unscheduled care

Opening the door to local services: the role of unscheduled care

Introduction

Unscheduled care services offer initial assessment, treatment and support to members of the public. Accident and emergency services, minor injuries units, primary care services in and out of hours, dental services, walk in services, NHS 24, rapid response services, emergency mental health services, emergency social services, telephone advice and triage lines provide the spectrum of unscheduled care. Unscheduled care services have traditionally looked after people who find planned care more difficult to access. The way we organise planned and unplanned care, therefore, can create perceived or real barriers to health and social care. Unscheduled care services provide urgent and opportunistic care for people with a complex mix of previously unknown needs and established problems. Patients range from those with overwhelming unpredicted illness, the consequences of drugs, alcohol, violence or injury, acute exacerbation of chronic conditions to self-limiting or practical problems. Understandably, people want to resume their usual life as quickly as possible. All unscheduled care services, therefore, try to establish what the problem is, offer rapid advice, treatment, and help to reduce the risk of the problem happening again. This may include referral to the GP or a specialist service so that the doctor (or other health professional) can plan and agree with the patient how care should be organised in future.

Lothian Unscheduled Care Service

Research points consistently to the central role of primary care in providing high quality planned care, outreach and unscheduled care in and out of hours. We know that the quality of primary care in Lothian is good and that the practices that serve some of our most deprived populations offer humane, effective and well-organised care for around 50 hours per week. For the remainder of the week, 118 hours, however, the Lothian Unscheduled Care Service organises primary health care, helps co-ordinate urgent primary care during major incidents and works closely with all of the other services that provide unplanned and urgent care.

Before the Lothian Unscheduled Care Service was established, a health impact assessment and public consultation were undertaken to guide the development of the service. The priorities that emerged were consisted with what is known about the factors that influence people's ability to benefit. These are shown in Box 1.

These concerns reflect the evidence that access problems, gaps in services and disparities in treatment pathways occur even in countries with generous health and social care provision. The rate at which different parts of the population request unscheduled care illustrates this problem. Young children, people with chronic conditions, those with limited social support and those who live in more deprived areas are more likely to use all forms of unscheduled care. The data from Lothian Unscheduled Care Service show the service being used mostly by children up to four years (crude rate 92.3 per 1000 population) and in people over 85 years (crude rate 134.9 per 1000 population). Patients living in the most deprived areas in Lothian were 1.6 times more likely to use Lothian Unscheduled Care Service than those in the most affluent areas. The findings are consistent with the research on other forms of unscheduled and out of hours primary care in Britain and elsewhere.

Preliminary evaluation of the Lothian Unscheduled Care Service suggests that, on the basis of the age, sex, geographical and social distribution of service use, the service is meeting the needs of the local population. For example, despite concerns about access, of the people who received care from Lothian Unscheduled Care Service, 59% were seen at the treatment centre, 24%, received a home visit and 16% received telephone advice. In line with the differing nature of the acute illnesses they experience just under 90% of those aged under 4 attended the centre while around 70% of those aged 85 or over received a home visit.

Colaborative working

Since the Lothian Unscheduled Care Service was set up in 2005, areas where their collaboration behind the scenes has improved the quality of care for patients include:

All the services that provide unscheduled care work together regularly to develop the service. The initial priority of this collaboration, which includes partnership representatives and patient involvement, was to simplify access and enable patients to be assessed, undergo tests and receive treatment more quickly. However, if unscheduled care is to help improve the health of local people and contribute to reducing inequalities, unscheduled care services must provide more than good treatment for today's problems. Urgent admissions to hospital, for example, also occur more frequently among people from lower socio-economic groups. This reflects variations in the burden of disease and exposure to health risks that have not been addressed fully by existing services. It can also reflect barriers to accessing planned specialist care, primary care and preventive services or differences in the nature and effectiveness of the care provided.

This contrasts with elective or planned care, for example, where elective surgery rates for several common, chronic conditions are at similar or higher rates among more affluent patients. This is despite the greater prevalence of disease, measurable by elective or planned care, among people from lower socio-economic groups. The way that we provide unscheduled care can help change this pattern by providing additional opportunities for some of our most vulnerable populations to receive effective care and improved outcomes.

Despite this imperative however, it proved difficult to assess the extent to which Lothian Unscheduled Care Service was fulfilling its potential to improve the health of those who attended as data about ethnicity, access to transport, special needs and details of diagnosis were limited. This, in turn, made it difficult to quantify the need for additional services that staff had identified, for example increased provision of assisted communication and translation services and access to additional expertise in caring for patients with mental health problems.

Further work is necessary, therefore to understand how best to organise unscheduled care services and how they should work with others to improve outcomes at population level. The next steps will include:

  1. Improving our knowledge and understanding of the needs of the patient populations that use unscheduled care. The data that are already collected need to be analysed and fed back to staff caring for patients, local people and used to guide the way that care is provided in future;
  2. Ensuring that unscheduled care services enable people who find it difficult to use other services to access services easily and in a timely way; and
  3. Identifying which needs could be met more effectively by redesigning the current ways that planned care or prevention are delivered.