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

Ablard, Suzanne; Kuczawski, Maxine; Sampson, Fiona; Mason, Suzanne

doi:10.1136/emermed-2019-208921

Cited by 8 publications

(9 citation statements)

References 17 publications

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“…Autonomy-themed healthcare outcomes (control, information, and safety) were poorly covered in these measures. Emergency care is unique in terms of its complexity, uncertainty, and consequent vulnerability [ 35 , 36 ]. Autonomy outcomes may be absent from identified instruments due to the inclusion of studies with hospital inpatient participants, who may have been in more stable health with less uncertainty.…”

Section: Discussionmentioning

confidence: 99%

A systematic review and recommendations for prom instruments for older people with frailty in emergency care

Oppen

Alshibani

Coats

et al. 2022

J Patient Rep Outcomes

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Introduction The current service metrics used to evaluate quality in emergency care do not account for specific healthcare outcome goals for older people living with frailty. These have previously been classified under themes of ‘Autonomy’ and ‘Functioning’. There is no person-reported outcome measure (PROM) for older people with frailty and emergency care needs. This study aimed to identify and co-produce recommendations for instruments potentially suitable for use in this population. Methods In this systematic review, we searched six databases for PROMs used between 2010 and 2021 by older people living with frailty receiving acute hospital care. Studies were reviewed against predefined eligibility criteria and appraised for quality using the COSMIN Risk of Bias checklist. Data were extracted to map instrument constructs against an existing framework of acute healthcare outcome goals. Instrument face and content validity were assessed by lay collaborators. Recommendations for instruments with potential emergency care suitability were formed through co-production. Results Of 9392 unique citations screened, we appraised the full texts of 158 studies. Nine studies were identified, evaluating nine PROMs. Quality of included studies ranged from ‘doubtful’ to ‘very good’. Most instruments had strong evidence for measurement properties. PROMs mainly assessed ‘Functioning’ constructs, with limited coverage of ‘Autonomy’. Five instruments were considered too burdensome for the emergency care setting or too specific for older people living with frailty. Conclusions Four PROMs were recommended as potentially suitable for further validation with older people with frailty and emergency care needs: COOP/WONCA charts, EuroQol, McGill Quality of Life (Expanded), and Palliative care Outcome Scale.

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Section: Discussionmentioning

confidence: 99%

A systematic review and recommendations for prom instruments for older people with frailty in emergency care

Oppen

Alshibani

Coats

et al. 2022

J Patient Rep Outcomes

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“…47 In addition, service users appreciated simplified healthcare provision from a single point of access. 48 It is not uncommon for early reports of new initiatives to be positive, but contradicted subsequently, 49 and our study is the largest of GPED services published to date. A similar phenomenon was observed previously in relation to nurse-led walk-in centres colocated with the ED, whereby initially positive reports were challenged by a subsequent large-scale evaluation that found 'no evidence of any effect on attendance rates, process, costs or outcome of care'.…”

Section: Discussionmentioning

confidence: 58%

“… 47 In addition, service users appreciated simplified healthcare provision from a single point of access. 48 …”

Section: Discussionmentioning

confidence: 99%

Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study

et al. 2022

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ObjectivesTo examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce.DesignMixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory’s four main constructs of coherence, cognitive participation, collective action and reflexive monitoring.Setting and participantsData were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available.ResultsThere was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient ‘streaming’ processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring).ConclusionsWe found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience.Trial registration numberISCRTN5178022.

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“…17 The NHS has committed to developing integrated urgent care services 8 and has published a detailed service specification describing what this should look like. 71 Historically, NHS 111 has been a separately commissioned and delivered service that refers callers to other, external services, such as GP out of hours. Individual services have formed more integrated partnerships, but there is now a national ambition to develop the 'provision of a functionally integrated, 24/7 urgent care access, clinical advice and treatment service'.…”

Section: Clarity Of Purposementioning

confidence: 99%

“…Individual services have formed more integrated partnerships, but there is now a national ambition to develop the 'provision of a functionally integrated, 24/7 urgent care access, clinical advice and treatment service'. 71 This will be staffed by multidisciplinary teams that include GP, pharmacy, mental health, dental and palliative care clinicians with NHS 111 (telephone and online) as part of the integrated urgent care service as the 'front door' to access. This means that users should expect their problem to be managed and resolved in a single encounter, described as a 'consult and complete' model of service delivery rather than 'assess and refer'.…”

Section: Clarity Of Purposementioning

confidence: 99%

Impact of NHS 111 Online on the NHS 111 telephone service and urgent care system: a mixed-methods study

Turner

Knowles

Simpson

et al. 2021

Health Serv Deliv Res

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Background The NHS emergency and urgent care system is under pressure as demand for services increases each year. NHS 111 is a telephone triage service designed to provide advice and signposting to appropriate services for people with urgent health-care problems. A new service, NHS 111 Online, has been introduced across England as a digital alternative that can be accessed using a website or a smartphone application. The effects and usefulness of this service are unknown. Objectives To explore the impact of NHS 111 Online on the related telephone service and urgent care system activity and the experiences of people who use those services. Design and methods A mixed-methods design of five related work packages comprising an evidence review; a quantitative before-and-after time series analysis of changes in call activity (18/38 sites); a descriptive comparison of telephone and online services with qualitative survey (telephone, n = 795; online, n = 3728) and interview (32 participants) studies of service users; a qualitative interview study (16 participants) of staff; and a cost–consequences analysis. Results The online service had little impact on the number of triaged calls to the NHS 111 telephone service. For every 1000 online contacts, triaged telephone calls increased by 1.3% (1.013, 95% confidence interval 0.996 to 1.029; p = 0.127). Recommendations to attend emergency and urgent care services increased between 6.7% and 4.2%. NHS 111 Online users were less satisfied than users of the telephone service (50% vs. 71%; p < 0.001), and less likely to recommend to others (57% vs. 69%; p < 0.001) and to report full compliance with the advice given (67.5% vs. 88%; p < 0.001). Online users were less likely to report contacting emergency services and more likely to report not making any contact with a health service (31% vs. 16%; p < 0.001) within 7 days of contact. Thirty-five per cent of online users reported that they did not want to use the telephone service, whereas others preferred its convenience and speed. NHS 111 telephone staff reported no discernible increase or decrease in their workload during the first year of operation of NHS 111 Online. If online and telephone services operate in parallel, then the annual costs will be higher unless ≥ 38% of telephone contacts move to online contacts. Conclusions There is some evidence that the new service has the potential to create new demand. The service has expanded significantly, so it is important to find ways of promoting the right balance in numbers of people who use the online service instead of the telephone service if it is to be effective. There is a clear need and preference by some people for an online service. Better information about when to use this service and improvements to questioning may encourage more uptake. Limitations The lack of control arm means that impact could have been an effect of other factors. This work took place during the early implementation phase, so findings may change as the service expands. Future work Further development of the online triage process to make it more ‘user friendly’ and to enable users to trust the advice given online could improve use and increase satisfaction. Better understanding of the characteristics of the telephone and online populations could help identify who is most likely to benefit and could improve information about when to use the service. Trial registration Current Controlled Trials ISRCTN51801112. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 21. See the NIHR Journals Library website for further project information.

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

Cited by 8 publications

References 17 publications

A systematic review and recommendations for prom instruments for older people with frailty in emergency care

A systematic review and recommendations for prom instruments for older people with frailty in emergency care

Do general practitioners working in or alongside the emergency department improve clinical outcomes or experience? A mixed-methods study

Impact of NHS 111 Online on the NHS 111 telephone service and urgent care system: a mixed-methods study

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