Background:

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives:

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design:

Mixed-methods sequential design.

Setting:

Four counties in southern England coterminous with a NHS 111 provider area.

Methods:

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings:

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking. Illness work involves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided by moral work: the legitimation and sanctioning done by service users. Navigation work concerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations:

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions:

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work:

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration:

This study is registered as UKCRN 32207.

Funding:

The National Institute for Health Research Health Services and Delivery Research programme.

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 14/19/16. The contractual start date was in October 2015. The final report began editorial review in February 2018 and was accepted for publication in July 2018. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Catherine Pope reports personal fees from UK higher education institutions, personal fees from the Norwegian Centre for E-health Research, personal fees from Macmillan, McGraw-Hill Education, John Wiley & Sons and the Authors’ Licensing and Collecting Society, grants from Health Education England Wessex and Health Foundation, other from University Hospital Southampton NHS Foundation Trust and other from the National Institute for Health Research (NIHR) Clinical Research Network, outside the submitted work. She is a member and Deputy Director of NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, and a member of the Health Services and Delivery Research (HSDR) Researcher-led Panel. Joanne Turnbull is a current co-collaborator on another HSDR programme project (15/136/12).

Disclaimer

This report contains transcripts of interviews conducted in the course of the research and contains language that may offend some readers.