Navigating and making sense of urgent and emergency care processes and provision

Pope, Catherine; McKenna, Gemma; Turnbull, Joanne; Prichard, Jane; Rogers, Anne

doi:10.1111/hex.12866

Cited by 36 publications

(64 citation statements)

References 30 publications

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“…A paper reporting findings from the citizens' panels was presented for the OBHC (Organisational Behaviour in Healthcare) conference, in Montreal, QC, Canada, in May 2018. 248 The theme of the conference was 'Coordinating care across boundaries and borders'. Our paper highlighted the use of citizens' panels as a way to arrive at shared understandings of health-care boundaries and barriers to service use.…”

Section: Planned Disseminationmentioning

confidence: 99%

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Turnbull

McKenna

Prichard

et al. 2019

Health Serv Deliv Res

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BackgroundPolicy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.ObjectivesTo describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.DesignMixed-methods sequential design.SettingFour counties in southern England coterminous with a NHS 111 provider area.MethodsA literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.FindingsThe literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).LimitationsThe sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.ConclusionsMuch of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.Future workA whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.Study registrationThis study is registered as UKCRN 32207.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Planned Disseminationmentioning

confidence: 99%

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Turnbull

McKenna

Prichard

et al. 2019

Health Serv Deliv Res

Self Cite

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“…The concept of clinically unnecessary use of health services is contentious . Patients face a moral dilemma in help‐seeking, anxious to take responsibility for their health whilst not being judged as wasting the time of a busy service . Judgements about the clinical necessity of demand may be shaped by the supply of services, where these judgements become harsher as demand outstrips supply.…”

Section: Introductionmentioning

confidence: 99%

‘Clinically unnecessary’ use of emergency and urgent care: A realist review of patients' decision making

O’Cathain

Connell

Long

et al. 2019

Health Expectations

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Background:Demand is labelled 'clinically unnecessary' when patients do not need the levels of clinical care or urgency provided by the service they contact.Objective: To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.Design: Realist review. Methods:Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context-Mechanism-Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.Results: Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment-seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual. Conclusions:Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability. K E Y W O R D Semergency medicine, heath care seeking behaviour, patients, urgent care

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“…Too often the impetus for creating new services has been to re-direct patients into what is deemed a more appropriate health service based on their presenting complaint. Evidence has shown policies aimed at shifting care away from EDs into alternative urgent care services have not achieved their intended effect of decreasing ED visits6; as rather than helping people get to the most appropriate place for their health needs, these alternative services have resulted in further confusion 7. As shown in our study, service users do not want to deliberately burden the overstretched UEC system, but due to the multitude of obstacles encountered; it is perhaps no surprise they inadvertently end up using services in a manner labelled ‘inappropriate’.…”

Section: Discussionmentioning

confidence: 99%

“…In the UK, these include: co-locating primary care services with EDs,3 walk-in centres,4 and telephone triage systems (eg, NHS 111) 5. However, evidence shows these services have not achieved their intended effect of decreasing ED visits6; but have led to further confusion about the most appropriate services for particular health needs 7…”

Section: Introductionmentioning

confidence: 99%

What does the ideal urgent and emergency care system look like? A qualitative study of service user perspectives

et al. 2020

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BackgroundPolicies aimed at diverting care from EDs to alternative services have not been successful in reducing ED attendances and have contributed to confusion for service users when making care-seeking decisions. It is important that service users are at the heart of decision making to ensure new services meet the needs of those who will be accessing them. In this study, service users were encouraged to think freely about the desirable qualities of an ideal urgent and emergency care (UEC) system.MethodsFrom September to February 2019, an open inductive methodology was used to conduct focus groups with service users who had used UK UEC services within the previous year. Service users that had contact with NHS111, ambulance service, General Practice out-of-hours, minor injuries unit, walk-in centre or ED were purposively sampled and stratified into the following groups: (1) 18–45 years; (2)≥75 years; (3) adults with young children; (4) adults with long-term conditions. Focus groups were structured around experiences of accessing UEC services and perspectives of an ‘ideal’ UEC system.Results30 service users took part in the study, across four focus groups. The ideal UEC system centred around three themes: a simplified UEC system (easier to understand and a single-point of access); more ‘joined-up’ UEC services and better communication between health staff and patients.ConclusionDesirable qualities of an ideal UEC system from a service user perspective related to simplifying access for example, through a single point of access system where health professionals decide the appropriate service required and improving continuity of care through better integration of UEC services. Service users value reassurance and communication from health professionals about care pathways and care choices, and this helps service users feel more in control of their healthcare journey.

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Navigating and making sense of urgent and emergency care processes and provision

Cited by 36 publications

References 30 publications

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

‘Clinically unnecessary’ use of emergency and urgent care: A realist review of patients' decision making

What does the ideal urgent and emergency care system look like? A qualitative study of service user perspectives

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