trusts. Deborah Bellamy looks at the report’s findings.
Urgent primary care services fulfil a vital function providing the first step in ensuring individuals are seen by the most appropriately skilled healthcare professional to deliver the right care in the most suitable environment.
Regulation of urgent care began in 2012 when the CQC began to register providers of NHS GP out-of-hours services. By their nature, such services are complex, rendering it difficult for the CQC to formulate a clear image of quality. Therefore, a flexible regulatory approach, mindful of different service delivery models, maintaining emphasis on both quality and safety of care for patients, has been required by the CQC.
The CQC is clear that urgent care services relieve pressure from other areas of the NHS at times of peak demand and are a fundamental part of the healthcare system. Such service provision has improved, with quality overall being good; however, 1 in 10 services needs some improvement, specifically with initial assessment and timeliness of response to urgent needs.
As a result of this report, the CQC has a better understanding of the challenges local health and care organisations encounter while working together to meet individual needs.
What does urgent care cover?
Urgent care services cover numerous areas of the NHS and are not designed to cope with life-threatening or long-term conditions or conditions/injuries that require a visit to A&E. They encounter a wide range of illnesses and injuries that are not life-threatening, such as:
sprains and strains
minor head injuries
minor eye injuries
minor cuts, bruises, burns, strains, insect and animal bites
stitches, wounds and dressing care
serious cuts or wounds and fractures
infections, rashes, hay fever
stomach aches, vomiting and/or diarrhoea
information and advice.
However, it is not uncommon for urgent care to deal with conditions that are potentially life-threatening such as:
The NHS definition of urgent care is that there is a need, or perceived need, for care on the same day. The reason for this may be:
a new medical condition
worsening of existing condition.
What services did the CQC inspect?
Services inspected by CQC’s Primary Medical Services Directorate covered:
NHS 111 services
urgent care/walk-in centres
GP out-of-hours services
the small number of GP practices that also provide a walk-in service for patients not registered with them.
Out-of-hours GP services
Most patients are directed to out-of-hours (OOH) GP services by NHS 111 or emergency departments. Some accept walk-in patients, while others require patients to have called NHS 111 prior to arrival.
Many services were set up in 2008/09 as part of Lord Darzi’s polyclinic scheme. They mostly use a combination of directly employed and sessional clinicians, while some are longstanding GP partnerships awarded a separate contract to provide urgent care and are normally staffed by partners, directly employed GPs and nurses.
OOH provide urgent primary care when GP surgeries are closed by means of face-to-face consultations, home visits and telephone consultations. Such services also utilise skills of nurses, advanced nurse practitioners, pharmacists and paramedics. Some practices provide standard GP services to their registered patient list as well as an urgent care service for patients registered with other practices or who are not registered with a GP.
Increased demand on services
There has been exponential growth in the number of calls to NHS 111 with NHS England reports that NHS 111 now takes 16 million calls each year, up from 7.5 million three years ago.
As with the wider NHS, there has been an overall increase in attendance at urgent care centres, with an increase of 57.1% for attendances at type 3 departments or urgent care centres.
Demand follows seasonal patterns, and established services can look back over years to monitor performance and trends, and implement plans to manage it. All areas of the urgent care system experience the most challenging workload in the winter.
Factors affecting the availability of the GP workforce
Recruitment and retention issues affect many urgent care providers who experience high staff turnover. To tackle the difficulty in recruiting GPs to work in this sector, organisations are adopting multidisciplinary models. This has proved to have been beneficial for patients with safe, effective care provision where it was embedded with appropriate clinical supervision and there was clarity of the competencies of individuals employed.
The CQC states that staffing and workforce planning present ongoing issues compounded by unsocial working hours and high reliance on self-employed clinicians.
Providers need to give careful attention to how they manage staffing issues including:
mapping capacity more effectively
considering knowledge, skills and competencies of multidisciplinary staff, adjusting patient pathways as appropriate and providing adequate clinical supervision.
It was found that recruitment and retention improved where NHS 111 organisations moved to an integrated clinical assessment unit model with call advisors, clinicians and GP support.
The report recommended that providers used technology and more innovative ways of working to map capacity against demand in a local area and provide better communication between staff and other services, for example, by using teleconferencing and other digital communication.
Access to records
The CQC found that many providers experienced problems accessing individuals’ medical records.
Short episodic care delivery is most effective when medical records can be accessed, ideally with individuals’ primary care records from their general practice and information about their mental health and end-of-life care plans during 111 consultations. However, while information from the summary care record should be available, it is often difficult for clinicians to access.
Following the use of urgent care services, information is usually communicated back to the patient’s practice electronically and incorporated into their primary care record. Some innovative local health economies are moving towards a more multi-agency approach using online clinical systems that can record, share and use real-time patient information to provide more efficient integrated care.
If the integrated urgent care sector is to achieve NHS England’s ambition, it must be adequately resourced, funding must be adjusted to reflect the true costs of running these services with realistically priced contracts.
Commissioners should provide support but act where providers are not meeting the specifications of their contracts. It is often found that once a poor CQC report is presented, commissioners were aware of issues but failed to address them through contractual levers.
The CQC is keen to welcome initiatives to help providers to improve quality. Such initiatives include NHS England’s work to embed pharmacy into the urgent care pathway by deploying prescribing pharmacists in integrated services, and the roll-out of the NHS Urgent Medicine Supply Advanced Service (NUMSAS), allowing NHS 111 services to direct patients who need emergency supplies of repeat medicines to participating pharmacies.
The CQC acknowledges that urgent care has the potential to relieve pressure from other areas of the NHS providing advice and treatment in one place. However, adequate resources need to be in place and commissioners should better support providers, taking appropriate action if contract requirements are not being met to enable more integrated service provision.
Changes need to be reflected in the CQC’s approach to inspecting urgent care providers according to the type of provider. Maximum intervals for re-inspecting services will be dependent on the rating and the level of risk determined.
There are plans to increase the core hours of GPs so that, by March 2019, everyone in England will be able to get an evening or weekend appointment, facilitated by the new GP contract agreement. In many areas, this is being provided through extended hours hubs, where GPs combine to offer such a service.
NHS England also plans to roll out new urgent treatment centres to create fast, effective urgent care more locally, offering a more uniform model of urgent treatment centres.