Emergency and acute medical care in over 16s: service delivery and organisation

Why this is important

Continuity of care improves patient experience, aids clinical decision‑making and could reduce hospital admissions. GPs' knowledge of patients enhances trust and promotes patient-centred care, especially when dealing with complex conditions. Currently, outside of standard GP hours (Monday to Friday, 08:00 to 18:30), people who need urgent primary care are triaged and treated by an out-of-hours GP provider and will usually be seen by a primary care clinician who is not familiar with them or their history, and who might not have access to their complete clinical records. Extended weekday and weekend access to their usual primary care team might reduce people's unscheduled use of secondary care emergency services. It might also increase opportunities to prevent exacerbations of chronic disease and thus reduce emergency hospital admissions. There is also likely to be less movement to secondary care if there is greater access to usual primary care because GP surgeries are often more conveniently located than more distant out-of-hours centres. Many extended access schemes currently in operation for general practice are for prebooked appointments only and do not provide emergency care. The focus of this research recommendation is on extending opening hours of practices for the full spectrum of GPs' clinical work.

Why this is important

A person with social care needs is defined as someone needing personal care and other practical assistance because of their age, illness, disability, dependence on alcohol or drugs, or any other similar circumstances. This is based on the definition of social care in section 65 of the Health and Social Care Act 2012.

At present access to social care differs throughout the country. Some areas have access to all social care services whereas others have very limited access. When social care services are substantially reduced, such as during weekends, collaboration and multidisciplinary planning between hospital, community health services and social care is difficult to achieve. This increases the number of avoidable hospital admissions and readmissions, and delays discharges.

NHS England has stated that community care services in hospitals, primary care, community care and mental healthcare must be available 7 days a week. This will support people to stay in the community and allow those in hospital to leave earlier. Extended access to community care has a direct impact on bed occupancy rates. Current figures suggest that 22% of hospital patients are waiting for a social care assessment so that they can be discharged. Extended access to social care would play an important role in alleviating this problem, particularly for the frail elderly.

Why this is important

Royal College of Emergency Medicine survey data suggest that around 20% of people who attend emergency departments could be treated by GPs. Extended access to GPs in their surgeries is a requirement of current health policy, but the impact of such provision on reducing emergency department attendances of people with acute illnesses is unknown. An alternative approach, proposed in a joint report from the Royal College of Emergency Medicine, Royal College of Paediatrics and Child Health, Royal College of Physicians, and Royal College of Surgeons, is that every emergency department should include a primary care out-of-hours facility. This approach deserves systematic research evaluation focused on the specific impact of GPs on secondary care and the wider urgent and emergency care system.

Why this is important

Older people are more likely to be admitted for medical emergencies, and to stay longer in hospital, than younger people. This is because there is more multimorbidity, frailty and polypharmacy in older people. Hospital services have adapted to the growing population of older patients by introducing liaison services such as Frail Older Persons' Assessment and Liaison (FOPAL) services. These are now widespread, and share characteristics such as medication reviews and the use of comprehensive geriatric assessments.

However, it is not clear whether there are additional benefits from admitting older people with multimorbidity and frailty to a specialised elderly care assessment unit or an acute frailty unit. Theoretical advantages could include better planning of investigation and diagnosis, multidisciplinary working, dedicated discharge teams, and direct links with community and social care. The question is important because of the potential for large reductions in length of hospital stays and readmissions, and improved quality of care. New units with varying designs are emerging throughout the NHS but there is currently no strong evidence for their effectiveness.

Why this is important

Good clinical decision-making depends on the provision of accurate information at the point of care delivery. Paper-based information systems cannot adequately serve the complex needs of people with frailty or multimorbidity. However, the experience of the NHS National Programme for IT has shown the need for an evolutionary and evidence-based approach to developing electronic systems with the capacity for clinical decision support. Examples of where such an approach could be used include managing cognitive impairment, polypharmacy, caring for people with multidisciplinary or complex care needs, and recognising a person's preferred place of death in palliative care. In many locations around the country, web-based patient information systems integrated between primary and secondary care are currently being set up. This research recommendation aims to ensure that where information systems are developed they undergo systematic parallel research evaluation.