What is the future of emergency and urgent care?

I recently presented findings from my research into NHS winter pressures at a policy event on the subject, held by the Health Foundation and Health Services Research UK (HSRUK). The presentation prompted debate in the room from senior NHS leaders, board members, policymakers and urgent and emergency care specialists about the future of emergency medicine.

There is no doubt that the emergency medicine brand is a hugely successful one – and one which has undoubtedly become a victim of its own success. Each year, more and more people trust the brand and turn to it for support for themselves and for their families. Levels of satisfaction with the service are high – people frequently come back. However, this leads to challenges in meeting the increasing demands being placed upon us while also delivering excellent, timely and cost-effective care.

Over the last 20 years, we have seen more patients seeking emergency care who suffer from chronic illness, social isolation, mental health conditions, cancer and the effects of ageing – all of which are difficult to manage in an emergency setting. We have also seen increased use of emergency services by patients either referred by other health care providers or who have problems that could be treated in a primary care setting. The reasons for this are complex but reflect the ongoing difficulties that primary and community care services are experiencing in managing an unscheduled care workload. The change in both the volume and the nature of patients we are seeing has pushed emergency care services to their limits. In turn, it has led to significant difficulties recruiting and retaining staff across all disciplines in emergency health care.

I have worked in emergency medicine for over 20 years, and have watched morale suffer as services struggle to manage these demands. As an academic trying to deliver evidence-based solutions to the challenges we face, I am increasingly struck by how complex the issue is. Urgent and emergency care systems are supply-rich, resource-poor and roughly 20 years behind where we need to be to meet the requirements of the public.

As a clinician, I experience a constant tension between wanting to provide high-quality care, while also not wanting to be the nation’s parent – providing health care advice and reassurance to everyone I see. This is something we can neither afford nor resource. Equally, however, it should not be the job of the clinician to decide who should be seen and who should not – we need a system that caters for everyone, sorting patients as safely and appropriately as possible from the first point of contact. So, what are the solutions?

Simple, accessible care 24/7

You can see how access to Amazon deliveries 24/7 may have led younger generations to assume their access to health care should be similarly simple – Dr Google can diagnose them in a matter of minutes. They no longer want to phone for an appointment, preferring to turn up whenever suits them, for easy access to reassurance from someone they trust. This risks further increasing demand. However, equality of access to all unscheduled care services needs to be addressed and must also be delivered out of hours – when the evidence tells us the public need and want it the most.

Improved care for the most vulnerable

Patients with acute mental health problems, complex chronic health problems or ageing patients often have little choice but to call an ambulance or come to A&E. Once there, these patients spend longer either waiting for a specialist assessment or for an in-patient bed. These are the most difficult patients to treat within the first precious four-hour window due to the complex and often undefined nature of their problems, some of which simply cannot be resolved in this environment. Evidence tells us many of these patients can be safely managed in the community, which would lead to significant reductions in A&E attendances and hospital admissions, thus saving money. Ambulance services could have a crucial role in assessing and, wherever possible, leaving patients in the community to manage their conditions. However, paramedics need to be empowered to access community services and able to make the difficult decision to refuse transport to some.

A workforce fit for purpose

Our A&Es are still largely staffed by junior doctors who sometimes lack the experience, confidence and support required to decipher which patients can be safely sent home and which cannot. Therefore decisions are delayed, testing rates rise, treatments are uncertain and reasons for admission are often dubious. Growing a workforce in the pre-hospital and A&E setting is crucial in rising to the challenges we face. We need staff who are experienced and confident in the management of emergency conditions, but this is increasingly something GPs are not trained to do and pharmacists simply aren’t going to manage it alone and without significant additional training. There is certainly a role to play for advanced practitioners who have paramedical or nursing backgrounds ideal for providing the expertise we need. However, their potential impact on existing workforces needs careful management.

Avoiding hospital admissions

In recent years we have seen an alarming increase in emergency admission rates, with many patients staying in hospital for less than 48 hours. There is an opportunity here to examine the types of patients we are admitting and to consider which strategies could be implemented to help reduce these admission rates. Measures might include increasing the delivery of ambulatory care or offering early access to frailty teams and mental health teams at the front door. There is also evidence that admission avoidance strategies in the community are effective in keeping patients out of A&E and therefore the hospital. Incentivising admission avoidance across the whole system is something we should be putting forward for discussion.

The fascinating discussion at the event highlighted the need for a clear policy direction on the future shape of urgent and emergency care that reflects the way the public want and need to access it both now and in the future. We all agreed the challenges are complex, but that fewer boundaries and closer working between community and hospital services will ultimately deliver the solutions that will provide greater flexibility and efficiency.

Suzanne Mason (@masons301265) is Professor of Emergency Medicine at the University of Sheffield