Understanding the choices people in Hull make when faced with a minor injury or ailment

56 Pages·2015·1.07 MB·English

by  Windows User

Understanding the choices people in Hull make
when faced with a minor injury or ailment

Research Report & Findings

Sue Pender,
Professional Practice Development Manager
City Health Care Partnership CIC
Business Support Centre, 5 Beacon Way, Hull HU3 4AE

City Health Care Partnership CIC is a not for profit Community Interest
Company responsible for providing NHS services in Hull and the East Riding.
Registered in England No: 0627 3905.
Understanding the choices people in Hull make when faced with a minor injury or ailment
Research Study Advisory group
Denise Everett, Head of Service Psychological wellbeing. Previously Senior
Operations Manager Practitioner-led services CHCP CIC
Graham Hill, Senior Pharmacist, CHCP CIC
Jo Scholes, Corporate Public Relations Manager, CHCP CIC

Chief Investigator & Address for Correspondence
Sue Pender, Professional Practice Development Manager, Business Support
Centre, City Health Care Partnership CIC, 5 Beacon Way, Hull HU3 4AE
Email [email protected]

Research Funder
Hull Clinical Commissioning Group 2nd Floor Wilberforce Court, Alfred Gelder
Street, Hull, HU1 1UY, Tel [phone]

With grateful thanks to the following for their assistance;
Kirsten Hamilton-Meikle – Commissioning Directorate, FHS Service for North
Yorkshire & Humber for advising about Hull pharmacy service provision
Hilary Lagopoulos, Nurse Practitioner, Minor Injury Units, City Health Care
Partnership CIC, for assisting with participant recruitment
Joanna Peacham, City Care Pharmacy, Hull, for assisting with participant
recruitment
Louise Walters & Suzanne Alexander, A&E Nurse Liaison Service, City Health
Care Partnership CIC, for assisting with participant recruitment

Declaration of competing interest of Chief Investigator and research study advisory group
The Chief Investigator and all the research advisory group members are employed by City Health Care
Partnership CIC which is the site of this research study. The Chief Investigator has no previous or current
operational or management responsibilities for any of the unplanned care services involved with the study.
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Understanding the choices people in Hull make when faced with a minor injury or ailment
Content Index
Research Advisory Group, Research Funder & Acknowledgments Page 2
Short abstract Page 4
Abbreviations & terminology used in the study Page 5

Section 1 Introduction
Context of research Page 7
Overview of the evidence Page 8
Why do people attend A&E depts.& What happens in A&E depts.? Pages 9 - 10

Section 2 Outline of Research Study
Rationale and aims & objectives for the study Page 12
Research questions & Interview schedules Page 12
Methodology Page 13
Recruitment process Page 14
Inclusion criteria, Special considerations & Exclusion criteria Pages 14 - 15
Ethical considerations Page 15
Analysis Page 16

Section 3 Scoping service provision
Non-Hull based services & web based services Pages 17 - 20
Pharmacies in Hull Pages 20 - 21
Minor Injury Units in Hull Pages 22 - 24

Section 4 Findings
Group 1 demographics Page 25
Terminology of services used by group 1 participants Page 25
Scenario Q1 responses Page 26
Scenario Q2 responses Page 28
Scenario Q3 responses Page 30
Additional findings from group 1 responses Page 32
Group 2 findings Page 37
Services accessed by group 2 participants Page 37
Care accessed for bleeding hand Page 38
Care accessed for ankle pain Page 38
Care accessed for insect bite Page 39
Reasons offered for service access Page 40
Additional findings from group 2 participants Pages 41 - 42

Section 5 Discussion & Conclusion
Discussion of findings Pages 43 - 46
Limitations of study Page 46
Conclusion Page 46

Section 6 References and Appendices
References Page 47
Appendix 1 Consent form Page 48
Appendix 2 Group 1 interview schedule Page 49
Appendix 3 Group 2 interview schedule Page 50
Appendix 4 Group 1 participants information leaflet Page 51
Appendix 5 Group 2 participants information leaflet Page 53
Appendix 6 Staff information leaflet Page 55

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Understanding the choices people in Hull make when faced with a minor injury or ailment

Tables Graphs & Illustrations

Number Title Page
1 Reason for A&E Attendance sourced from Hospital Episodes of Care (Nov 2013) 8
2 Care conducted in A&E sourced from Hospital Episodes of Care (Nov 2013) 8
3 A&E Data summary sourced from HSCIC (Dec 2013) 9
4 ‘Google’ search results 18
5 Treatment or advice for bleeding hand 18
6 Treatment or advice for painful ankle 19
7 Treatment or advice for insect bite 19
8 Map of pharmacies in Hull 21
9 Minor ailment scheme conditions that can be treated 21
10 Minor Injury Units in Hull opening times 22
11 Map of accident treatment locations in Hull 22
12 Age & gender of group 1 participants 24
13 Q1 scenario self-care examples offered by group 1 participants 26
14 Examples of where group 1 participants would seek care if bleeding persisted 26
15 Q2 scenario self-care strategies offered by group 1 participants 27
16 Q3 scenario self-care strategies offered by group 1 participants 29
17 When would group 1 participants seek intervention for Q3 scenario 30
18 Group 1 overall immediate responses to all scenarios 31
19 Immediate healthcare advice or service offered by group 1 participants 32
20 Choices made by one group 1 participant 35
21 Group 2 minor injury or ailment experienced 36
22 Group 2 access to services 36
23 Illustration of events leading to GP consultation 38

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Understanding the choices people in Hull make when faced with a minor injury or ailment
Abstract
Background: Research findings indicate ‘up to 40%’ of hospital Emergency
Department attendances are considered ‘inappropriate’ i.e. people presenting with a
minor injury or ailment that does not require medical intervention and in the view of
healthcare professionals could easily have responded to self-management or
remedies. Despite a growing number of alternative sources of healthcare advice or
direct treatment, there is little evidence to indicate whether people are aware of other
service provision, their location, accessibility, function or how these choices are
taken into account when people are faced with a minor injury or ailment.
Research question: The study aims to understand the choices that local people
make if they are faced with a minor injury or minor ailment and explore the reasons
behind their decision.
Research design: This is a small scale single site study comprising of two stages:
The first stage consisted of scoping the provision and access to sources of minor
injury or minor ailment care, treatment or advice that is accessible to people in Hull.
The second stage consisted of conducting semi structured interviews with two
groups of people firstly, members of the public to ask what they would do if faced
with three minor injury or ailment scenarios and secondly, with service users who
had experienced one of the injuries or ailment used within the scenarios to
understand their reasoning behind their choice.
Findings: In total 30 local people participated in the research interviews, and the
analysis of the findings produced some common themes. Members of the public are
not medically trained and may experience difficulty in ascertaining the severity of
their injury or ailment and therefore be confused as to where to seek assistance. For
those who may ‘Google’ for advice, there was an overwhelming number of
unvalidated electronic sources of healthcare information found - none of which direct
the person to a Hull based Minor Injury Unit. When considering where to attend, the
findings highlight just how prominent Emergency Department attendance features in
people’s minds coupled with some people indicating confusion regarding the opening
times, role and function of alternate sources of advice or care. The main reasons
participants offered for seeking healthcare intervention were to seek reassurance, a
belief that investigations may be needed, and belief that treatment will avert any
deterioration.
Discussion of the main findings provides an insight into how the people of Hull make
a decision about when and what advice or direct care to seek when faced with a
minor injury or minor ailment. The findings from this study may add to the debate
about how to direct people to access and optimise the use of the most appropriate
service when faced with a minor injury or minor ailment.
_____________________________________
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Understanding the choices people in Hull make when faced with a minor injury or ailment

Abbreviations and terminology used within this report

A&E – Accident and Emergency
ED – Emergency Department
CCG – Clinical Commissioning Group
CHCP CIC - City Health Care Partnership Community Interest Company
HES – Hospital Episode Statistics
IRAS – Integrated Research Application System
MIU – Minor Injury Unit
NREC – National Research Ethics Committee
RMG – Research Management Governance

Categories of Emergency Departments within the UK
 Type 1 A&E Dept - A consultant led 24 hour service with full resuscitation
facilities and designated accommodation for the reception of accident and
emergency patients.
 Type 2 A&E Dept. - A consultant led single specialty accident and emergency
service (e.g. ophthalmology, dental) with designated accommodation for the
reception of patients.

 Type 3 A&E Dept. - May be doctor led or nurse led. It may be co-located with
a major A&E or sited in the community. A defining characteristic of a service is
that it treats at least minor injuries and illnesses (sprains for example) and can
be routinely accessed without appointment.

 Type 4 A&E department / Urgent Care Centre / minor injury units
(MIUs)/Walk-in Centres /Urgent Care Centre, primarily designed to deliver
care for minor injuries or ailments with a limited scope of practice. Can be
accessed without an appointment.

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Understanding the choices people in Hull make when faced with a minor injury or ailment

Section 1
Understanding the choices people in Hull make when faced with a minor injury
or ailment

Context of the research
The Keogh report (1) drew attention to the growth in the number of people using
hospital emergency services, proposing that these were key factors which have led
to increased pressure and mounting financial costs upon services. Shortly after this
publication the government called for ‘a fundamental change to alleviate the
pressure on Emergency Departments’ (2) whilst taking a critical look at the use and
functioning of Emergency Departments across the country. A systematic review of
published research studies had suggested that ‘up to 40%’ of hospital attenders are
considered to be ‘inappropriately using the service’ by hospital healthcare
professionals (3)
Despite both national and local media advertising campaigns informing the public of
non-hospital based sources of advice, treatment or support for their perceived health
care needs - the attendance numbers and demands upon the hospitals continue to
be excessively high. The NHS Confederation when considering why people opt to
attend a hospital A&E department have offered that ‘people go where the lights are
on’ suggesting that the public generally knows where their nearest A&E department
is located and by nature of its location within a hospital it follows that the service is
accessible ‘round the clock’ i.e. functioning day time and night time.
Yet, there are other ‘round the clock’ alternatives available across the UK. Accessing
the right health care at the right time requires people to have the knowledge of what
can be delivered, where they are located and what days and times they can be
accessed and what steps they could make to undertake their own appropriate self-
care to prevent any attendance.
Locally, 17% of the Hull Clinical Commissioning Group (CCG) budget is spent on
unplanned care. The CCG’s 2012 / 2015 Strategy (4) sets out the ambition to reduce
the reliance for unplanned care on secondary care providers and shift the care
provision closer to the patient’s home i.e. within the primary/community care setting,
stating;
‘… improving unplanned care impacts positively upon the care pathway,
reducing duplication and health and social care resources’
Furthermore, the Strategy suggests that there is a ‘lack of clarity about what services
are available, when and for whom’ and this has been a factor in the Unplanned Care
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Understanding the choices people in Hull make when faced with a minor injury or ailment
Board challenging local care provider organisations with specific targets including
‘reducing conveying people to secondary care’, ‘integrating care pathways to provide
‘joined-up’ care and providing both choice and access to local people when faced
with an unplanned health care event’, such as a minor injury.
Whilst undertaking this research study the subject of the ‘use and misuse’ of hospital
Emergency Departments has escalated within the national media reporting on the
increasing pressures upon Emergency Departments and the frequency of the
breaches of their 4 hour targets. More locally, the ‘Hull Daily Mail’ newspaper printed
an article stating that due to the increasing demand upon hospital services ‘hospital
chiefs were urging people not to attend the hospitals Accident & Emergency
department and advised people to use Minor Injury departments or Walk-In Centres
if possible’ noting that ‘we are seeing a significant number of people who could have
received an appropriate level of treatment elsewhere and probably been seen more
quickly too’ (5)

In order to appreciate the context in which this study has taken place, it is important
to understand why people go to a hospital Emergency Department.
Data from Hospital Episodes of Care collated by Health & Social Care Information
Centre (Nov 2013) indicates the following reasons for attendance*
Table 1: Reasons for A&E Attendance
2009/10 2010/11 2011/12 2012/13
Other 64.0% 65.6% 67.1% 69.4%
Other accident 25,3% 24.1% 22.2% 21.0%
Sports injury 2.0% 2.2% 2.3% 1.8%
Road traffic accident 1.6% 1.5% 1.6% 1.3%
Assault 1.2% 1.1% 1.1% 0.9%
Deliberate self-harm 0.7% 0.7% 0.7% 0.6%
*Report indicates that data is of a ‘very limited scope’.

Table 2: What happens during patients Emergency Department attendance?

2009/10 2010/11 2011/12 2012/13
None 25.5% 33.0% 40.4% 41.1%
X-ray (plain film) 27.9% 28.8% 26.6% 25.2%
Haematology 4.9% 5.4% 6.4% 6.9%
Other 5.8% 4.7% 5.4% 5.3%
Other classified 13.6% 15.5% 16.0% 16.9%
Total valid records 77.7% 87.3% 94.8% 95.4%
Total invalid records 22.3% 12.7% 5.2% 4.6%
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Additionally data indicates:
Table 3: A&E Data Summary
 The peak time for arrival at the department is between 9.30am – 12md
 Type 1 Depts. are seeing a higher proportion of attendees from older patients
and a lower proportion from younger patients.
 On average 13 of every 20 attendees were referred by themselves to the
Emergency Department while 1 in 20 were referred by their GP
 Users of mental health services were more than twice as likely to have
attended the Emergency Department than non-users
 40% of all attendees were recorded as having NIL investigations undertaken
with 1 in 3 attendees recorded as having ‘Guidance /advice only’ – although
those aged over 64 were less likely to receive ‘guidance/advise only’
 Just over 2 in 10 of all attendances ended with an admission to hospital –
with around 5 in 10 attendances for those aged over 64 ending in hospital
admission.
 The rate of re-attendance within a week remains consistent between 7 – 8
per cent
Source HSCIC Focus on Accident & Emergency. December 2013
http://www.hscic.gov.uk/catalogue/PUB13040

Overview of the evidence
A literature search utilising the indexing services of AMED (Allied Medicine &
Complementary Health) HMIC (Health Management Information Consortium)
MEDLINE, (General medical database) BNI (British Nursing Index ) and Health
Business Elite was conducted using the following terms;
o “Minor injury” and
o “Accident * and / or emergency * Self-referral/referring and
o “Primary Care” or “Community care” or “Self-care”
o “Patient choice” or “patient expectations”
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Understanding the choices people in Hull make when faced with a minor injury or ailment
Over 15,000 articles were initially identified before combining, adding limitations of
Adults, UK only studies and those published from 1999 to the present day. Once
duplicates were removed the search ultimately yielded 42 relevant published articles.
Reviewing the literature indicated no universal definition of what an ‘inappropriate’
attender to emergency services constitutes. Studies tended to be presented from a
healthcare professionals perspective of what constitutes ‘inappropriateness’,
although some common themes emerge within the literature namely:
 ‘non-accidents and non-emergencies’ (6)
 those with pre-existing symptoms that have lasted over 24 hours (7),
 those who did not undergo hospital interventions(8)
 conditions that could be adequately managed by a GP or an alternative
source of non-hospital source (8,9,10)
A review of 34 world-wide studies by the Health Policy(8) review focused upon the
question to what extent primary-secondary care substitution is possible in emergency
unplanned care. The reviewers noted their difficulties in the absence of a universal
definition of ‘inappropriate emergency department attendance’ and cautioned against
drawing generalised conclusions with healthcare systems from other countries as
their structure and systems tend to vary greatly from the UKs NHS model.
Additionally UK studies tended to be based on a single site, descriptive design, with
service provision within the UKs MIU’s/primary care provision across the UK
varying tremendously in their organisation and operational approaches (i.e. may be
medical or nursing led, co-located within a hospital setting or have access to A&E
specialists)
A systematic review conducted in 2013 (3) of over 9,000 studies concluded that
healthcare professionals consider ‘up to 40%’ of those who attend hospital Accident
and Emergency departments to be ‘inappropriate attendees’ who could have
received their care (if needed at all) from alternative non-hospital/ emergency/
accident care services, including up to 8% which could have been managed by
pharmacies.
Few studies have sought to identify the specific expectations of people when they
seek minor injury care. One study (11) reported that 23% of people who self-referred
to a hospital emergency department reported that they expected to have an X-ray,
other studies have explored why people attend a hospital emergency department
and have produced broadly similar findings highlighting that the most common
reasons people cite for attending the department are; anticipating the need for an
investigation (such as X-rays) or a treatment (such as suturing or bandaging).
The most common themes from published MIU case studies are patient’s
acceptability of the service and less waiting time than a hospital emergency
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