Evaluating changes to emergency and urgent healthcare in England

The work presented here is for the degree of PhD by publication. I have selected seven papers for consideration, published in high quality academic journals between 2002 and 2011. I am the lead author on four papers and joint author on three. These papers derive from projects undertaken during my fifteen year research career at the School for Health and Related Research (ScHARR), University of Sheffield. Whilst the services I evaluated varied in scope, my research forms a coherent body of work informing the evidence base on policy driven initiatives implemented within emergency and urgent care. I have contributed to the evidence base around three key aspects of evaluation: acceptability (patient, carer, and workforce), effectiveness, and equity with respect to three of the most significant recent changes within emergency and urgent healthcare in England: telephone delivered healthcare, new roles within the workforce and, extended access and patient choice. Specifically, I have identified: • Telephone delivered healthcare did not significantly change demand for services: patient reported data suggested that NHS Direct was ineffective in reducing demand for other health services across the whole system of emergency and urgent care. • Inequity in the use of new telephone triage services: those from poorer socioeconomic groups or with communication difficulties were less likely to have used NHS Direct than other groups. • Problems with acceptability within a newly established workforce: although the majority of NHS Direct nurses were satisfied with this new way of working, a minority of staff found the work to be monotonous, posing a challenge to the retention of staff. • Clinical effectiveness of new roles within the workforce: a community based service utilising paramedics with extended skills demonstrated that paramedics can be trained to safely assess and treat older people with minor conditions which in turn led to a reduction in the need for attendance at an emergency department. • Patient and carer acceptability of new roles within the workforce: whilst minor acute health episodes do impact on patients and carers, initiatives such as utilising paramedics with extended skills in the community have a positive impact on the lives of these groups. Indeed, both groups reported high levels of satisfaction, and carers reported needing to provide less input with physical caring activities as a result of this new role being implemented. • Where patients choose to seek care and their satisfaction with this care during an emergency and urgent care episode: the majority of patients use multiple services on their care pathway, a daytime GP as their access point to emergency and urgent care, and are satisfied with their overall care during an episode. My work has demonstrated both the strengths and limitations of the policy related initiatives which I have evaluated. In particular my evidence regarding NHS Direct indicated some limitations regarding this telephone based service. Policymakers must take note of this given their plans for the national roll out of the non-emergency healthcare telephone service ‘NHS 111’, and if the telephone is considered as the medium for a single point of access to emergency and urgent care in the future. In contrast, the evidence that I have provided regarding paramedics with extended skills was overwhelmingly positive. Policymakers should support, and commissioners should explore, this model of service delivery when considering how to utilise emergency care practitioners within a locality. As policymakers continue to move forward with a vision for integrated emergency and urgent care healthcare attention must be directed towards the potential impact this has on users of the emergency and urgent care system