Health Service Focus

Diversion is failing – co-location is the answer

NHE talks to Dr Chris Moulton, a consultant in emergency medicine at Bolton NHS FT and vice-president of the Royal College of Emergency Medicine, about the need for more services in A&E departments.

When four medical royal colleges made joint recommendations last year in their ‘Prescribing the remedy’ report to address the challenges facing urgent and emergency care services, top of the list was co-location: ‘Every emergency department should have a co-located primary care out-of-hours facility.’ 

A follow-up report in February, ‘Ignoring the prescription’, found only limited evidence that the colleges’ recommendations – endorsed by the NHS Confederation – had been acted on. On co-located primary care services specifically, a survey of clinical leads from 225 UK emergency departments (response rate: 63%) suggested that fewer than half (43%) of emergency departments have fully implemented such services, while a quarter had partially done so and a third not at all. 

The Royal College of Emergency Medicine (RCEM) was blunt in its assessment of these results: “Failure to implement this service results in increased pressure on emergency departments and compromises patient care.” 

It recently repeated its call for co-location at Urgent Health UK’s annual conference. 

Winning round the national organisations 

Speaking to NHE after the conference, RCEM vice-president Dr Chris Moulton said despite these less-than-stellar findings, there are some causes for optimism – especially because organisations once opposed to co-location or uncertain are now firmly behind it. 

He said: “NHS England wasn’t really 100% in favour of it when they started on the Keogh report; the Royal College of GPs (RCGP) wasn’t 100% behind it until this autumn; Monitor came on board last year.” 

With the support of the other royal colleges and the NHS Confederation, this means that “the big players are all in favour now”, he said. Urgent Health UK – representing social enterprise providers of urgent care services – is among the RCEM’s closest allies on the issue, Dr Moulton added, and the Patients Association and Healthwatch England also back it. “This is a good thing for everybody. It’s a good thing for CCGs because it will save money. It’s a good thing for emergency departments because it will decongest them. And it’s a wonderful thing for patients. 

“Co-location isn’t just about GPs – it’s about co-location of services. So, it is GPs and primary care, but it’s also frailty specialists, people who can help the elderly get back into the community, dentists, pharmacists; it’s everybody the patient needs when they have an urgent healthcare need, all in one place.” 

The problem is not now the national organisations, but rather the local ones – most notably, CCGs. 

Dr Moulton said: “A lot of the local CCGs, who after all do have the actual administrative power now, and a lot of autonomy, are not in favour of it.” 

Diversion and deflection schemes have proved ‘absolutely useless’ 

Instead, many of those CCGs are wedded to a tactic that is now discredited, as far as the RCEM sees it – what it calls ‘diversion and deflection’. 

Trying to discourage people with less serious conditions from attending A&E departments has proven costly and “completely ineffective”, it says, and in our interview Dr Moulton went further: “‘Diversion and deflection’ schemes frankly have proved absolutely useless.” 

The RCEM survey of its clinical leads also asked them where last winter’s £700m to support urgent care actually went. Its respondents said that only a “derisory” 1% (£6.7m) was spent directly on emergency department services. 

Dr Moulton acknowledged that the survey’s response rate was only just over 60%, and said: “It’s possible the other 40% of clinical leads saw the whole lot, but a lot of it went on paying off debts, and on these diversion and deflection schemes.” 

He explained: “Our explanation for this is that the A&E brand, the red sign, is just too strong. It offers the whole forces of the NHS, in a hospital, with big diagnostic facilities, open 24 hours a day; you don’t need an appointment, it’s free at the point of use, and it’s got everything there – you’re very likely to get sorted out by doctors who are quite highly motivated. 

“Plus, now, you don’t have to wait so long because of the four-hour target,” he concluded, raising one of the perverse incentives that has arisen from the improvement in A&E waiting times.  

Suspicious GPs 

Despite the RCGP’s backing, some CCG intransigence comes from the fact that many GPs themselves remain suspicious and sceptical. 

“A lot of GPs think the idea of this is for us to ‘dump’ the patients we don’t like on hardworking GPs,” Dr Moulton said. “That isn’t the plan at all. It’s not about dumping people on GPs, it’s actually about using their incredible experience and community skills to join us. It’s about having the right people there. 

“Nowadays, urgent care is very big, it has a lot of people and a lot of specialties. It’s very hard for one group of people to do the whole lot effectively.” 

The call for co-location is part of RCEM’s wider ‘STEP’ campaign (staffing, tariffs and terms, exit block and primary services), and CCGs are now the “number one target” for its message, Dr Moulton said. “Though we’d also like NHS England to take a stronger line. They take the line of ‘we recommend this’, [but] we’d like them – as near as possible – to mandate it.” 

The RCEM said in its briefing: “Consultants agreed that the most effective way to reduce pressure on urgent and emergency services is to invest more in social and mental health systems and co-locate primary care out-of-hours services.” 

Co-location of primary care services with A&E departments was first recommended 15 years ago in both the Carson Report and the 2001 Reforming Emergency Care strategy.

Prof Keith Willet, NHS England’s director for acute care, who is heading a new review into urgent care (more details in the previous edition of NHE), said: “A fundamental redesign of the NHS urgent care ‘front door’ is much needed and now underway. This includes A&E, GPs, 999, 111, out-of-hours, community and social care services.” 

Although plenty of hospital trusts employ their own primary care clinicians, the RCEM is clear that it’s not just about individuals, even though they do make a “great contribution” – it’s about the wider primary care and commissioning infrastructure being fully involved. 

Community pharmacy 

RCEM also welcomes the initiatives to place community pharmacists into hospitals, though it is sceptical about the results of a West Midlands pilot project from 2013-14 that suggested almost 40% of patients in emergency departments could instead be dealt with by pharmacists with advanced clinical practice training skills. Dr Moulton said: “We think the 40% figure is over-egged. The idea that 40% of emergency patients could be seen by pharmacists, we think that’s grossly high.” 

The RCEM’s own research suggests that only about 15-20% of patients presenting at A&E are suitable to be seen by a GP, and the figure would be “much less” for community pharmacists. “Though we do definitely think they need to be on board – they are part of the solution.” 

Government incentives can even make such on-site community pharmacies cost-neutral to run, he added.

The benefits of A&E co-location with primary care services 

Extract from ‘Acute and emergency care: prescribing the remedy’: 

It is unreasonable to expect patients to determine whether their symptoms reflect serious illness or more minor conditions. Co-location enables patients to be streamed following a triage assessment. 

This also enables collaborative working including sharing of diagnostic facilities, reduces duplication of administrative tasks and permits patients to be easily re-triaged should further assessment require so. 

Extract from NHS England’s ‘Transforming urgent and emergency care services in England’, also known as the Keogh Review: 

The co-location of primary care out-of-hours services with emergency departments provides opportunities for collaboration, routine two-way transfer of appropriate patients and can help decongest emergency departments.

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