People Requiring Urgent and Emergency Care

• Emergency Departments provide a service for life threatening illnesses or accidents which require immediate, intensive treatment
• Around 250,000 Emergency attendances in the last year in SNEE – around half of these classified as ‘Majors’

• Over 77,000 ambulance journeys in the last year – an average of about 6.5 thousand a month. In winter months it is over 7,000

• According to The Health Foundation’s analysis, emergency admissions have grown 42% in the last 12 years
• In 2015/16, one in three emergency patients admitted for an overnight stay had five or more health conditions, up from one in ten in 2006/07
• Biggest increase for older patients, up by 58.9% since 2006/07 for people aged 85 years or older

Urgent Treatment Centres work alongside other parts of the urgent care network including primary care, community pharmacists, ambulance and other community-based services to provide a locally accessible and convenient alternative to the Emergency Department for illness or injury that requires urgent attention but is not a life-threatening situation.

Urgent Treatment Centres usage has seen an increase in the last three years

•  NHS 111 has clinicians and call advisors to give patients advice, book patients in to be seen at their local emergency department, or an urgent treatment centre, emergency dental services, pharmacy or another more appropriate local service – as well as send an ambulance should the patient’s condition be serious or life-threatening.

• Not all people are seeking help elsewhere before going to ED – people are still often unaware of alternatives
• People often report the difficulty in accessing alternative services when they need them
• Some people will still attend an Emergency Department anyway, as they consider that it offers easier access into health care than other services or see them as the most convenient option for them

20190311 Submission to NHSE Clinical Standards Review – AE – final. docx_0.pdf (healthwatch.co.uk)

The King’s Fund recently reported that pressures are rising on A&E departments and patients are waiting longer for the care they need due to:

• More people accessing A&E – 25 million attendances in 2019/20 compared to 21.5 million in 2011/12.
• More emergency admissions to hospital, combined with fewer available beds.
• Delays in transferring patients out of hospital
• Advances in medical practice, meaning more people can be treated in A&E rather than being admitted.
• Staff shortages throughout the urgent and emergency care system

A&E attendances are twice as high for people in the most deprived areas as in the least deprived.

The King’s Fund highlights that research shows:

• people living in deprived areas are more likely to prefer A&E departments over their GP to get tests done quickly
• people in areas of deprivation find it more difficult to get an appointment with their GP and think A&E doctors are more knowledgeable than GPs.
• people who frequently attend A&E often face housing insecurity, homelessness and mental health issues.

• Poorer people make more use of NHS services – especially emergency services
• People from the most deprived areas tend to have more health problems, making them more likely to require admission to hospital
• People living in the most deprived fifth of neighbourhoods in England have nearly two and a half times as many preventable emergency hospitalisations as people living in the least deprived fifth
• Nuffield Trust compared indicators measuring the quality of NHS care for the 10% of people living in the most deprived areas and the 10% of people living in the least deprived areas of England to see how the results differ
• 4th from top inequality on list of inequality scores (after avoidable mortality and smoking) is the rate of admissions for ambulatory care-sensitive conditions. The gap between the most and least deprived hasn’t changed in over 10 years

Non-accidental injuries in children increased during the Covid 19 pandemic. The NSPCC highlighted that among infants:

• Between 23 March and 23 April 2020, 10 children with suspected abusive head trauma were seen at Great Ormond Street, which is 15 times higher than the average for the same period over the previous three years.
• Between April and October 2020, Ofsted had over 300 serious incident notifications, almost 40% of these were about babies, over a fifth more than for the same period the previous year. Over half of the cases about babies related to non-accidental injuries.
• Between April and September 2020, there was a 31% rise in incidents of death or serious harm to children under 1 when compared with the same period in 2019.

The NSPCC reported that increased risk factors for non-accidental injuries heightened by Covid 19 included:

• Social isolation from the support that friends and family usually provide to parents and carers.
• Less access to services including health visits, childcare and mental health services. Social distancing also reduced the ability of professionals to pick up on early warning signs.
• Financial uncertainty linked to an increase in abuse and mortality from non-accidental head trauma.

An Ageing Population

“patients who were most able to manage their health conditions had 38% fewer emergency admissions than the patients who were least able to. They also had 32% fewer attendances at A&E, were 32% less likely to attend A&E with a minor condition that could be better treated elsewhere and had 18% fewer general practice appointments” (The Health Foundation)

• Close to half of all emergency admissions are in those aged 65+
• Evidence suggests that in middle aged and older adults, frailty is significantly associated with multimorbidity in those with four or more long term conditions.
• Long term conditions associated with frailty include multiple sclerosis, chronic fatigue syndrome, chronic obstructive pulmonary disease, connective tissue disease and diabetes.
• Between 2017 and 2035, the number of people aged 75 over admitted to hospital due to a fall is expected to rise by 70%.
• The older population with immobility, incontinence and self-care limitations is predicted to rise significantly

Children With Long Term Conditions

In 2017 The Nuffield Trust found children and young people with asthma, diabetes and epilepsy from the most deprived areas are consistently more likely to go to A&E and to need emergency hospital treatment than those from the least deprived areas. Emergency admission rates in the most deprived areas was:

• Asthma: double the rate of the least deprived among school-aged children (2005/6)
• Diabetes (all types): twice as likely among 20–24-year-olds (2015/16).
• Epilepsy: improving, with the most progress in reducing unplanned admissions for the most deprived groups.

Suggested causal factors included:

• The effect of wider social determinants of health and deprivation: housing, pollution, smoking, nutrition, educational attainment, and health literacy.
• Less timely recognition of illness and inadequate community management of illness: quality and accessibility of services; children and families’ ability to self-care and seek appropriate support.
• Deprived populations are less likely to access primary care: lower level of GP registration (particularly during adolescence), greater difficulty in getting a GP appointment, and poorer perception of the quality of primary care.

Recommendations included:

• Short term – health policies that engage and focus on families living in deprivation.
• Long term – reducing economic and material deprivation and improving the social determinants of health

The Stroke Association highlights:

• Each stroke is different and a person’s risk of stroke can depend on a number of things.
• Research is yet to find signals specific to stroke that can easily and accurately predict if someone will have a stroke.
• Certain health conditions, like high blood pressure, high cholesterol and diabetes increase the risk of stroke.
• By giving people the right treatment and advice, we can help them manage these conditions to reduce their risk of stroke.

 

After a stroke, you are at an increased risk of another stroke. When you’re coping and adapting to life after stroke, it can be particularly hard to take action to avoid another stroke, like doing physical activity.

As a result the Stroke Association has developed an online resource, selfhelp4stroke.org which covers:

• keeping well (including sleep and managing stress)
• being active, emotional support (including relationships)
• coping with setbacks by recognising and managing early warning signs such as lack of motivation, stress, or not managing daily living as usual.

Allergy UK has developed a Patient Charter to ensure that everyone has access to the high quality care they need and a supportive environment to enable a good quality of life.

The Charter includes rights to a quality standard of care, and to accurate information, but also highlights the need for equality in society:

• The Right to live without fear of discrimination, exclusion or prejudice.
• The Right to an education system and childcare provision that is informed, trained in allergy awareness, and can manage the healthcare needs of pupils living with allergic conditions.
• The Right to clear and accurate information needed to make safe food choices to confidently eat in or out of the home without the fear of allergic reaction.
• The Right to travel with confidence knowing that the needs of those living with allergy will be catered for.
• The Right to carry the medication needed to respond to allergic reactions at all times.
• The Right to access emergency medicines at all times and in all places.
• The Right to live in a society that understands the lifelong impact of allergic disease.
• The Right to live in a society that takes allergy seriously.

During the Covid-19 pandemic alternative settings were found to carry out mental health assessments that would normally happen in A&E (assessment elsewhere in A&E or on the hospital site, in a mental health service, or at home with telemedicine assessment). The Royal College of Psychiatrists asked liaison psychiatry services about the benefits and drawbacks of these settings. It found:

Main benefits of the alternative care pathways and assessment facilities:

• More appropriate environment for assessment – calmer, better ‘front door’ to mental health services, less time pressure for mental health assessors.
• Reduced emergency department workload – less pressure on acute hospital staff.
• Greater accessibility of mental health expertise – especially for children and young people.

The main drawbacks:

• Risk of physical illness being overlooked – including misinterpreting delirium and brain injury as mental illness.
• Potential increase in the stigmatisation of mental illness by acute hospital staff – reinforcing these people are ‘different’ and ‘not theirs’.
• Staffing – less multidisciplinary care, de-skilling of A&E staff, splitting MH resources across sites requires extra staff.
• Delays in the emergency mental health care pathway – time taken transferring patients between sites.
• Need to clarify legal status of patients in mental health settings – are they inpatients or outpatients?

Statistics » Integrated Urgent Care Aggregate Data Collection (IUCADC including NHS111) Statistics Apr 2022-Mar 2023 (england.nhs.uk)

Reducing-Emergency-Admissions-long-term-conditions-briefing.pdf (health.org.uk)

Healthy Ageing Needs Assessment Summary (healthysuffolk.org.uk)

https://www.bmj.com/content/372/bmj.n798

General Practice Workforce Inequalities 2022 | Tableau Public

How has the COVID-19 pandemic impacted primary care? (health.org.uk)

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice | BMJ Open

Operational Oversight – Power BI

Tendency to call an ambulance or attend an emergency department for minor or non-urgent problems: a vignette-based population survey in Britain | Emergency Medicine Journal (bmj.com)

Ambulance use for ‘primary care’ problems: an ethnographic study of seeking and providing help in a UK ambulance service | BMJ Open

A&Es under pressure: what the data can tell us – The Health Foundation

20190311 Submission to NHSE Clinical Standards Review – AE – final. docx_0.pdf (healthwatch.co.uk)