If you have suffered a sudden major physical trauma or life threatening episode, then A&E is of course where you must be treated. But if your injury or illness is less serious you could probably be treated more quickly and effectively, closer to home.
And in fact, says Karen Kay, urgent and emergency care executive lead for Cornwall and the Isles of Scilly, turning up at A&E by ambulance represents a gap in the efficiency of the health and care system at an ear-lier stage.
“Ambulances are for life-threaten-ing emergencies or where clinical intervention or observation is required en route,” she says.
Interestingly, demand for emergency care reduced – instantly and substantially – when RCHT had its most recent critical incident, report-ing they were reaching capacity and had ambulances queuing outside.
“When you say the hospital is in meltdown, the number of people who come in goes down,” says Karen.
On an average day – between 115 and 125 ambulances arrive at the Royal Cornwall Hospital – normally higher on a Monday and Tuesday. On the Tuesday after the most recent critical incident in July, only 86 ambulances arrived – the lowest figure ever. Average daily arrivals over-all at the RCHT ED are between 220 and 250 people. On that day the figure was 164. So, what happened to the people who would normally have shown up?
“There weren’t, as you might expect, 40 extra ambulances the day after to compensate; it took about four days to gradually return to normal,” says Karen. “That is leading me to research what influences people’s behaviour.
“People make choices about location. Do they go to the Helston minor injuries unit or do they drive past and go to the emergency department at RCHT? Why is it that people turn up at ED in the evening and most ambulances arrive in the afternoon? How long do people give it before they decide it is urgent?
“Everyone’s vision of what is urgent is different, too. Some people might have had a problem for three weeks and it hasn’t got any better. Others might think it’s the weekend coming up and maybe they ought to be seen. For some people it is when they really feel on the point of col-lapse. We need to understand people’s choices so we can better address their reasons and help them make better choices.”
Beyond genuine urgent scenarios, the emphasis for the future of health and social care in Cornwall and the Isles of Scilly is on more planned care. That means anything a plan of treatment can be formed around, whether that is a persistent skin rash or an elective hip replacement. The knock-on effect of good planned care is that it can negate the need for a lot of urgent and emergency care, as well as reducing hospital stays.
It is a model that relies on prevention, education, early diagnosis, self care and time-sensitive, defined pathways that offer effective intervention and avert complications.
“The ambition is to value people’s time and to provide support and treatment to patients in the right place at the right time,” explains Ethna McCarthy, director of planned care for Cornwall and IoS Health and Care Partnership.
“We need to identify at-risk patients and take early action to manage any deterioration proactively. You can’t predict unplanned crises, but health and care partners can work together to support people so they can be cared for at home or as close to home as possible in a care home or community hospital.
“It’s also about getting people to think about their own health and how they can prevent problems. Exercise and diet can stop you having high blood pressure – what is the starting point and what can you do about it?”
Karen adds that there are questions the NHS and local authority partners are now asking: “If some-one comes to A&E with respiratory distress, what has been happening in their health and care to date. Did we do a health check early enough? Did they get access to stopping smoking advice? Do they know how to take their inhalers correctly? Have we addressed their damp housing conditions?
“They arrive at hospital in an unplanned way with something that could have been managed better and earlier. How can we make sure someone’s health and care needs don’t get urgent?”
A lot of work is currently going on around this theme, with initiatives targeted at specific common health and lifestyle issues.
We know that older people can lose five per cent of their muscle strength per day of treatment in a hospital bed. Supporting patients to remain independent and well in their own homes is therefore of vital importance.
Falls, which are often avoidable, are one of the top reasons for an older person to end up in a hospital bed in Cornwall. Fractured hips are very common Sadly, forty per cent of people who fracture a hip are unable to go back to the place they were admitted from – whether that was their own home or a care setting – and that has a huge implication for the individuals affected – as well as their need for subsequent social care.
In a pilot scheme, people, “at risk” of falling, are offered preventative measures – local balance and stability classes for example and a bone density scan for osteoporosis – a major complicating factor.
“Now, when people are treated for a fall, they have a risk assessment to see if they are likely to fall again and how these risks can be minimised, rather than simply being patched up and sent home,” explains Ethna.
Sensible and efficient use of both practitioners’ and patients’ time, and a holistic, long-term view of people’s problems, are paramount to the whole vision.
For common musculoskeletal issues like lower back pain, for example, early access to physiotherapy, potentially at your GP practice, could prevent years of suffering.
“There is lots of evidence that if you have physio in the early stages it is much less likely to become a chronic problem” says Ethna. “Plus, other aspects come into play when you experience pain. Treat it early and you might avoid these, such as being able to keep working and not have financial problems.”
The traditional outpatient model is also ripe for reinvention, with potential for more provision close to people’s homes, more targeted and effective use of clinicians’ time and more use of developing technology. For instance a routine follow up appointment after hospital treatment, if there are no complications, could be done by Skype or by a GP or member of the community team.
Using dermatology as an example – when you have an appointment, all symptoms might have gone away but if you had fast access to specialist advice when you do have a flare-up, a doctor might be able to identify the triggers. A swift video consultation could be just as valuable as a face-to-face appointment.
WHERE TO GO FOR URGENT HELP
THERE’S a wide range of options available before making a 999 call or going to A&E. It’s important people know how to make the right choices.
For urgent advice and assessment you can access:
- 111 NHS online (24 hours)
- 111 on the phone (24 hours)
- Your GP for an on-the-day appointment (including some minor injuries treatment)
Your local pharmacy
Urgent treatment for non life-threatening injuries or conditions, can be accessed at Minor Injuries Units at local community hospitals or the urgent treatment cen-tres at Truro or West Cornwall Hospital at Penzance.
The 111 out of hours service in Cornwall is operated by Kernow Health CIC and staffed by local GPs, nurses and paramedics. It’s the best performing in the South West.
The online 111 service is cur- rently getting 1,200 hits a month.
Also 111 works closely alongside ambulance services and RCHT emergency services to ensure only people who really need hospital care are taken to the emergency department.