Accessing emergency care: making it happen
| Access to Healthcare Seminar BMA House 5 November 2002 Chair: Nick Ross |
At a meeting of representatives from patient groups, the medical profession and the NHS several ideas were put forward to improve patient access to emergency care. As the BMA report ‘Waits and Measures: improving emergency care for today’s patients’ revealed, patients still face long waits and accident and emergency departments across the country are understaffed and underfunded.
The seminar was held to discuss the problems facing A&E medicine and suggest, wherever possible, ways in which the provision of emergency care could be improved. Whilst recognising that funding and resources are key factors in any discussion on A&E, the aim of the seminar was to examine other ways of improving emergency care under current financial and staffing restrictions.
The following report is intended to provide an overview of the topics discussed during the seminar and is divided into two main parts, the first considers the problems facing emergency medicine, the second examines ways of improving patient care when accessing emergency services.
Accident and emergency medicine: problems
Bed occupancy
It was widely agreed that one of the main problems facing A&E was ‘upstream’ of the A&E department, in the hospital itself. Many hospitals run with a bed occupancy of over 95 per cent, with little space for new patients. This in turn means A&E is used as a ‘stacking’ unit, with patients who need to be admitted forced to wait in the A&E department.
A&E attendance
When patients need care quickly or in an emergency, they have a number of access points into the NHS, eg their GP, a walk-in centre or the A&E department. A number of patients come to A&E with problems which could be dealt with by a GP. For many people the choice of where to go for emergency care is confusing, in Edinburgh, for example, there is a minor injuries unit at one end of the city and an A&E department at the other, and patients are often unsure which to go to for treatment.
Access to diagnostic tests
This was identified as one of the ‘key stumbling blocks’ facing A&E medicine. Diagnostic tests allow doctors to make early diagnosis, rule out life threatening conditions and avoid unnecessary admissions. Yet a shortage of specialists, eg radiographers plus, a lack of diagnostic services available as a 24 hours a day, 7 days a week service means that obtaining diagnostic tests can be a time consuming process, delaying diagnosis and ultimately the admission/discharge of a patient. This ‘mismatch’ of service provision extends beyond diagnostic testing to other parts of the hospital service.
Under-investment and understaffing
It was widely agreed that A&E departments have been seriously underfunded over the last few years. The recent increase in funding to some units has only been able to soak up some of the chronic underfunding rather than fundamentally change and improve service to patients. Recruitment of staff was also a problem, with many departments finding it difficult to recruit and retain nurses.
Skill-mix
It was recognised that by widening the roles and responsibilities of staff other than doctors, the efficiency of A&E departments could be greatly improved. One of the main obstacles in the way of increasing the skill-mix in A&E departments was the process which has to be followed in order for staff, other than doctors, to be given increased responsibility. The bureaucracy attached to the introduction of new protocols is off putting. A perceived increase in ‘blame’ culture within the NHS also blocks the introduction of changes in skill-mix – it can be difficult to find staff prepared to take on new responsibilities in an increasingly litigious society.
Disruptive patients
Disruptive patients are a big issue for both staff and patients. Sitting next to a person whose behaviour could be perceived as threatening is an unpleasant experience. A&E is often the place people with mental health problems, or drug and alcohol disorders turn to when they need medical help, but it may not always be the best place for them to receive treatment.
Accident and emergency medicine: possible solutions
Education
Whilst it was recognised that educating patients may go some way to reducing the number of admissions to A&E, most delegates thought education could not resolve the problem. For many people, A&E would remain the best place, in their eyes, to seek unscheduled care. However, some people thought that schoolchildren should be educated about the NHS, the services on offer, and the best way to access healthcare, and that more should be done to inform the public of how best to use the healthcare services available to them.
Integrating primary and community service with A&E
There was general assent for the principle that GPs should be present in many A&E departments, especially in inner cities. They are able to siphon off some of the non-emergency pressure and integrate care beyond the hospital, notably with other primary care facilities. In countries like Australia it is very common for a GP to work out of an A&E department. A GP who is part of a co-op which works with a local A&E department found that working so closely with A&E was beneficial for the A&E department, the GP and the patient. However, the seminar did recognise that placing a GP in every A&E department in the UK, would be difficult to do, and in some cases, unnecessary.
Some of the GPs at the seminar also felt that placing GPs in an A&E setting may fragment services rather than integrate them. It was also recognised that a better integration of care between all care services would benefit patients. Working closely with community services, for example, can help to speed up a patient’s discharge from hospital to community care facilities, eg a nursing home.
Skill-mix
A&E nurses are often discouraged from developing into new roles by the fact they are ‘hemmed’ in by traditional bands of what a nurse ‘does’. If nurses were given more responsibility, they would be more likely to continue working in A&E medicine. It was widely agreed that widening the group of people who can order tests, refer to specialists, discharge people, and prescribe low risk medication, would improve the efficiency of A&E departments. This would neither ‘de-skill’ the process nor simply shift problems from one group of professionals to another; an integrated team would actually help streamline the department. There should be protocols to guide most clinical decisions in A&E, applicable to doctors as well as other staff. It was also agreed that there needs to be a standardisation of the emergency nurse practitioner (ENP) grade. At the moment an ENP grade can be awarded to a wide range of people, some have trained for two weeks or less, others may have a BSc or an MSc.
There was recognition that some patients would prefer to have a doctor, rather than a nurse refer them on to a specialist. However, the majority of delegates felt that giving nurses the power to refer patients on would result in an efficient service and more timely referrals. With the correct protocols in place, nurses could take on more responsibility without falling victim of ‘blame’ culture. Training medical students alongside nurses, and other health professionals was considered to be an effective way to encourage team work.
Services on a 24 hour a day, 7 days a week basis
The main solution to providing this type of care would be an increase in funding and the introduction/extension of bedside testing which would allow for more efficient diagnostic testing. It was also suggested that the solution may lie in redesign, with the A&E forming the ‘hub’ of hospital care, as it does in Australia, rather than acting as a ‘bolt on’. However, it was suggested that the move towards ‘family friendly’ working for medical staff may actually take the service further away from the concept of 24 hours a day, 7 days a week hospital service. It was also agreed that the quicker a patient sees a senior member of the A&E team, then the quicker their condition can be diagnosed, and they can be treated. Early input by a senior doctor can also mean unnecessary admissions are avoided. However, this level of care from senior staff is reliant on a huge increase in hours for the doctors involved, or an increase in the number of senior staff in the department.
Disruptive patients
It was recognised that there is a huge diversity of conditions being dealt with within one system, and many felt it was ambitious to think that A&E could deal effectively with them all, and in particular when people are suffering from mental illness or from an addiction to drugs/alcohol. For people with alcohol and drug problems there are crisis centres which can provide treatment, but many turn to A&E when they need care. It was agreed that the best way to deal with difficult patients is to treat them first, despite the fact that other patients may resent this apparent ‘queue jumping’.
The seminar was also asked to take part in break-out groups to consider in more detail three problem areas facing emergency medicine and to identify key action points.
1. The first issue was where should the patient go for treatment? When a patient needs emergency care, or treatment out of hours, it is not always clear whether they should be seen by their on-call GP or go straight to A&E. The group thought the following points needed to be considered when attempting to tackle the issue.
- There is only a limited amount of education that can be done so patients are better informed of where they can go for treatment.
- A&E staff, other than doctors, should be given greater responsibility and increased powers, eg the right to prescribe, order tests and refer to specialists.
- Patients should be able to access a primary care package in A&E
- Diagnostic tests need to be more readily available.
- There is no one size fits all solution – problems need to be tackled at a local level.
- Improved access to patients records – care often fragments because there is a lack of information about the patient.
- Improved access to diagnostic tests.
- Patients should have early access to specialist care – via helplines and paramedics trained to treat people at home.
- Skill-mix – increasing the responsibilities of staff eg where nurses can facilitate a greater continuity of care for patients.
- There should be more non-medical staff in A&E who could help with the running of the department, talk to people, advise on waits etc…
- Improvements to the waiting room environment, eg a café, different areas for children and adults, classical music, fast-tracking of violent patients.
- National publicity – to help inform the patient of how best to use primary care and A&E.
- The input of expert patients should be sought, they could contribute to staff training, and advise on improvements that could be made to the current system.
- More beds and more staff – would lessen the wait and improve the experience for all.
The key issues discussed during the seminar were:
Problems
The single biggest problem facing A&E is a lack of available beds throughout the rest of the hospital. Other problems include a lack of staff and funding and the fact that A&E departments operate on a 24 hours a day, seven days a week basis but some parts of the hospital, and other services, do not. Obtaining diagnostic tests from A&E can be a time consuming process, delaying diagnosis and ultimately the admission/discharge of a patient.
Solutions
Multi-skilling: nurses and other healthcare staff want and could take on new roles including prescribing, making referrals, and ordering tests. GPs should be provided in some A&E departments, especially in inner cities where appropriate or feasible. Waiting room environments could be improved with better facilities, such as a café, and a waiting room with different sections for different groups of people. Disruptive patients should be dealt with as quickly as possible. There should be more information available to the public to inform them about the healthcare services available to them. It is important to realise that there is no single solution – different hospitals have
different problems, which need to be tackled at a local level.