Accident and Emergency: ‘but not as we know it Jim’

By Gail Beer, Director of Operations at 2020health

A recent survey by The National Audit Office found that one person in four is unaware of out-of-hours care offered by GPs and that one person in five in England is unaware of the new NHS 111 urgent phone service. (BBC 11^th July 2014)

The report highlighted a number of reasons why people don’t use the out-of-hours services and the impact this has had on A&E services.  We have heard all this before and it should, by now, be obvious: people access services in the way they find easiest.

One comment really resonated with us, from Dr Cliff Mann, of the College of Emergency Medicine, who said, “Rather than persuade patients to find their way to services, we need to provide a range of services where the lights are on 24/7.”

In our recent publication ‘Going with the Flow’ (2020health, 2014) we made much the same point.

For years, various initiatives have encouraged patients to use centralised out-of-hours services, call NHS Direct and now NHS 111 – yet we have failed to encourage patients to use these facilities. The plethora of ways to contact your GP, an out-of-hours GP, or summon help and advice when you are taken ill in the middle of the night are confusing and can cause anxiety.

Are you a minor injury, in need of urgent care, needing to see your GP, are you a ‘walk- in’?  When you need help or need reassurance, negotiating your way through the complexity of the system is daunting.  With help seemingly not at hand, it is easiest to go to your A&E where you know the door is open.  People are prepared to travel and wait in these busy departments, with the usual dramas that they offer, rather than stay in the comfort of their own homes waiting for the GP.

We have lost confidence to care for ourselves and there has been a real loss of confidence in the OOH service. The public express fear about what happens at night if they need medical care, especially as many still have a problem with getting to see a GP at short notice, so many just go to their A&E.

In our report we highlight that we have lost the current battle to encourage people to stay away from A&E. Let’s embrace the fact that people want to go to a 24 hour campus. Let’s structure the ‘Out-of-Hours’ services to make sure that we offer reassurance and treatment to those who can go home or need to be followed up by their GP  and provide the care required for those  needing admission and urgent intervention.

We are where we are and the public have, to date, rejected the initiatives.  Maybe they just don’t get them and when they do they don’t like what is on offer. As with any discerning consumer you vote with your feet.

So what to do?

We could start by stopping calling them ‘out-of hours’ services; in all my years as a clinician, ill health never timed itself to be ‘in hours’. The very term implies risk and causes anxiety. It is not out-of-hours for the sick, it is out-of-hours for the professional.

Stop changing the numbers and names of the services; make them simple to understand, let them do what it says on the tin.  Accident and Emergency is a clear signpost, albeit that the professional may have a different perception about the function of an A&E from that held by the public.

Accept that the local hospital is at the heart of the community and that, for those needing care out of GP opening hours, it seems obvious to go to the local A&E.  In ‘Going with the Flow’ we advocate that we stop telling people not to go to hospital, start simplifying the message and enable more strategic planning.  Recognising that it is impossible, and indeed unsafe, for all hospitals to do everything, we suggested that we classify hospitals into ‘Blue’ and ‘Red’.

Blue Hospitals, being specialised, would provide for serious A&E cases and complex trauma, with emergency surgery readily available.  You would be taken there by ambulance or helicopter or referred on by another Dr or paramedic. Heart attack and stroke services would be located in these units,   24-hour consultant cover in A&E would be provided. The public would know the designation by the simple labelling of specialised hospitals as ‘Blue’.

Alongside them would be ‘Red’ General Hospitals, providing a 24/7 emergency service in one place, including OOH GPs, with the support of nurse consultants, emergency nurse practitioners, paramedics, social care and pharmacists and of course some hospital Doctors. These hospitals would be treatment or triage centres  and could treat and manage a large range of conditions, from the simple to the complex, admit,  give advice, run education programmes on health, and follow people up, refer them on or  refer them back to the GP.  People think about ‘their’ local hospital and ‘their’ local GP.  We need to build on these sentiments and encourage the involvement of the neighbourhood in a meaningful way. We must accept that not all A&Es would look as they do now but they could be something more,  tuned into what the public want in order to allay their fears.

To enable this reorganisation to Blue and Red hospitals to happen will require some brave decisions: not least integrating services with the care record at the core, and building a service around the public and the 24-hour world in which they live.

And yes, this does go against the flow of current thinking, but the public don’t like or get our current thinking. We haven’t made a coherent case for closing or indeed changing A&E departments, the OOH service is obviously missing the point with the public, so let’s give them what they want but make it better than they have now. In that way we can begin the process of focusing on the other big issues around, like  Long Term Conditions, obesity and social care   We’re clouding the issues  with A&E and OOH and it appears the public think it is clouded enough already.