Research into A&E Use

Request

I am writing to request information under the Freedom of Information Act 2000. Please provide a response within 20 working days, as outlined by the statute.

If my request is denied in whole or part, I ask that you refer to specific exemptions of the act. I will also expect to you to release all non-exempt material. I, of course, reserve the right to appeal your decision to withhold any information or to charge fees.

I understand the SHA has carried out work looking at the reasons behind people referring themselves to A&E when more appropriate services are available.

Please send me any documents, including interview transcripts, reports, analysis and recommendations carried out as part of this work. Please also send me any available information on the piloting arrangements developed following these recommendations.

Our response

I refer to your email requesting information in respect of work NHS East Midlands  has carried out into looking at the reasons behind people referring themselves to A&E when more appropriate services are available.

I can confirm in accordance with S.1 (1) of the Freedom of Information Act 2000 (FOIA) that we do hold the information that you have requested.

I thought it would help if we set out some of the initial thinking that went on before we commissioned the research.

This project is a joint initiative involving all the PCTs in the East Midlands. The research concentrated on people who self-referred to Emergency Departments but who were not admitted  to hospital. This group adds to pressure on A&E departments when another health service, for example GP, pharmacist, walk-in centre or self-treatment, might prove to be more appropriate. We made no initial assumptions about what might be motivating these decisions instead we analysed existing data to uncover which groups most typically presented, but were not admitted.

We then set about exploring what reasons motivated these decisions with the aim of making a series of interventions that in time will change the presenting decisions that people make.

1.    Why we concentrated on the groups that we selected.

We reviewed data from across most of the East Midlands PCTs (key data sets included: referral sources , disposal methods, arrival times, activity across days of the week, diagnosis codes, multiple attendances by single patients (4+ attendances)).

We found a trend in the 0-4 and 15-24 age group where people were self-referring (either themselves or their children) to A&E but departing with a Vo4, Vo6 or Vo8 HRG code.  A further theme which presented was the spike in attendances between 7am and 11am, suggesting there might be an issue with patients waiting overnight before attending A&E, when there were alternatives available. 

We hypothesised that these patients might have used an alternative NHS service rather than A&E.  The research was to help us understand why they chose to attend A&E rather than use another NHS service.

2.    What they amount to in numbers of people presenting a year

How much this would cost across the region

Extrapolated to NHS East Midlands level:

I will allow the report, attached for your information in pdf format, to speak for itself. We have already implemented some of the research findings – that of improved messaging on the Choose Well campaign literature and posters.

We are taking forward to the pilot stage four of the recommendations: 

The Discharge Card: Targets public who are using A&E when other services would be more appropriate. Directly provides feedback to patients on their service choice, influencing future decisions. Informs patient on what is expected during their recovery and what to do/where to go if they have concerns (rather than returning to A&E).  Provides information on how to manage the condition if it reoccurs in the future.

Whilst discharge information is a routine feature of patients who have been admitted, it is not a universal practice at A&E departments as a device to advise patients who have not been admitted.

Improve feedback routes between A&E departments and primary care: Targets clinicians and non-medical staff who are referring to A&E when other services are more appropriate. Provides feedback to services about what could have been treated elsewhere. Clinicians can act on advice directly and alter procedures within practice (such as receptionist guidance). More consistent services improves patient perception and experience of services which impacts on their future service choices.

Job Shadowing: Targets clinicians who refer to A&E unnecessarily. Clinicians gain better understanding of the services (i.e. the systems, capabilities, resources) and a more coherent and well-rounded perspective of the most appropriate care for the patient. Clinicians review their current referral process. Findings from the job shadowing are documented and shared with others in the department/practices.

Receptionist Training: Targets non-medical staff who advise patients to go to A&E unnecessarily. Provides non-medical staff with consistent information to provide to patients when accessing care. Reduces service inconsistencies of the conditions that will and will not be seen, therefore improving their perception and experience of services which impacts on their future service choices.

This is aimed primarily at GP receptionists however the solution may involve consideration of the skills mix of the staff on reception desks and/or other GP access issues.

We are just moving to piloting these recommendations in the East Midlands. The findings will be shared across the service. Many of the principles that relate to the service users identified in this research should be applicable to other groups. This holds the prospect of making savings over and above the very conservative figure - £768,000 per year – identified in the initial analysis.   

I hope that this information is of use.  If you are dissatisfied with the way in which we have dealt with your request you can ask us to review our decision by writing to:-

Mr Moosa Patel
Director of Corporate Affairs
NHS East Midlands
Octavia House
Interchange Business Park
Bostock's Lane
Sandiacre
Nottingham
NG10 5QG

If at the conclusion of any review you remain dissatisfied you may complain to the Information Commissioner who can be contacted at:-

The Office of the Information Commissioner
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF