Date Published: 26 September 2008

Healthcare watchdog calls for new drive to improve the system for delivering urgent and emergency care

The Healthcare Commission has called for renewed efforts to improve the system for delivering urgent and emergency care in England. This follows its publication of a major review of all urgent and emergency services, which for the first time assesses how the whole system works together. The review includes ambulance services, A&E, out-of-hours GP services, NHS Direct, urgent care provided by GPs, and urgent care centres including walk-in centres and minor injuries units.

The Healthcare Commission has awarded a rating for these services within 152 localities, set by the boundaries of the primary care trusts (PCTs), the bodies responsible for commissioning local NHS services. The categories are:

  • 'Best' Perforance - 50 areas (33%)
  • 'Better' Performance - 41 areas (27%)
  • 'Fair' Performance - 33 areas (22%)
  • 'Least Well' Performance - 28 areas (18%)

Urgent and emergency care services have received significant local and national attention in recent years. The Government has set a range of targets and introduced new services such as NHS Direct and NHS walk-in centres. As a result, significant improvements have been achieved, the Commission says.

For example, the review found that the number of people dealt with within four hours in A&E has increased from 91.2% in 2003/04 to 97.9% in 2007/08. The number of category A (immediately life threatening) ambulance responses arriving within eight minutes has increased from 74.6% in 2002/03 to 77.1% in 2007. These improvements have been made at the same time as there has been an increase in the numbers of people using emergency services. In 2007/08, there were 19.1 million visits to A&E and urgent care centres, compared to 16.5 million visits in 2003/04.

The review also shows that it is important for PCTs and healthcare providers to work more closely together to address gaps in the system. It says that PCTs and the Government must now drive improvements through the whole system to ensure people get the right care as quickly as possible.

The Commission assessed three themes in each PCT area: how services are accessed and delivered; how they work together to provide effective and efficient care to patients; and how they are managed.

People in the best performing areas are more likely to get the care they need promptly and have their needs met effectively. Those in the worse performing areas tend to have weaker GP out-of-hours services, wait longer for care and services are less likely to meet the needs of people with disabilities or long term conditions.

Anna Walker, the Commission’s Chief Executive, said:

Urgent and emergency services are to be congratulated for the work they have done to improve access to services. There have been real improvements in the number of people getting urgent care quickly.

But more could be done to get these services working together so that the right care is provided at the right time and in the right way.

People often don’t know which services to use, and too often have to repeat their story time and again because services don’t always share information effectively. Navigating between services can be difficult and confusing for patients and this can have a real impact, especially on people with more complex needs, such as older people and people with disabilities. Integrating services across a local area will help address these challenges.

We are calling on the Government and healthcare organisations to renew their efforts to get the whole system working together so people can get the right care when they need it.”

Key national findings on each of the three themes are listed below.

On access and delivery of care, the report says that access to individual urgent and emergency services is generally good, with most people able to get an ambulance in an emergency and get A&E care within the four hour maximum. But services still fall short in some areas, often where there have not been national targets. The review found:

  • 97.9% of patients who visit an A&E department or urgent care centre were dealt with within the target four hours, however this varied from 100% in the best performing units to 90% in others.
  • 77% of ambulance responses to Category A (immediately life threatening) calls arrive within the eight minute target. However performance varies between different areas from 61% to 94%.
  • For urgent but not life threatening calls (category B), in two thirds (64%) of PCT areas fewer than 95% of these calls were reached within the 19 minute target. Although category B patients may not be in immediate danger of dying, they may still be in need of urgent medical attention or be in severe pain.
  • When the Commission checked on the quality of care for a particular group - children with a fractured limb who present to A&E –the results varied widely. In the best units 100% of children in the audit received pain relief within an hour but in the worst performing units only 20% received pain relief within the target time.
  • The provision of services for disabled people in A&E departments and urgent care centres was variable. For example, only 54% of units had a hearing loop in place for hearing aid users, and of these a third did not test it regularly. Forty-one percent (41%) of units produced information for patients in “easy read” formats suitable for people with a learning disability. Only thirty-eight percent of units had undertaken an audit of facilities for disabled people that had involved disabled people.
  • In 65% of areas, out-of-hours GP services met the requirement that they start telephone assessments within 20 minutes of a patient’s initial contact if a patient’s needs were urgent, and within 60 minutes otherwise. In some areas, less than 80% of assessments are started within these timescales.
  • NHS Direct exceeded the target for starting telephone-based assessments within 20 minutes for urgent calls (priority 1) and 60 minutes for other urgent calls (priority 2) in 95% of cases. It achieved this for 98% of priority one, and 99% of priority 2 calls.

On working together to deliver effective care: the report says that the transition between services can be difficult and people are often confused about which services to use. It found that:

  • There is great variation in how often ambulances get back on the road after delivering a patient to A&E. The proportion of ambulance journeys where the ambulances was back on the road within 15 minutes varied from 95% at some A&Es to less than 10% at others. Ambulances that are not able to get back on the road quickly are not able to go and assist more ill patients. The Healthcare Commission will be working with the Department of Health, ambulance trusts and hospital trusts to determine the reasons for these variations.
  • In some areas, more needs to be done to ensure that patients do not attend A&E when other appropriate services, such as out-of-hours GPs, could be used. For example, in some areas over fifty percent of visits to A&E could be avoided if other services were used.
  • Only 44% of out of hours GP services had arrangements to divert calls made to GP surgeries during the out of hours period. This means that patients who need urgent care outside of normal working hours may have difficulty getting through to the correct service, which can be distressing if they are anxious about an urgent situation.
  • Important information on patient care is often not shared between different parts of the urgent and emergency care system. For example, only 20% of A&E departments are able to receive electronic data from ambulance services and only 30% of urgent care centres reported that all GPs in their area were able to receive electronic information about their patients.
  • In 75% of areas, out-of-hours GP services had access to care plans for vulnerable people and those with long-term health conditions. These care plans are normally held by GPs and describe what action should be taken if there is an emergency and details of any medication prescribed. Systems to share care plans with ambulance services and A&Es are only in place in around 12% of areas.

On management, the Commission assessed how well services are managed by PCTs as commissioners of urgent and emergency services. Overall, 30% of PCTs performed well across the managerial aspects of the review (this includes establishing networks, planning services, monitoring performance and engaging with patients and the public), 40% scored poorly and the remainder were in-between. In particular:

  • Almost all (98%) of PCTs are part of a network of healthcare providers responsible for planning and delivering urgent and emergency care. However, only a third (34%) of these networks appeared active and well developed. For the system of urgent and emergency care to further improve, these networks must work together to plan the effective delivery of services.
  • 96% of PCTs had an urgent and emergency care strategy in place or under development and had discussed it with the main local urgent and emergency care services. However, not all had discussed these plans with other services involved in meeting people’s urgent care needs (for example, 30% had not discussed it with NHS Direct and 42% had not discussed it with local pharmacists).
  • Many PCTs (74%) could be making better use of data on the performance of individual services in order to determine where further resources are required. For example, only 30% of PCTs monitored levels of patient safety incidents in A&E departments. And while 25% of PCTs monitored monthly use of urgent and emergency services by patients per GP practice, 44% do not regularly monitor this aspect of care.
  • 73% of areas had conducted public awareness campaigns to improve understanding of when to use particular services, but only 40% of these campaigns had been evaluated.

The Commission makes seven recommendations to PCTs and Government to use the information in the review to improve the way services work together.

In particular, the Commission called on PCTs to:

  • Work with patients and the public to plan and deliver services, especially for people with more complex needs.
  • Have a clear plan for the delivery of integrated urgent and emergency care services across their area.
  • Ensure that they make effective use of information and collect whole-system data to inform the development of services.

The Commission called on service providers to:

  • Fully engage with PCTs in addressing the results of this review.
  • Assist in the design and collection of whole-system data.

The Commission called on the UK Government to:

  • Ensure the organisational stability that PCTs and providers need to effectively plan future services.
  • Support the integration of services and simplify the way services are accessed, for example, through piloting of a single telephone number for urgent care services. A single telephone number has the potential to ensure fewer people attend the wrong services.
  • The Government also needs to use consistent terminology to describe different types of services and make clear what each service provides. This should help patients know which particular service they should attend.
  • Review urgent care targets, which at the moment only measure individual parts of the system, and support the development of a whole-system approach, which measures performance from the time a patient seeks care to the time they receive it.

The Healthcare Commission will be working with those organisations in the ‘least well performing’ areas to develop plans to improve their performance.

Source(s): The Healthcare Commission (England, UK),
formerly at http://www.healthcarecommission.org.uk - website no-longer live.

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