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Size A&E to be discharged, admitted or

Size of the problem

Although healthcare across
the NHS has significantly improved, increased demand on emergency care has led
to a strain on resources and capacity to meet performance standards of UEC. Across
2016/17, 23.4 million attendances to A&E facilities in England were
reported – of which 65 per cent were at major A&E departments (NHS England
and Digital, 2017, pp.4). This is a 22 per cent increase since 2007/8 (NHS England
and NHS Digital, 2017, pp.4). Furthermore, research suggests that A&E
attendances on average are increasing faster than population growth – particularly
in people aged 65 and over (CSP, 2014 and NHS England and Digital, 2017, pp.3).

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Likewise, the performance of
UEC facilities against the national four-hour waiting standards are not being
met. This standard requires 95 per cent of patients attending A&E to be
discharged, admitted or transferred within four hours or less (DH, 2013, pp. 9).

However, currently, only 89% of patient attendances spend four hours or less in
A&E departments (NHS England and Digital, 2017, pp.7). This is also
reflected nationally, whereby these targets, with the exception of some
individual months, have not been met annually since 2013/14 (NHS England and
Digital, 2017, pp.7). The percentage of patients spending more than four hours
in A&E was detailed as the highest in over a decade at major A&E
departments in 2016 (House of Commons, 2016). These findings demonstrate that
not only are UEC services underperforming against key standards of care, they
are also overpopulated.

of the increased pressure in emergency care

Demographic changes such as
an ageing population, whereby people are living longer, is considered a major
contributing factor to the challenges faced across UEC. Demand for emergency
healthcare has been associated with increase in the population of older people
(George and Todd, 2006). Nearly two-thirds of people admitted to hospital are
over 65 years old (NHS England, 2013, pp.12). Studies suggest that about one
third of attendances to A&E by older people follow trauma (a fall or other
accident) or minor illness (Downing and Wilson., 2004). Equally, increased
attendance has been associated with the winter months when the risk of falls
and respiratory illnesses increase (Downing and Wilson., 2002).


In 2016/17, the largest
growth in volume of attendances to A&E departments were among those aged
between 65-79 (NHS England and Digital, 2017, pp.5). Research exploring the
experiences of older patients in emergency care identified that, once admitted
– older people stay longer, require more time to manage and are more likely to
be readmitted following a short time of discharge (Aminzadeh et al., 2002; Cornwell
et al., 2012, pp.7 and George and Todd, 2012). These factors inflate healthcare
costs and curtail capacity across emergency departments (ED). Several publications
in literature suggest that older
people account for the majority of health expenditure in the NHS (NHS England,
2013, pp.12). On average, healthcare expenditure on people aged 75 and over
were thirteen times greater than that of the rest of the adult population
(McKinsey & Company, 2013, pp.9). Equally, emergency admission
reports show that despite a reduction in the total number of acute beds used,
people over 65 still account for nearly 70 per cent of hospital emergency bed
days per year (Imison et al., 2012, pp.2).  


Besides an ageing
population, people living with one or more long-term condition (LTC) escalates
pressure, costs of healthcare and consumption of resources within emergency
services (NHS England, 2013, pp.13).   Individuals living with multiple LTCs present
with markedly poorer quality of life, poor clinical outcomes and longer hospital
stays (King’s Fund, 2010, pp.7) – and therefore, constitutes towards the exhaustive
service-user population of UEC and acute services (DH, 2012, pp. 3). In total,
around seventy per cent of healthcare expenditure in England is attributed to
caring for people with LTCs (DH, 2012, pp.3). Additionally, this changing
burden of disease is associated with age and lifestyle (DH, 2012, pp.8).

Independent reports based on survey data found that the prevalence of LTCs
generally increased with age (DH, 2012, pp.8). These findings propose that not
only are older people more likely to access and expand emergency healthcare
costs; they are also more likely to contribute to underlying patient demands
such as acute bed occupancy and increased dependency on medical care following
prevalence of LTCs.


Demand across emergency
care is also impacted by rising public expectations for convenient standards of
care (NHS England., 2017b). Health professional surveys report that patient
expectations regarding information specific to their treatment, involvement in
decision making and access to the latest treatments have significantly
increased (The EIU, 2009, pp.8). Following, advancements in medical treatments,
technology and accessibility to the internet, a rise in healthcare consumerism
(The EIU, 2009, pp.7) has boosted public awareness and involvement.

Consequently, these factors could attribute to misinformation and inaccurate
use of UEC services by the public, further escalating inefficiency, unnecessary
admissions and reduced patient flow.


effects of increased demand on UEC

As a result of the
accumulating demands on UEC services, efforts to achieve safe and timely
performances across the NHS are becoming progressively challenging. Performance
standards and targets primarily because of overcrowding and long waits in
A departments affect patient safety and experiences of care. Hospitals
are unable to maintain the flow of patients out of their ED into wards and on
to safe discharge (House of Commons, 2016, pp.3).  Equally, reduced bed capacity has contributed
to the system-wide pressures and underperformance (House of Commons, 2016, pp.3).

This demonstrates an imbalance between capacity and demand. Research regarding
general principles of good patient flow in emergency settings suggests that the
importance of balancing capacity and demand avoids the development of
‘bottleneck’ delays along healthcare pathways (NHS England, 2015, pp.11).


Alternatively, it should be
mentioned that caution is required when applying the terms ‘demand’ and
‘capacity’ in the analysis of performance standards data – as there lacks
clarity over what factors encompass a demand or capacity. For instance, it
could be argued that referring to hospital beds as ‘capacity’ is misnomer
because capacity relates to a service’s ability to treat (NHS England, 2015, pp.12).

Whereas beds are places where patients wait to be treated. Therefore, this
could lead to a misrepresentation of the actual effects of increased demand on


role of physiotherapists in re-designing UEC services in the NHS

and emergency care settings

Physiotherapists (PT) undertake
extensive and advanced roles in A&E departments by providing specialist
knowledge and skills to a wide range of patient groups (CSP, 2014). Namely,
extended scope physiotherapists (ESP), frontline emergency physiotherapy practitioners
(EPP) and members of multi-disciplinary therapy teams in A&E / medical
admissions units (CSP, 2014) are recent PT roles established within emergency
care. Specialist roles such as ESPs and EPP describe autonomous PTs with
additional skills in assessment, diagnosis and management (McClellan et al.,


Despite the drive and
development of PT roles across emergency care being a fairly modern aspect of
the transformation of UEC – current literature provides a spectrum of research
evidence for the effectiveness of these roles. Jibuike et al., (2003) found the
role of ESPs in soft tissue injury management in emergency departments (EDs)
significantly reduced referrals from A&E admissions and saved medical time.

Correspondingly, rapid access to PT in A&E departments has been shown to
have significant impact on recovery time following soft tissue injuries (Darwent
et al., 1998). Sohil et al., (2017) also found that prompt PT intervention in
EDs reduced levels of disability and pain in patients with non-traumatic neck
and back pain compared to standard care. These results suggest that early intervention
from emergency PT practitioners in managing musculoskeletal injuries in EDs can
significantly improve patient outcomes and efficiency of UEC services. However,
with low methodological quality and small sample size, caution must be applied
when interpreting these results.


Previous studies have also
demonstrated the impact of PT services across emergency care on patient
satisfaction. McClellan et al., (2006) found that ESPs services in an EDs
achieved superior patient satisfaction compared to emergency nurses and doctors
– 55 per cent of patients strongly reporting they were satisfied with ESP
treatment compared to less than 38 per cent satisfaction on average for nurses
and doctors. These findings are consistent with other studies that found that
patients who received PT intervention expressed greater levels of satisfaction
with UEC facilities (Richardson et al., 2004; Bethel., 2005; Anaf and Sheppard.,
2007 and Lau et al., 2008). The advanced knowledge and communication skills of
ESPs / EPPs provides an explanation for these outcomes. Studies found that
advice regarding the progression of conditions and explanations of clinical
results provided patients with better understanding to improve patient
satisfaction (McClellan et al., 2006 and Sheppard et al., 2010).


Conversely, these results
stem from qualitative publications based on self-reports. The lack of testing
to identify any statistical significance in qualitative research compromises
the external validity and generalisability to the wider population (Atieno.,
2009, pp.17). Also, the use of self-reports compromises the internal validity /
accuracy of the findings. Limited awareness of the scope of PT practice could
also have misled patient responses. and the reliability of the aforementioned findings.

Anaf and Sheppard (2010) found that patients in EDs had limited knowledge of
the scope of PT practice, with most associating PT roles in EDs with
musculoskeletal management. Based on this assumption, the reliability of the
aforementioned findings is also questionable.


Nonetheless, these findings
highlight how the integration of PT services in UEC networks can aid the delivery
of high-quality care. As a result, this could influence overall patient
experiences and meet rising expectations of emergency care services.


Multidisciplinary team
research further emphasises and exhibit the significant impact PTs in EDs have
on delivering care to older people. Integrated teams of therapists, nurses,
social workers and care assistants provide streamline services in EDs evidenced
to provide a solution to the ageing population. Cole., (2017, pp.29;30)
reported significant reductions in A&E admissions, reduced treatment times
and improved discharges following the set-up of a physio-led frailty clinic. Through
interdisciplinary work and joint assessments / intervention, the team work
closely with community partners to make rapid decisions that enable the safe,
timely and effective discharge of patients’ safe environments – this has
resulted in a 30 per cent increase in avoided admissions. Similar outcomes have
been reported by Candler and Gallon (2015) who found improved discharges, patient
outcomes and staff experience with the introduction of a seven-day service
therapy teams in EDs.


These findings not only
demonstrate that PTs can attain effective leadership positions across emergency
care but also provides support to physio-led solutions of managing demands and
reducing patient flow at the front door of A departments. This is in
alignment with current strategy plans of the NHS 5YFV to promote more front
door clinical streaming and appropriate management of patient flow (NHS
England, 2017a). Furthermore, it could be argued that streamline initiatives
involving PTs can enable UEC providers avoid costs associated with the clinical
risks of hospitalisation of older people such as delirium, loss of function and
susceptibility to hospital acquired infections (Oliver., 2008).


This helps
tackle and bridge the gap between disparities’ in the continuity of care for
older people throughout emergency care pathways. Research suggest that medical
problems associated with ageing overlap with other medical problems for older
people (King’s Fund, 2012, pp.6). Older people frequently present with complex
medical and social needs over and above the clinical cause of their attendance
(Bentley and Meyer, 2004). Therefore, a multidisciplinary approach could
function as the optimal clinical guidelines for dealing with this population
and reducing demand on emergency care. Additionally, this could enhance
performance times, capacity and resource (acute bed space) availability within
A departments by allowing medical staff to directly attend to ‘sicker’
patients. The aforementioned findings suggesting better integration of health
disciplines help reduce A attendances accords with earlier publications
detailing the barriers to improving admissions to UEC (DH, 2013, pp.10).

However, closer integration is susceptible issues with funding, performance
management and ability to share patient information (DH, 2013, pp.10).


Physiotherapists and the community

Recent initiatives and
expansion of PTs roles in the community could provide further solutions to
support the vision of the NHS Business plan.  Research evidence by Hunt (2017, pp.26) convey
the importance and involvement of PTs in developing specialist health teams to
manage individuals living with LTCs. They identified that the new pathways that
incorporated direct access to mainstream and specialist acute pathways reduced
admissions to and reliance on emergency care. Likewise, ‘hospital at home’ programmes – involving specialist PTs that offer
hospital-level of care services to older people in the community has produced
promising results particularly on hospital bed numbers (McMillan., 2017, pp.36).

These findings directly target the NHS Business plan for UEC services to be
delivered closer to homes (NHS England, 2016, pp.26).


Overall, there are
considerable amounts of research evidence exploring the roles of PTs, to
solidify their professional capacity to support the NHS Business plans to
re-design UEC systems. Nonetheless, a lack of coherent methodological quality, quantity
of research evidence and authenticity of findings implicates the formation of a
definitive conclusion. For instance, majority of literature is based on PTs
occupying the roles of ESPs / EPPs in the same field. Furthermore, majority of
the research evidence investigated PT roles in major EDs. This limits the reliability
of the findings as PT performance cannot be compared or generalised to smaller
EDs or minor injury units. On the other hand, the notion that PT roles in EDs
is a recent, evolving phenomenon in healthcare gives some explanation for the
lack of empirical research in literature.  


In addition, research also
suggests a disadvantage of PT practitioners in EDs is that the scope of
practice for PTs in EDs depends on local need (Bethel., 2005). As a result, this
could influence opportunity to obtain a larger evidence base to establish vigorous
results. Further, no clarity is given for the cost-effectiveness of PTs in
emergency care. Research findings dictate that physio-led interventions across
could prove more expensive than routine care (Ball et al., 2007; McClellan et
al., 2013 and Richardson et al., 2004) – possibly due to the number of
follow-ups and prolonged time returning patients back to baseline function. This
could be detrimental to establishing an understanding of the scale of impact
PTs could potentially have on large systems like UEC, as economic factors drive
the sustainability of the service.


In conclusion, research
evidence strengthens the pivotal role PTs in emergency and community settings have
in providing and supporting change across UEC systems in the NHS. They also
provide support and encouragement for physio-led teams that produce significant
impact on hospital admissions, patient satisfaction and effective flow
management. However, the strength of the impact PTs in EDs is difficult to
determine given the lack of diversity and empirical research. Hence, from a systems
and providers’ perspective, there is an imbalance of evidence to justify the
benefits of PT services for UEC systems and service-users.



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