A&E: Facts from the front line

22^nd May 2014

Dr Michelle Tempest and Dr David Royse on the need for urgent reform to A&E

A joint report by Candesic and the College of Emergency Medicine (CEM) analysed over 3,000 patient records who visited twelve Emergency Departments (A&Es) across the country and found that most people (85%) who attended A&E needed to be seen in an emergency setting. This number is different from the number that NHS England based their A&E reconfiguration blueprint on; it claimed 60% of people needed treatment and that 40% could be treated elsewhere. Rather than quibble over data, what positive action can be taken? And what does the future hold? Here we discuss three issues:

First, A&E attendees; second, the A&E payment system and staffing levels; and third, ideas to solve the problem keeping in mind the ‘can-do’ ethos of our emergency services who deliver 24/7 care.

A&E attenders:

Today the BBC reported “efforts to redirect patients away from busy A&E departments will not work.” Despite expensive campaigns to try and redirect people away from A&E, there is little evidence to say that such campaigns work. The trend for better “sign posting” and “self-care” education and apps are likely to have only marginal effects. In fact, our report found that children were the most likely group to be brought to A&E despite the fact clinically they could have waited to be seen the next day. Though who could blame an anxious parent, worried about their child? The saying ‘better safe than sorry’ must surely be in any parents mind at time of worry. So perhaps a better strategy, and one supported by the CEM, would be that people could be triaged to the correct ‘point-of-care’ after arriving at the A&E door. Welcoming people at their time of need and directing them to the care they need. The full spectrum of triage – from booking a GP appointment to wheeling them through to the resuscitation room.

A&E payment system and staffing levels:

No one can escape economic reality and the NHS is no different. But A&Es have become low priority for investment among acute trusts, as the current tariff system ensures all type 1 A&Es are a financial drain on these organisations. As the CEM have highlighted before the A&E tariff system is ‘not fit for purpose’ and is based on old data. The system is analogous to going into a shoe shop and buying a pair of the latest shoes for last year’s price or the price before – the customer may be happy (like getting good treatment in A&E) but the business model is not sustainable. Dr Cliff Mann President of the CEM said “The CEM is in the vanguard of the drive towards efficient, effective and sustainable urgent and emergency care. They will continue to campaign for both tariff reform and contract changes to ensure neither hospitals nor clinicians are disadvantaged by delivering or choosing emergency medicine.”
Solving the problem:

The future must be to design emergency settings to be optimally configured, to include:

• Access to urgent care centres to book next day GP appointments;
• GPs working within the emergency department and able to use the department’s facilities; and
• Early access to specialist emergency medicine doctors.

There is already strong support for the notion of co-located urgent care centres alongside every emergency department. This symbiotic arrangement has clear advantages as not everyone can be expected to determine whether their symptoms represent a time critical illness. Similarly co-location offers economies of scale, common governance arrangements and the reassurance that any triage errors can be quickly and reliably corrected.

With Simon Stevens at the helm of the NHS, the opportunity could not be greater. He has indicated he is keen to hand over more power to Clinical Commissioning Groups (CCGs) and the CEM would like this to evolve. Local vision and innovation would allow Emergency Departments to be part of the solution and not left stuck in a silo, with more integration, not division, between A&E and GPs.