Overflow in Urgent Care: Are Non-Urgent Patients the Culprit?

Imagine going to the Emergency Department (ED) in pain or distress, only to wait hours before you're even seen. Since 2010, the National Health Service (NHS) of England set a target: 95% of patients walking into the ED should either be discharged, admitted, or transferred within four hours [1]. But like all ambitious targets, the specifics have shifted over the years. What hasn't changed, though, is the core goal – to cut down those long, often painful waits. Some argue that the delays are partly because of patients who don't really need urgent care. Think of someone with a minor ailment that a primary care clinic or a pharmacy could handle. These non-urgent visits can clog up emergency rooms, making it harder for those with genuine emergencies to get timely care.

We conducted research to try to answer this question. We used a detailed dataset, the Emergency Care Dataset (ECDS) [2], which provides a comprehensive look at why patients visit EDs and what happens to them. We have also tried to understand the post-pandemic urgent care attendance trends. 

How we define the non-urgent patient:

You might wonder, "How do we know if a visit was non-urgent?" For that, we used a method from a study published in 2018 [3]. Using this method, we focused on people coming to a major type of emergency department (Type 1) for the first time. The attendances we are focused on are those that can reasonably been seen and treated in an alternative setting to the Emergency Department. To be labelled "non-urgent", the visit had to tick all these boxes:

1.Not requiring urgent investigation in, and

2.Not requiring urgent treatment, and 

3.Discharged from the ED without treatment or referred to their GP.

What each of these means is presented in the box below:

In this study, we looked at 42 million emergency department (ED) first time visits in England from April 2019 to March 2022. Out of these, about 14.5% were non-urgent using our definition.

COVID-19 Impact:

During the pandemic from January 2020 to April 2021, there was a notable decline in both overall emergency department visits and non-urgent visits. The proportion of non-urgent attendances also fell, but this decrease eroded as the pandemic ended. Our analysis indicates that while all attendance at ED has been above the expected level post-pandemic this has been within the 95% confidence interval for what was expected. Non-urgent trends were found to have exceeded the expected level by the last period of our analysis (March 2022), rising to up to 20% of the proportion of all first time attendances.

(OLS fitted from April 2019 to January 2020 inclusive and extrapolated to the rest of the data)

Younger generation:

Over the course of three years, the majority of non-urgent attendees were for attendees under 60 years of age. We found that the highest proportion of non-urgent attendees (25%) was in the youngest age group (<11) while the lowest (2%) was in the oldest age group (90+). 

Regional difference: 

Regions have been impacted differently by COVID-19, with some experiencing more severe consequences such as regional lockdowns, high numbers of cases, and fatalities, while others have been less affected. Table 3 displays the breakdown of attendance types in the various regions throughout England. The regions with the most significant increase in non-urgent attendance in 2021/22 were London, the Midlands, the North West, and the South West.

Deprivation: 

We also wanted to know if the type of area people live in, defined according to level of deprivation, was a driver of attendances. For this, we used a measure called the Index of Multiple Deprivation (IMD) [4], where 1 means an area is very deprived (or poor) and 10 means it's not deprived at all. The data we had tells us where patients’ regular doctor (GP) was located. We figured that where a person's GP is might give us a clue about where they live and how deprived their area might be. Table 4 illustrates that the upward trend in both types of attendance is consistent across various IMD groups. Between the 2019/20 and 2021/22 periods, the percentage increase ranges from 1-4%, with no significant difference observed among different levels of deprivation.

Wrapping up, our exploration of routine NHS data gave us some important info about the number of people coming to English emergency departments with a low acuity problem that could easily be managed elsewhere. Between April 2019 and March 2022, about 14.5% of all new visits to the emergency room weren't emergencies. Younger folks were more likely to come in when it wasn't urgent, especially the really young. The number of these non-emergency visits grew from 15% in April 2019 to 20% by March 2022. This could indicate that there is a lack of provision in the NHS to help people who may need to be seen but are not a true emergency. Further efforts are needed to understand why people attend the emergency department with a low acuity problem, especially those who are very young. Why these numbers are increasing? Does this trend suggest shortcomings within the NHS system's functioning?

References

[1] Great Britain. Department of Health Social Care (2022) Handbook to the NHS Constitution for England. Available at: https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england [Accessed: 03 April 2023]

[2] NHS Digital. (2022) Emergency Care Data Set. Available at: https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/emergency-care-data-set-ecds [Accessed: 03 April 2023] 

[3] O’Keeffe, C., Mason, S., Jacques, R. and Nicholl, J., (2018). Characterising non-urgent users of the emergency department(ED): a retrospective analysis of routine ED data. PLoS One, 13(2), p.e0192855.

[4] Ingram, E. et al. (2021) Household and area-level social determinants of multimorbidity: A systematic review. J. Epidemiol. Community Health 75, 232–241 

Authors

Dacheng Huo, Sebastian Hinde, Laura Bojke, Colin O’Keeffe, Richard Jacques, Suzanne Mason from our Urgent Care Theme.

Funding and data disclaimer

The research was funded by the Applied Research Collaboration (ARC) Yorkshire and Humber. The views expressed are those of the author(s), and not necessarily those of the NIHR or the Department of Health and Social Care.

This work uses data provided by patients and collected by the NHS as part of their care and support. The Emergency Care Data Set (ECDS) are copyright © 2017-2022, NHS England. Re-used with the permission of NHS England. All rights reserved.

24 October 2023