Why clarity and consistency are essential to realise the benefits of integrated urgent and community care
For the NHS to truly address pressures on emergency care, the integration and standardisation of urgent community response services is essential, writes Lisa Harrigan, Senior Consultant at NHS Arden & GEM CSU.
All integrated care systems (ICSs) are required to provide an urgent community response (UCR) service which delivers urgent crisis support to people in their own homes. Alongside the development of urgent treatment centres (UTCs), these services are a core part of national efforts to alleviate pressure on accident and emergency (A&E), ambulance services and primary care. Well-intentioned national guidance has helped to shape more community-based urgent care services, but the nature and maturity of these services, and the way they are delivered, varies considerably, limiting the potential for systems to realise much needed benefits.
Identifying inconsistencies
UCR is designed to deliver clinical support to patients who might otherwise face a long wait for an ambulance and for whom there is no immediate threat to life. UCR provides a response within two hours, to assess the patient, make them comfortable, administer pain relief and fluids, and, where appropriate, stand the ambulance down. Integrated care boards (ICBs) are finding, however, that the efficacy of this service can vary considerably across their system, with multiple providers operating in different areas, all delivering a slightly different service. While they may all meet the minimum national standards, lack of consistency means use of the service is inconsistent.
UCR should be set up to take referrals from 999, 111, ambulance crews, GPs, pendant alarm companies, care homes and, in specific cases, directly from patients. In our experience, however, this is rarely the case. Some providers take regular referrals from out of hours GPs but have no relationship with their local ambulance service. Others work closely with the ambulance service but have limited contact with GPs or care homes, limiting the community-level support they are able to provide.
Clinical support varies too. Some providers are GP or senior nurse-led, while others are staffed by more junior nurses. Simple elements such as opening hours can also be inconsistent, all of which impacts the level of care the UCR is able to provide. Collectively, these inconsistencies make it challenging, both for ICBs to understand the quality and consistency of provision across their system, and for individual services to make best use of UCR support.
Similar challenges exist when it comes to UTCs. Some centres are nurse-led, some GP-led, some offer a wide range of diagnostics while some provide much more limited services. Yet they are generally grouped under one definition, making it more complex for broader services such as 111 and alarm companies to provide confident signposting to patients. If these and other referrers are not confident in their knowledge of what is available, where and when, they will be less inclined to refer patients to these community-based services and opt to rely on more familiar services such as A&E and the ambulance service.
Addressing the challenge
In developing more consistent solutions, systems require a clear understanding of their local needs, existing provision and what will be required to make meaningful impact. The first step is to understand your starting point. For example, we worked with NHS Humber and North Yorkshire ICB to conduct a detailed review across the seven providers operating within their system to give a detailed picture of their overall UCR service, with recommendations on how the service could be strengthened. This has enabled the ICB to identify gaps and variation and consider a way forward which will provide a more consistent service for patients.
Engaging directly with providers and referrers can help identify and resolve hidden barriers. For example, we discovered that direct patient referrals were limited due to a lack of understanding of the ask. Once providers understood this would only be for previously known users, such as those with long-term conditions that may require frequent urgent support, those limits were addressed.
But this is also about identifying where the ICB can play a role in supporting providers to deliver a more consistent service. In Humber and North Yorkshire, our recommendations included developing a workforce plan to support providers with recruitment challenges, access to professionals, skill mix variation, competency updates and training with the aim of providing a more resilient, consistent service.
Providing clear, up to date information to all referrers about the services available in their area, including clinical and diagnostic variations and available referral routes, can also help to address barriers and enable better take-up of community-based urgent care services.
A holistic approach
There is much to be gained by taking a more holistic approach in integrating urgent and emergency care with community care, looking beyond the necessary to consider what achievable enhancements could significantly improve outcomes. For example, while national guidance suggests that UCR is delivered using a multidisciplinary team approach with staff ranging from a Band three to a Band seven nurse, data shows that more senior clinical expertise, especially where there is medical input, is likely to result in a greater reduction in conveyances to A&E, which can improve patient experience, alleviate system pressures and save money.
Furthermore, understanding what similar services are already available that can support the wider demand on urgent and emergency care can further enhance impact and reduce duplication. UCR and UTCs, for example, often prioritise physical health needs but the huge growth in mental ill health and subsequent pressure on community services contributes to patients attending GP practices and A&E where access and/or specialist support is often limited. Charities such as Age Concern and Samaritans offer experienced preventative care and crisis response services which systems could look to tap into as part of an integrated approach to urgent and community care, making best use of existing resources and reducing duplication. In taking a broad view of urgent care needs, commissioners have an opportunity to draw together expertise across all system partners to provide more joined-up services.
The NHS is constantly looking at different ways to address some of its most pressing challenges, and opportunities to alleviate pressure on the ambulance service and A&E are high on the priority list. However, there is a danger that this results in a series of siloed solutions, rather than a more cohesive, consistent approach. As systems mature, taking time to fully assess, adjust and integrate existing services will help reduce unnecessary duplication and create the headroom needed to enhance care quality and consistency for patients and staff in the face of growing demand.
