Title: Drivers of Demand for Emergency and Urgent CarE (DEUCE)
Funder: Department of Health and Social Care

Abstract: In England, urgent care is provided by a range of services including emergency services (999 ambulance service, emergency departments and hospitals dealing with emergency admissions), urgent care services (GP out of hours, minor injury units, walk-in centres, NHS 111) and in-hours general practice (requests for same day appointments and telephone advice). Concerns have been expressed about the increase in demand for some of these services (specifically ambulance, emergency department and in-hours general practice) and their capacity to deal with this demand. A key concern is the use of a higher acuity service than is clinically necessary. For example, people attending an emergency department when their problem could be dealt with by general practice. We need to know more about attitudes to seeking health care, reasons for people’s decision-making, and what might help people to make choices. We plan to undertake three sequential studies. Work Package (WP) 1 is a realist synthesis of how people make decisions to use different types of services for urgent care. We will build on recent reviews which identify the range of factors affecting demand for emergency and urgent care services by identifying underlying reasons for the decisions people make, potential ways of reducing clinically unnecessary use of services, and gaps in the evidence base in terms of important sub-groups which have not been studied sufficiently. WP2 is a qualitative study, interviewing people about how they make decisions to use emergency services, urgent care services, routine or self-care. We will interview three sub-groups of the population who have been identified as making clinically unnecessary use of services but where little qualitative research has been undertaken. Selection of these groups will depend on WP1 but may include deprived communities in highly urban areas. 48 face-to-face interviews will focus on why people make decisions to contact different services, trying to understand what lies at the heart of their behaviour and what might help them to use non-urgent services or self-care when it is not clinically necessary to use emergency or urgent services. Three focus groups will identify potential solutions to help people in their decision-making. WP3 is a national survey of 3000 adults in Britain, undertaken as part of the NatCen British Social Attitudes survey. Questions will be informed by a recent rapid review (Turner 2015), the findings from WPs 1 and 2, a PPI event, and the HS&DR-funded Turnbull study on sense-making and burden of care in urgent care. We will ask about attitudes towards seeking help from different providers of emergency and urgent care, including perceptions of availability of services, expectations of a 24/7 culture, preferences for emergency care services, risk perception, awareness of alternative services and health literacy. We will measure the proportions of people who have different attitudes and which of these affects the propensity to use levels of services that are not clinically necessary. We will look at how these attitudes vary by different population sub-groups. This study will complement organisational interventions aimed at improving emergency and urgent care as part of the current new models of care/vanguards policy (NHS England 2014). The intention is that it will help policy makers to plan future ways of managing demand so that service provision works for patients and is sustainable in the future.

Lay abstract: In England, urgent care is provided by a range of services. This includes services set up to deal with emergencies (999 ambulance service, emergency departments), services set up to deal with urgent problems (GP out of hours services, minor injury units, walk-in centres, NHS 111) and services set up to provide a mix of urgent and routine care (in-hours general practice). Concerns have been expressed about the increase in demand for some of these services, in particular 999 ambulances, emergency departments and general practice. Staff running these services are worried about maintaining their levels of performance with current demand and the likelihood of increased demand. Increases in demand are not simply explained by increases in the population. A key concern is the use of a service when it is not clinically needed. For example, people attending an emergency department when their problem could be dealt with by general practice, or people using urgent appointments with GPs when scheduled appointments or self-care could be used. We need to know more about attitudes to seeking care, reasons for people’s decision-making, and what might help people to make choices. We plan to undertake three studies in the following order. First, in Work Package (WP) 1 we will look at research that has already been undertaken on how people make decisions to use different types of emergency and urgent care services. We will try to understand fundamental reasons why people make the decisions they do. Next we will undertake WP2 where we interview people about how they make decisions to use different services. We will interview three groups of the population who have been identified as making use of services when this is not clinically necessary but where not enough research has been undertaken. Selection of these groups will depend on WP1. We may include deprived communities in highly urban areas. We will interview a diverse range of 48 people alone and then interview more people in three focus groups. A focus group is where people who have something in common discuss the issue in a group e.g. parents of young children. In the focus groups we will explore what people think would help them to make decisions. Then in WP3 we will undertake a survey of 3000 people. This will be representative of the population of Britain. We will see how decision making differs within different groups of the population. The survey will be part of the British Social Attitudes survey run by an organisation called NatCen. Questions will be informed by a recent rapid review of research (Turner 2015), the findings from WPs 1 and 2, a PPI event, and an ongoing study on sense-making and burden of care in urgent care. We will ask about attitudes towards seeking help from different providers of emergency and urgent care. Questions will focus on perceptions of availability of alternative services, expectations of a 24/7 culture, preferences for emergency care services, risk perception, awareness of alternative services and health literacy. We will measure the proportions of people who have different attitudes and which of these affects the tendency to use types of services that are not clinically necessary. We will look at how these attitudes vary by different population sub-groups. The intention is that this study will help policy makers to plan future ways of managing demand so that service provision works for patients and is sustainable in the future.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE