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Special investigation: Solutions to the A&E crisis

A&E diversion pilots showing promise and proving popular with nurses


Early results from pilot schemes to divert patients away from busy accident and emergency departments are showing promise, though nurses warn they are not the whole answer to the current crisis.

Early success for pilots in Barking and Bolton

Trusts taking a tougher stance on diverting patients from A&E – including telling people to simply go home and rest – appear to be successfully relieving pressure on hard-pressed emergency nurses and doctors, Nursing Times has learnt.

“We need to stop talking about A&E and educate the next generation”

Tim Collier

The results from two recent pilots in different parts of England suggest patients who show up at A&E with minor conditions can safely be sent home with basic advice on “self care” or information on getting a GP appointment.

The trusts in question say the trials have been welcomed by emergency nurses and doctors and enabled them to concentrate on caring for seriously ill patients.

However, emergency care experts have warned diversion tactics can only go so far to lifting burdens on over-stretched departments and highlighted the need for wider reforms.

Early results from a pilot by Bolton Clinical Commissioning Group and Bolton Foundation Trust suggest their redirection pilot at the Royal Bolton Hospital, is helping improve performance on waiting times targets, said Tim Almond, senior clinical commissioning manager for urgent care at the CCG.

“It has gone better than expected,” he told Nursing Times. “We were hoping to hit about 20% deflection in the period and we’re running at about 22.5-23%. Some days this was as high as 39%.”

The trial, which ran for the first two weeks of August from 6.30pm to 10.30pm, Monday to Friday, and between 4pm and 10pm on Saturday and Sunday, saw an advanced nurse practitioner located in reception to assess whether children or adults coming in to A&E needed to stay or could be seen by primary care.

Bolton NHS Foundation Trust

Trust launches maternity care review after baby death

Royal Bolton Hospital

Those sent to primary care were then seen by a triage GP close by who would either send patients home with advice on looking after themselves, seeking further help from a pharmacist or making an appointment with their own GP, or refer them to an on-site out-of-hours GP for a full consultation.

All GP practices in Bolton have committed to seeing patients deflected from A&E and are alerted when this happens. Meanwhile, signage around the trust makes it clear patients coming to A&E “may be turned away and redirected to another NHS service that is more suitable”.

During the trial period, 239 patients were diverted from A&E and there was “no evidence of additional pressure on GP practices during the trial period”, said a trust spokeswoman.

Nearly two thirds – who had come to A&E with straightforward respiratory issues, headaches and other minor ailments – were sent home by the triage GP, noted Mr Almond.

A survey from nearly 50 patients diverted from A&E in the first week found about 93% said they had enough time to discuss their medical problem with the doctor and 91.5% said they felt it was appropriate for them to be streamed to see a GP.

In all, 64% described their level of satisfaction as “good” or “excellent”, 17% said it was “satisfactory”, while 15% said it was “poor” and 4% said “very poor”.

Royal Bolton NHS Foundation Trust

Exclusive: A&E diversion pilots hint at relief for nursing staff

One of the signs in sue at Bolton

Mr Almond said the scheme had been welcomed by A&E clinicians, who had “now almost come to rely on” it, with staff using the service as a “release valve” and starting to actively identify cases that could be treated in primary care.

While it was early days, there was some evidence to suggest the scheme was helping the trust achieve the 95% four-hour waiting time target for A&E, he said. This was at just over 82% at the start of the trial but the trust exceeded 95% for three days straight towards the end of the fortnight.

The trust and CCG said they were continuing to develop the model and Mr Almond said the plan was to replace the triage GP with a triage nurse and eventually scale back to one GP as a key finding was they did not really need two GPs on duty – due to the high proportion of patients that did not need an urgent appointment.

The organisations were also working on a targeted urgent care communication strategy to encourage the public to use appropriate health services, which could include information in a wider range of places like pubs, gyms and shops and going into schools to educate children.

“We stick stuff – as does everyone across the country – on the side of buses and in bus shelters, and in the hospital but it is too late by then and people see it fleetingly – don’t go to A&E, don’t do this at A&E or that at A&E. All we ever reinforce is the word A&E,” said Mr Almond. “We need to stop talking about A&E and educate the next generation.”

“The staff have really welcomed it and responded brilliantly”

Mairead McCormick

Meanwhile, a two-week pilot by Redbridge CCG and Barking, Havering and Redbridge University Hospitals Trust in mid-July, which saw an emergency consultant or GP redirecting adult patients from A&E at Queen’s Hospital in Romford from 8am to 8pm, was extended for another four weeks.

The trust’s deputy chief operating officer, Mairead McCormick, said the pilot was “going really well”, with a high percentage suitable for “self care” and advised to go home, take painkillers and rest, visit a pharmacy or make a GP appointment.

“On average there was a good 50 to 60 patients per day that we could turn around quite safely and promptly without any intervention,” she said. “We haven’t had any patient upset or complaints because they seem to accept the advice and leave knowing what they need to do.”

Barking, Havering and Redbridge University Hospitals NHS Trust

Exclusive: A&E diversion pilots hint at relief for nursing staff

Mairead McCormick

She said the majority of those sent home had “very minor coughs, colds and sore throats” or were people who’d had chronic problems for months or years best served by primary care. Those felt to need a same-day GP appointment were seen at the hospital.

A key consideration for the pilot was whether the trust and CCG needed to look at creating extra capacity in primary care or out of hours service but “currently it does not look like we do”, said Ms McCormick.

Another issue was the fact there was some anecdotal evidence to suggest the message had got out was it was better to show up at A&E after 8pm if you wanted to be seen.

She said the trust had not noticed a post-8pm surge but there was monitoring the situation “because that would cause a big problem in the evening, which is the most difficult time at the moment”.

She said staff had embraced the scheme. “It has released the time of the junior doctors and nurses to care for the more sick patients in the majors and resus area,” she said. “It has de-crowded the department, if you like, and enabled them to focus on the more acute patients.

“The staff have really welcomed it and responded brilliantly,” she said. “They believe it is the right thing to do and are particularly pleased the patients have responded well because they were anxious about that and the fact we haven’t had complaints and patients have been quite compliant has made it easier.”

Queen's Hospital Romford

Queen’s Hospital Romford

Queen’s Hospital Romford

Ms McCormick said the scheme was a “working model in progress” and one recent change was to try deploying a consultant nurse in the “demanding” redirection role as opposed to a doctor.

However, she said there was some evidence it was “the seniority of the emergency consultant or GP that made the difference” and senior nurses preferred to redirect to another service on site or a booked appointment rather than actually sending people away.

She said the trust and CCG had decided not to redirect children who came to A&E because that was “a different level of risk”. However, they were exploring “redirection to emergency health appointments” for younger patients, which would involve “using all of the external capacity to its max”.


Royal colleges back emergency ‘hub’

The findings from the two pilots coincide with the recent publication of a report by the Royal College of Emergency Medicine and Royal College of Nursing, which warned that emergency care services were at “crisis point” due to increased demand and staffing shortages.

The report emphasised the need for wider changes in education and training, workforce planning and the way services are organised and work together.

However, the Royal College of Emergency Medicine said it had concerns about redirection strategies.

“With the mixture of patients attending A&E presenting with a wide variety of health problems and injuries, we are cautious about a redirection strategy unless clear patient safeguards are in place,” said a statement from the college.

“Our preferred approach is to co-locate services around the emergency department to create a hub of services,” it said.

Co-location was one of the key recommendations in the colleges’ joint report – The Medicine needed for the Emergency Care Service.

Under the A&E hub model – emergency services would operate alongside out of hours urgent primary care, pharmacy and crisis mental health services.

Create service ‘hubs’ to ease A&E crisis, says RCN

Anna Crossley, professional lead for acute, emergency and critical care at the RCN, said it was partly about “embracing the fact people are going to come to A&E”.

“Co-location is a model that makes sense. Patients are happy because they are where they are supposed to be – more or less – and get seen, treated and sent away by an appropriate person in a more efficient timeframe,” she said.

Special investigation: Solutions to the A&E crisis

A&E diversion pilots hint at relief for nursing staff

Anna Crossley

She highlighted the need for a culture change within the health service with more cross-speciality collaboration and joint working.

“Emergency departments have historically been quite good at that – they are used to working as a team of emergency nurses, doctor and allied health professions,” she said.

“But there needs to be a change that goes across even more specialities to understand that patients can be seen by a professional who maybe they’re not so used to working with like a pharmacist or phsyio.”

At the same time, she said there was a need for more dialogue between acute, community and primary care.

“It is about understanding the pressure on all parts of the system,” she added. “If you understand what other people’s pressures are you are more likely to be able to talk together and decide what is appropriate. This is about how integrate emergency care is going to work going forward.”


The need for wider service reform

Other experts also pointed to the need to look beyond emergency services for system-wide reform.

Consultant nurse Mandy Rumley Buss who works with the Emergency Care Improvement Programme and Acute Frailty Network said services – especially primary care – needed to change to reduce the number of people seeking help at A&E.

“Many people would argue these diversion tactics are hitting it in the wrong spot,” she said. “Once a person gets to A&E then something needs to happen. But what are we doing to divert people before they get there through admission avoidance schemes in primary and community care?”

She said patient education strategies were not working. “We have been trying to educate people not to go to A&E since 1961 and haven’t achieved that,” she said.

Special investigation: Solutions to the A&E crisis

A&E diversion pilots hint at relief for nursing staff

Roisin Devlin

Instead, GP services must be geared up to analyse data on inappropriate A&E attendances and take action to support people to access primary care. This should include schemes for those with long-term conditions “who need support but are obviously not getting it if they feel their only recourse is to go to A&E”, she noted.

“We need to try something else,” she said. “The whole system needs to recognise this is not just an A&E problem and primary care needs to do its part.”

Roisin Devlin, lead nurse in the emergency department at Northern Ireland’s Southern Eastern Health and Social Care Trust, said the government’s Choose Well campaign to encourage the public to think more carefully before calling on emergency services did not seem to have had much impact.

“It’s all well and good wanting to stop patients coming to the emergency department,” she said. “However, until we create more GP out of hours appointments as opposed to an on-call service and more accessibility for outpatient appointments and clinics, people are always going to come because we are open 24 hours and they know they will be seen by someone.”

She said emergency hubs could be part of the solution but said services in her region were “not talking about it yet”.

Crystal Oldman

Crystal Oldman

Crystal Oldman

Meanwhile, Crystal Oldman, chief executive of the Queen’s Nursing Institute, said workforce planning – especially when it came to capacity in community services – was key.

“Our research into discharge planning suggests there is frequently a shortage of community nurses available on Fridays when many patients are discharged home,” she said.

“Workforce planning is at the crux of the matter as is the capacity of the system to deal with patient need, particularly at periods of high demand,” she added.


Readers' comments (3)

  • I have been working on this type of project for the last 18 months, employed by a primary care source and funded by commissioners; sometimes it is successful but often it is an uphill struggle, particularly regarding differing ED teams who are on duty at the time. Despite being trained to Masters level in autonomous care, with 20+ years of first contact care in ED, MIU, WIC, GP surgeries and primary care, I still cannot see anyone at the door but have to wait for everyone to be triaged first by a band 5/6 nurse, a job I was doing 20 years ago. I always felt I should be standing at the front door or at reception weeding out those that simply should not be there before they booked in rather than being tucked away in the department being handed patients they felt were awkward, laborious, difficult or time consuming.

    Added to this, there is a need for mass public education of how to manage their own health care; rather than leave things until the last minute (I rarely see anyone who has a new presentation of a primary care problem). The public seem oblivious to the problem of lack of GP's and cuts to services, as do many staff in ED who think that GP's spend their time surfing the net or having a cup of tea with an elderly patient; whilst in reality it is probably the worst area of the health service to work in at the moment due to the daily rise in demand from our increasingly ageing population and rise in immigration.

    Of course there has to be safe practice, and diverting people without cursory inspection and history is dangerous. I believe there should be public information films broadcast on TV before Eastenders or Coronation Street along the lines of the the information films of the 70's and 80's asking patients not to request home visits if you are able to get to the surgery. The one with the little girl with the sore throat playing on the swing in the garden when the doctor arrives springs to mine.

    Every area seems to be trying to offload onto another area at the moment and there is a lack of knowledge by staff of how bad each area is. Its about time that all staff were aware of what other disciplines do rather than think they are the only ones who have it hard. They ALL do a vital professional job; but the biggest fault is with the Government's austerity policy and the lack of community care staff who can help with basic human needs in the home. Privatising these services was never a good idea.
    It will be interesting to see how proposed tuition fees affect the nursing workforce. There may not be enough staff to deal with the fall out of this Government and all patients will be left to deal with their own healthcare problems in the future if they cannot afford to pay the fees of a privatised health service.

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  • One of the real problems is that GP overload their books to get the money but so many only work a few hours per week.
    A shortage of GP's is not the problem, it is the shrotage of GPs working full time that really needs to be addressed.
    They should cap the number of patients allowed on on their books for full time GP's then reduce that number according to the number of hours the GP actually works in the surgery, then you will see GP's making effort to care fro the patients they get paid to care for.
    Being a GP must be the only job where you have a contract to deliver a service and get paid, regardless of the few hours they work.

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  • An interesting project, but it is perhaps important to clarify some detail and analyse in some greater depth.

    To the best of my understanding, the quoted 'deflection' rates of 22% refer to those initally considered potentially 'deflectable' at triage and streamed to the deflection GP, rather than all comers. The denominator is quite important here and I wonder whether the project lead Mr Almond could clarify on this point.
    If my belief is correct, then the large % of this highly selected population who could not in fact be deflected underline the inherent potential risk in this strategy if expanded.

    In the article the terms 'streaming' 'diversion' and 'deflection' are used inter-changeably, when in fact they represent fundamentally different strategies. This project was not deflection. The patients were all seen by at least one fully qualified GP for a full assessment, and ONLY THEN advised on self care. It would be an error to imagine that a cursory triage assessment could perform the same function safely and it is essential that this pilot is not extrapolated in this way. This was in fact streaming to primary care, which was in place previously at this trust for a number of years before funding was withdrawn.

    The effect on the Emergency Department is sadly also less revolutionary than this article suggests. 'De-crowding' was never going to be achieved by decanting a small number (3 patients/hr based on 239 patients over the 64 hours of the project) of 'well' patients who would otherwise have been sitting in the waiting room.

    The A&E performance against the 4 hour target varies widely on a daily basis, most commonly based on bed availability and much less often based on minors attendances. Putting an improvement in the 4 hour target from 82% to >95% down to deflecting 3 patients an hour for 4 hours a day is mathematically improbable given the numbers of attendees at this department, even if all those patients would otherwise have breached. Regardless, even if the 'improvement' (which is due to the usual variation in bed occupancy and attendees) was fully attributable to this project, it has not been sustained despite the continuation of the project. Reviewing the effect on the 4 hour target over a longer period, or in comparison with a similar period last year would have more validity and I would urge the project team, and anyone hoping to implement a similar scheme to undertake such an analysis.

    Finally perhaps the team could comment on the cost of the project. Based on the information in this article, using 3 clinicians (1 ANP and 2 GPs) each for 64 hours (all out of hours and therefore likely at a premium) = 192 clinician hours.

    192 clinician hours, to divert 239 patients.
    With no meaningful impact on overcrowding.
    And no apparent meaningful or sustained impact on the 4 hour target.

    If those clinicians had instead been seeing patients, based on a generous 15 mins/patient, 48 patients could have been seen and treated per day, or 768 over the course of the 2 week pilot.
    Co-location, or a hub model as supported by RCEM could see these clinicians being used to their full potential.

    Perhaps it is a little premature to be calling this project a roaring success.

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