This fieldwork exercise was a visit to the ‘Minors’ Department within Accident and Emergency (A&E) for a large London National Health Service (NHS) hospital, to observe and interview an Emergency Nurse Practitioner (ENP) within the Department, and link their role in relation to primary health care (PHC).
I had expected to learn further about the main connection between PHC and an acute care setting such as A&E, assuming that it would be due to poor PHC management and issues with accessibility. These assumptions were based on some experience in A&E as an Agency Nurse, along with colleague’s, patients’ and media reports.
2.0 VISIT TO ‘MINORS’ IN ACCIDENT & EMERGENCY
My fieldwork exercise began with ‘covert observation’ in the A&E waiting room, waiting for my fellow Nurse Practitioner (NP) student to arrive for a Saturday night shift. There were around 15 people and one child within the waiting room; a relatively calm environment, albeit for quiet restlessness, sighing, guarding and rocking, questioning companions as to when they would be seen, alongside comparing with others who had ‘got in’.
Reception was a glass-shielded counter staffed by two personnel, informing patients registering, that there was a three hour wait. An electronic sign above reception welcomed patients, friends and relatives to the hospital, also informing them that “we endeavour to see you in 4 hours”; a reference to the Department of Health’s (DoH) target, for patients to be discharged, admitted or transferred within four hours of presenting, in 98% of cases. The sign also requested for those with a minor illness, to attend the adjacent walk-in centre (WIC).
Of note, aside from a clear focus on hygiene, was a sign notifying patients that treatment may not be free if not a United Kingdom (UK)/European Union citizen or resident. Such signage brings a principle of the Alma Ata declaration into question. The Alma Ata declaration arose following a joint World Health Organisation-UNICEF international conference, with a vision for healthcare for all people worldwide, with PHC at the heart (World Health Organisation, 2010). Although it can be argued that international guests are not paying into the NHS, and healthcare in the UK is not essentially free, given the National Insurance levy, the declaration views healthcare as a right for all, and not just those who are in a position to pay.
On arrival, my fellow NP student showed me around A&E. Within the adults section, the Department can be broken down to:
Table 1: A&E layout
+1 paediatric cubicle
Including 1 psychiatric cubicle
Investigations and short term treatment (not more than 24-36 hours)
Ear, Nose & Throat
Adjacent CT room being built next to Resuscitation
The hospital is one of London’s major hospitals, opening in the 1700s in central London and developing into a main teaching hospital. With the increase in healthcare demands, more space was needed, and the hospital relocated to its present day location in the 1950s. In the 1970s, construction on the present hospital building began, and by the early 2000s, building and the final relocation of one of its hospitals was complete (Hospital website, 2009a).
The A&E Department is a 24 hour service, seeing around 100 000 patients per year, and of those, around 21% are admitted to hospital. Twenty two percent are children, to which a separate paediatric A&E between the hours of 9am and 2am is available (Hospital website, 2009b).
From April this year, the A&E Department will become one of London’s four major trauma centres (MTC), and one of eight acute stroke centres (Healthcare for London, 2010). Preparations for this new designation were evident by the building of a computerised tomography scanner next door to Resuscitation, enabling suspected stroke patients to be scanned within two minutes of arriving.
I spent most of my visit in ‘Minors’, a Department with 12 cubicles, which is staffed by two to three ENPs, one Senior House Officer, Registrar support, and a General Practitioner (GP) on Saturday and Sunday evenings. Despite having an adjacent WIC, this section of A&E is dedicated to patients with minor injuries and illnesses. The most common presentations are due to infections (mostly ears, nose and throat, and urology), foreign bodies, wounds, fractures and head injuries.
Numbers seen can vary, and around 150 patients had already been seen that day. There is a difference between days and nights, with days mostly seeing occupational injuries and GP referrals, with alcohol, drugs, domestic violence, assaults and foreign bodies featuring in the nights. In addition, weekends and evenings can see Minors taking on the role of an extended hours GP practice; supporting my hypothesis of poor PHC management and accessibility, as being a key cause of PHC in A&E.
The Department closes at 3am to reduce costs, but is sometimes too busy to do so. From next year, Minors will be a 24 hour service, with the aim for a Nurse-led service with Registrar support. This is to release medical staff for the new MTC, and in response to recommendations in Lord Darzi’s review on healthcare for London, discussed further in this assignment.
The most surprising element of my visit, was to find out that ENPs are viewed and treated as “junior doctors”. This was mirrored by the consultation: history taking, examination, assessment, plan of care and documentation was that of seeing a medical doctor. While I was aware of the advanced and autonomous role of a NP, enabling diagnosing, prescribing and referring, I was taken back that NPs, certainly in this Department, have shifted from the nursing side of healthcare, and are now affiliated with medicine. The ENPs’ line management is a Registrar, who also supervises and signs off competencies. Any problems or concerns which need to be escalated, are dealt with by the Consultant. The A&E Matron, and ultimately, the Director of Nursing are nowhere in the ENPs’ reporting line.
The role of NP, reviews of urgent care, and PHC management are the topics I have chosen to base my discussion on.
3.1 Urgent care reviews
The key review of urgent care in London is Lord Darzi’s ‘Healthcare for London: A Framework for Action’ report. It was commissioned by NHS London in December 2006, in order to fulfil London’s healthcare needs over the next 5 to 10 years. The report acknowledged that many patients presenting to A&E for minor illnesses and injuries would be better looked after in “polyclinics” or urgent care centres (UCC) with longer opening hours. Patients presenting to A&E is not optimal due to the waiting period and being seen by junior doctors rather than GPs, who more suited to these complaints along with managing long-term health conditions (Healthcare for London, 2007a).
The report proposes UCC with diagnostic equipment, where patients will have access to a Nurse or GP, recommending 24 hour access if based in A&E (ie. Minors), or to be open on weekends and afterhours for those not hospital based (Healthcare for London, 2007a). A co-located UCC within A&E can be important, in diverting urgent care away from attending A&E/MTCs (Healthcare for London, 2007b). However, the ENP reported problems recruiting fellow ENPs with appropriate qualifications and experience, and was unsure whether Minors would be a Nurse-led 24 hour UCC, to coincide with the transformation of the main part of A&E into a MTC in April.
The Darzi report received criticism, largely directed at cost cuttings, cashing in on privatisation, the ‘demotion’ of acute hospital services, the question of elderly care, and that future predictions on PHC and A&E usage was an understatement. There is also criticism that recommendations have been made without practicalities, including ‘polyclinic’ staffing, failings and costs of minor injuries units, and the future of healthcare staff (London Health Emergency, 2007).
The ENP reported a poor skills mix at the adjacent WIC, such as not being able to read x-rays or suture, with patients being referred on to Minors. Alongside the question of resources being doubled up, such referring on leads to disjointed care and greater waiting lengths to be treated. It could also be confusing for patients to know where the best place to attend is, especially having been diverted from A&E to the WIC on the advice of the Reception sign, only to end back up in A&E. Clarity and streamlining of services is needed to improve patient experience.
The Royal College of Nursing (RCN) survey found that Emergency Nurses were under huge strain to meet the DoH’s four hour target, termed as “unrealistic” (RCN, 2010: website). The survey also reported that the majority of respondents felt that patients with various and complicated needs, have had their care rushed to meet targets, and 59% of respondents feeling the responsibility lying solely within Nurses (RCN, 2010). Yet the ENP I spoke to was happy with the target, which gave momentum if a patient needed to be seen by a Registrar and had been waiting over an hour, this would then be escalated to a Consultant. On questioning, the ENP felt that the target was realistic, practical and they had the resources.
3.2 Primary health care management and accessibility
London has the most A&E attendances and admissions than anywhere else in England, and many of the 83% of patients not admitted could be treated elsewhere, with 40% of complaints able to be resolved through PHC. However, access to PHC services in London after hours is inadequate; a main thought behind A&E attendance. A&E patients are more likely to be fulltime workers and may take reassurance in knowing that they will be seen in four hours, rather than a wait of up to (or longer than) 48 hours to see their GP (Healthcare for London, 2007b). According to the ENP, patients report issues making GP appointments and that A&E is quicker than seeing their GP, as the main reasons for presenting with PHC matters.
The Healthcare Commission’s (HCC, now the Care Quality Commission) review on urgent care in England, found that more than 50% of patients have problems calling their GP surgery, and a quarter of patients found GP hours were not convenient, and avoided going (HCC, 2008). Incentives for GP surgeries to provide afterhours care was a recommendation by The Royal College of General Practitioner (RCGP) in their review on urgent care (RCGP, 2007). Yet, the HCC’s review found that where GP services provide afterhours care, less than half had organised a phone diversion with local GPs, to divert afterhours calls to their services. The majority of patients attending afterhours GP services are seen within two hours after an initial telephone assessment (HCC, 2008). This is not only faster than attending A&E, but a more appropriate use of resources.
The review found that many people are not aware of healthcare services other than their own GP and A&E, or they might be unsure of using them. There were also examples of patients being referred to services that were not accessible. Work needs to be done to increase both patients and healthcare professionals understanding of alternative healthcare services, and when to use them (HCC, 2008). This is a view shared by the RCGP, along with GP practices implementing systems to deal with urgent care and GP training (RCGP, 2007).
The ENP expressed frustrations with GPs making inappropriate referrals to A&E, rather than to Specialists, generally noting the practice of ‘defensive medicine’. Despite referring back to the GP on discharge, patients were bouncing back for simple things, such as to have their dressings attended to. The ENP rarely had time to speak with GPs, but when they did, it was mostly to phone to question why they had referred. In respect to patients, the ENP felt that they were either not taking responsibility for their health or there was poor self management, possibly due to poor or no patient education, such as not taking analgesia and attending A&E to request. The RCGP also note the need for improved patient education and self management promotion in their review (RCGP, 2007).
The ENP was also very critical of NHS Direct, England’s telephone advice line for healthcare. They felt that the service was inadequate, as it was not possible to make an assessment over the phone, and “defensively” referring to A&E. Yet half of callers to NHS Direct were given advice on self management at home (NHS Direct, 2010).
3.3 The role of the Nurse Practitioner
This fieldwork exercise has been a valuable experience. It has demonstrated the impact PHC has on A&E, an already stretched resource, exacerbated by poor PHC management and accessibility.
For these reasons, I will bear in mind my present practice and on qualification as a NP, to make seamless and appropriate referrals.