That seems to be the question which is currently challenging health politicians and the media. Of course it is not a new question for those working in healthcare, since it is perfectly possible to track each and every attendance and episode of care that takes place. Even before I stopped being a commissioner at the end of 2011, senior managers were scratching their heads about the increase in ‘unplanned care’ and trying various methods of ‘managing activity’.
There is no doubt that attendance in emergency / unplanned care has increased, but why? The analysis we are given doesn’t tell us about when people attend, but in trying to answer the question, they point to changes in GP out of hours services. That suggests that there are no problems with the availability of GP services ‘in hours’. However, when a new Urgent Care Centre was opened in this County, it was discovered that faced with the chance to attend and be seen immediately rather than wait for an appointment at some of the less well run GP practices, people chose the former. It wasn’t all about out of hours services at all.
The lack of ownership by GPs in out of hours care is also blamed, but many out of hours services are literally owned by GPs as well as provided by them (it just isn’t obvious since they are contracted out). Of course, if you contact these services you are unlikely to see your own GP, therefore you might as well go to an urgent care facility. When you get there though, you might find yourself triaged into a GP service, where the same doctors providing out of hours care are also based. Funny how that isn’t mentioned.
Patients and their individual needs, are quite rightly being recognised as central to health provision. But with that recognition comes the realisation that people will use those services in the way that feels right for them. That might mean accessing emergency care for things that they perceive as needing attention now, even if those providing the care don’t think that is what is needed. If you feel you need to see a health professional and you know you have to plan to need it to attend your own GP surgery what will you do? Probably access a place you know is always ready to take you.
Then there are the telephone advice services – first NHS Direct and now 111. In deciding to change the focus of these services, a decision was made to completely dismantle the former in order to start up the latter. As NHS Direct ran down, then more people were referred to A&E. Everyone knows that assessment and triage of the patient are the most important parts of deciding what is wrong with someone, who is best placed to help them and what should be done. The more experienced the person doing this is (on the phone or in person), then the more effectively that problem will be dealt with. It stands to reason then that if you get rid of qualified staff before the new system is in place you are asking for problems.
Finally something that no one has mentioned. Children are some of the biggest users of emergency care. They become ill quickly, in an unplanned way. Parents rightly worry that they need attention right now and take them to A&E. We know that the birth rate has been rising steeply, we know school places are under massive pressure. I wonder if some of the increase in attendance relates to the increased number of under 5’s?
Like most issues in healthcare, this is complex. I doubt there is no easy answer nor a single cause. The propensity of politicians to blame in turn the previous government or GPs is simplistic and plainly wrong!