Inequalities, Health and the Accident and Emergency Response Sue Laughlin & Alastair Low, Corporate Inequalities Team, NHSGGC

To explain the rationale for investigating pattern of use of A and E services and the nature of the response To summarise the research and its findings To consider NHSGGC response to research findings To summarise current steps being planned To invite feedback on this approach Aims of presentation

People shouldn’t start with “inappropriate referral”. Patients always have a reason why they are in the right place. Senior Nurse, A&E

Why consider A and E from an inequalities perspective? 15% population use 50% of NHS services Key access point to the NHS for people experiencing health symptoms of social inequality Potential cornerstone of a whole system approach to maximising NHS contribution to addressing inequalities Contributes to addressing the Inverse Care Law Research aimed at identifying challenges in inequalities sensitive approach

Purpose of the research 1.To describe and quantify the relationship between social inequality and A&E attendance 2.To map perspectives on care provision in relation to inequality 3.To explore examples of good practice and identify gaps in provision

Methodology Local & National Policy Review Quantative Data Analysis 52 individual Interviews, 8 group interviews with: A&E, NHS24, OOHrs services Acute Liaison services Corporate Community Groups Voluntary Organisations Service Users

A+E attendance by SIMD Quintiles June 08-May09 Comparative total NHSGGC Population breakdown by SIMD: SIMD 1 – 35% SIMD 2 – 17% SIMD 3 – 14% SIMD 4 – 14% SIMD 5 – 18%

“Society is changing. There’s a reduction in trauma e.g. car accidents, but much more chronic illness” (Senior Nurse) “We’re frontline…. It’s our job to undertake a social assessment and refer on where appropriate” (Senior Nurse)

Why are people attending? Poor health: Chronic conditions and disabilities Health literacy Historical and cultural reasons Poverty and chronic stress Unpredictable lifestyles associated with addiction issues Dissatisfaction with/inaccessibility of GP services Accessibility, familiarity, confidentiality

User perspectives on A&E practice Main issue : Staff attitudes and understanding “Staff are good.. Calm you right down…explained things in laymen’s terms” “The first rule of medicine is to do no harm… but the way drug addicts are treated does them harm” “I think they are in the dark ages about mental health. A couple of years ago I was very suicidal and overdosed. While I was behind a curtained area in A&E I heard one nurse say to another “These people who take overdoses, I just wish they would do it properly”

Differing staff views on the role of A&E To treat only those who have an acute presenting problem and re-direct ‘inappropriate attendees’ To treat all attendees and to educate about alternative, more appropriate services. To treat presenting symptoms only. No time for identifying or addressing underlying needs To care for people who have assessed themselves or have been assessed by others as in need of emergency care

Differing Staff Views on the Role of A&E “Staff are aware of attendees stresses and anxieties but not appropriate or no time to enquire and advise” “Problems are upstream….A&E can only pull them out the water, patch them up and return them to the community” “Staff in A&E services have a role to play in identifying underpinning social care needs and in endeavoring to facilitate responsive care” “ We’re frontline – its our job to undertake a social assessment and refer on where appropriate”

Challenges to Meeting Wider Health Issues Time Physical environment Staff attitudes, knowledge and skills Lack of supporting infrastructure – systems for information sharing, onward referral Lack of knowledge of local services Staffing : numbers and experience

Model of good practice: Homelessness Care Pathway 1.Motivated staff, attuned to patient context and knowledgeable of care pathway, through training and regular updates 2.Protocol developed with nursing staff to guide practice and support follow-on care 3.Simple screening tool for identification of homelessness on admission to A&E 4.Good links with Acute Homeless Liaison Team who proactively monitor and support attendees 5.Link nurse role in updating and supporting practice

Sensitive Enquiry into Domestic Abuse Importance of understanding GBV “Got to know about this to look after patients holistically” “Important to direct people on to appropriate agencies” “Important not to turn a blind eye…. But to have the knowledge to do something about it” Impact on Practice “Definitely more aware. I wouldn’t have asked at all before…now I follow through” “I wouldn’t have asked before…I would have left it up to someone else. Feel as if I can now” “More aware, more confident

Responding to the results Consideration at the NHSGGC Attendance Steering group Agreement at CMT Stakeholder engagement meeting Implementation process

Next Steps Develop and implement an approach to assessment and care delivery Create different types of physical environments Engage with out of hours services to develop and deliver an integrated and consistent model. Develop more meaningful information systems Assess the potential benefit of a referral route from A and E to GEMs for complex medico social patients who would be dealt with by primary care in day time services.

Next Steps (continued) Develop multi-partner case management approaches Development single point of contact within each Partnership for the referral of older people into community health and social care services Scope how medico-social complex patients could be routed from A and E using similar methodology and processes. Establish in each CHCP/CHP a route by which patients who require addictions services can be referred directly from A and E by ‘phone or and promptly and assertively followed up.