PPL blog: In case of emergency, communities should break A&E glass

PPL blog: In case of emergency, communities should break A&E glass
posted 06 June 2014

Sam Benghiat, manager at PPL, wrote this article in reaction to the findings in a survey commissioned by the College of Emergency Medicine that suggest 85% of current A&E attendances are appropriate.

It appeared on The MJ's website on 30th May. Thanks go to the features editor, Jonathan Werran, for his kind permission to reproduce the article here.

A link to the original piece in The MJ can be found here: http://www.themj.co.uk/In-case-of-emergency-communities-should-break-AE-glass/197263

In a recent press release picked up by national media and specialist press, the College of Emergency Medicine released survey results that purported to shatter the consensus around A&E policy-making.

The findings suggest 85% of current A&E attendances are appropriate, calling into question NHS England’s claim that up to 40% of A&E activity could be managed in other settings.

Although an interesting piece of work that makes valid points, we believe that the way this has been reported significantly under-estimates the number of A&E patients that could be treated by a GP.

We know this not because of any detailed survey work, data analysis or clinical audit, but through practical experience of real urgent care services operating across London today. 

In recent years, we have worked with nine GP-led Urgent Care Centres (UCCs) in the London area. Of these, six consistently handle in excess of 60% of total A&E activity. A further two fall short of this threshold because they are not open 24 hours a day and operate according to a narrow specification that excludes treatment of minor injuries. 

CEM’s own figures suggest a further 22% of A&E activity “could be appropriately managed by a GP working in the emergency department with access to A&E resources”, implying that 37% of current A&E attendees could be treated safely in a UCC.

Yet even taking this larger figure into account, CEM’s logic implies that a UCC handling 60% of total A&E activity must be clinically unsafe. 

If this assertion were true, we would expect to see evidence such as abnormally high UCC to A&E transfer rates and unacceptable numbers of serious untoward incidents. In reality, we observe neither of these things.

Based on data from the UCCs we have worked with, UCC to A&E transfer rates and SUI frequency are no higher at UCCs managing with 60% of A&E activity than at any other UCC.

How can we explain this discrepancy? Most UCCs are GP-led for a reason. A&E clinicians are highly skilled specialists trained to deal with situations where a patient’s life is in immediate danger.

It is therefore entirely understandable that precautionary tests are requested and precautionary admissions are made that a clinician from a primary care background may not always deem to be clinically necessary.  

CEM’s survey of A&E clinicians was consequently always likely to result in a conservative estimate of the proportion of A&E patients that could be treated by a GP. To the doctor with a hammer, every problem looks like a nail.

A primary care ethos is one of the great strengths of the UCC model, ensuring that patients receive care that is proportionate to their need, and that unnecessary investigations and admissions are minimised. 

On the wider question of the proportion of UCC/ A&E activity that could safely be treated outside of hospital, the evidence is less clear cut. We have conducted extensive patient engagement to try to understand why some people attend UCCs in preference to their own GP. 

Respondents rarely mention access to hospital resources, and instead return consistently to the theme of primary care access. Patient pre-occupation with GP opening hours, waiting times and ease of booking an appointment suggests that for many people, UCC attendance is driven by practical rather than clinical considerations.

There is a debate to be had about whether it is clinically desirable (or even cost effective) to re-direct people from UCCs and A&Es back into the community.

What we do know for certain is that CEM significantly under-estimates the number of A&E patients that could be treated safely by GPs in other settings of care. UCCs across the country demonstrate this every day. 

Sam Benghiat is manager at PPL - an independent consultancy working on practical projects promoting health, wellbeing and economic success across the UK