Reimagining Emergency Medicine in India: Lessons From the NHS
By Arunima Rajan
In an interview with Arunima Rajan, Dr Hannah Brew, a UK based GP and occupational health physician, discusses what India can learn from the NHS emergency medicine model.
Emergency medicine in NHS has become a global benchmark. Could you describe the important elements or protocols that drive this efficiency?
Within the National Health Service (NHS), emergency medicine acts as a primary point of contact, seamlessly connecting primary care, specialty care, and inpatient services. Its effectiveness is underpinned by several crucial elements and protocols. These include major incidents, mass casualty events, and patient safety incidents, all with a strong emphasis on prioritising patient care. To meet the growing demand for emergency services, the NHS has introduced innovative care solutions such as SDEC (Same Day Emergency Care), GPOOH (General Practice Out Of Hours Service), and Urgent Care Services. These initiatives complement traditional emergency services by alleviating pressure and directing resources towards cases that require immediate attention, while minor illnesses are redirected to more suitable settings.
When a patient arrives at discharge in an NHS emergency department, what is the patient journey like?
Patients arriving at the ED can be classified into two main categories: heralded and unheralded. Heralded patients are those whose arrival is anticipated by the ED, such as those arriving by ambulance or those who have pre-booked after consulting a clinician in another setting, like NHS 111 or a GP. Conversely, unheralded patients are not expected by the ED. This group includes individuals who self-present without prior contact with a clinician in another healthcare setting and those advised to attend the ED by a clinician in 999, primary, or community care.
The process typically begins when a patient enters the emergency department. The triage process considers two main factors: the primary complaint or suspected diagnosis and the urgency or severity of the condition, which determines how quickly patients are seen. Patients are categorized as resuscitation for immediate emergency intervention, major for urgent care, and minors for standard emergency situations.
The NHS has set targets for EDs, stipulating that 95% of patients should be admitted, transferred, or discharged within four hours of arrival (Swancutt et al., 2017). This goal focuses on minimising the time patients spend in the department and enhancing operational efficiency.
After triage, patients receive the necessary treatments or diagnostic tests. Delays often occur due to waiting for test results or bed availability, impacting waiting time and overall
patient satisfaction. Efficient care coordination is essential to avoid bottlenecks in patient flow. The final stage involves transferring patients to a suitable care site or discharging them from the ED. The discharge process can be delayed if there is prolonged waiting time for discharge instructions or transportation arrangements.
Implementing efficient management strategies such as team triaging and point-of-care testing can significantly reduce delays and improve patient throughput.
What role does tech play in NHS emergency medicine, what outcomes have you observed?
Technology is pivotal in NHS emergency medicine, particularly in facilitating remote consultations for virtual wards and clinics, data sharing, data storage, and multidisciplinary team decision-making. These technological applications enhance collaboration and knowledge exchange among healthcare professionals.
Moreover, digital solutions such as self-check-in kiosks have been implemented to streamline patient intake processes. These systems are designed to reduce waiting times and improve patient satisfaction by enabling efficient triage and prioritization (Sehgal et al., 2024).
What kind of triage system is used by NHS, and how it helps manage patient inflow and resource allocation?
The NHS implements a range of strategies to manage patient inflow and resource allocation in emergency departments, with triage systems being essential. The National Early Warning Score (NEWS) is a well-validated track-and-trigger system that identifies and responds to patients at risk of deterioration. This system effectively reduces waiting times for urgent cases and balances the demand for emergency care with the limited available resources.
How does UK balance cost with quality of emergency medicine? In India, most people pay out of pocket.
The NHS is funded by the state, supporting emergency medicine through a mixture of taxations, national insurance contributions and initiatives designed to manage rising demand. The current system has been criticised as unaffordable and fragmented, leading the government to introduce the recent NHS Fit for the Future 10-year plan. This plan emphasises preventive care, AI, and neighborhood health delivery to alleviate the pressure on emergency services and the NHS as a whole.
What are the parameters that emergency medicine departments in UK use to evaluate the performance? How does transparency of these parameters affect clinician accountability and patient care?
Many EDs are guided by the 4-hour national target, along with other parameters such as the number of patients who left without being seen, re-attendance rate, time to initial assessment, time to treatment, and total time in the ED. Measuring these quality indicators helps enhance accountability and quality of patient care.
Is burnout an issue?
Burnout is a condition characterised by physical and emotional exhaustion. It often arises from prolonged stress in the workplace, or from working in a physically or emotionally demanding role for an extended period. According to the NHS Staff Survey 2023 results, burnout is more common among staff in clinical roles. Emergency Department (ED) work environments are reported to be the most intense and high-pressure, with clinical staff experiencing the highest levels of burnout compared to other specialties. Workforce retention has been at a crisis level for over a decade and is now worsening, with minimal progress despite targeted initiatives. Safe delivery of Emergency Care (EC) continues to be a serious threat.
What would be top two recommendations from NHS experience to improve standard of emergency care in India?
To enhance emergency care in India, drawing from the NHS A&E experience, my two main recommendations would be to establish a robust triage system and to optimise patient flow through the department.
An effective triage system would ensure that patients receive appropriate care based on the severity of their condition, whereas improved patient flow with clear guidelines on target waiting times would prevent overcrowding and delays.
Efficient patient flow involves ensuring that patients transition smoothly from triage to assessment, treatment, and finally to discharge or admission. The benefit for India is a reduction in waiting times, overcrowding, and infection risks, thereby enhancing patient experience and potentially saving lives.
If implemented effectively, these two recommendations can make emergency care in India more efficient, safe, and patient-centered by leveraging the strengths of the NHS model and adapting them to India's healthcare system.
References
Swancutt, D., Thomas, D., Pinkney, J., Brant, H., Allen, M., Joel-Edgar, S., Byng, R., & Benger, J. (2017). Not all waits are equal: an exploratory investigation of emergency care patient pathways. BMC Health Services Research, 17(1). https://doi.org/10.1186/s12913-017-2349-2 Sehgal, H. L. K., Greenfield, G., Neves, A. L., Harmon, M., Majeed, A., & Hayhoe, B. (2024). Efficacy and safety of a digital check-in and triage kiosk in emergency departments: a systematic review protocol. BMJ Open, 14(7), e084506. https://doi.org/10.1136/bmjopen-2024-084506
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