Urgent Care- is it time for a “Chain of Urgent Care”
Chair – Professor Stuart Maitland-Knib
The webinar highlighted a lot of work, in the NHS, to meet the challenges of providing Urgent Care. Recent developments such as on-line triage, increasing numbers of telephone consultations, the increasing the sensitivity of NHS Pathways, the 19 million triages undertaken each year using NHS Pathways, the development of multi-disciplinary working, the potential to use Community Pharmacists more effectively. Highlighted was the volume Urgent Care provision provided by the ambulance service and the ability to link triage data to Emergency Department and hospital discharge data and produce high quality evidence to guide service improvements.
Also raised were issues that need development, including training of a multi-disciplinary workforce, training in telephone consulting, high intensity users, providing greater clarity for the public on how to access Urgent Care and the need for a body to robustly lobby for Urgent Care. The Faculty of Pre-Hospital Care (FPHC) will, over the next 6 months, try collect information and promote discussion on these issues and timetable another webinar for late 2022 or early 2023. For information on developments and the next webinar please visit https://fphc.rcsed.ac.uk/examinations/diploma-in-urgent-medical-care/news A recording of the webinar will be available to all until ??????? and after this date will still be available to RCS Ed members https://www.rcsed.ac.uk/professional-support-development-resources/learning-resources/webinars/faculty-of-pre-hospital-care/urgent-care-is-it-time-for-a-chain-of-urgent-care
Colville Laird introduced the webinar stating that the FPHC feels that Urgent Care is an incredibly important part of Healthcare in the UK and thinks that clinicians should be encouraged to see UC as a career choice.
Urgent Care and Pre-Hospital Emergency Medicine (PHEM) have much in common and exams were pivotal to the development of PHEM, this was the reason for setting up the Diploma in Urgent Medical Care as a multi-professional exam to evidence professional development in Urgent Care
PHEM has also highlighted the importance of systems of care such as the Chain of Survival and Regional Trauma Systems and the FPHC thought it would be useful to look at the components of urgent care provision in the UK with the hope that this will lead to discussion on how urgent care providers can help each other for the benefit of patients.
NHS 111 Online
The first speaker Martin O’Keeffe reviewed the work of NHS 111 online. This service deals with approximately 30% of NHS 111 demand, provides an emergency prescription service, a repeat caller service, an Emergency Department streaming and redirection tool and support to redirect users to NHS.UK for advice and self-care. The work includes translation of NHS 111 pathways to digital online content. This work, the governance, data collection and collection of feedback were outlined
As a result of contact with NHS 111 online patients are referred to :-
- Primary Care – 41.7%
- Urgent and Emergency Care – 26.5% (ED 14.1% and 999 12%)
- Clinical Assessment Service – 12.4%
- Self-care – 7.4%
- Dental – 7%
- Urgent repeat prescription – 4.8%
- Other – 0.5%
As an example of NHS 111 online work, 565,554 online sessions were completed in April 2022, that was 28% of NHS 111 sessions, 95% of sessions were completed and the average duration of a session was 80 seconds.
James Phelan described the work of NHS Pathways in writing the clinical content for NHS 111 services and six of the eleven 999 services in England. These pathways are used in 19 million triages every year (50,000 + calls/day). These are mostly managed by non-clinically trained Health Advisors. Key to this service is not aiming for a diagnosis but to provide an appropriate outcome which can range from an emergency ambulance to self-care. James highlighted was the value of the data produced by the huge volumes of patient contacts providing a high quality evidence base. This is strengthened by the linking of triage data to Emergency Department and hospital in-patient data allows for the verification of pathways.
NHS Pathways produces a monthly infographic triage report, which James demonstrated, and is well worth accessing.
Clinical Governance in NHS Pathways
Agnelo Fernandes, Chair of NHS Pathways National Clinical Governance Group outlined the work of this group which provides external scrutiny of NHS Pathways and includes representation from all the royal medical colleges, the ambulance service, Public Health England and the Royal Pharmaceutical Society. The importance of this group is two fold. As evidence changes pathways have to be changed and this group provides scrutiny of these changes. Secondly as huge amounts of data are collected on the system and linked to outcome data it becomes possible to review pathways to make better use of resources. As a example, by analysing data for chest pain in patients under the age of 35, pathway changes have been made which will reduce the number of Category 2 ambulances required for these patients by 120,000/year. In July of this year changes will be made to the Allergic reaction pathways which should reduce Category 1 ambulance calls by 7,000/year and Category 2 calls by 40,000/year. It has to be recognised that a balance required, when you have finite resources, of pathways using resources to allow for very rare possibilities against reducing resource availability for other emergencies. Built into this governance is a system to react quickly to serious incidents involving NHS Pathways.
Urgent Care in The Ambulance Service
Dr Leon Roberts, Executive Medical Director of East Midlands Ambulance Service outlined the work of a regional ambulance service. 3,500 calls, 2,000 responses.
- 13% dealt with by a phone call, redirecting to make own way or to a pathway
- 33% dealt with by see and treat and discharge on scene
- 54% to a destination
28% of work and 16% of responses is Urgent Care not Emergency Care.
The Ambulance service workforce varies widely in training in experience and training from community responders, patient transport, technicians, paramedics, ambulance nurses to specialist and advanced practitioners. The more senior the practitioner the lower the conveyance rate. It is important to recognise that whilst many ambulance professionals are well practiced in handing over patients in Emergency departments they are less experienced at handing over urgent care patients to other urgent care clinicians. It is important they are seen as “ trusted referrers” and the ambulance service welcomes being part of a “ Chain of Urgent Care”
The Royal Pharmaceutical Society Speaker, Kirsty Dunlop highlighted that there are over 13,000 community pharmacies in the UK, many open 7 days a week and some with extended hours. Contracts allow for redirection to community pharmacy for minor ailments or those requiring urgent prescriptions. Arrangements for community pharmacists vary throughout the UK. In Scotland all pharmacies can use Patient Group Directives ( PGDs) to prescribe for minor infections and bridging contraception and pharmacists, with prescribing rights, can prescribe for common conditions within an agreed formulary. In England referral from a GP or NHS 111 is required to access these services. Data from October 2021 suggests that only 800 of the 6,000 GP practices in England are fully utilising this service which allows the urgent provision of prescription only medicines, appliances and advice. Some areas of England have expanded the service to use PGDs. Wales have recently updated to similar arrangements to Scotland with prescribing by PGDs and independent prescribing by pharmacists who have gained prescribing rights. The potential for using community pharmacies to provide urgent care has a lot of underused potential. Currently there is a strong focus on encouraging pharmacists to obtain independent prescriber qualifications and for universities to allow student pharmacist to graduate with prescriber qualifications. Contracts need to change for this service to achieve its full potential.
Urgent Health UK
Dr Simon Abrams from Urgent Health UK that providers set up as social enterprises provide about 40% of urgent primary care provision in England.
One issue is that the lay population and some of the NHS are not familiar with this part of Urgent Care provision and this needs addressed. The question is who is best placed to help address this problem.
There is a shortage of GPs to provide Urgent Care. Multi-disciplinary teams including GPs, Pharmacists, Paramedics, Advanced Nurse Practitioners and Physicians Associates are all working well and progress in the development of Multi-disciplinary teams will progress. Technology is also helping to make the best use of limited resources.
Providers must be capable of meeting changes necessitated by advances in care and evidence based guidance. This includes empowering patients to look after their own health.
Continuity of Care is an issue, as structures change, but continuity is possible and we must try to provide this.
UHUK works with its members by networking, benchmarking using an NHS audit body, identifying problems, finding solutions and sharing best practice. Despite the challenges standards of care are improving.
Question and Answer Session.
- High intensity Users were discussed and it was highlighted that it was good practice for every service to collate high intensity use. High intensity use could be across multiple services. The patients needs are not being met. There is now a national lead for high intensity use. The solution requires high intensity input to address the patients issues. This requires significant one to one input and the NHS does not have this resource. The voluntary sector is being looked at to help address this issue.
- Training was identified as having major issues. The following points were made.
- There are good governance frameworks for non-doctors but no national standards so organisations have to create their own systems.
- The purpose of multi-disciplinary teams is that you direct the patient to the most appropriate clinician and job descriptions are different in different organisations.
- Job descriptions are different in different organisations.
- Inputs – no national standards for already qualified standards.
- GP registrars no longer have to do OOH and should be addressed
- Standardise training for telephone consultation.
- Would NHS benefit from a 24/7 service Urgent Care Service ?. It was the opinion of the panel that NHS 111 provides this but this could be further developed.
- Can we achieve a Chain of Urgent Care?. It was felt this might be difficult to develop but could be useful for informing the public regarding points of access to Urgent Care.
- Is there a need for a College of Urgent Care as they have in New Zealand? It was felt that Urgent Care is part of a continuum and that there was risk of disturbing this, but there is need for consistency of Multi-disciplinary training in Urgent Care. No need for a College but need for a Faculty. Dr Leon Roberts pointed FPHC has really helped Pre-hospital Care.
For more information on the DipUMC examination please visit our website, and to view the webinar please follow the link below. Please note, you will need to be a member of the Faculty to view the webinar.