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NHS services have been under increasing pressure in recent years, particularly since the start of the Covid-19 pandemic. We have previously reported on the NHS’s efforts to tackle the backlogs in elective care and its progress with improving mental health services in England. This report gives an overview of NHS services that may be used when people need rapid access to urgent, emergency or other non-routine health services, and whether such services are meeting the performance standards the NHS has told patients they have a right to expect. It covers: general practice community pharmacy 111 calls ambulance services (including 999 calls) urgent treatment centres accident and emergency (A&E) departments. Key findings Population changes are contributing to increasing demand for healthcare. Demand for unplanned or urgent care is increasing. The number of general and acute hospital beds has increased slightly following a downward trend before the Covid-19 pandemic, but occupancy rates have also risen and patients are now staying longer in hospital compared with previous years. The number of NHS staff has increased, including those working in unplanned or urgent care. he number of staff vacancies across the NHS rose from the start of 2021 but has recently fallen. Spending on the NHS continues to increase. The total budget for NHSE in 2022-23 was £152.6 billion, some £28.4 billion more than in 2016-17 at 2022-23 prices. Patients’ access to services for unplanned or urgent care has worsened. There is considerable variation in service performance and access, both between regions and between different providers. Covid-19 had, and continues to have, an adverse impact on the NHS’s capacity to meet healthcare needs. The NHS has not met key operational standards for unplanned or urgent care since before the pandemic. Performance against operational standards, and more widely, has deteriorated further since the onset of the pandemic. Overall performance of the unplanned and urgent care system has been worsened by delays transferring patients from one service to another. The NHS has not been able to secure the full benefits of increased spending and staff numbers and productivity has fallen since the onset of the Covid-19 pandemic. NHSE has a plan to reduce waiting times and improve patients’ experiences.

In this blog, Carl Heneghan, Urgent Care GP and Professor of Evidence-based Medicine at the University of Oxford, looks at how the shortage of doctors working in urgent care is affecting patient safety. He tells the story of a patient with a blocked catheter, highlighting that with early intervention, this should cause few complications, but if not treated promptly, it can cause bladder damage and chronic kidney failure. This example highlights the need to ensure patients are seen quickly if they have an urgent need in the community. The blog points out that current Government plans to scale up urgent community response teams are inadequate as they only cover 12 hours a day and there is a shortage of GPs willing to work in urgent care.

In this on-demand webinar, professionals across the NHS discuss how their speciality areas interact with urgent care, and how digital health can be used to relieve pressure in relevant areas. Speakers: Dr Tom Micklewright, Medical Director at ORCHA and NHS GP Helen Hughes, Chief Executive at Patient Safety Learning Chris Efford, Clinical Lead Physiotherapist and Digital Fellow, University Hospitals Dorset and DNHS Dorset Digital Services at Home Team Dr Simon Leigh, Health Economist and Director of Research, ORCHA View presentation slides from the webinar

This report by the Primary Care Foundation considers the question: 'Is the drive to improve outcomes and the quality of integrated urgent care being compromised by poor data quality?' The report highlights that monitoring the performance of NHS contracts is vital to allow commissioners to understand and compare the effectiveness of services, and that this monitoring cannot occur without accurate data. The authors conducted a detailed study of current data before exploring how issues in the system might be overcome. The report aims to build consensus for change within the urgent care sector. The report makes some key observations around patient safety in relation to the patient journey through integrated urgent care: "Although cases are passed from one organisation or IT system to another there is less functionally integrated management of the resources between the two parts than was envisaged, there is little management reporting of the whole of the IUC journey and there are unnecessary delays because of the number of steps involved, each with its own queue. This results in a service that is less effective than it could be in getting the patient to the right place for treatment, that makes less effective use of the resources available within the system than it could do and that can delay patient care to such an extent that clinical risk begins to rise."

The Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it. Background In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network. The model can be summarised as: A more integrated, informed, calm approach in the way we respond to individuals that have unique needs during a crisis and A better form of multi-skilled, personalised support after the crisis event is over. So in July 2013 the Serenity Integrated Mentoring (SIM) model of care was proposed. This is how it works: SIM brings together all the key urgent care agencies involved in responding to high-intensity crisis service users around the table, once a month. This multi-agency panel selects each individual based on demand/risk data and professional referrals. They use a national 5-point assessment process to ensure that the right clients are chosen and in a way where we can ensure a delicate balance between their rights as an individual but our need to safeguard. Selected individuals are then allocated to a SIM intervention team. The SIM team is led principally by a mental health professional (who leads clinically) and a police officer (who leads on behaviour, community safety, risk and impact). The team supports each patient, to better understand their crises and to identify healthier and safer ways to cope. In the most intensive, harmful or impactive cases, the team also does everything it can to prevent the need for criminal justice intervention. Together, the mental health clinician, the police officer and the service user together create a safer crisis plan that 999 responders can find and use 24 hours day. The crisis plan is then disseminated across the emergency services. The SIM team reinforces these plans by training, briefing and advising front line responders in how to use the plans and how to make confident, consistent, higher quality decisions. What are the benefits and risks of this approach? Benefits: It is claimed that this is a more integrated, calm and informed approach to responding to individuals in crisis and the HIN provides "better multi-skilled, personalised support after a crisis event was over". The HIN website states: "Across the UK, emergency and healthcare services respond every minute to people in mental health crisis and calls of this nature are increasing each year. But did you know that as much as 70% of this demand is caused by a small number of ‘high-intensity users’ who struggle with complex trauma and behavioural disorders? These disorders often expose the patient to higher levels of risk and harm and can simultaneously cause intensive demand on police, ambulance, A&E departments, and mental health crisis teams." Risks: This approach has been subject to strong criticism from some users of mental health services, mental health clinicians and mental health support organisations. Concerns have been raised about whether the HIN/SIM approach is safe, effective or appropriate. I believe we need an open and inclusive discussion about High Intensity Networks, with users of mental services leading the debate. As a former mental health nurse in an Assertive Outreach team I'm keen to learn: How users of services were involved in the initial development of the model? What are the similarities and differences between High Intensity Networks and an Assertive Outreach model? How this approach compares with approaches in other countries? How users of services are involved in evaluating and adapting the model? What the specific benefits are for users of services and are there any risks to this approach? Does this lead to a long term improvements for users of services? I hope people will feel able to contribute openly to this discussion, so we can learn together. #HighIntensityNetwork #mentalhealth