Source: Cutting A&E use and health inequalities | Practice | Nursing Times
Many people are increasingly going to accident and emergency departments when they could visit a GP. One scheme aimed to improve education and cut attendances
IN THIS ARTICLE…
Annie Ford is diversity programme manager at Merton; Debra de Silva is head of evaluation at The Evidence Centre; and Sima Haririan is general manager at Merton Healthcare.
Ford A et al (2013) Cutting A&E use and inequalities. Nursing Times; 109: 24, 14-16.
In south west London, nurses, community workers, GPs and others have worked together to develop a programme that supports migrant communities, resulting in a reduction in their use of accident and emergency services. The programme included setting up community education sessions, six-week courses, and bilingual advocacy and interpretation services. Its success relied heavily on the team getting to know local communities, working in partnership and making time to develop trust. The lessons learnt from establishing these services are discussed to help readers improve their equality and diversity .
5 KEY POINTS
Merton is a leafy borough in south west London, perhaps best known for housing Wimbledon. It may be surprising to learn that 27% of Merton’s population is from minority ethnic groups (Office for National Statistics, 2011). Like many areas, the population in Merton is increasing and getting older, while health and social resources are limited and a large proportion of the health workforce is heading towards retirement (Merton Council, 2007). People from migrant communities are often not registered with a or tend to visit accident and emergency departments rather than using primary care.
Given resource and staffing constraints, it is not sustainable for whole groups of the population to bypass primary care. By not attending GP clinics, this group is also missing out on essential preventive services and support - often coping with progressively deteriorating conditions until they reach crisis point.
Throughout the UK, there is a strong link between deprivation and health inequalities, with the most deprived areas generally having the lowest life expectancy (Randhawa, 2007). These areas also tend to have a higher prevalence of smoking, obesity, unhealthy eating and risky drinking behaviour (Johnson, 2006). This is of particular significance in Merton, where it is not uncommon for a third of geographic wards to be made up mainly of those from minority ethnic populations, including people from eastern Europe and South East Asia.
We audited local data and found 43% of A&E attendance occurred on weekdays, in working hours. GP practices with the highest number of weekday A&E users were in areas of socioeconomic deprivation and high multi-ethnicity.
Aims of the programme
In 2010, we met with nurses, doctors, community groups and commissioners to address how to reduce the high rates of A&E use. We aimed to target migrant communities with education and support.
Government policies highlight the need to support diverse groups (Department of Health, 2010; Home Office, 2010) and health and social services are required by law to undertake equality and diversity assessments, and implement diversity plans (University of Stirling, 2009). We took a more proactive approach, with nurses and other professionals working side by side with community groups to support a change in mindset in the hope that changing how people think and feel would ultimately lead to behaviour and more sustainable use of health services. The broad aims of the programme were to:
Setting up the programme
Over the past two years, the Government Office for London funded Merton Healthcare (now part of Merton Clinical Commissioning Group) to provide targeted support for migrant communities. This work is being expanded into neighbouring areas with funding from NHS South West London Public Health.
Our programme involved three key strategies:
Outcomes of the programme
The programme has had a marked effect on how organisations work together, migrant people’s health behaviours and the use of hospital services. Some of the programme outcomes are listed below:
It is important to note that there is a towards reducing the tidal wave of unnecessary A&E attendances in Merton. Since 2002, attendances at A&E departments across England have risen sharply. In 2009-10, over 20.5 million people attended A&E - an increase of almost 5% from the previous year (DH, 2012). This increase is thought to be due to confusion over GP out-of-hours services and a rise in migrant populations, members of whom are less likely to register with a GP and, therefore more likely to use A&E services.
In Merton, increases were also apparent (Table 1), but the health diversity initiative is helping to address this trend. Since the programme began in 2010, overall A&E usage rates have declined by 3%. This reduction is even more marked in the five practices serving the most deprived areas, which have received targeted support. Here, there have been reductions in A&E usage of around 10% (Table 2).
There remains work to do, but the trends are positive.
Implications for practice
The lessons learnt in Merton are applicable to many other areas; Box 2 outlines how to set up user-friendly services for minority ethnic groups.
The issue tackled here is pertinent throughout the UK - birth rates are rising and people are living , while there are increasingly diverse groups of people from different cultures, religions and demographic groups. Finances are becoming scarcer so commissioners, nurses and others at the frontline need to focus on preventive services and early interventions and to target people with higher levels of need.
Department of Health (2012) Reforming Urgent and Emergency Care Performance Management.
Department of Health (2010) Equity and Excellence: Liberating the NHS. London: The Stationery Office.
Johnson MRD (2006) Racial and Ethnic Inequalities in Health: A Critical Review of the Evidence. Warwick: University of Warwick.
Merton Council (2007) Ethnic Minority Strategy. Merton: Merton Council.
Office for National Statistics (2011) Population Estimates by Ethnic Group: Greater London Authority. London: Office for National Statistics.
Randhawa G (2007) Tackling health inequalities for minority ethnic groups: challenges and opportunities. Better Health Briefing 6. London: Race Equality Foundation.
University of Stirling (2009) Single Equality Scheme 2009-2012. Stirling: University of Stirling.