Improving the safety and effectiveness of urgent and emergency care

ABSTRACT

Delays and waiting in urgent and emergency care (UEC) services are causing avoidable harm to patients and affecting staff morale. Patients are often having a poor experience of using UEC services, increasing stress and anxiety for both their families and themselves, delaying their recovery. Despite the constraints of available permanent staffing, funding and competing NHS priorities, changes along the whole UEC pathway in and out of hospital, admitted and non-admitted pathways need to be made safe, timely and accessible, to provide clinically appropriate care for patients. Changes in clinician behaviour, culture, and training toward the management and sharing of clinical risk differently along the whole UEC pathway are also required. Modifying operational processes with a focus on patients in different UEC settings will improve productivity, flow and the patient experience. There is a need to do things differently rather than continuing as we are and expecting a different result to unlock the perennial UEC crisis.

Introduction

Emergency care involves care for patients with life-threatening illnesses or having had an accident that requires immediate treatment from the ambulance service (via 999) and emergency department (ED/A&E) involvement. Urgent care involves any non-life-threatening illness or injury needing urgent attention but not necessarily in an ED.

For safe, timely, accessible and clinically appropriate care for patients, changes are needed along the whole urgent and emergency care (UEC) pathway in and out of hospital in both admitted and non-admitted pathways through transformation with innovation despite the constraints of available permanent staffing, funding and competing NHS priorities. Avoidable delays and waiting for UEC services is causing harm to patients and affecting the moral of staff. Patients often have a poor experience of using UEC services, causing both themselves and their families increased stress and anxiety, delaying their recovery.^1–3

Winter comes every year, yet we see a crisis in UEC services every winter and increasingly throughout the year. Over decades, there have been numerous costly initiatives to solve problems that had been resolved previously. However, learning is not embedded given that the NHS is ‘an organisation without a memory’, resulting in constant reinvention. Unless the thinking and narrative of doing ‘more of the same’ changes to ‘doing things differently’, we will not make solutions ‘business as usual’. Every year, there is a new UEC recovery plan with essentially more of the same,⁴ based on traditional perceptions of the causes of UEC service challenges rather than an overarching transformational approach. Such an approach is needed based on professionals in UEC services understanding and managing ‘clinical risk’ differently and a strategic ‘whole-UEC system approach’.

‘Patients at greatest risk of harm or death are those with serious or life-threatening conditions at home waiting for an ambulance’

All other changes in the UEC pathway and system should then transform and adapt to provide a timely ambulance response, rapid handover in the ED and flow in both the admitted and non-admitted pathways by: (a) influencing clinician behaviours, culture and training toward understanding and managing clinical risk differently along the whole UEC pathway, in and out of hospital; and (b) reviewing pathways and processes in different UEC settings to prevent patient harm by reducing waiting and delays and improving productivity.

Influencing clinician behaviour, culture and training toward understanding and management of clinical risk differently along the whole UEC pathway in and out of hospital

Preventing harm in healthcare is essential for patient safety and the overall quality of care.⁵ Clinicians are usually aware of different harms and avoidable harms caused to patients in healthcare and might be aware of the National NHS Patient Safety Strategy.⁶ However, clinicians (doctors, nurses and allied health professionals across the NHS in hospitals, the ambulance service, general practice, primary care or community services) might not fully appreciate the link between delays and waiting times in UEC and patient outcomes.^7–10 Impacts on the morale of staff working in UEC services caused by delays and waiting times preventing them from providing the care that they would like to provide to their patients are also now being described.^11,12

The UEC system is complex, involving multiple organisations and professionals with different skills, training, ability to make complex decisions, and where management of clinical risk can vary. This can sometimes adversely impact on patients directly or other parts of the UEC system within departments, organisations and between UEC organisations. Therefore, understanding the ‘whole UEC system’ is crucial in the training of all UEC clinicians to manage clinical risk appropriately.

Clinicians' ability and willingness to take calculated and informed risks is the key to unlock the UEC crisis¹³

The ‘whole UEC system’ is generally not fully understood by clinicians. The whole UEC system is not in any one department e.g. ED, ward or specialty, and not in any one organisation, such as hospitals, ambulance service, GP practices, GP extended access hubs, urgent care hubs, community rapid response services, NHS 111 service or mental health crisis services. The whole UEC system pathway starts and ends with the patient at home, with nearly 90% of urgent care provided in the community, outside hospitals. It might involve virtual self-care information from NHS 111 online, GP online tools, the NHS 111 telephone service or in person at GP surgeries, pharmacists, GP extended access hubs, urgent treatment centres (UTCs), or emergency care requiring an ambulance or care in an ED.

Behavioural and cultural change and training are needed for clinicians to manage clinical risk appropriately across the whole UEC system, both out of and in hospital. Fig 1 shows how clinical risk could be better managed at every level of the UEC pathway. Clinical risk and advice to patients are managed through evidence-based algorithms when patients with a perceived UEC need use NHS 111 Online¹⁴ or GP practice online tools¹⁵ or contact NHS 111 on the telephone or subsequently speak to a clinician via the NHS 111 Clinical Assessment Service (CAS).¹⁶ In general practice, a GP or clinician managing an acutely ill patient on the telephone, video or face to face must balance the risk and decide whether the problem can be managed with self-care, medication or with social support in the community, or if it can be dealt with or supported by acute specialist community services, or is a problem that requires specialist in-hospital opinion or care. If there is an understanding of the ‘wiring’ of local UEC services, the option is not always ED because specialist opinion can be obtained via direct hotlines to medical, surgical, paediatric and mental health specialists¹⁷ or Same-Day Emergency care (SDEC) for both medical and surgical problems.¹⁸ Similarly, a common misunderstanding is that delays in hospital discharges and bed availability result mainly from social care delays. However, over 50% of delays are caused by NHS factors, including discharge processes or clinical risk averse behaviours that determine a patient medically fit¹⁹ or a lack of hospital clinician understanding of community specialist resources resulting in underutilisation of such resources, including virtual wards.²⁰

Fig 1.

A resource setting out ways in which clinical risk could be better managed at every level of the urgent and emergency care (UEC) pathway.

Largely because of the slow spread of innovation or resistance to service transformation to be more patient-focused, as well as ‘custom and practice’ in hospital specialities, variation exists in service provision in different areas, such as patients being taken directly to SDEC by ambulance services and ‘Think 111 First’ for booking appointment slots in ED following assessment by NHS 111.²¹ Behavioural and cultural change and training are needed for clinicians to better understand the ‘whole UEC system’ to manage clinical risk appropriately both out of hospital and more specifically in different specialities and among different hospital clinicians.

Despite increased NHS funding and workforce headcount mainly across hospital staff,²² productivity in UEC within hospitals has deteriorated significantly,²³ demonstrated by worsening ED performance.²⁴ At the same time, despite a reduced number of GPs, GP practices are now required to offer an increased number of appointment slots.^22,25 A focus on quality and safety, especially reducing delays for patients, will improve clinical outcomes, productivity, staff morale,^26,27 NHS finances and patient experience, especially access to ED services. In a recent survey, only 30% of those surveyed were very or quite satisfied with ED services, whereas 40% were very or quite dissatisfied. This is the largest change in dissatisfaction in a single year since the question on A&E services was first asked in 1999.^28,29

The ‘Delivery plan for recovering urgent and emergency care services' in England (January 2023)³⁰ aims to support improvements in UEC services for both physical and mental health needs in time for winter. This includes the ambition to increase capacity with more hospital beds, more ambulances and better flow of patients through existing hospital pathways, improving discharge and out of hospital care, including virtual wards. This plan goes some way to restate the fundamentals of improving flow of patients through the UEC pathway in both the ambulance service and in hospitals, yet it fails to address influencing clinician behaviours, training or operational culture in the NHS, clinical management of risk along the whole UEC pathway in or out of hospital or evidence-based high-impact areas to improve quality with transformation and free up NHS finances in the process.³¹ Given the high cost of UEC services, embedding the learning from the reinvented changes to improve flow in hospitals with short-term additional funding year after year and from crisis to crisis remains the greatest challenge for the NHS, that is, ‘doing what has always been done and expecting a different result’. Further research is needed on how to embed and share learning in the NHS to avoid the perpetual cycle of reinvention while causing harm with delays for patients and inefficient use of funding.

Review of pathways and processes in different UEC settings to prevent patient harm by reducing waiting times and delays and improving productivity

UEC services and clinicians need to trust the assessment of clinicians in other UEC services to add value to a patient's care and to reduce waits and delays, especially when NHS 111 is used as a single point of contact with the ability following an assessment to book an appointment with other services. (Fig 2 shows the concept of “Think 111 First” as a single point of access for UEC.) Such services include UTC, ED, SDEC, GP out of hours services, GP practices, GP extended access hubs, community pharmacists or community rapid response services, within individual service contractual arrangements.

Fig 2.

How the concept of ‘Think 111 First’ operates as a single point of access for urgent and emergency care (UEC).

Although general practice is not considered an urgent or emergency service, patients access their GP practice on the same day³² with acute problems, including serious conditions that can require a 999 ambulance for conveyance to the ED or to be seen by specialists in the SDEC service. General practice has the largest share of patient contacts in the NHS:³³ General Practice provides over 300 million patient consultations each year, compared to 23 million A&E visits. So, if general practice fails, the NHS fails. Yet a year's worth of GP care per patient costs less than two A&E visits’.³⁴ Small changes in access to general practice can result in disproportionate increases in acute secondary care services as a result of the ‘gearing effect’. GP practice appointments have increased substantially compared with prepandemic levels,³³ despite a reduction of 2,133 full-time equivalent fully qualified GPs between 2015 and June 2023.^35,36

The latest ‘Delivery plan for recovering access to primary care’ in England³⁷ aims to ‘empower patients' with tools to manage their own health and know how their request will be handled when they call their GP practice, expand community pharmacy services, and increase investment in digital telephony in GP practices. Rather than through the core GP contract, GP access improvements have been through Primary Care Networks (PCNs), extended access hubs and additional staff.^38,39 Access to general practice remains a challenge, as reported by the national GP patient survey,⁴⁰ raising the question of whether the additional funding could have been better invested in the core GP Contract to focus on retaining and recruiting more GPs as ‘expert generalists’⁴¹ with better renumeration and conditions, while improving access to both continuity of care and episodic care depending on patient needs.⁴²

General practice has a pivotal role in managing increasing demand for healthcare, especially same-day urgent care.⁴³ Additional ‘winter’ pressures funding has been provided to acute hospital trusts and ambulances services;⁴³ however, general practice and primary care have not been similarly supported. This anomaly potentially unmasks the strategic challenge among policy makers or a lack of understanding of the patient journey from their home across the wider urgent care system and flows and dependencies. Providing winter pressure funding to GP practices directly could make a difference by adding appointment capacity cost effectively and reducing the burden of patients with low-acuity problems accessing higher cost Integrated Urgent Care (IUC) such as NHS 111, Clinical Assessment Service (CAS), out-of-hours GP services and attending ED or UTCs.

Although welcomed, the ‘NHS Long Term Workforce Plan’⁴⁴ is less transformational on the immediate need to retain the medical workforce. Increased workloads, stress, burn out, pay erosion and not feeling valued are issues to be tackled for retention of experienced medical staff. Continued and prolonged industrial action for pay restoration by junior doctors⁴⁵ and hospital consultants⁴⁶ has left an essential NHS workforce feeling marginalised and undervalued, which will inevitably impact on retention of experienced doctors and impact on the delivery of UEC services.

Across the whole UEC system, patients at greatest risk of harm or death are those with life-threatening conditions at home waiting for an ambulance.⁴⁷ Although more staff and ambulances will make only a marginal difference to response times, a greater impact on ambulance availability would result from for ambulance handover times meeting the standard (<15 mins) at EDs. The current narrative describes hospital bed availability as the main cause of ambulance handover delays and aims to increase hospital bed capacity and flow through hospitals, and more staff and investment in out-of-hospital care, including social care.^48,49

However, the best option to reduce ambulance handover delays without overcrowding ED is by improving organisational processes and utilising the resource of hospital as a whole, in addition to managing clinical risk differently, including avoiding unnecessary admissions and accelerating flow through and from the ED.⁵⁰ Further research is required to see why this approach is not embedded in every hospital as ‘business as usual’ rather than only during crises, if at all.

To reduce the burden of patients with low-acuity problems attending ED, all EDs should have colocated UTCs delivering to the national specification.⁵¹ UTCs should have appropriately trained staff with early senior involvement and decision-making pathways to improve productivity and flow. Changes to the national UTC guidance from being GP or primary care led has resulted in many colocated UTCs operating as ED ‘Minors' led by experts in ‘emergency care’ rather than experts in ‘urgent care’. Together with a low level of understanding of out-of-hospital services, general practice, or wider primary care services, this has led to clinical risk management of patients with non-emergency low-acuity problems having unnecessary investigations, referrals to specialities or even hospital admissions. This has contributed to poor productivity and flow in ED and to unnecessary delays for patients, overcrowding and poor use of NHS resources. A greater emphasis is needed on improving leadership, culture, productivity and efficiency within EDs with revised pathways that are genuinely patient-focused, as well as a focus on ‘exit block’ and more effective use of hospital beds.

There is now a diverse clinical workforce in EDs, including international medical graduates, locum doctors, doctors in training, paramedics, emergency care practitioners (ECPs), registered nurses, emergency nurse practitioners (ENPs) and physician associates (PAs), who are predominantly acute hospital focused with varying risk management skills or understanding of the whole urgent care system.⁵² Therefore, further training and specific assessment in urgent care would be beneficial toward developing a holistic understanding of the wider urgent care system beyond ED, and the patient journey that starts and ends in their home in the community.⁵³ GPs' core skills involve managing uncertainty and clinical risk in undifferentiated illness presentations.^54,55 GP specialty training usually involves a rotation in ED. Studies of the impact of care provided by GPs to non-emergency patients in ED shows significant differences from care provided by usual ED staff in terms of process outcomes and ED clinical quality indicators. GPs working in ED have been found to request fewer blood tests, X-rays and other investigations as well as fewer referrals to specialists and admissions, and are more productive in completing episodes of care in far shorter times. GPs in ED tend to manage self-reporting minor cases with fewer resources compared with standard care in ED, without increasing reattendance rates after 7 days.⁵⁶ GPs working in EDs or UTCs need to be working within their certificate of completion of training (CCT) competencies for indemnity and employing organisation governance structures.⁵⁷ Data show that 90% of all healthcare is delivered by primary care and most urgent care presentations are managed in general practice. However, GPs are leaving the profession almost as fast as they can be recruited because of the unprecedented service demands and burn out, resulting in not enough GPs to work in core general practice let alone in different urgent care settings, including EDs or UTCs.⁵⁷

The ED front door would benefit from innovative and effective ‘streaming’ capable of booking patients directly into timed slots to be seen in UTC, ED (adults and children), SDEC or Community Urgent Care Services, direct booking from NHS 111⁵⁸ as well as direct pathways to an Early Pregnancy Unit (EPU) or to a gynaecologist via modernised vaginal bleeding pathways.

Processes in ED warrant a review and transformation to reduce waiting times and delay for all patients whether with low-acuity urgent care needs or requiring an emergency response.^21,59 There is a clear association between ED length of stay and in-hospital mortality in older patients.⁶⁰ For many years, The Emergency Care Improvement Team (ECIST) visits to different hospitals, UEC services and systems has provided invaluable learning opportunities from some of the best-performing services across England.⁶¹ Culture, executive leadership, shared vision, purpose based on quality, and safety driven by evidence and enabled with data are common criteria for improvement and success.

A genuine ‘patient-focused’ transformation of UEC services is needed, with waiting time for patients becoming a prime quality indicator. Clinicians all along the UEC pathway, but especially in hospitals, need to manage clinical risk differently at every stage to reduce waiting times, delays and harm to patients, and make better use of NHS resources by embedding learning and ‘thinking and doing things differently’ rather than ‘more of the same and expecting a different result’.

This requires a fundamental change in the strategic focus of policy makers, senior NHS managers and senior clinical leaders at every level in the NHS, to be held accountable for improving patient care within burgeoning additional resources to the NHS predominantly to hospitals, with transformation rather than always anticipating national financial bail outs. ‘Necessity is the mother of invention’ with meaningful accountability.

The following figures illustrate just some examples of innovative and transformative approaches for consideration. Fig 3 gives the example of a virtual head injury assessment pathway through NHS 111. The NHS is not lacking in innovative ideas but needs behavioural changes to better share and spread innovation (eg Fig 4 and 5 set out the ‘Call before you convey’ approach for ambulance paramedics) and even more challenging is to overcome the ‘not invented here’ syndrome for adoption and implementation of innovation and a resistance to change; Fig 6 shows transformation of the traditional ED model with a senior led ‘consultant first’ pathway to improve efficiency and productivity, make better use of resources and improve patient experience.

Fig 3.

A virtual assessment service for head injury referrals from NHS 111 to reduce both the need for attendance and the length of stay in the emergency department (ED) if required to attend.

Fig 4.

Potential workflows for ‘Call before you Convey’, a single point of access with a multidisciplinary team (MDT) approach for ambulance paramedics.

Fig 5.

Implementation of ‘Call before you Convey’ for ambulance paramedics.

Fig 6.

‘Consultant First’ model in accident and emergency (A&E) to improve efficiency, productivity and the experience for patients and to make better use of resources. Putting the most senior doctor at the front of the patient journey improves direct referrals and reduces unnecessary investigations and training of central doctors as well as registrars. Following consultant plans with front-loaded investigations will improve outcomes and quality of patient care. Communication of plans to patients should then improve, leading to an enhanced patient experience.

Feedback to clinicians

If we want to improve outcomes and sustainable learning, then providing consistent outcome feedback to referring clinicians is essential. For example, if an ambulance clinician was to see the proportion of referrals that they convey to hospital that are discharged on the same day, this would support a behaviour change and consideration of referrals to alternative same-day services. In London, through collaborative working, an app is being developed that links the ambulance record with the hospital record within an integrated care system (ICS), which aims to give personal feedback on patients conveyed by individual clinicians. This is the type of technology needed to support changes in clinician culture and behaviour. Similar forms of individual clinician feedback of patient outcomes arising from their actions, investigations or referral rates to all clinicians along the whole UEC pathway, out of and in hospital, will support learning and the behavioural changes needed to share and manage clinical risk more appropriately and understand the ‘system risk’.

Remote assessments across UEC supporting right care, right place and right time

Managing clinical risk and decision making with remote consultations on the telephone or via video are embedded in general practice and supported with training and assessment through the Royal College of General Practitioners. Many systems across the country now use secondary care clinicians in remote decision making to support care in alternative settings, such as SDEC or at home under care of Hospital at Home clinicians. (Fig 7 illustrates the Remote Emergency Access Coordination Hub (REACH) model.) The curriculum for the Royal College of Emergency Medicine and Royal College of Physicians does not currently include training in remote assessments, and this is an area post pandemic that needs to be actively considered.

Fig 7.

The Remote Emergency Access Coordination Hub (REACH) model implemented in North East London.

Information sharing along the whole UEC pathway to enhance continuity of patient care

Access to the full patient care records including medication, from the community as well as secondary care, including care plans for end of life and resuscitation decisions by patients, or long-term conditions, is important to support a new way of working. London as a region is investing in the ‘Universal Care Plan’⁶² to support this. However, access to secondary care plans for high-intensity users is often only visible on the individual Trust records. Digital integration will be a key enabler to decision support across the whole UEC pathway. In 2023, the NHS Digital Booking and Referral Standard was published to allow systems to work with suppliers to develop a digital solution for booking patients into services across UEC. An Information Standard Notice (ISN) was published in April 2023 and can be accessed via https://data.standards.nhs.uk/published-standards/nhs-booking-and-referral-standard. Despite this, clinical support and collaboration will be required to realise the benefits of direct referrals across UEC, which also supports the trusted assessor model. It is by doing this that the need will be reduced for multiple triages and touch points that impact on referral failure and ED being the genuine catchall for referrals, given its genuine no-barrier process.

The right health professional working differently

NHS 111 currently refers ∼12% of callers to the ED across England. In systems where ED clinicians remotely assess these referrals, the outcomes have been promising in reducing the need to attend the ED, or even improving the timing of when and where to attend hospital. Examples include Remote Emergency Access Coordination Hub (REACH) in North East London, Virtual ED Waiting Room in eastern England and the Virtual Head Injury Pathway in Oxford.

Summary

• Patients at greatest risk of harm or death are those with life-threatening conditions in the community awaiting a clinical response.

• There is a need to influence clinician behaviours, culture and training toward understanding system and whole-journey risk rather than episodic risk.

• Consistent access is required to senior clinical decision support to unlock all the alternatives to ED.

• Trusted assessments of different health professionals to reduce touch points and avoid decision failure in conjunction with robust feedback to improve learning along the whole patient journey pre-hospital, in hospital and after discharge.

• Reduce ambulance handover delays by utilising a whole-system approach rather than a single front-door offer.

• System-wide access to records both to support decisions and documenting them with the use of BaRS to improve digital referrals directly into EHR providers across UEC.

• Culture, executive leadership, shared vision, and purpose based on quality and safety driven by evidence and enabled with data are common criteria for improvement and success.