‘Urgent’ or ‘emergency’? Confusing boundaries of care

We have combined the data from the panels and both interviews here to reflect participants’ initial understandings of urgent care. Before they took part in the panels or the interviews, most participants said that they had not explicitly thought about the concepts of emergency and urgent care. However, it is important to note that the research process itself challenged them to construct meanings as part of the data collection process. P9, for example, illustrates how the interview process prompted them to differentiate between urgent and emergency after initially they had viewed these terms as interchangeable:

Interviewer:

If I mention urgent care to you, what would you think of?

P9:

I’d think of 999, or A&E, predominantly, I think, sort of, life-threatening is what I would think of.

Interviewer:

And if I said to you emergency care, what would you think of?

P9:

I think of A&E again, but probably less 999. I don’t know why, I just think urgent is, sort of, then and there . . .

Interviewer:

So, what do you think are the similarities and the differences between emergency and urgent care?

P9:

I don’t . . . Maybe they both involve, life-threatening as, sort of, an overview . . . I don’t know, thinking about it more, urgent sounds less like an emergency than emergency care.

Younger

The literature review of policy and research identified a clear hierarchy that placed emergency (broadly, life-threatening or serious events that need immediate attention) above urgent care (less serious conditions that require a less immediate response). Service users’ accounts were reasonably consistent with this policy view in defining ‘emergency’ and they talked about the seriousness of the symptom (life-threatening or very serious), how quickly help is required (immediately) and the response or service required (999 or ED response):

I hadn’t really thought about that before . . . well emergency I think it’s just the time scale. If it’s an emergency . . . it would needed to be dealt with now . . . but if it’s urgent it’s still, you still need it to be dealt with soon but you may live with it for a couple of hours . . . So for me emergency is the highest level of urgency and if it’s any lower level then I can either still go to A&E but wait to be treated or I could see an even lower urgency level then I can go to . . . the minor injuries unit or the GP at the lowest level.

P71, East European

Emergency is where life is threatened or health to a large degree is threatened and it has to be dealt with quickly and by highly qualified personnel I would say. Whereas urgent care there are things that still need to be attended to quickly but they wouldn’t be life-threatening.

P4, East European

For a minority of service users, the term ‘emergency’ was not necessarily associated with ED care:

Emergency care, probably something a bit less severe than A&E, but a lot of them . . . Again, there’s no real fine line, is there?

P28, older

However, defining ‘urgent’ was more challenging; there was less consensus and more uncertainty about the term. Although service users understood ‘emergency’ as a term applied to more serious, or life-threatening conditions, they also used the word ‘urgent’ to describe these health-care needs. Terms were often used interchangeably (by participants from all population groups):

P14:

Urgent care, I would think of, probably, well, an ambulance, A&E, you know, if it was urgent, yes. Otherwise it would be just a trip up the doctors to see what the problem is, you know.

Interviewer:

Yes. OK. And if I mention emergency care, what do you think of?

P14:

Emergency care is, well, the same thing, really. Yes. I mean, if I could see there was a major problem with anything . . . well, if it really looked bad, you’d have to ring the 999, I think.

Younger

Reflecting our review of the policy literature, service users often described urgent care in relation to emergency care, using language such as ‘less urgent’ or ‘not an emergency’ to define urgent care:

Well I know that urgent care is not emergency. Emergency is life-threatening, yes? Or at least you think it’s life-threatening. I mean if somebody was in pain I definitely would think that it was emergency and they needed somebody now and then, now. But if it’s something that you thought could be not dashed off straight away I would think it was less urgent.

P29, older

A variety of different terms were used to describe urgent care. Descriptions of health conditions suitable for urgent care services ranged from ‘less serious health problems’ (e.g. ‘not critical’ or ‘minor’) to descriptions that indicated high acuity (e.g. ‘serious’, ‘life-threatening’ or ‘severe’). Similarly, when using a time frame to define urgency, the term ‘urgent’ elicited a broad range of responses ranging from ‘immediate’ to ‘be seen within a day’ (or ‘can’t wait until morning’). The public panels, particularly, suggested that ‘urgent’ need required ‘being seen there and then’, ‘immediately’, ‘instantly’ or ‘quickly’. However, when asked to suggest their own definitions of urgent care, the general public panel struggled to articulate how time factored into the need for health care:

I think I say ‘no time limit’ because once you’ve got time you get . . . if there’s a certain target once you put a time limit on it, that’s then a target . . . I mean that would have to make that a time period. Time in there, and we’ve got 24-hour care. So you’re all saying to me is around timing. That’s what we want to, to imply isn’t it? You know, it’s something that’s as soon as possible. Requiring urgent care.

CP5, general public panel

Several East European participants suggested that there was little distinction between the words ‘urgent’ and ‘emergency’ and that the terms did not directly apply to their experiences of other health-care systems. Participants from Poland and Hungary reported that both ‘urgent’ and ‘emergency’ would apply to emergency services:

Yes, [urgent might be] something that can’t wait for very long or maybe can wait longer than emergency [. . .] But maybe it’s because in . . . Polish I think we don’t have separate words for these two. Maybe that’s why . . . It’s language problem as well, but in Polish, emergency and urgent . . . urgent sounds pretty serious. So maybe that’s why we struggle to distinguish. I don’t know . . . linguistic problem.

P3, East European

P33b [wife]:

We don’t use two different words, emergency and urgent. This is why for me it’s the same. Yes, not in health-care terms.

P33a [husband]:

Yes, not in health-care terms. So for me it’s no different.

Interviewer:

There’s no difference. And do you just have the term emergency in Hungarian? What would you call it . . . that would be perhaps a translation here?

P33b:

So, emergency is more connected with danger, and urgent is something you have to hasten rapidly. Emergency is something that, emergencies, critical, like fire.

Interviewer:

But not the hospital?

P33b:

Yes, probably there is just one service in the hospital, like the ambulance maybe. Yes, but it’s all linked, so you don’t think the ambulance is separate. It’s just the thing that takes you from A to B and tries to preserve your life.

East European

Additional confusion was created through the use of the words ‘urgent’ and ‘emergency’ in different health-care services. For example, the words ‘urgent’ and ‘emergency’ are used in the context of same-day general practice appointments but were understood as different from ‘urgent’ or ‘emergency’ in the context of the ED. For some, daytime general practice was viewed as an urgent care service:

Interviewer:

You’ve talked a little bit about [urgency] in terms of offering same-day appointments. Do you think that is urgent care, or do you think that’s something slightly different?

P2:

I would think that is urgent care, because . . . it is quick. It’s the same . . . it could be within a couple of hours . . . or even sooner. They sometimes say, ‘oh we can see you in half an hour’. Can you make it? . . . You can get that initial assessment really, really quickly.

East European

Right, I think if I need urgent care, I can phone up the surgery and get an answer and possibly get an appointment that day. If it is out of hours, then you dial 111 and you speak to a colleague on the end.

P7, older

The boundaries between types of health-care services were described as muddled and opaque. The range of services that the general public and health-care professional panels identified as potentially available for urgent and emergency care needs included expected answers such as 999 and the ED, NHS WICs, pharmacies, NHS 111 and general practice. However, panel members also talked about an extended network of specialist services such as mental health, end-of-life and hospice care, geriatric medicine, physiotherapy and dental services, as well as information and advice services, and non-health services including social services, the police, and patient transport. Services were often perceived as equivalent rather than hierarchical, and the boundaries between them were often viewed as flexible at best, or ambiguous. The general public panel struggled to define the boundaries of services.

There was confusion among public panels and from interview participants about what UCCs and MIUs were. Some regarded these as ‘another name for A&E’; although the commissioners’ panel suggested that the boundaries between urgent and emergency care were demarcated by the NHS 111 (urgent) and 999 (emergency) distinction, they also listed same-day GP appointments, MIUs, WICs and the ED as part of the urgent care system. The general public panel thought that pharmacies offered advice for ‘little ailments’ and were a place to ‘seek second opinion’ rather than occupying a clear position within the remit of urgent care services:

So ultimately it’s about providing services that are easier to access, that the public understand. We had a conversation here, didn’t we, about the confusion, and how do you know what to do. And actually, you know, if you’ve used services a lot you know what to do. But if you’ve had an urgent care incident, and you’ve only had one in the last 20 years, how do you know what to do? So it’s . . . For me it’s about getting policy and providers to do a bit more than stick an advert on the back of the bus.

CP6, general public, urgent care ideas exercise

Participants could articulate what particular services might be used for (e.g. NHS 111 for ‘non-emergency’ cases) but typically did not recognise ‘urgent care’ as an umbrella term for a range of services:

P16:

So 111 would be more toothache and a nosebleed and mum’s slight bleeding from her rectum . . . But an emergency is an emergency . . . yes, phoning the ambulance if there was somebody not breathing or passing out or . . .

Interviewer:

Yes, so there’s urgent care centre, minor injuries, which you talked about with the sprains, and 111. So . . .

P16:

Urgent care - is that like an A&E or not? Is that . . . urgent care? I suppose that would be an A&E, wouldn’t it? I don’t know, I really don’t know . . . what the difference would be . . . is it a walk-in centre?

Older

Variation in what different UCCs, MIUs and WICs offer can create confusion for service users and the public. Health-care professionals acknowledged this confusion; indeed, often health professionals were equally confused:

I just think it’s so vague as well. I think that, you know, we have a problem with the definition of emergency, which people don’t tend to . . . [ ] The view of an emergency is so drastically different to a vast proportion of the public . . . And if there’s a vagueness around that, like, an urgent care centre, I mean, is even vaguer. And I don’t even think it’s just patients who don’t really appreciate what it is. I think, actually, the reality is most health-care professionals don’t really understand what an urgent care centre does [ ].

CP1, professionals’ panel

Now, if I struggle to know what unit will accept what, you know . . . They’re forever ringing up and saying ‘Will you see this?’ Because we don’t know what their agreement is, you know? Some will do X-ray, some can’t do X-ray. Some will, you know, be nurse-led, the other will be GP-led. So, I don’t know what hope we have.

CP2, professionals’ panel, urgent care services exercise

The East European panel offered a more restricted list of services under the umbrella of urgent and emergency care, but noted that access to an on-call doctor was important (direct access to doctors was something that recent migrants from Poland said that they had experience of). East European panel members were surprised to learn that policy-makers considered community pharmacies to be part of the urgent care network of services. In addition, interview participants from East European communities suggested that the ways in which services are named pose particular challenges for people whose first language is not English:

For people who come over here from a different country, they take names literally. They don’t see it as an umbrella of things, different services are available to them. They look at the name, and they see the name and they just associate the help with . . . Accident and emergency . . . Emergency, I need to be seen quickly, it’s critical, I need help . . . And then you’ve got out of hours. In the name, itself, it doesn’t have anything to convince you . . . that you would be seen quickly. Emergency, right I can be, sort of, fast-forwarded and be seen quickly. Out of hours, fine, they will see me, but God knows how long the wait will be because there’s no sense of urgency in the name, it’s just out of hours. Minor injury unit, again, injury, it sounds as if someone will take it more seriously than out of hours. So just the way you name things . . . To someone who doesn’t use them regularly, who has no experience of using them, they sort of put them in an order just depending on what they are called.

P2, East European

Both members of the public and health professionals felt that the term ‘urgent care centre’ was problematic: for many it was viewed as suitable for health problems that were ‘more urgent’ than those dealt with by NHS 111 or NHS WICs. Many believed that ‘urgent care centre’ was the name for an ED:

Urgent care centre, I think the word urgent you straightaway think that something is really wrong and you need to be seen straightaway. You think of all possibly the worst outcomes. Minor injuries I just associate with really long waiting queues, a lot of people in casts, a lot of broken arms, broken fingers – that’s what it says on the tin really, minor injuries.

P37, younger

Minor injuries? I don’t think I’ve . . . Oh no, I have been . . . Have I been to minor injuries? Urgent care? You mean accidents and emergencies?

P61, older

Minor injuries units seemed to be less well known, possibly because coverage of these across the country is patchy. The name ‘walk-in centre’ seemed to blur the boundaries of what is viewed as urgent because it conveyed notions of convenient access and not needing an appointment. For some service users, NHS WICs were a convenient alternative service to general practice:

The walk-in centre, to me, never seemed to be urgent care [ ] You’ve got your emergency service and then urgent care confuses me. Because those things aren’t urgent. They’re just us wanting to be seen quicker. You see, urgent, to me, if it was urgent . . . do we have urgent care clinics . . . do we have them? Have we got them in [name of city]? Have we? Where’s our urgent? [ ] Because I’ve never thought of [the walk-in centre] as an urgent care centre because . . . well, I suppose it is, isn’t it? Yes, but because it’s just a walk-in centre . . . I think that because it’s used by people who can’t get appointments at the GP.

P16, older

P30:

Walk-in seems so casual. Pop in and out if you want. But urgent, urgent care centre makes it seem . . . If I were to see those two things and you would say to me do you think these two are, you know synonymous or do you think they are, you know two totally opposite things I would probably say a walk-in centre and an urgent care centre seems two different . . . just by the words that are in the names . . . And then what was the third one?

Interview:

A minor injuries unit?

P30:

No clue. I have no clue. Can you tell me?

Younger

NHS 111 was widely recognised by both citizens’ panel and interview participants, and most conceptualised it as a service for information and advice, or for signposting to other services. NHS 111 was not strongly identified as an urgent care service, and it appeared that the advertising of NHS 111 as a ‘non-emergency’ service contributed to this conceptualisation. Younger people in particular viewed NHS 111 as a service for ‘inquiries’ and ‘general health information’:

Interviewer:

OK, great and what about the telephone service?

P48:

The telephone service 111 is more for inquiry type stuff than it is for emergencies.

Younger

Interviewer:

If I was to say to you urgent care centre, a minor injuries unit or the 111 telephone service, what do you think the differences are between those three?

P51:

I think 111 is non-emergency I think isn’t it. And then you’ve got minor injuries which I guess is probably something you’d go for . . . I’m guessing it’s an A&E service which goes for minor, or possibly not A&E. Possibly not A&E. No, I don’t think it’s A&E.

Younger

Only a minority thought that NHS 111 was for more urgent or serious cases:

So 111 telephone service I think it would be very serious like maybe someone’s fallen unconscious or they’re unable to get out that sort of thing or, you know, if they’d had a fall or, yes . . . they can’t get to where they need to go or they’re not able to move them I think 111 is definitely the [service].

P46, younger

Moral positioning in making sense of urgent care

In making sense of the boundaries between ‘urgent’ and ‘emergency’ and between different services, people judged and positioned themselves relative to other people and behaviours. Service users often recognised or judged that other people misused services but then rationalised their own behaviour as legitimate, calling on notions of exceptionalism. ‘Others’ included both people known to them (often close family members) and people unknown to them (the general public). The latter were especially prominent in people’s sense-making narratives. Overall, while service users often described their own health service use and that of close family members and friends as legitimate, ‘others’ (i.e. the ‘general public’) were often characterised as ‘time wasters’, seeking help for ‘trivia’. The moral work entailed in making decisions about urgent care and its impact on help-seeking behaviour is explored further in Chapter 5.

Here we focus on how perceptions of legitimacy factor into sense-making. In the panel and interview data collection, we sometimes prompted participants for their views about other people’s use of urgent and emergency care services (we did this as neutrally as possible, avoiding value-laden language such as ‘inappropriate’).

‘Time wasters’ and undeserving cases constituted the construction of moral categories that framed people’s sense-making around what services were for. Medical trivia is a common theme in the wider literature and is often discussed in relation to ‘inappropriate’ service use. Trivia was characterised as illness that could be self-managed, could wait or could be seen somewhere else (e.g. coughs, colds, headaches), or conditions seen as self-inflicted or resulting from behaviour, rather than for reasons of medical seriousness (e.g. resulting from the use of alcohol or drugs). Disapproval was predominantly reserved for those who use the ED unnecessarily:

There was a girl when I was waiting who had cut her finger on Christmas Day, that’s why she was there. But they would be able to dress it and clean it. I mean, those sort of small traumas are not what I think A&E should have to deal with. Yes, I mean, I think it should be sort of really serious things, you know, people who’ve had a stroke or you know, somebody who’s had a coronary . . . that sort of thing . . . I mean, I certainly do not think that it should have to deal with people who have had too much to drink.

P20, older

P75:

In hearsay, in stories you sometimes hear about people who have got something absolutely piffling and yet they have gone to A&E or even called an ambulance.

Interviewer:

And what would piffling be for you?

P75:

You’re coughing a lot or you have cut your finger on the tin opener or you have burnt your wrist on the oven shelf, you know really minor things, or you have got a temperature . . . a lot of people now apparently go to A&E because their child has croup and that I assume is because they have no idea what it is, and it is terrifying when you see it.

Younger

Behaviours such as alcohol and drug use that resulted in health service contact were often viewed as less deserving and irresponsible; however, occasionally service use was considered justified. Several younger service users had made contact with urgent or emergency services, often for a friend who was drunk, but these accounts often provided legitimisations, for example saying that this was a rare event, or, in the quotation below, suggesting that the presence of an underlying health condition might make attendance acceptable even when drunk:

Interviewer:

What other things do you think people go to A&E for?

P45:

Being too drunk. That’s, being too drunk, OK yes I can imagine if you’ve already got a health condition that’s worsened by being too drunk then you might need to go to A&E but, you know if you’re paralytic go home and sleep it off. Go home and be sick, eat something, drink plenty of water and go to sleep. Don’t go to A&E.

Younger

Some interviewees also highlighted that ‘undeserving’ people make health services more unpleasant for others and may deprive others of the care that they need or are entitled to:

That has happened recently to a friend of mine, whose dad died . . . It’s very easy to call up a 999 in that situation . . . They shouldn’t have done, but they did. But then he ended up dying sort of on the other side of curtain, with somebody who’s . . . Some sort of drug-related problem. The nurse sort of grabbed . . . Have you, you know . . . ‘Have you got any drugs up your arse? We need to . . . Concentrate. Can you concentrate? I need to know if you’ve got any more drugs up your arse?’ And it was all awful while they were saying goodbye to their dad.

P18, older

He said they had been to a party and had some drinks so they wouldn’t be able to come down straight away. Don’t worry I said, I will look after her, we have called the ambulance; and the ambulance couldn’t come because they were dealing with drunks and drug addicts and they were full.

P24, older

This was also linked to beliefs that ‘others’ should take responsibility for their own health more generally:

Because the resources . . . so, how many people we know have been treated by NHS and people are getting older . . . but also I think people are not taking care of themselves from what I can see. And maybe it’s an exaggeration, but sometimes walking through [name of city] . . . I think that people are just not taking care of themselves. I don’t know whether the statistics can show that, but they just don’t look healthy and that is a difference I can see with going back to Poland. I think people look healthier there than here, and there is some responsibility on people themselves to actually look out for being hugely overweight, diabetes, and it’s just like some kind of responsibility is not there.

P54, East European

There was also some disapproval of people using urgent care services for minor ailments such as coughs and colds:

This is an education problem. I think this is most important. Because otherwise maybe lastly we go to the [urgent care] centre for ridiculous problems, like coughing or I don’t know what it is. Don’t call. If they know what they have to do, they stay at home.

P33, East European

I’d like to know what priorities each service treats. I mean, some people must ring up 111 for a headache or something stupid like that. Well that should be made quite clear, that you go to your doctor if you’ve got a headache or any minor cut or anything like that. You don’t ring them and waste their time because you get people who have had too much to drink and they’ve fallen over and they think, ‘oh well I’ll ring the hospital or ring the walk-in centre or whatever is available’. Whereas they could just as well wait until the next day. I feel very sorry for these people [health services] because they’re overstretched all the time by a lot of idiots.

P36, older

There was a perception among the older participants interviewed that other people may lack the necessary knowledge or skills to understand, articulate and interpret health problems, which leads them to make unnecessary contact with health services. Older interviewees used this kind of account as a prelude to a presentation of him- or herself as someone who understood how to use services responsibly (a theme to which we return in Chapter 5):

I think other people get worried . . . Basically, they don’t have the same type of knowledge in their heads that I have, so therefore I think their worry and anxiety is more profound . . . I think it’s worry and anxiety possibly to do with their condition and possibly lack of . . . lack of knowledge . . .

P7, older

I think I have used the 111 on one occasion . . . I would like to think that my husband and I are relatively articulate people, so that we can say what they would need in order to give us information back, but a lot of people couldn’t describe things or would be too stressed, in too much of a panic you know, to handle that.

P20, older

Some were more sympathetic:

You know, we’re not simple people but there are a lot of simple people in the . . . in the world that are even worse off than we are who can’t navigate anything, or maybe they find it easier because they just go and camp outside until somebody looks after them.

P5a, older

However, younger service users were singled out as lacking the education or knowledge to make the right decision, and were considered ‘hypochondriacs’ or ‘attention seekers’. Interestingly, this characterisation of younger service users was often made by those in the younger group:

I think people need reminding of that because I think this generation is full of hypochondriacs. I think they just need to chill out a little bit and educate themselves instead of thinking that, you know minor flu is going to kill them and they need to go sit at A&E. I think it’s a shame that people do that because, like my mum for example has got so many health problems and she’s had to wait because of time wasters, I shouldn’t really say time wasters, but people who are not educated enough for, people that just go there for the attention. Sometimes I’ve found . . . I have personally known people that have gone and there’s not actually been anything wrong with them. They’ve just wanted some attention.

P45, younger

One of things that drives me mad is when you’ve got people there with viral infections that go to A&E . . . You do see it when you go into the waiting room, people taking up time they don’t necessarily need to be there [ ] Usually panicked mothers, to be honest. Yes, mums that are very scared about their children. And also probably young teenagers. And I think a lot of it as well is teenagers who just need a bit of attention, maybe not necessarily for health conditions . . . I’ve seen a lot of people that definitely don’t need to be there and a lot of minor cuts that could probably be done at [MIU].

P49, younger

There was also a belief that others had unreasonable expectations or used services because they were lazy:

For some people it’s just easier, it’s a, kind of, laziness, they think I’d rather go there and wait than go through the palaver of having to make an appointment in the surgery.

P4, East European

Inappropriate service use was linked to perceptions of the consumer society: the idea that people ‘expected’ services to be available 24/7 (i.e. 24 hours a day, 7 days a week) in the same way that many shops and services are:

I think people want things to happen straight away. I think everything’s instant, so if I want something, like, from Amazon I’ll get it straight away; so in the same way people want the doctor to be available 24 hours a day. And I think they abuse . . . I do think they abuse the out-of-hours service. And listening to people talking about the surgery, I think their expectation of what they can get from the NHS and social services isn’t there. I think there’s an expectation but you can’t bridge that gap so everybody’s going to be disappointed; so they go in disappointed, they go in angry.

P16, older

I get really mad when people, like, slate the NHS and A&E because they think they’re the only person with something wrong with them when there’s so many more people who are way more serious [ ] So, because actually there was a time my nan had cancer and she was, like, dying. And she couldn’t breathe and I phoned . . . 999 and they got us in and we went straight in and someone [another patient] was so mad that we’d gone in but she was, like, dying, like. But they were just sat in A&E and they were really mad. And I was just, like, ‘how can you even do it, like, it’s just non-urgent selfishness’ [ ] I think they’re quite selfish in the way that they want to be seen, they want to be seen first. And that’s why you get, like, the arguments in A&E . . . because people think that they’re so much poorlier than someone else. It’s more do with, like, the lack of knowledge and understanding and not knowing that other things are available.

P43, younger

Reimagined boundaries of urgent care

The two themes presented above have demonstrated the confusion and moral positioning at play in people’s sense-making about urgent and emergency care. Sense-making is rendered problematic because of a lack of clarity about the definitions and boundaries between urgent and emergency health needs and care services. This is complicated further by the moral positioning that features in sense-making, which serves to reinforce understandings and legitimise one’s own help-seeking while marking out others as inappropriate services users.

The final theme from our data about sense-making is drawn from the exercise in the citizens’ panels where we asked participants to look at the ‘Keogh triangle’,¹ a diagram used to depict the urgent and emergency care service landscape (Figure 5). We asked them to consider the range of services that should be included and the routes to accessing these services, as well as the visual representation.

FIGURE 5

The ‘Keogh triangle’: proposed look and design of the new system. Figure reproduced with permission from NHS England (2013).

When asked to redraw or adapt the diagram to match their sense-making about urgent and emergency care, the panels’ pictures looked very different (Figure 6). Some groups, such as the commissioners, clearly ‘knew’ this visual representation, but we asked the panels to discuss this representation and reimagine it.

FIGURE 6

Panels’ representations of the urgent and emergency care system. (a) Commissioners; and (b) general public 1.

One general public group reproduced the inverted triangle used in the Keogh visualisation, but, like the commissioners’ panel, they began to edit this during the discussion as they considered which services should be identified as urgent care. Both these groups were keen to explore a range of ways to access services:

I think it’s more important to have the definitions of urgent and emergency rather than the outcomes. So that people understand when they should be calling and which service to be calling. We sort of did it . . . And obviously panic is quite subjective, but green being sort of like, oh I’ve got a cough not . . . Like I’m OK, I can make it through. Amber being a bit like, OK, I’m a bit panicked by this, I’m worried, and you know, to being like I’m really, really panicked, whether it’s . . . Which is obviously pretty subjective, but as a general rule.

CP1, general public panel, discussion on Keogh diagram exercise

The discussion around this panel task confirmed that people wanted much clearer information about what different services did to inform their sense-making. Rather than using relational language, they favoured specific examples of the kinds of illness and injury that would be treated at each service. Several public panel members were confused about the placement of the ED at the base of the diagram and felt that this, and the bold red used, drew attention to this service and perhaps encouraged people to attend. This was particularly confusing in the light of the fact that the lines at the top of the diagram (denoting 111 and 999) placed 999 above 111 (the reverse of the diagram):

CP2:

In the diagram but not with the fonts and I didn’t like the lines at the top. That’s forcing you to use 999 first.

Facilitator 1:

OK, it sends the wrong message?

CP2:

Yes.

Facilitator 1:

Would you all agree with that?

CP2:

Yes [it would be better] on the side.

CP3:

Or even underneath it.

CP2:

Underneath, yes.

East European panel, discussion on Keogh diagram

In their reimagined drawings, some groups drew traffic lights and other representations that attempted to help make better sense of where to go (Figure 7):

FIGURE 7

Panels’ reimagined representations of the urgent and emergency care system. (a) Professionals 1; (b) general public 2; and (c) general public 3.

So we thought we’d have a traffic light system which was red, amber and green. With special leaflets for people who’re colour blind. And so the green will be the GP and the internet where you have time to think, you just go, have a little think about it, I’m not too . . . Or perhaps I . . . Perhaps I better see the GP on Monday or whatever. Or the internet reassures you, whatever it might be. So less important, but in green, we’re not sure where to put it.

CP4, general public panel, discussion on Keogh diagram

Two groups also specified a role and place for self-care and wanted this to feature prominently in the diagram to support people’s decision-making:

We felt definitely there needed to be more emphasis on this [self-care is in a separate bubble]. In fact, at first [panel member name] didn’t even notice that it was there. So we were saying if that was going to be the flow chart, you should have to go through self-care before you even get the option to go to emergency or urgent.

CP2, professionals panel, discussion about Keogh diagram

The East European panel provided insights into their understandings of different services. Some members suggested that they did not trust telephone services (such as NHS 111) and wanted to see a doctor face to face, which prompted them to seek help at A&E:

We don’t trust phone calls. We don’t use them. Quite often, we don’t communicate well enough to explain what’s happening and take the message from the doctors on the phone. They don’t have Polish speakers or any other languages, you know, on the 111. So that’s why they don’t call and they would like to see a doctor, because the doctor will explain. If they cannot explain, they draw it or they show it on a picture. So then she knows.

CP3, East European panel, discussion about services map

However, in the interviews several East European participants reported that they understood that NHS 111 provided help and advice about urgent health conditions and said that they would use the service. Some of these panel participants also mentioned that language barriers, as well as more direct experiences of racism, influenced their choices about accessing care. These experiences, combined with experiences of the health-care system (e.g. in Poland) and less knowledge of the NHS, led them to read the triangle map of service provision in very different ways. This was an unexpected finding that alerted us to cross-cultural differences in sense-making about urgent care.

Summary

Our exploration of sense-making about urgent and emergency care confirmed that the boundaries between urgent and emergency care are ill-defined and that there is considerable confusion about the appropriate use of the many services on offer. The general public, health-care professionals and service commissioners share this confusion, and this may explain why they find it difficult to navigate this service landscape. Given that the policy review revealed a lack of specificity in defining ‘urgent’, it is perhaps not surprising that the public struggled to articulate what urgent means and to make sense of the care options available. It was interesting that professionals and commissioners also shared this confusion at times. Our panels and interviews suggest that, unlike emergency, the term ‘urgent’ is particularly problematic: it holds little meaning for most people. The term ‘urgent care’ is often used interchangeably with ‘emergency care’. Although much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine and is clearly distinct from these, the public, in particular, struggle to distinguish it from emergency or routine care in this way.

Although the public in our panels and interviews often found it difficult to articulate the differences between urgent and emergency care, they had strong moral views on the kinds of illness and injury, and the kind of person, deserving of ‘emergency’ care. Although the public recognised a range of contingent factors and special cases that influence people’s help-seeking, their sense-making with regard to emergency care tended to be judgemental and polarised. Fewer moral judgements were made about the ‘misuse’ of urgent care services, perhaps reflecting the lack of clarity about these. This moral positioning is further explored in Chapter 5, when we examine the moral work that service users do when choosing urgent or emergency care.

The panels demonstrated that the public sought a clearer sense of service priorities. Their redrawings of the Keogh diagram attempted to capture a triage system that might help navigate a confusing landscape and aid sense-making about urgent care. Although the Keogh diagram reflects the policy rhetoric that expects people to use NHS 111 as a gateway to urgent care, the public members of our panels and our interviewees were still less familiar with this model. Sense-making about urgent care is varied and complex, and our findings suggest that we cannot simply assume that providing a signpost in the form of NHS 111 will direct patients to the right service at the right time. Chapter 5 of our report examines the data about how sense-making influences people’s choices about which service to use, and probes more deeply into their experiences of help-seeking and the work involved in accessing, navigating and using urgent and emergency health services.