IPCHS. Integrated People-Centred Health Services



The urgent care system is at breaking point. NHS figures from the winter of 2017-2018 were the worst on record with January 2018 marking the 30th month in a row that the four-hour target has been missed. This was even after the large-scale cancellations of non-urgent treatment that occurred in order to prioritise urgent and emergency care. Over 80,000 patients waited on trolleys for more than four hours at A&E in January, 1,000 of which were waiting for over 12 hours - the highest numbers since records began. Their 4th Annual Urgent Care Conference: Delivering Integrated Solutions will seek to address how we can avoid crises like these in the future.

Sustained austerity measures over the last several years have led to reports regularly hitting the headlines of the continuous problems within urgent care. Bed-occupancy for overnight acute beds have risen from an average of 87.1% in 2010-11 to 90.4% in 2016-17. Some hospitals have been at 95%. In addition, 13% of patients spent longer in A&E than the four-hour standard during 2016-17.

The amount of day-only beds (used when patients require same-day procedures) has risen by over 520% since 1987-1988. With the UK population expected to grow to 74 million by 2039, increasing and improving NHS capacity as a whole is becoming ever more important. Moreover, with an ageing population to take care of and, with those aged over 80 having the highest rates of A&E attendance, there is likely to be ever more strain on urgent care services. Their conference programme will examine in detail the many facets of urgent care and what can be done to improve the situation and provide practical solutions.

The NHS is under unprecedented strain. Nationally the NHS has failed to hit any of its main targets in each of the last 12 months, including the system benchmark of seeing 95% of A&E patients within four hours. A&E Departments built fifty years ago to see maximums of 350 patients a day are recording 500 to 700. A&E units managed to treat and then admit, transfer or discharge just 77.1% of arrivals within the four-hour target in January 2018. Staff are overworked and patients are feeling the impact. Over 80,000 patients waited on trolleys for more than four hours at A&E in January, 1,000 of which were waiting for over 12 hours - the highest numbers since records began. Furthermore bed occupancy levels in hospitals were recorded at 95% in January 2018, far above the 85% limit that health experts have stressed should be the maximum in order to prevent the spread of infection diseases such as MRSA.

Alongside the increasing rise in patient demand for urgent care there are additional pressures on health and social care resources. Demand for NHS services is rising at around 4% a year but funding is rising at the slowest rate since the service was founded in 1948. In the last seven years NHS funding has risen in real terms by 1%, prior to this was at 4% each year, and this financial year it will be 0.7% meaning that trusts will again be tasked with making savings. A study from January 2018 ‘Population and patient factors affecting Accident and Emergency Department attendance in London: an analysis of linked primary and secondary care records’ by Queen Mary’s University showed that the sheer number of patients, rather than a lack of GPs, is causing more A&E admittances and therefore longer waiting times. The research further indicated that A&E attendances had tripled over the last 50 years.

So how can the healthcare services ensure next winter care improves? Winter 2018/19 is coming and with it the well recognised conditions that create sudden surges in demand or reduce the NHS’s ability to meet this demand. Usual suspects include influenza-like illness, respiratory diseases associated with colder weather, and infectious winter vomiting bugs like norovirus that can close entire hospital wards. These impact on NHS staff as well as patients, further adding to pressures on services as staff sickness increases over winter. Bed-blocking remains a major problem for many hospitals and this is especially true in winter. There was only one day last winter where bed occupancy was under 85% - Christmas Eve.

Pressures on social care are adding more strain on urgent care. Fullfact have reported that the number of elderly people being rushed to A&E from care homes has risen by 62% since 2010. This only adds to the huge pressure already on A&E services. NHS figures from 2017 have shown that up to 100,000 patients over the winter had to wait in ambulances before being able to enter A&E due to overcrowding. A lack of patient awareness of what medical issues require urgent care also contributes to over-demand. Initiatives such as the Patient Awareness Measure (PAM), multispecialty community provider vanguards, the 111 System and the recent Stay Well Pharmacy campaign have aimed to ease patient flow. Reflecting on how these programs have been received will further help shape improvements in urgent care.

Of the four home nations, Scotland is leading the way in meeting the four-hour standard. This is followed by England, Wales and Northern Ireland respectively. Comparing different systems is a useful tool to understand the best approaches. There is not one simple solution to the urgent care crisis but it is clear a more whole-system approach is needed. Gathering the necessary data and looking at evidence to find best practices will help improve urgent care. Different services are too often inadequately joined-up such as sufficient social care not always being in place for patients upon being discharged from hospital, thereby leading to delays. Different stages of care such as primary, ambulatory, social and community and others must be more integrated.

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United Kingdom