Monday, 2 July 2018

Improving the emergency and territory services: defragmenting the system

Xavier Bayona



In several articles of this blog you can read that one of the challenges to overcome in our and in most healthcare systems is the excessive fragmentation in health care that inevitably leads to duplication of tests and other dysfunctions that create pockets of inefficiency and malfunction. Several proposals to improve the continuity of care and reduce fragmentation have been presented with the aim of improving the quality of citizen attention, increasing the effectiveness and efficiency of the system.

Fragmentation is also present in emergency services. So if we look to the NHS, we can find a report published by the Royal College of Emergency Medicine with the Patients Association (Time to Act-Urgent Care and A & E: the patient perspective) published in May 2015, which concludes that primary care emergency services should join with those of hospitals. In this regard, as early as 2013, Bruce Keogh, medical director of the NHS, made the same recommendation. it’s commented within 2015 report that joint placement services should include emergency physicians, family physicians, nurses, frailty care, palliative care and mental health teams. It’s also commented that pharmacists and dentists could also contribute to the efficiency and effectiveness of the service.

Although it’s not uncommon to hear that some activities of hospital emergencies should be passed on to primary care, this argument should not be the reason for reorienting urgent care. Any assistance act should be performed mostly by those who know how to do it best, those who have the means to do so and all at a reasonable cost. If we look at what happens in Catalonia, we see that emergency management followed a path that has focused on reducing fragmentation by improving coordination. This coordination has increased mainly through the promotion of the "061" telephone service which has centralized the management of emergencies and the mobilization of resources according to needs. The problem is that only a very small proportion of the demand made by citizens for emergency services has been guided (I prefer this term to "filtered") by "061". Another problem is that hospital and primary care services are contracted for different concepts: hospitals, as is well known, are financed by activity and primary care by providing the service (because they are available).

There are already different experiences in our environment in which the emergency service of the hospital and primary care share spaces and facilities (General Hospital of Vic, Consorci Sanitari de l'Anoia, among others). I haven’t yet found data that analyze this operating model, but on the basis that patients are classified according to their degree of urgency when they make the demand, following the Andorran model of triage, it’s obvious that the less serious cases are mostly derived to the primary care specialists who attend to a larger volume of patients, and the serious cases go directly to the second level of care. In this way, the outcome is that the rate of admission of patients visited by hospital professionals is higher than in fragmented systems and at the same time, professional empowerment and shared knowledge of professionals of the first and second level of care is encouraged.

Another variable to take into account is the waiting of patients in the emergency services. If patients are stratified according to their level of severity and more coherent and participatory circuits are made by different professionals, waiting time for the less serious cases decreases while their satisfaction increases and at the same time if a patient must be evaluated by Hospital professionals, referral is much more agile.

Although the above is a possible solution, there are others. For example, an integrated hospital-primary care program for the management of patients with heart failure in an area of ​​more than 300,000 inhabitants of the city of Barcelona. Heart failure is the most frequent cause, along with respiratory failure, of consulting the hospital emergency services and admission. Once the results were analyzed, the study concluded that this model was associated with a significant reduction in patients' morbidity and mortality. The key to the success of the project lies in pro-activity, multi-discipline, the use of non-physical care and the empowerment of the patients and their families. There are other examples that demonstrate, in the environment of mental illness, that the benefit of co-localization of the primary care and the mental health specialist also bring added value to medical care, and this has also been the case in different experiences aimed at improving health care for older patients.

By way of conclusion: to reduce the fragmentation of the system, it’s necessary to enhance the mutual knowledge of professionals, encourage multidisciplinary teams and pro-activity (taking advantage, among other tools, of communication and remote follow-ups), setting common goals and empowering patients and their families. 

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