It doesn’t have to be like this

Primary Care Urgent Care

It’s been a very difficult week for the NHS with hospitals across the country struggling to deal with significant pressures on their services.  While the political spotlight which comes with the start of an Election year hasn’t helped, talking to colleagues in the acute sector I am clear those pressures are very genuine and I am full of admiration with the work which they (both  front line staff and managers) have been doing to address them.  Furthermore as Nigel Edwards, Chief Executive of the Nuffield Trust, stressed in his blog on the issue while the problems are serious they are not catastrophic and performance is still good compared to historical and internal comparison.

As most informed commentators have flagged up what is happening is not straightforward.  It is the winter with the usual seasonal upturn in illness and a corresponding upturn in demand at the front door.  Yet by all accounts that increase in demand is not unprecedented and it appears that A&E activity was higher in the summer.

Delayed discharged is also an issue.  Some of this, unsurprisingly, has been due to pressure on social care budgets but a greater proportion of delays have been caused by issues around the co-ordination of NHS care.

Linked to this the impact of a greater number of frail elderly and often isolated people in the community means there are more people with more complex needs who are at greater risk of needing hospital care and for whom the process of returning them safely to the community can be more complex and take longer.

Finally there is the impression of what is a complex and stressed system operating close to capacity which becomes increasingly less able to absorb the pressure of significant if in some ways predictable demand.

I do not claim to the have the answers to the woes of A&E but the recent events have reminded me of issues which arose when I worked in this area in my time at NHS Direct about how the urgent care system  operates and how we want to support the public in using it.  It also highlights key fault lines in the way in which we organise care and support, which while undoubtedly well recognised, need to be addressed with urgency.

So on that basis I have a list of 5 things which we should use the present challenges to prompt us to make sure are different about access to urgent care in the future.

First, in my view, there are strong arguments for a primary care led front door to the NHS round the clock and round the year.  As they are in hours, primary care clinicians are best placed to make a rapid initial assessment of the seriousness  of someone’s condition and whether to use the phrase of a clinician I worked with at NHS Direct, they are “big sick” or “little sick”.  In the small number of cases where there are good reasons for doubt there should be the scope for rapid referral for further assessment by hospital specialists.  We have been talking about this kind of changes in urgent care for years.  Now is the time to make it happen.

Second we need to ensure that when patients are at risk of going into hospital their medical records and pre-existing care plans are able to follow them.  History and the knowledge of what support may already be in place for individuals makes a crucial difference in many of the cases where admission could be avoided.  As well as struggling with the technological solutions to enable this we still appear to be tying ourselves in knots in terms of information governance.  We should rapidly get to a position, which I am sure the vast majority of patients would support, that with appropriate but simple safeguards, information about a patient is able to follow them around the health and social care system.

Thirdly we can longer afford a system where there is an institutional division between the delivery and, very crucially, funding of health and social care.  With the scale of pressure on local authority budgets it in the last couple of years there can be no surprise that there are difficulties in discharging frail elderly patients from hospital who need social care support.  Many commentators, most recently the excellent Barker Commission, have made the logical, moral and economic case for bringing these systems together.  Our next Government must grasp the nettle and make a reality of this in the next Parliament.

My fourth point is to recognise that A&E has in too many cases become a default point of access for a range of groups, for instance people with mental health problems in crisis, who should have access to a more appropriate response to their specific needs.  Just before Christmas research by Paul Burstow MP suggested that in 2014 the number of people visiting A&E   with mental health emergency could have topped a million, a threefold increase from 2002.  This vividly highlights the impact of growing demand on mental health services during the period of austerity and the crucial need for investment to deliver parity of esteem.

My fifth point is the need to think about the psychological as well as physical aspects of urgent care.  Many of the factors which drive the need to seek urgent help, which exacerbate symptoms or which erode the capability of family carers to cope are ground in psychological factors and in particular the difficulty of containing anxiety.  Such factors can also impact on staff working in highly stressed and unforgiving systems.  The development of and training in psychologically informed practice has a significant role to play in helping us design a holistic urgent care system which is fit for purpose.

That leads me onto the issue of the conversation we want to have with the public about how they use A&E.  We need to recognise that there are variety of reasons why people come to A&E but in the vast majority of cases they are legitimate.  For many, unexpected ill health is a source of significant anxiety.  In some cases the difference between “big sick” and “little sick” is obvious but in many cases it isn’t.  The consequences of getting it wrong, especially if you are making that judgement on behalf of your child or an elderly relative.  It was one of the strengths of NHS Direct that it accepted that anxiety on a non-judgemental basis and provided support and reassurance which might help patients manage symptoms without needing urgent care.  If we want to support patients to take self-care seriously we must invest in those sources of information and reassurance which empower them to do so not spend money on advertising campaigns which tell them they might be stupid enough to think that A&E might be there “to kiss it better”.

So for this week the right response to the difficulties in A&E is to praise the efforts of staff across health and social care that have gone the extra mile to ensure care is available for those who need it.  However it is doesn’t have to be like this and, together, we need to accept the challenge to change the system to make sure it isn’t.

Paul Jenkins is the Chief Executive of the Tavistock and Portman NHS Foundation Trust. This article is reproduced by his kind permission from his personal blog.