Policy responses and statements

Name of organisation:

Department of Health

Name of policy document:

Direction of travel for urgent care - A discussion document

Deadline for response:

5 January 2007

Background: People's expectations of health and social care are changing. People want to be sure that when they need care, it will be available quickly and close to or in their own homes. They want to feel that they can get the advice and care that will keep them safe. At the same time, changes in medical technologies, in IT and in the NHS and social care workforce are making it possible to seek ways of providing care differently.

Locally it makes sense to review the range of services available in each health and social care community and grasp the opportunities offered through changing technologies to provide better, faster, more accessible care for people.

The Department of Health wants to develop services that are more responsive to people, more efficient in the way resources are deployed and make the most of opportunities from medical and technological advances to deliver better care and support more conveniently for people.

This means a consistent way of assessing what people need when they contact services with an urgent care need, whether by telephone or in face-to-face settings. It may mean changing the way services are configured locally, re-deploying existing resources for optimal care.

Understanding how people access urgent and emergency care will help commissioners and providers shape services in a way that best responds to changing local needs and the changing healthcare environment.

The Department has already carried out some discussions with stakeholders. It has used that discussion to produce a Direction of Travel for Urgent Care. This document asked for views on how the Department should take its thinking forward

COMMENTS ON
DEPARTMENT OF HEALTH
DIRECTION OF TRAVEL FOR URGENT CARE
- A DISCUSSION DOCUMENT

The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on its discussion document on the Direction of travel for urgent care.

General Comments

The College applauds the aims of the document but considers much of the content to be disappointing and dominated by (largely) unsupported claims of improvements as a result of recent changes. 

It is the College’s belief that the best way to provide health care for patients with urgent (but non-emergency) needs is in the community, whenever possible, with strong links to the patient’s general practice.  There has, however, been an increasing trend, very much accelerated by the introduction of the new GMS contract and subsequent policy changes for patients, to seek Out Of Hours (OOH) and urgent care from Hospital based Emergency Departments, leading to pressure on medical acute receiving units.  This was entirely predictable.  There have been a number of initiatives in recent years which have purported to improve urgent care, but they have tended to be reactive responses to increasing need, and have often been ill thought out and planned.  They have all been of limited impact and a number have undoubtedly resulted in further increasing demand.

The level of evidence presented in this document is disappointing.  The 4 case studies are undoubtedly examples of poor practice, but no balance is given in presenting examples of existing good care.

The College fears that this initiative may result in yet further ‘new’ approaches which will be expensive, unpiloted and unproven.  It would, perhaps, be more appropriate to build on the strengths within the current system, namely, to sustain:

a)      A community based service, Primary Care and OOH with seamless transition between the two, and perhaps with greater involvement of members of the extended team – Emergency Care Practitioners (ECPs), Paramedics and Emergency Nurse Practitioners (ENPs) 

b)      ED departments for the next level - emergent care.

Introduction and Section 1

The College agrees that there needs to be a consistent way of assessing what people need when they contact services with an urgent care need, but we are extremely concerned that this should rely on a software/protocol driven call handling service.   The current system has led to enormous frustration and the public have undoubtedly voted with their feet because of long delays and perceived inappropriate responses.  The result of this has placed more pressure on emergency services when urgent or routine care was required. 

The College notes there are fundamental flaws in a referral system that places undue reliance on public ability to diagnose accurately the acuity of health problems.  However, our Fellows are aware of instances of the public getting it right but then being inappropriately advised on where to attend for care.  The emergency department is frequently used as a default option or ‘just in case’ because it has open access.  This may be because the initial contact fails to assess the condition appropriately, or because a more appropriate core option has less easy access eg the 4 hour time target in Emergency Departments can make this a preferable option for patients.

As a very general principle, it needs to be reiterated that the system does not need further major additions or more complication.  If the existing ‘bits’ could work as they should, it would be a major step forward.

The identified ‘six principles’ are self evident, but they are occasionally contradictory and this can create difficulties.  The College has no other comments on the first 6 questions.

Section 2

This section contains much about the importance of ‘getting it right’, although there is little detail on how this might be achieved. 

Questions 7 -11.  The College has concerns about the definition of urgent care.  We believe that urgent care should be delivered by the primary health care team or its OOH service.  Large numbers of urgent problems are arising because of acute episodes of chronic illness.  The ‘extended’ primary care team should be supported to deal with this, utilising emergency care practitioners or equivalent rather than establishing a completely new service.

Questions 12, 13.  The College has significant problems with the proposals and concerns about how the complex model will achieve consistent assessment, given the obvious difference in advice that can be given following face to face or telephone consultation.  We already have effective evidence-based triage in Emergency Departments whereas NHS Direct, NHS24 and Ambulance priority base dispatch have been very expensive with limited impact.  At worst, they over triage and ‘risk minimise’ leading to increased pressure on hospital based emergency services, particularly out of hours.  Telephone protocol assessment cannot constitute a ‘consistent and rigorous way of assessing the level of urgency’.

Section 3

The College agrees that a great deal of confusion has been created by the plethora of different terms in urgent and emergency care.  Without exception, the examples listed have come about under recent policies and this should be avoided in the future.  Patients and staff are unsure of the full range of locally available services because of recent changes and the over complication of what was and should remain a relatively straightforward area.

Questions14 - 19.  There has to be public involvement but also well established communication mechanisms to explain and reconcile differences between public preferences and clinical and service needs.

Questions 20 - 21.  As stated previously, the current arrangements are over-complex.  There should be 2 choices:

• The community health care system, based on the extended primary health care team
• The Emergency Department and 999 system

Questions 26 - 31.  No specific comments.

Questions 32 - 37.  No specific comments.

Questions 38 - 43.  No specific comments.

Questions 44 - 49.  A number of these areas have been explored and, in some instances, put in place.  There is a danger in imposing the same solution in all locations, regardless of differences.  Health/Social Care access requires improvement, and this will require a cultural shift in addition to organisational change.

Questions 50 - 54.  Change is required, but it may not need to be radical.  Development of existing systems, not new ones.  Simplification is required.   

Protocol driven assessment is not the solution to assessing urgency and should be reviewed immediately including a cost benefit analysis.  The NHS must make best use of its resources to provide reliable and high quality chronic, urgent and emergency care and remove the current difficulties resulting from shifting workload because of inconsistent assessment and   access problems.  Budgets currently committed to supporting assessment could be reinvested more appropriately in local clinical services to support the provision of urgent health care services in the community, allowing the emergency services to focus on the real emergencies.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324    ext 608
Fax: 0131 220 3939

[5 January 2007]