What impact are emergencies having on the health sector?

Published 5 noviembre 2018

With medical emergencies topping the list of medical negligence claims, Radhika Holmström examines the pressures on emergency staff and looks at how some trusts are trying to ease demand.

Last year emergencies accounted for the highest proportion of clinical negligence claims. Indeed, according to NHS Resolution “the greatest number of claims received across all our clinical negligence schemes [during 2017-2018] relate to the emergency medicine speciality (13%)… in 2017-18 we received 1,395 new Casualty/A&E claims, which is an increase of 88 claims (7%) on the previous year.”

In addition, emergency admissions are on the rise, year after year. The National Audit Office (NAO) calculates overall emergency admissions rose by 10.2% between 2012-2013 and 2016-2017, with emergency readmissions increasing at a much higher rate.

To complicate matters, ‘emergencies’ are not always defined in the same way. NHS England’s own methodology records admissions through A&E and ‘other emergency admissions’. The NAO’s recent report Reducing emergency admissions admits freely that the data has been inconsistent, particularly before October 2017 when NHS England launched a new dataset.

Readmission data is especially problematic, as well as the fact that some hospitals do and others do not record day case emergency care as an emergency admission.

The NAO also points out that care records are not consistently recorded, or linked, at local level as patients move through other parts of the health and social care system. “Emergency admissions may not even go to an A&E department, though I would imagine that the majority do come through an emergency department,” says Dr Adrian Boyle, Consultant Emergency Physician at Addenbrookes Hospital and Chair of the Royal College of Emergency Medicine’s (RCEM) quality emergency care committee. It is not surprising that the House of Commons Committee of Public Accounts report called for data collection to be improved and clarified.

The story behind the statistics

Successive bodies, including the NAO and the Health Foundation, have published reports into emergency admissions, their impact on the rest of the hospital and indeed the wider trust, and on how these admissions can be reduced.

NHS Resolution monitors the figures and the NAO points out, however, that “when the health and social services are not working effectively, the pressure is usually felt within accident and emergency (A&E) departments. For example, if patients are not accessing appropriate primary care, community care or social services, they may turn up at A&E departments, placing additional pressure on A&E services.”

A report to the House of Commons Committee of Public Accounts in June 2018 concluded baldly, that 24% of the emergency admissions in the previous year might have been avoided if people had had more effective community healthcare and case management to stop them becoming so unwell that they needed emergency hospital care.

This is underlined by the fact that 53% of growth in emergency admissions came from people aged 65 and over between 2013-14 and 2016-17. The Health Foundation adds that the proportion of emergency patients admitted for an overnight stay who have five or more health conditions has increased dramatically in the past ten years; in 2006-2007 it was one in ten and nine years later it was one in three. All of these put additional pressure on the hospital’s resources – and, obviously, disrupt elective activity.

NHS England and its partners have set up a number of initiatives aimed at reversing the rise in admissions, with a particular emphasis on integrating health and social care and improving access to primary care. These do seem to be having an effect, albeit with the significant point that there are issues with data quality.

Community services: the vanguard sites

In particular, several bodies have noted that the 50 new care model ‘vanguard sites’ and the 33 ‘sustainability and transformation partnerships’ (STP) appear to be driving down the rates of emergency bed days. And although Vanguards are not new, and are an initiative borne of the Five Year Forward View, there are now some positive trends as a result of the work in this area to date.

Analysis by NHS England indicates that, in areas covered by population-based vanguards, the number of emergency admissions to hospitals has grown more slowly, on average. In the 12 months to March 2018, compared with 2014-15, emergency admissions in vanguard areas grew by 0.9% in MCPs and 2.6% in PACs, compared with 6.3% elsewhere. The two most striking examples are Better Care Together in Morecambe Bay, which has seen a 7.8% decrease in admissions and Encompass (Whitstable, Faversham & Canterbury), where admissions have dropped by 7.3%. Within that, there are even more striking examples; for instance, the Principia vanguard in Rushcliffe, Nottinghamshire has reduced A&E attendances by 29% for care home residents.

These areas do not have a specific focus on ‘emergencies’; instead, they focus on the kind of community-level support that stops people reaching the emergency ward in the first place. In Millom (covered by Better Care Together), residents can use a telehealth link between the GP practice in the town and the Emergency Department at Furness General Hospital to receive advice on their condition, rather than take the 40-mile journey. The care home residents in Rushcliffe receive an ‘enhanced care package’ which includes regular visits from a named GP and independent support from Age UK Nottingham and Nottinghamshire. In Encompass, GPs can access a specialist geriatrician every day.

The common theme running through this is communication – which also means getting the underpinning data in place. DAC Beachcroft Partner Hamza Drabu and his colleagues have been advising vanguard sites and other health systems seeking to collaborate on the legal issues that support their work. “Most have put in place collaborative arrangements, usually in the form of an alliance agreement, which is effectively a document setting out all the parties’ roles and responsibilities, and working out how best they can avoid unnecessary hospital admissions.”

A number of health systems are using ‘risk stratification’ to support the clinicians who lead this strand of work. This requires the sharing of data across organisational boundaries. “Risk stratification is about using personal data to understand which patients are most at risk of certain outcomes,” says Drabu. “It is essential that NHS organisations have written, legally binding arrangements to underpin how they are sharing this data. We have worked with systems to put in place data sharing arrangements across over 200 organisations to enable more integrated care. A big part of this work comes from ensuring the technical solution is properly catered for in the data sharing agreement.”

“If you are clear about what you are signing up to do, that can be the difference between collaboration working or failing. Local health systems need to be clear, both with each other as well as with patients, when it comes to data. The communication and engagement with patients is fundamental.”

The emergency specialists

As Boyle explains, emergency medicine has been an established speciality in the UK for over 50 years. “We undergo a training programme that is equivalent to all other hospital doctors. We are almost unique among the medical colleges in that we’re defined by the speciality rather than the profession: we need to be a multidisciplinary group, focused on the practice of the medicine.”

“The thing that strikes me most often is that you are dealing with the entire spectrum of medical presentations,” adds Dr Gregor Campbell-Hewson, Consultant in Emergency Medicine at the Royal Hospital for Sick Children and the Royal Infirmary in Edinburgh. “Our expertise is wide but it’s spread more thinly. A neurosurgeon may not feel you’ve done a great job but you also have to have expertise in assessing and managing a woman with abdominal pain, a baby with a fever or an adult with chest pain. We are the GPs in hospital, but the difference is that you’re dealing with a different, much sicker, patient population.”

Campbell-Hewson adds to Drabu’s point about the importance of data and documentation. It is also a vital tool in his department’s day-to-day work – especially in regard to conditions that can occasionally become very serious, and for which the management may be questioned. “There are very specific things that you would document, which would dictate your further management. Often it takes more time to write things down than do them – and you’re never going to write down everything – but there are key things that you need to have in the summary, with each condition, that will inform your diagnosis and the management process.

“It will also, to some extent, justify your course of action. It may be that if it proceeds to a negligence or complaint process, at least your word is there. If you have no documentation, that weakens your position.” By extension, Campbell-Hewson adds, that also supports the hospital more widely. “It’s not the individual being sued, it’s the trust.”

A multi-factorial solution

Drabu adds that there is a common aim across local health systems to tackle the systemic issues that underlie unnecessary emergency admissions. “It is fair to say the system is geared to reward activity in hospitals, rather than incentivising care in the community. So many local health systems are trying to find ways for acute, community, mental health and primary care providers to collaborate to ensure that people are treated in the most appropriate setting.”

This is certainly what Boyle and his colleagues at the RCEM want to see too. “The college is very clear that attempts to reduce emergency attendances over the years have largely failed,” he says. “We believe the best way to reduce demand is access to primary care, and access to good social care. We are aware that our colleagues in primary care are under enormous pressure, but a truly effective healthcare system is rooted in strong primary care. Community alternatives need to be available right across the week.”

In the event of error

Inevitably, some medical emergencies do have adverse outcomes. “If that happens, and you are the healthcare provider, you are not alone – and you shouldn’t be alone,” says Campbell-Hewson. “One survey demonstrated that 90% of doctors have either been involved in an error or a near miss. You should be looking to be supported by your colleagues and by your most senior colleagues in particular.

“You’re also not necessarily the best person to make a judgement about it; it’s probably better to leave that to someone who has a more dispassionate view. It doesn’t necessarily have to be a clinician, but it does need to be someone who understands the process – who knows, for instance, that the only place you can get an MRI scanner outside normal surgical hours is a specialist centre.”

Gregor Campbell-Hewson (Consultant in Emergency Medicine), alongside Tim Draycott (Consultant Obstetrician and Gynaecologist) and David Pemberton (Consultant Orthopaedic Surgeon) has provided advice on dealing with complaints and claims in DAC Beachcroft’s video for junior doctors. The video collates 90 years of experience in dealing with claims, in seven minutes. Watch the full video here: www.dacbeachcroft.com/junior-doctors   

To discuss the issues raised in this article, please contact Hamza Drabu on +44 (0)20 7894 6411 or hdrabu@dacbeachcroft.com