Urgent Care

“the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly. “(Department of Health – [Archived Content])

Key resources

The Keogh Urgent and Emergency Care Review – updates and documents relating to the comprehensive review of the NHS urgent and emergency care system in England by Sir Bruce Keogh

Transforming urgent and emergency care services in England (NHS England)
Details of the Urgent and Emergency Care Review being led by Sir Bruce Keogh and the review of Emergency care in London.

Urgent and emergency care [Archived Content]
Department of Health

Out-of-Hours Services – A Commissioning Handbook for CCGs (PCC 20 August 2012)
This document is about commissioning out-of-hours services and the interface between GP out-of-hours services and the wider health and urgent care systems, including the NHS Commissioning Board.

College of Emergency Medicine –  clinical guidelines relevant to Emergency Medicine produced by external organisations, including Paediatric and  End of life.

Urgent Care in General Practice (Primary Care Foundation)
Research commissioned by the Department of Health examining the management of urgent care in general practice. Work on developing a web based tool to support implementation of the recommendations is ongoing.
See also Informing the Intentions of New GP Commissioners of Urgent Care – a presentation given by Primary Care Foundation at the Advanced Health & Care annual conference, 25th May 2011

Keep up to date

Search the contents of the Kings Fund library or NHS Evidence or NHS Networks Commissioning Zone (Limit search results by Topic filters including A&E and Urgent Care)

Pulse Commissioning Topic –  Emergency admissions (Registration required) – News and case studies available as RSS feeds.

Key organisations

Primary Care Foundation – established to support the development of best practice in primary and urgent care.

Royal College of Emergency Medicine (formerly College of Emergency Medicine) – standards, guidelines, policies lots of other useful material around implementation.

Royal College of Paediatrics and Child Health

Emergency Care Improvement Programme  A clinically led programme that offers intensive and practical support to 28 urgent and emergency care systems. Website includes a range of tools and resources around emergency care.

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Key reports and policies

Dorset Vision Compendium of Clinical Evidence December 2014. A collection of guidelines and standards to support a clinical service review, including Urgent Care.

Primary care factors and unscheduled secondary care: a series of systematic reviews. (Centre of Academic Primary Care, University of Bristol 2014)
Analysis of factors at primary care organisational level that impact on levels of unscheduled secondary care and  implications for commissioning. Based on 48 papers published 2000 – October 2012.

Walk-in centre review: final report and recommendations (Monitor Feb 2014)
This review of walk in centres found that the provision varies greatly by location reflecting local health economies and populations. Common themes identified were: walk-in centre closures may adversely affect patients’ access to primary care, the division of commissioning responsibilities for walk-in centres is causing confusion, and walk-in centres would work better for patients if payment mechanisms were reformed.

Accident & Emergency Performance England 2013/14: national and regional data (House of Commons, 14 April 2014)
An analysis of the DH’s Weekly A&E Data from April 2013 to March 2014. Includes Weekly data, highest and lowest attendances per area team, Major A&E dept attendances per 1,000 population, Population-relative A&E attendance per region by type, highest and lowest attendances by NHS trust, Variation in the percentage of patients waiting over four hours per area team, Highest and lowest % of patients waiting over 4 hours at major departments by month, number of emergency admissions via type 1 departments as a percentage of type 1 attendance.

Evidence to inform Urgent and Emergency Care Systems (Centre for Reviews and Dissemination., March 2014) an overview of the evidence for a range of interventions that seek to improve the delivery of urgent and emergency care. (Interventions include Telephone consultation, primary care front end to the emergency department involving GPs, other workforce models (emergency care practitioners and nurse practitioners). Interventions with limited evidence of benefit (in terms of reduced waiting times and or length of stay) include ‘fast-tracking’, rapid  assessment zones, triage liaison doctors and allowing triage nurses to order tests.

Focus on preventable admissions: Trends in emergency admissions for ambulatory care sensitive conditions, 2001 to 2013. QualityWatch October 2013. This study examined the pattern of admissions across England for people with ACS conditions over the 12-year period from 2001 to 2013 as an indicator of how well primary and preventive care were working to reduce emergency admissions.

Hospital accident and emergency departments: planning and design DH 11 June 2013
The strategic background, uncertainties and evidence base for decision-making in the design and planning of A&E departments.

High quality care for all, now and for future generations: transforming urgent and emergency care services in England – The Urgent and Emergency Care Review established by the government into the way the NHS responds to and receives emergency patients (June 2013)

Review of the provision of walk-in centre services in England Monitor, May 2013
An examination of the extent to which the closure of walk-in centres has limited people’s ability to choose where and when they access routine or urgent primary health care services without appointment.

A&E Improvement plan from NHS England (May 2013) – A plan to strengthen performance in urgent and emergency care to help hospital A&E departments meet demand and tackle waiting time pressures. Includes as an Appendix the “Emergency Care Checklist – Urgent and Emergency Care: A review” for NHS South of England (The King’s Fund, March 2013)

Quality in the Emergency Department College of Emergency Medicine, 14 May 2013
The report, based upon the results of a comprehensive survey of 131 Emergency Departments makes ten recommendations across 4 domains – system redesign to manage workloads and decongest the ED, expansion and sustainable working practices for staff, a radical change to the way in which emergency care is funded, a better system to measure the success of improvement rather than 4hr system performance alone.

The Silver Book – quality standards for the emergency care of older people from the British Geriatrics Society (2012), focusing on the skills and competencies needed by healthcare staff to ensure they are better able to assess and manage frail older people.

Effective Approaches in Urgent and Emergency Care – a series of reports from NHS Intensive Support Teams (IMS) (2012):

  • Paper one: Priorities within acute hospitals
  • Paper two: Rapid assessment and treatment models in emergency models
  • Paper three: Whole system priorities for the discharge of frail older people from hospital care
  • Paper four: Improving ambulance handover – practical approaches

Directory of Ambulatory and Emergency Care for Adults, 4 ed compiled by the NHS Institute and Ambulatory Emergency Care Delivery Network, November 2014
New practice and examples of AEC, and identifies emergency conditions clinical scenarios that have the potential to be managed in an ambulatory way. 

Patient Reported Experience Measure (PREM) for urgent and emergency care RCPCH with Picker Institute Europe, October 2012
A tool developed to measure the experience of paediatric patients 0-16 years in all urgent and emergency care settings including; GP practices, out-of-hours centres, A&E departments and the ambulance service.

Urgent Care Centres – What works best? A review of Urgent Care Centres. Primary Care Foundation October 2012
“Urgent care centres of various types have evolved as a way of meeting these needs. But we found little published evidence that they reduce attendances at A&E and some suggestion that they might increase the total burden on the NHS.”

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Driving Improvement in A&E Services – FTN Benchmarking A&E 2012 (Foundation Trust Network, 26 October 2012)
This FTN Benchmarking study brings together 11 acute trusts with A&E services. A number of the key messages relate to the relationship between primary/community services and A&E services and the impact of older people attending A&E.

Getting to grips with integrated 24/7 emergency and urgent care: a practical way forward for clinical commissioners (NHS Alliance October 2012)
Based on meetings held by the NHS Alliance with those involved in urgent care in East Kent and the North West (July 2012). Includes challenges and opportunities and key questions for CCGs.

Out-of-Hours Services – A Commissioning Handbook for CCGs (PCC, 20 August 2012)
This document is about commissioning out-of-hours services but it will also touch on the interface between GP out-of-hours services and the wider health and urgent care systems.

Older people and emergency bed use: Exploring variation (Kings Fund 9 August 2012)
This report is based on a new analysis of HES and local population-based data.

Paediatric emergency and urgent care (Royal College of Paediatrics and Child Health)
The latest policy and publications relating to paediatric emergency and urgent care from the RCPCH including:

Standards for children and young people in emergency care settings (RCPCH May 2012)
This revised guideline provides healthcare professionals, providers and service planners with measurable and auditable standards of care applicable to all children and young people in urgent and emergency care settings in the UK. This updated edition reflects changes in the way care is delivered: there is a new chapter focusing on mental health and substance misuse and the document takes a ‘pathway’ approach to aid a multi-professional workforce.

Unplanned admissions of older people: exploring the issues – NIHR Service Delivery and Organisation programme; 2011.
An analysis of how nine English councils and their partners approached the challenge of reducing emergency bed days for older people, the interventions they adopted, the opportunities and difficulties encountered, and the consequences for patients. The analysis “found no simple association between the model of governance adopted within the study sites and the outcomes achieved.”

The Emergency Medicine Operational Handbook (The Way Ahead) v2 (College of Emergency Medicine, December 2011)
This guidance is for clinicians, managers and commissioners involved in the delivery of Emergency Medicine. Recommendations for a core service and facilities, workforce, skillmix and Quality Standards for Emergency Departments.

New ideas and resources for clinical commissioners on the journey towards integrated 24/7 urgent care (Primary Care Foundation, NHS alliance, November 2011)
“A series of suggestions about how urgent care of the future could be more joined up, provide better value for money and offer better patient care.”

Review of Evidence on What Drives Economies of Scope and Scale in the Provision of NHS Services, Focusing on A&E and Associated Hospital Services: (Compiled by Centre for Health Economics, University of York for OHE Commission on Competition in the NHS, 2011)
A review of the evidence around co-location and scale of urgent care hospital services.

Guidance for commissioning integrated Urgent and Emergency Care:  A‘ whole system’ approach (RCGP Centre for Commissioning, 2011)
Using the Clinical Commissioning Cycle, the guidance describes what a good urgent and emergency care service looks like based on local and national evidence. It shows how to redesign services leading to more integrated care pathways and draws on the QIPP programme and other measures to deliver the required efficiency savings. See the summary in GP Online Urgent care – How to commission urgent care

Managing emergency activity – urgent care (Kings Fund, 2011)
Number 10 of the Kings Fund report “Ten top priorities for Commissioners”
“Making the urgent care system easier to navigate and integrating it to manage demand more effectively could have a major influence on health outcomes.”

Managing ambulatory care sensitive conditions (Kings Fund, 2011)
Number of the Kings Fund report “Ten top priorities for Commissioners”
“Ambulatory care sensitive (ACS) conditions are chronic conditions that include congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension. Actively managing patients with ACS conditions – through vaccination; better self-management, disease-management or case-management; or lifestyle interventions – prevents acute exacerbations and reduces the need for emergency hospital admission.”

Avoiding hospital admissions: What does the research evidence say? (Kings Fund, 2010)
A compilation of the research evidence to establish which interventions work in avoiding emergency or unplanned hospital admissions.

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Primary Care and Emergency Departments (Primary Care Foundation, March 2010)
A study of the different models of primary care operating within or alongside emergency departments across England to provide a viable estimate of the number of patients who attend emergency department with conditions that could be dealt with elsewhere in primary care.

Managing emergency demand (Kings Fund 2010)
In : Approaches to demand management Commissioning in a cold climate, p11-14 (Kings Fund, 2010)
Different approaches including: An acute visiting scheme in general practice, Use of risk stratification data in general practice,Virtual wards in the community,New approaches to the use of 999 and the ambulance service.

A service delivery model for urgent care centres: Commissioning advice for PCTs (Healthcare for London, 2010)
Includes a discussion of the patient pathway, information sharing and systems, integration with other services, standards and performance measures, governance and procurement.

Urgent Care in General Practice (Primary Care Foundation, 2009)
A spotlight on the differing ways urgent care is, and can be, managed in day-to-day general practice, offering key insights into how we can all improve our patients’ care and access making best use of existing resources and identifying areas and practices that require additional resources.

A guide to patient and public involvement in urgent care (NHS Centre for Involvement, 2008)
The NHS Centre for Involvement has produced a guide for commissioners and providers that provides a step by step process to implement an effective system of patient and public involvement in urgent care.

Not just a matter of time : A review of urgent and emergency care services in England (Healthcare Commission, 2008)
This review looked at out-of-hours GP services, A&E services and urgent care centres, emergency ambulance services and, to a lesser extent, urgent GP services delivered during usual surgery opening hours and NHS Direct. We gathered data from all these services to produce a combined assessment of urgent and emergency care across each local area, based on the boundaries of each of the 152 primary care trusts (PCTs) in England.

Urgent and Emergency Care Service Mapping & Social marketing project (South Central SHA, 2008)
A presentation on social marketing which includes some of the findings of the service mapping project.

Urgent Care Project: Best Practice Review (University of Warwick, UK. 2008)
A summary of evidence around models to reduce unplanned emergency admissions.

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Indicators / outcomes / tools

The Mental Health Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis. It sets out how organisations will work together better to make sure that people get the help they need when they are having a mental health crisis.

A&E clinical quality indicators: (Department of Health)
The new quality Indicators for A&E which took effect April 2011. Read the College of Emergency Medicine Guide to Implementation here.

A&E Waiting Times and Activity on the NHS England website
The Weekly A&E collection collects the total number of attendances in the week for all A&E types, including Minor Injury Units and Walk-in Centres, and of these, the number discharged, admitted or transferred within four hours of arrival. Also included are the number of admissions via A&E, and any waits of over four hours for admission following decision to admit. Data are shown at provider organisation level and is available back to November 2010.

Health & Social Care Indicator Information Portal – includes data on emergency/unplanned  admissions under CCG Indicators and Compendium of Health Information Indicators

Urgent and Emergency Care Clinical Audit Toolkit (RCGP, 2011)
Practical guidance on the implementation of clinical audit in urgent and emergency care provider service settings.

Improving access, capacity and the management of urgent care in general practice : a web based tool (Primary Care Foundation)
A simple way for all practices to assess how easily patients can access care, the match between demand and availability for appointments and how staff respond to urgent demand for care.

Toolkit for commissioners of the emergency and urgent care system
In:The emergency and urgent care system (Medical Care Research Unit, Sheffield University, 2011)
1. Calculating indicators for commissioners to monitor the performance of their emergency and urgent care systems (eucs) using data that are available routinely
2. Undertaking a survey of system users’ experiences and views
Manchester Triage System

A triage system used widely in A&E departments widely across the UK.
Described in Emergency triage 2nd ed (Blackwell, 2006)

New urgent care dashboard for GPs (NHS East Midlands)
GPs in Bolton have already been piloting the clinical dashboard on their IT systems which aims to significantly cut both A&E attendances and unscheduled admissions by identifying those patients who are over-using urgent care. The high level aim is to make the urgent care clinical dashboard (based on NHS Bolton pilot) available to all PCTs /GP consortia across England over the next two years starting with the 10 pioneer sites, including Northamptonshire.

Clinical Dashboards: An Update on the National Urgent Care Dashboard – a presentation (Sept 2012)

NHS Comparators (login required) Discontinued March 2015

Quality Indicators to support commissioning of unscheduled care (NHS London, 2009)
This proposed delivery model for unscheduled care includes potential outcome measures and indicators.

Tackling demand together: a toolkit for improving urgent and emergency care pathways by understanding increases in 999 demand (DH, 2009) [Archived Content]
A toolkit produced by a group of ambulance providers and primary care trust commissioners together with the Department of Health to offer practical analysis, worksheets and tools to help all commissioners and providers improve urgent and emergency care services through better understanding of the factors affecting significant rises in 999 demand.

Urgent and Emergency Care (PSNC Briefing 093/13: September 2013) – a briefing to assist LPCs in their discussions on urgent care at local level to promote community pharmacy’s role in tacking these challenges, and to highlight key areas where community pharmacy can support the provision of care and reduce demands on GPs, NHS 111 and A&E.

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The NHS 111

Research evidence

Triage and minimising crowding in emergency departments -Spring 2015. An Effectiveness Matters summary of the evidence from CRD, University of York.

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems. Health Serv Deliv Res 2014;2(48)

High quality care for all, now and for future generations: Transforming urgent and emergency care services in England The Evidence Base from the Urgent and Emergency Care Review, NHS England June 2013

Primary care professionals providing non-urgent care in hospital emergency departments. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD002097. This systematic review found only three studies, providing inconclusive evidence regarding the effectiveness and safety of care provided by GPs versus EPs for non-urgent patients in the ED.

Review of the Models of Care Managing Emergency Department Attendances (Early Adoption Centre, East of England NHS, 2011- Note the EAC closed September 2012, report loaded here with permission)
An examination of the evidence and models of care around the effectiveness and cost effectiveness of shifting minor illnesses and diseases from Emergency Departments to lower cost settings .

Act & early to avoid A & E (National End of Life Care programme, 2011)
For patients who need end of life care, ensuring that there is planned 24/7 provision of community support can reduce unnecessary, and expensive trips to Accident and Emergency with crisis admissions to hospital.

Exploring the effect of changes to service provision on the use of unscheduled care in England: population surveys
BMC Health Services Research 2007, 7:61
In a population survey of 50,000 people over 5 years (response rate 69%) 16% or respondents had an unscheduled episode in the previous four weeks. However new services such as NHS Direct and walk in centres did not affect the use of traditional unscheduled care services, with a large proportion of the population continuing to turn to their GP for unscheduled health care.

‘Inappropriate’ attendance at an accident and emergency department by adults registered in local general practices : how is it related to their use of primary care
Journal of Health Services Research and Policy, 2002 vol 7(3) p160-165
Findings of a case-control study matched for age, sex, distance from the AED, social class and registered general practice and set in a single AED and two health centres in South Essex found that GP-registered, ‘inappropriate’ attendees at AEDs utilise primary care services more than matched controls; this pattern of service utilisation appears to be unrelated to chronic physical illness. Thus, simply providing new, directly accessible primary health care services may not significantly reduce AED use.

Direction of Travel for Urgent Care (Department of Health)
A consultation and evidence review to support the development of urgent care services 2007 onward.

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What are other NHS Trusts doing?

GP support in care homes reduces unplanned hospital attendances by 25%
Gloucestershire CCG, March 2015
An ‘enhanced service’ for older people living in care homes in Gloucestershire has seen a fall of around 25% in the number of residents attending hospital and a reduction of around 5% in unscheduled admissions.

Evaluation of a general practitioner-led urgent care centre in an urban setting : description of service model and plan of analysis. (Journal of the Royal Society of Medicine, 2013, vol./is. 4/6, 2042-5333)
Description of an integrated urgent care model, which was commissioned by NHS Hammersmith and Fulham in 2009 to manage the rising number of urgent attendances at local hospitals and its associated evaluation. The evaluation will include examining the effect of the system on outcomes and effect on unplanned hospital admissions.

Avoiding admissions from care homes – case study Pulse 9 May 2013 – registration may be required
Description of a GP practice based care home team supported financially by a LES which allows the practice to do all out-of-hours calls 24 hours a day, 365 days a year on a rota with a GP always available for advice by phone. Supported by a healthcare assistant in the practice, a pharmacist, the CCG Macmillan nurses and three CCG advanced nurse practitioners.

NHS SW London: Croydon Borough Urgent Care Strategy & Work Programme 2011/12

NHS Great Yarmouth & Waveney – Procurement of Integrated Urgent Care Services (Memorandum of Information)

NHS Bucks and Oxon cluster – ImPACT  (National Archives webpage)
A description of some of the18 workstreams which are developing the changes to urgent care services through the Improving Public Access to Care and Treatment programme.

NHS Derby – Urgent Care in Derby
Description of the Integrated Care Model developed in NHS Derby. (June 2010)

NHS Liverpool: diverting patients from A&E
Working with local practices and the Royal Liverpool University Hospital Trust, NHS Liverpool set out to divert admissions to the emergency department of patients whose needs could be managed more appropriately in primary care settings. Since the scheme began 6% of patients have been successfully diverted, improving the use of A&E resources and generating potential savings of up to £184,000 a year.

NHS London – Unscheduled care including:

  • Quality indicators: unscheduled care
  • Study: unscheduled care in 6 PCTs
  • Unscheduled care commissioning model
  • Unscheduled care information collection and sharing study
  • Urgent care centres delivery model

NHS Peterborough – The Right Care at the Right Time
Consultation documents (including a Business Case) around the Primary care and urgent care consultation May – August 2011.

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