Year in and year out we have been used to hearing about the winter pressures that the NHS and indeed, other Healthcare systems are facing. We predict them in advance and then respond to them with the funding available, often with annual re-occurring emergency funds (how often does an emergency fund have to re-occur yearly to be considered as normal funding?). Targets for A&E waiting times of 4 hours for 95% of patients are quietly put to one side as the immediate challenges are met with the stoic attitude of ‘best foot forward’, ‘let’s get through this’ and ‘we can rest in between winter seasons.
The reality is though, that as measured since 2011 by the Kings Fund, the UK’s performance to the 95% target has continued to decline to the point where for a type 1 A&E (A consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients) we are at 77% of that target during the winter pressures and around 85% at other times. And as you can see from the graph this is declining year on year.
There used to be a collective sigh of relief as we climbed out of the busiest periods during the cold winters into the welcoming spring days where everything seemed so much brighter, patient numbers tailed off seemingly in proportion to the hours of sunlight in the day and the pressure was able to be released until later in the year when Autumn brought the reverse effect and everything started again.
But chat with the heroes of our A&E departments today, as well as the rest of the hospital clinical staff (A&E are the gatekeepers, but what happens downstream is directly related to what happens in A&E) and they will tell you about a worrying change over the past couple of years which is perhaps reflected in the overall downward trend of the statistics above. Simply put, there isn’t the recovery period anymore, it doesn’t slacken off, there is no chance to take a breath, they simply grin and face the next crisis.
This then of course means that as A&E is the primary entry point for emergency admissions into the hospital (71% in the UK in 2013), that all wards downstream of A&E are also being pushed to stretching point.
There is also another dimension to these statistics, nationally in the UK in 2013 patients were recorded as receiving no treatment or advice only in approximately 47% of attendances at A&E departments and no investigation in 41% of attendances. Furthermore, reviews have concluded that between 38% – 47% of visits to A&E could have been dealt with by a Primary Care visit instead of a visit to A&E. When you couple this with the knowledge that by percentage of visits, GP’s are referring less and less to Secondary Care, then you can see why a big focus of the NHS Forward View is around Primary care and which promises to deliver ‘more convenient access to care, a stronger focus on population health and prevention, more GPs and a wider range of practice staff, operating in more modern buildings, and better integrated with community and preventive services, hospital specialists and mental health care’
The eHealth Ireland strategy of ‘Shift left, stay left’ mirrors this and ‘advocates innovative technology solutions to support specialised, integrated care from acute settings to community to a home setting more quickly or to avoid trips to hospitals at all’. This borrows heavily from IT terms to create a ‘Moore’s law’ for Healthcare in Ireland by shifting services from Acute to Primary/Community and Home Care with a desire to focus on prevention/proactive Healthcare in the future. It remains to be seen how the monolithic procurements of the past will make way to allow this innovation to take place….
So how are we doing with this shift in thinking from Secondary Care to Primary Care?
Well for example, in England I recently needed to seek out of hours (weekend) treatment for a medical issue that wouldn’t wait till my GP surgeries still archaic opening times (8 – 6 Monday to Friday, non-urgent appointments bookable online by prior arrangement (typically in 2 weeks’ time), emergency appointments by phone, 1 person answering the phone, normally a 30 min wait, no call back facility. I called NHS Direct on 111 and after answering the various questions they decided that they wanted me to be seen by a Primary Care Physician within 4 hours. They then contacted the local Urgent Care Centre (5 miles as opposed to 30 miles for A & E) who contacted me within the hour with an appointment time in 2 hours time.
So, it’s a failure for my local GP and a success for the 111 telephone service and an example of an Urgent Care pathway rather than a more expensive A&E visit? Not quite, you see although the diagnosis process and waiting time (essentially in my own home till it was time to drive to the Urgent Care Centre for my appointment) was very efficient when compared to waiting 4 hours in a drafty A&E department, what didn’t work was the flow of information. My Urgent Care Centre was ready for me and dealt with me quickly and efficiently but didn’t have a clue what was wrong with me in advance as none of my records were available to the clinician who finally treated me. Worse still when I did finally visit my GP to renew my prescription, they knew nothing about either my 111 referral or the treatment I got at the Urgent Care Centre (less than a mile away from the GP surgery).
So, a failure in integration? As a previous Blog mentioned, no Junior Dr to run around making sure that all of the relevant information, forms and results were available for all concerned! I do think that the concept of moving less ill patients away from the Acute setting to Primary or Community is a good one, but we have to start understanding that integration, not building bigger data silos, is going to be at the heart of the challenge and we have to ensure that if we want to innovate to address these problems then we have to find a different way to evaluate the solutions available, that doesn’t see yet another purchase of dated, monolithic IT solutions that are expensive to procure and even more expensive to make work, without a Junior Dr running around to provide the integration.
Kings Fund Quarterly Report – March 2018 – https://www.kingsfund.org.uk/publications/how-nhs-performing-march-2018
NHS Five year Forward View – https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/primary-care/
eHealth Ireland – Shift Left, Stay left – http://www.ehealthireland.ie/News-Media/News-Archive/2018/Stay-Left-Shift-Left.html
JRSM – Journal of the Royal Society of Medicine – Emergency hospital admissions via accident and emergency departments in England – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4224646/
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