Urgent health care: will the social care model prevail?

A discussion paper on urgent care has unexpectedly taken on a social care model, writes Bob Hudson

Urgent care – the services required by patients when they have a health problem that requires immediate or early attention – is an issue that has been rising rapidly up the NHS priority list since the turn of the decade. However, despite an avalanche of policy initiatives, the position remains fragmented and confused, and this has resulted in a new discussion document from the Department of Health that seeks to identify a “direction of travel”.(1) It is a development with significant implications for social care.

The reason for the growing policy interest in urgent care is simple – it is placing growing demands on an over-stretched health service. Emergency admissions to A&E have risen by 29 per cent since 1997, and are currently rising at a rate of 5 per cent year on year. The biggest demand comes from poor areas with low numbers of doctors, and the most frequent admissions (the derogatorily termed “frequent flyers”) tend to be older people suffering from a long-term condition. These trends constitute the single greatest source of pressure on the acute sector, with the causal chain extending to other parts of the healthcare system – over 90 per cent of patients experiencing delayed discharge, for example, were first admitted as an emergency.

There has been no shortage of measures intended to address this situation over the past few years, many of them triggered by the withdrawal of GPs from the provision of out-of-hours cover for their patients. We have seen a wider role for ambulance services, the creation of NHS Direct, local walk-in centres, minor injuries units and unscheduled care centres, and even the emergence of a brand new profession in emergency care practitioners. 

However, this flurry of activity has not addressed the problem of expensive and inappropriate use of acute hospitals, and in the white paper Our Health,Our Care,Our Say it was stated that: “During 2006 we will  develop an urgent care strategy for the NHS, providing a framework within which PCTs and local authorities can work.”

The new discussion document, open for consultation until 5 January 2007, is the response to that pledge. The tone is set by a proposed new definition of urgent care which for the first time acknowledges the role of social care services. It is defined as “the range of responses that health and care services provide to people who require – or who perceive the need for – urgent advice, care, treatment or diagnosis. People using services should expect 24/7 consistent and rigorous assessment of the urgency of their care need and an appropriate and prompt response to that need”.

It is acknowledged that despite efforts at improvement a number of consistent concerns remain. These include:

● Organisations that provide urgent care have not developed ways of identifying and responding to people’s experience of their services.
● There is confusion among the public as well as staff about what services are available locally, and how and when to access them.
● Users and carers are asked to repeat information to different parts of the service. 
● People are not experiencing prompt access to a consistent and rigorous assessment of the urgency of their need for support. ● The needs of some particular groups have not been well addressed, including people with mental health needs, learning difficulties and people at the end of their life.

In seeking to address these difficulties, the discussion document begins by identifying six principles that are defined from the viewpoint of a user or carer:

1 My voice as a service user or carer is clearly heard and acted upon.
2 I know how to access services if I have an urgent need.
3 If I have an urgent need I can access care quickly and simply.
4 My safety is paramount to everyone who cares for me.
5 I can rely on getting the right care (including support to self-care), whenever I need it and whoever I am.
6 The care I receive meets my needs appropriately, taking account of the urgency and value for money.

The interesting thing about these principles is that the language and sentiments sound more like a social care framework than a traditional medical model. This is an important point, for previous conceptualisations of the problem have been firmly rooted in a medical model of care, with social care either ignored or tagged on as an afterthought – a feature that has been reflected in most local approaches to service delivery.

Now, at last, there seems to be recognition that requires a “whole system” response. It is suggested that urgent care will only be truly effective when it is able to respond in an integrated way to urgent health and social care needs. The role of direct payments and individual budgets needs to be explored – raising the possibility of exploring an extension of these models to health care. 

There should be seamless voice and data information between a range of providers. Users with predefined needs, especially those with a long-term condition, should hold details of agreed personalised care plans, and their health and social care records.

Services should be mapped and commissioned jointly by PCTs, practice-based commissioners and local authorities.

In principle these proposals should receive a warm welcome from social care for they constitute an overdue recognition that  problems in the acute sector are inextricably linked with what goes on in the community – the very basis of Our Health, Our Care, Our Say. However, while it is relatively straightforward to reconceptualise the urgent care problem and propose a new direction of travel, it is more difficult to find a robust mode of implementation for such a wide range of partners – service users and carers, local government, social care and independent sector providers, GPs, pharmacies, dental practices, community nursing, out-of-hours providers, mental health trusts, ambulance trusts, A&E and acute medicine, strategic health authorities, PCTs and practice-based commissioners. 

 In this regard the discussion document is silent, and we await the new guidance on joint commissioning due from the DH next month. Without some robust interagency governance arrangements it is hard to see how the aspirations of the discussion document can become a reality.

But it is not just the absence of a co-ordinating mechanism that is problematic. The government has yet to explain how on the one hand it can propose whole system partnership working as a means of addressing urgent care, but simultaneously pursue a raft of policies that will almost certainly create a more fragmented and divided system. The most notable features in this respect  are payment by results, the private finance initiative, foundation trust status and practice-based commissioning.

What is really needed here is to link concerns about urgent care to the wider debate on user driven outcomes for health and well-being, and the discussion document fails to make this link. It means taking more seriously the activities of the Innovation Forum(2) based on the idea that good housing, a range of facilities for transport, leisure and entertainment, families and friends can all help older people thrive and stay healthy. And, if any of this is to come about, it means a firmer strategy than currently exists to ensure there is a sufficiently significant transfer of funding from acute to community settings.

BOB HUDSON is visiting professor of partnership studies at the school of applied social sciences, University of Durham.

TRAINING AND LEARNING
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

ABSTRACT
Responding to people’s need for urgent health care has become a high policy priority, and a discussion document from the Department of Health outlines a new direction of travel. Unlike previous publications this envisages a key role for social care. This article outlines the new proposals but warns that there are some difficult issues to be addressed if they are to be a reality.

REFERENCES
(1) Direction of Travel for Urgent Care: a Discussion Document, Department of Health, 2006.
(2) G Wistow, D King, Reducing Emergency Hospital Stays for Older People: Innovation Forum First Year Report, Kent Council, 2006

This article appeared in the 23 November issue under the headline “An urgent discussion”