A&E: making it ‘different’, and relieving the pressure

This week (17 June), the Government promised NHS England ‘an extra £20bn a year by 2023’, says BBC News. This was billed as a 70th ‘birthday present’, by Theresa May – and is funding that will, undoubtedly, be welcomed by all at a time when the NHS has been struggling to meet increasing demand and demographic change. But will it help address the crisis facing A&E departments across the country?

The short answer, we believe, is that pressure in the system will only be relieved if the extra funding is invested in system-wide transformational change, which means integrated pathways and a shift away from expensive hospital care and into community-based services.

A&E in crisis

A&E is a good measure for pressure on the health service more broadly. It’s the front door for so many to NHS care. But it’s buckling under the strain – a sure sign that our care pathways are not working effectively, and no longer meet the needs of a growing, ageing population.

Some A&E departments that were meeting the 4-hour standard only a few years ago, are now failing. Full Fact reports ‘a record number of A&E attendances – almost 24 million – in England in 2017/18’. ‘A&E performance reaches a new low’ reads this headline from the King’s Fund. ‘Walk into an A&E department this month [January 2018] and you will see a service under tremendous pressure. Departments built to see a maximum of 350 patients a day are seeing 500 or 700.’

And the pressures don’t just occur in winter anymore – though they are more pronounced then – it’s all year round. The Guardian quotes Dr Nick Scriven, President of the Society for Acute Medicine, as speaking of ‘the eternal winter we now face in the NHS’.

So, what are possible and sustainable solutions?

Improving patient flows

There are initiatives afoot to help people understand A&E waits, and potentially navigate them. (WaitLess for Kent Community Health, for instance, tracks waiting times and traffic news, at the point you need to know where to head.) But the problem isn’t anyway only with the ‘front door’ – it’s the flow through A&E and out the other side (the ‘back door’).

The King’s Fund found 8 per cent of patients are admitted or transferred ‘in the 10 minutes before they would cause a breach of the standard by spending more than four hours in A&E’. (This isn’t necessarily reassuring. Has the decision really, always, been made in the patient’s best interests?)

Plus, of course, many hospitals have reduced their bed base: ‘since 1987/8, the total number has more than halved from around 299,000 to 142,000’, says The King’s Fund.

Fundamentally, there are issues around provision, in the community, of ongoing care, especially for the complicated cases presented by our increasingly frail elderly population. Taking a personalised and preventative approach should help address at least some of the worst, chronic pressures faced today by A&E departments.

Integrated approach

The NHS can’t do this alone. We also need to work with social care providers and with community and voluntary sector organisations to prevent ill-health and support wellbeing. Those people who do end up needing A&E need the right support at home or in the community to get them back on their feet again.

GPs have a part to play, and they’re trying to play it. Some employ their own paramedics to make home visits, or improve access to GP services through extended hours, and offering telephone and Skype consultations. There are also GPs working fruitfully on the frontline in A&E.

The onus on GPs to work in networks or federations should also increase their capacity and resilience – enabling primary care to offer patients a wider-range of services closer to home. This in turn should reduce numbers queuing in A&E.

Designing care around patients

The Primary Care Home initiative offers promise. This is about developing a real, personalised and preventative approach to care, delivered by a multidisciplinary fixed team. Primary Care Home seems to have exactly the right thinking at heart: ‘the model brings together a range of health and social care professionals to work together to provide enhanced personalised and preventative care for their local community’, says the National Association of Primary Care (NAPC) website.

Crucially, also, those directly involved seem massively encouraged. Dr Ash Peshen, Thanet Health Primary Care Home Lead, for instance, in this short film describes how the recently-devised Acute Response Team effectively puts ‘a safety net around those patients’ – elderly, or with long-term conditions – so they can be cared for and treated at home.

There’s clearly something about it that really works – not least, the fact it seems to spell a return to ethical basics for the staff involved. ‘It’s about clinicians designing care around the needs of their patients’, says Caroline Rollings, Managing Partner at Newport Pagnell Medical Centre. ‘That kind of phrase has been used a lot – but this is different.’

Perhaps it’s exactly the kind of ‘different’ we need – to move forward, and address the problem today facing A&E. Ultimately, it is only by investing in measures to prevent ill-health and to provide treatment, rehabilitation and reablement at home or in the community that we will really turn things around.

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