Physiological factors in defining urgent care

Physiological need is the definition most frequently used in policy documents to describe urgent or emergency care. This relates to the seriousness of symptoms and/or whether the need is life-threatening.^1,3,8 Examples are offered of particular conditions or symptoms as being suitable for particular services^57,58 (e.g. the speed with which a person needs to be seen,^56,59 the onset of illness and the time frame in which a condition or symptom requires treatment) (Table 8).

TABLE 8

Physiological factors in policy definitions of urgent care in the UK (compared with emergency care)

‘Urgent’ may be described as serious but not life-threatening.^57,60 The National Audit Office describes urgent care services as being for ‘people who feel urgently ill’ (p. 37),⁵⁹ while NHS Choices sets out that ‘If your injury is not serious, you can get help from a MIU or UCC rather than going to an ED’.⁵⁷

Some definitions are circular: the word ‘urgency’ is used to define the ‘urgent care’, providing little insight into what is really intended or how one might decide whether or not something is urgent. By contrast, emergency care is defined as those illnesses or injuries that are life-threatening. Broadly, descriptions that relate to emergency services include the words ‘major’ or ‘severe’, in contrast to urgent care, which can include ‘minor’ or ‘problems usually dealt with by a GP [general practitioner]’.⁵⁸ Definitions of both urgent and emergency include ‘unforeseen’ need and refer to people requiring care that is ‘unscheduled’ or ‘unplanned’.^2,50 Unscheduled care is defined as:

services that are available for the public to access without prior arrangement where there is an urgent, actual, or perceived need for intervention by a health or social care professional.

Reproduced from Guidance for Commissioning Integrated Urgent and Emergency Care. A ‘Whole System’ Approach, p. 11⁶².

Royal College of General Practitioners

Some policies include reference to specific time frames in which particular symptoms should receive treatment; for example, a medical problem needs ‘immediate attention’.^1,57 Although physiological definitions of urgent (and emergency) need appear clear or more objective, this assumes that users are able to accurately interpret the likely seriousness of their symptoms and judge what constitutes ‘less’ or ‘more serious’ illness and/or injury in order to utilise the ‘appropriate’ service.

Relational language

A second theme in policy adds a relational dimension, contrasting emergency with urgent care. Urgent is compared with emergency as ‘not life threatening’ versus ‘life threatening’, or as ‘serious’ versus ‘more serious’.^8,49,60,62 A key example of this relational definition is the strapline for NHS 111, which is ‘when it is less serious than 999’ (the UK national emergency number).^59,62 Indeed, much of the NHS 111 advertising is presented in this way:

When you need medical help fast – but it’s not an emergency.

© Crown copyright 2012⁶³.

Crown copyright

Policy documents sometimes group urgent and emergency care needs as a single category, labelled as unplanned or unscheduled care,^8,64 and so the boundary between urgent and emergency is avoided.^52,62 It is sometimes argued that it is too difficult for patients to distinguish between services because the terms mean different things to different people.^62,65 Elsewhere it is suggested that these services need to be fully integrated and possibly co-located.⁶⁶ However, when service users self-refer to services (e.g. the ED, WICs, MIUs) they require an understanding of what different services offer,⁶⁷ so it continues to be important that service users are able to disentangle these terms and these services.

The language used to conceptualise urgent care has changed over time. In policy documents from the 1990s, general practice out-of-hours services were the main source of ‘urgent care’ and urgent care was closely linked to primary care. From 2010 onwards, the term ‘out of hours’ was replaced by the term ‘urgent care’ and this began to be discussed in relation to emergency care rather than general practice.^1,3,49,61

Health service organisation and provision definitions of urgent care

Currently there are a range of emergency, urgent and routine care services. In addition to established emergency services, there has been an increase in urgent care services, for example NHS WICs, MIUs and UCCs, and other facilities. These are often overlapping and inconsistent in the services or facilities they offer and the time of day they are open (Table 9). Some policy documents define urgent and emergency care by the types of services (or the range of responses) that are available to users, but it has been recognised that efforts to increase access to urgent care by creating service choices have created a fragmented, complex service, creating further confusion.^1,65

TABLE 9

Characteristics of urgent, emergency and routine care

Urgent care has been defined by the services offered to users, including the skill level of providers and the facilities provided. Emergency care is presented as highly specialised in terms of staff and equipment:

For those people with more serious or life threatening emergency care needs we should ensure they [users] are treated in centres with the very best expertise and facilities in order to maximise the chances of survival and a good recovery.

p. 22.¹

Contains public sector information licensed under the Open Government Licence v3.0.

NHS England

Urgent care, on the other hand, is conceptualised as a less specialised service for everything that is not an emergency:

walk-in service developed to have a ‘see and treat’ approach to less serious yet immediate illness or injury

p. 42.¹

Contains public sector information licensed under the Open Government Licence v3.0.

NHS England

Elsewhere, urgent care services are defined by opening times (i.e. operating in the evenings, at night and at weekends)⁶⁸ but, more recently, policy emphasis has shifted towards describing the range of ‘urgent care’ services that users might access over 24 hours (e.g. some MIUs, NHS 111).

Notions of ‘urgency’ may be defined by where a particular health problem is treated, which might be determined by what services are available in any given location at any given time of day. For example, a broken bone is classed as urgent rather than emergency (see Table 8) and therefore suitable for treatment at an UCC, but when this service is not available the patient would need to attend an ED. Thus, the definition of urgency is fluid depending on service availability:

MIUs and UCCs can treat: sprains and strains; broken bones; wound infections; minor burns and scalds; minor head injuries; insect and animal bites; minor eye injuries; injuries to the back, shoulder and chest. If no minor injuries unit in your area, these services will also be provided by an A&E department.

© Crown copyright. Contains public sector information licensed under the Open Government Licence v3.0⁵⁷.

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Patients’ perceived need

There is a recognition on the part of policy-makers and professionals that the responsibility for judging both the seriousness and the suitability of a particular service often lies with the patient. Policy documents from the UK make some reference to this:

Urgent care is the range of responses that health and care services provide to people who require – or who perceive the need for – urgent advice, care, treatment or diagnosis.

p. 12.⁵⁰

© Crown copyright. Contains public sector information licensed under the Open Government Licence v3.0.

Crown copyright

More recently, policy-makers have sought to reframe urgent care, taking into account a wider range of influences that are involved in the decision-making (e.g. perceived severity of symptoms as well as social factors such as caring commitments).

The importance of patients’ perception of their condition has led to the development of the ‘prudent layperson standard’ in the USA, which promotes a symptom-based determination of urgency. This standard was developed by listing common symptoms and conducting a large-scale survey to determine if a ‘prudent layperson’ would reasonably interpret them as an emergency.⁶⁹ What is interesting here is the recognition on the part of policy-makers and professionals that the responsibility for judging both the seriousness and the suitability of a particular service often lies with the patient, yet the decision to intervene is a professional one:

[It is the] responsibility to consider other care options prior to visiting the emergency department.

Guttman et al.⁷⁰

Language around what is ‘appropriate’ for particular services or what is a ‘genuine’ medical complaint appears in descriptions of emergency care in the research literature. However, such terms are largely absent from policy, with the exception of a sentence on NHS Choices about what is legitimate for emergency care use:

An A&E department . . . deals with genuine life-threatening emergencies, such as: loss of consciousness; acute confused state and fits that are not stopping; persistent, severe chest pain; breathing difficulties; severe bleeding that cannot be stopped [ ] Less severe injuries can be treated in urgent care centres or minor injuries units.

© Crown copyright. Contains public sector information licensed under the Open Government Licence v3.0⁵⁸.

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Clinical ‘appropriateness’

Unsurprisingly, like the policy definitions discussed, the seriousness of the illness or injury appears to be evident in health-care provider conceptualisations. ‘Inappropriate’ ED use is synonymous, and interchangeable, with service use that is ‘less urgent’, ‘non-urgent’⁷⁸ or ‘low acuity’⁷⁹ or for ‘minor illness or injury’,^16,17,80 ‘non-life-threatening health problems or injuries’⁸¹ or primary care reasons.

Physiological definitions of urgency include assessment of the severity of symptoms and how quickly symptoms need assessing or treating^{74,75,82–90} and/or whether the condition(s) could be assessed only in the ED or could be addressed elsewhere.^{41,87,89,91–98} Many studies of inappropriate ED use do not explicitly specify how attenders were classified as ‘inappropriate’ or ‘non-urgent’.^76,99–103 However, some research has developed explicit criteria for assessing appropriate use,^{74,75,85,104–106} which include items that assess the severity of illness; the urgency of treatment or intervention needed; referral or transfer from other medical source; and confirmation by diagnostic testing. In such definitions, markers of appropriateness can include both presenting symptoms (prospectively defined) and diagnosis (retrospectively defined).

Koziol-McLain et al.⁸³ suggest that the term ‘severity’ is embedded in the ‘medical framework of physiologic dysfunction or disease’ so that emergency care is defined as ‘those health services provided to evaluate and treat medical conditions of recent onset and severity’. The term non-urgent is often used in the context of emergency care services and may describe a minor medical problem that is non-acute and non-life-threatening, and does not require immediate attention^78,82,107 (i.e. it can be left for several hours or days⁷⁸ and/or it is short in duration, e.g. it lasts less than 24 hours).⁹³ This might include symptoms such as coughs, sneezing, weakness or tiredness,⁷² those that are musculoskeletal,¹⁰⁸ or cases that are deemed to require only ‘prescription, bandage, sling, dressing, and steristrips’.¹⁰⁹ Minor illness or injury/’non-urgent problems’ were characterised are those that could be managed by a GP (see next section).^{73,78,85,104,109}

Health professionals (and researchers) have defined non-urgent ED use by making reference to treating a health problem that could wait until the next day (> 12 hours) for treatment.¹¹⁰ This is illustrated by a study designed to assess agreement between health-care professionals about ED attenders’ need for urgent care in an urban hospital in the USA, which used a quantitative chart review of 266 patients¹¹¹ and defined urgency using terms such as ‘major’ illness or injury, whereby a possible danger exists to the patient if the condition is not medically treated within 20 minutes to 2 hours. A non-urgent or ‘minor’ injury or illness, when the patient is usually ambulatory, can be seen between 4 and 6 hours. Another US survey study measuring perceptions of urgency asked ED nurses and physicians to define urgent and non-urgent care.¹¹² Physicians defined ‘non-urgent’ as something that could be addressed after ≥ 1 hour without the patient’s health being affected, while nurses gave times that ranged from > 30 minutes to up to 4–6 hours.

Assessment of patient urgency differs among types of health professional irrespective of patient condition, even when the same criteria of urgency and appropriateness are applied.^99,107,111 In New Zealand, Richardson et al.¹⁰⁷ found that there was no clear consensus between ambulance staff, ED surgeons, registrars and consultants, ED nurses, GPs and hospital managers about a definition of ‘inappropriate’ attendance. Different groups of professionals used different factors to assess appropriateness; for example, ambulance staff were more likely to see patient admission as an indicator of appropriateness, whereas ED doctors and nurses were more likely to see patient perception of urgency or seriousness as a reliable indicator. In the USA, O’Brien et al.⁷¹ assessed levels of agreement between internists and emergency physicians reviewing the ED nurses’ triage notes of 892 adult patients and reported only moderate agreement (κ = 0.47) between these groups. Emergency physicians were 10.3 times more likely than internists to classify those with minor discharge diagnoses as appropriate for ED care. Health professionals and patients also differ in their assessment of how quickly patients need to be seen. Poor agreement among health professionals raises questions as to how objectively ‘appropriateness’ can be measured and, in turn, how urgency can be defined.

Demarcation of definitions according to place

In defining urgency in the context of the ED, professionals and providers distinguish between condition(s) that could be assessed only in the ED and those that could be addressed elsewhere.^{41,87,89,91–98} These definitions echo the ‘right place’, at the ‘right time’, treated by the ‘right professional’ phrasing found in some policy documents. However, in a study of health-care professionals’ perceptions of the effectiveness of a UK GP-led WIC, professionals were more likely to deem service use as appropriate if the user was referred from the ED.¹¹³ A recent qualitative interview study of staff at a GP-led UCC in the UK suggested that health-care professionals believed that patients were ‘unaware of what the GP-led Urgent Care Centre is. They simply want someone to see them’.¹¹⁴ They also reported that staff believed that patients used the UCC because it was convenient or because they had difficulties accessing other services (e.g. GP appointments).

There is also a strong tendency for health-care providers to define urgency in relation to the lack of emergency. The academic literature about ED use frequently uses relational terms to define degree of urgency, for example describing service use that is ‘less urgent’ (compared with something that is considered an emergency),^81,99,115 although concepts of ‘less urgent’ vary. Backman et al.⁹⁹ suggest that:

Less urgent users were assessed as being more suitable for primary care and judged to be able to wait for more than 24 h for a medical examination without risk of medical harm.

Backman et al.⁹⁹ (emphasis added by authors)

Pileggi et al.¹¹⁵ define urgent as ‘conditions that could possibly progress to a serious status requiring emergency intervention, perhaps those associated with significant discomfort or dysfunction at work or activities of daily living’ and less urgent as ‘conditions relating to age, distress, or potential for deterioration or complications that would benefit from interventions or reassurance within 1–2 hours’. These are different from ‘non-urgent’:

conditions that are acute and non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration.

Pileggi et al.¹¹⁵

What these studies highlight is that urgency is often positioned in relation to emergency care, and it is less clear from these studies how urgent care problems are understood.

Value judgements about patient perceived need

Health providers and professionals sometimes recognise that patient perceived need and the subjective nature of lay assessment of symptoms are legitimate components of making sense of urgent care. However, health-care professionals also make value judgements about patient use of services and this shapes how they make sense of urgent care.

There is some evidence that health professionals recognise that service users draw on ‘rational reasons to initiate care’. This can include consideration of access to primary care and the context of how the medical problem developed. In a Canadian study, a survey of patients and physicians examined the appropriateness of WIC visits.⁷. Of 142 attendances, physicians judged more than half of the visits as appropriate, compared with most patients, who scored their visits’ urgency as low or medium. The authors concluded that doctors appeared to judge patient factors such as anxiety and access to services as legitimate reasons for attending these services. Similar findings have been reported elsewhere; health-care professionals often approve of patients’ decisions and believe that they act appropriately.^116,117 A qualitative study of 87 patients and 34 health-care professionals, using interviews and direct observation, examined the decision-making patterns of families using EDs, as well as paediatric staff responses. Staff ‘incorporated the realities of daily living under trying circumstances, such as difficulty in contacting primary care for appointments, problems with transportation, financial barriers, and other practical issues’.¹¹⁷

It appears that the more vulnerable the patient, the more likely the health-care provider is to take societal context into consideration when a ‘non-urgent’ visit is made or being reconsidered. Recognition of the social contexts in which people use emergency services for low-acuity problems has been acknowledged in other studies.^75,117,118 In the ED context, health professionals were more sympathetic to those perceived as ‘inappropriate’; for example, in a study of the use of unscheduled services by people with long-term conditions, health-care professionals felt that use of unscheduled care was a necessary component of care because exacerbations were inevitable in long-term conditions.¹¹⁸

An American study of non-urgent ED use developed a typology of how providers conceptualised appropriateness of service use including restrictive, pragmatic and all-inclusive provider ideologies.¹¹⁹ Some professionals held a pragmatic viewpoint: ED use was legitimate if other service options were limited or unavailable, including at times the need for medically non-urgent care. Conversely, other professionals believed that the ED is appropriate for only the most urgent care, that it should not, for example, be used for ‘trivial reasons’ that could be treated in primary care. What this study highlights is that, even within a single setting, health-care professionals hold a range of views about what is ‘appropriate’. This lack of consistency at the supply end raises questions about how service users can be expected to make decisions on the basis of lay knowledge alone if those with medical training have different positions on where people should go to seek care under different circumstances.

The extent to which professionals judge patients as ‘deserving’ of care is relevant to conceptualising ‘appropriateness’. Discussion about the ‘abuse’ and ‘misuse’ of services is particularly apparent in relation to emergency ambulance services.¹⁰¹ In one study of ED use of ambulance services in the USA, emergency medical services (EMS) providers and patients were asked, ‘Do you think this patient’s medical problem represented a true emergency requiring EMS transport?’ (emphasis added by authors).¹⁰³ However, what constitutes a ‘true emergency’ is not defined or described. Muller et al.¹⁰² described how [high demand] ‘inevitably make it more difficult to provide genuine emergencies with rapid treatment, leading to deterioration in the quality of emergency services’ (emphasis added by authors).

Similarly, in telephone-based UCCs, call advisors tended to construct shared understandings about the ‘inappropriate use of services’ and the extent to which patient concerns were ‘genuine’ or not.¹⁸ This is echoed elsewhere in the out-of-hours literature that makes reference to ‘trivial and self-limiting conditions’.¹²⁰ Such findings reflect those of Jeffrey’s¹²¹ seminal paper of ED staff perceptions of appropriateness. Notions of ‘genuineness’ also featured in a survey study of GPs who were asked about the appropriateness of UK out-of-hours care use.¹²² The study found that there was broad consensus about what constituted an appropriate call:

Genuineness was a key concept and the word ‘genuine’ occurred frequently, as in ‘genuine unwellness’ and ‘genuine anxiety’. Calls about potentially serious symptoms, severe symptoms or life-threatening conditions were regarded as appropriate.

Smith et al.¹²²

There is some evidence that health-care professionals judge some age groups as more vulnerable and that they may deem them as ‘special cases’ who either are more deserving of care or have more reason to make ‘inappropriate’ use of services, for example the elderly,^78,122,123 children^78,117,124 or patients who are ‘genuinely’ frightened or anxious about the threat of serious illness.¹²⁴ In an ethnographic study of ED use in the UK, professionals were more likely to perceive elderly patients and patients who articulated that they did not want to ‘bother’ services as legitimate attenders.¹²³ Users were also considered more favourably if they had an understanding of the other services available to them, when to approach them, and by which professional they should be seen. In the UK, a study of UCC staff identified a set of motives perceived as ‘more legitimate’ for making contact.¹¹⁴ These included having acute health needs, access problems (those who ‘honestly’ cannot get an appointment with their GP) and anxiety, and also people not registered in the system (e.g. tourists, students). Conversely, less legitimate motives included convenience (‘claiming’ they cannot get an appointment) and those seen to be ‘playing’ the system.

Symptoms

Studies about symptom interpretation in relation to out-of-hours or urgent care services have highlighted that symptoms that are perceived to be prolonged, severe,^{41,67,79,125–128} unusual, worsening or causing pain trigger the help-seeking process.^{7,120,129–135} Users’ perceptions of urgency were associated with an awareness of potentially fatal illnesses or conditions (such as meningitis and appendicitis) that were likely to compel contact with emergency or urgent care.^129,131,136 People may also call urgent care services when they are unsure about the severity of their condition^67,133 and/or to rule out or prevent serious disease.¹³⁷ This suggests that urgent care services provide a preventative/risk management function. There are similar reasons for using the ED for non-urgent illness, whereby attenders typically perceive their problem as urgent or severe,^138–150 recent and sudden in onset,¹⁵¹ and/or requiring emergency treatment or ‘immediate’ or ‘rapid’ attention.^{102,110,140,152} One study found that half of all parents were unsure about the seriousness of their child’s symptoms⁹⁸ and this prompted ED attendance. Pain is also a common key driver of ED attendance.^{70,140,141,146,151} In a study of ED attendances for people with asthma, Becker et al.¹⁵³ sum up the dilemma that a patient faces when having to navigate definitions of urgency:

Individuals with asthma are caught in a bind by extremely narrow definitions of appropriate symptoms in the delivery of health care in the emergency department: they must not delay too long or seek help too soon.

Becker et al.¹⁵³

Studies that have compared health professionals’ perceptions of urgency of illness with those of patients attending an ED^154–156 suggest that there are substantial differences. Kalidindi et al.¹⁵⁵ reported that most parents believed that their child’s illness required urgent care (defined as care needed within 24 hours), whereas physicians considered 30% of the ED visits as non-urgent (care that could safely wait until the next day). A New Zealand study has attempted to define a ‘health emergency’, a definition based on physiological factors.¹⁵⁴ This study used patient and ED ratings of urgency, and compared these with published literature and policy guidelines. The study reported congruence between the patients’ and health professionals’ perceptions of what constitutes a health emergency and suggested that a combined definition of these two perspectives would be reflected as:

A health emergency is a sudden or unexpected threat to physical health or wellbeing which requires an urgent assessment and alleviation of symptoms.

Morgans and Burgess¹⁵⁴

However, Morgans and Burgess¹⁵⁴ acknowledged that such physiological assessment is difficult because a health emergency is complex, changeable and not dichotomous.

One UK qualitative study that attempted to define urgent care from the user perspective⁶⁷ found that participants were unable to identify a lay definition for ‘urgent care’, suggesting that ‘urgent’ could indicate the need for emergency services only or the need to be seen quickly by ‘non-emergency services’. Participants were more consistent in defining the term ‘emergency’ as an illness and/or injury requiring ‘blue flashing lights’ and an ‘ambulance’.

The literature about service users highlights the role of anxiety, feeling helpless or being unsure of what to do in relation to assessing the seriousness of symptoms when contacting urgent care^{41,67,120,129,132,135,157} or emergency care.^{78,150,158,159} Users make contact with services for medical care, but also to seek reassurance from a health service to alleviate anxiety about symptoms.^{78,135,146,151,158,160} Anxiety and reassurance appear to be viewed as a legitimate use of services from the patient perspective^70,135,161 and sometimes from the professional perspective.^{7,116,117,122} There is commonly a positive correlation between anxiety and level of pain¹⁵¹ or between anxiety and participants’ perceptions of the seriousness of the problem.⁴¹

Ambiguous organisational arrangements

Whereas Dale et al.¹⁶² reported that patients choosing between attendance at a MIU or an ED made an appropriate choice, other studies of urgent care have found that people often do not know where to go or who to contact, particularly at night,^67,127,162 or when it is appropriate to contact a particular service.¹³³ A UK study of out-of-hours services found that some service users were unsure if their condition was ‘serious enough’ to warrant contact and some believed that the service was ‘only for seriously ill people’.¹³³

A study of an English NHS WIC reported that participants were uncertain of the centre’s purpose and its role within the health-care system.¹⁶³ A further study based on a survey suggested that most people did not make an ‘active choice’ to attend a WIC. More than half of attenders were unaware of the type of facility that they were attending, and believed that they had been treated in an ED.¹⁶⁴ Cook et al.¹⁶⁵ reported similar confusion about NHS Direct, with some participants believing that it was a WIC or that it provided an out-of-hours service.

Furthermore, service users do not always know what to expect on attending urgent care facilities. Chapple et al.¹⁶⁶ found that half of all interviewees expected to find a doctor at the WIC, with some suggesting that ‘nurses only deal with minor problems’. NHS staff beliefs about service users’ perceptions is that they do not distinguish between the ED, WIC or UCC, and were unaware of the UCC service and what it provides.¹¹⁴ This confusion suggests that service users may not have a clear conceptualisation about what urgent care services are and what they can offer. Conceptualisations of urgent care are likely to be influenced by familiarity with, or previous experiences of, using these services.^127,128,167

User conceptualisations of urgent care also consider which service is available and able to carry out the care they deemed to be appropriate.^127,163 A qualitative study of NHS WIC attenders found that service users often had some idea or certainty that they knew what was wrong with them and what treatment they required and, as such, they were seeking support to carry out a predetermined treatment plan.¹⁶³ In the UK, Shipman et al.¹⁶⁸ reported that if parents had sought GP advice prior to self-referral and if the GP was not able to come out for several hours, then they went to the ED. Over half of participants suggested that they would have contacted their GP had the practice been open. Similarly, service users often report using the ED because other care – either general practice or urgent care – is not available.^{83,95,156,169–173} A study from the USA reported that participants initially tended to tolerate symptoms until pain increased to a level at which self-care was no longer possible – and when non-emergency care settings were full.⁸³ A lack of availability of urgent care may result in ‘urgent cases’ becoming emergency ones. The notion of ED care being used as a GP substitute is not new. Calnan¹⁵⁰ reported that patients sometimes made contact with the ED when they believed that the circumstances were inappropriate to contact a GP, for example during the night or at weekends.

There is a tendency for people to use emergency and urgent care services interchangeably depending on perceptions of the availability of services and what they can offer. These might include the perceived unavailability of timely appointments in primary care settings; preference about facilities and staff expertise;¹⁷⁴ perceived shorter waiting time; ease of access; and wanting a second opinion when not content with primary care in-hours treatment.^{78,120,146,158,168,170} People sometimes use hospitals because they believe that these will provide better care,¹⁴⁴ for example that they can offer specialist expertise and facilities that community care cannot.^{126,128,143,153,175,176} The focus on expertise and equipment is particularly notable in ED settings.^147,173,177

Choices about access include consideration about personal convenience and the shortest delay.^127,164,165 Chalder et al.¹⁶⁴ found that people initially chose to attend services with a co-located ED and WIC (rather than a ‘traditional’ ED service) because they expected a shorter wait for treatment or that it would be quicker than getting a GP appointment’. NHS Direct ‘users’ identified awareness, ease of use and convenience as facilitators that influenced their decision.¹⁶⁵ Studies of ED use suggest that convenience of location included offering a timely source of care^{83,145,147,149,156,173,177–179} and proximity.^170,173 A Swedish study of ED use found that it takes less time to go the ED and obtain help than to go to a GP, who may refer the patient to the ED anyway.^156,171 What is convenient in terms of being seen quickly has most salience for those who are working and those with caring responsibilities.^83,127

Perceived need and legitimacy

Like health-care providers and professionals, seekers of urgent care services use notions of what is ‘appropriate’ or ‘inappropriate’ based on perceptions of severity of illness, the time frame in which a problem needs to be addressed, and service availability.

Unsurprisingly, most service users perceive their own attendance or need for contact as legitimate, appropriate or deserving^67,133,180 but may judge others’ attendance as ‘inappropriate’. Services users may judge others as ‘time wasters’ who are less rational or cannot justify their help-seeking behaviour.⁶⁷

A mixed-methods study of UK service users of primary and emergency care¹⁸⁰ using vignettes about the ‘appropriateness’ of using NHS urgent care reported that 65.6% believed that others had used GP or ED services inappropriately. Similar findings were reported in a UK study¹³³ based on focus groups and telephone interviews in which some participants expressed concern about other people who misused services for minor complaints, while emphasising that their own reasons for calling were serious and appropriate. However, unlike in Adamson et al.,¹⁸⁰ some participants also expressed concern for other users around inequality of care. Participants were concerned that the onus was on the patient to convey the urgency of their situation to health-care professionals and that people less articulate and less able to communicate might not get the care they need.

Users of urgent care often express the wish of not wanting to be seen as a ‘burden’ on the service, to place themselves before other NHS users deemed to be in more need, or to place excessive demands on an overstretched health service.^157,181 Service users are aware of potential ‘inappropriate’ use of publicly funded health services that provide universal access.^163,182 Richards et al.¹³³ reported that users of out-of-hours care said that they worried about calling the service. They also feared wasting the doctor’s time or ‘abusing the system’. Similar findings are reported in attenders of EDs unwilling to go to an ED without medical sanction.¹⁸² This reluctance to use services is particularly observable in older age groups^181,182 and among palliative care patients who were found to be reluctant to contact out-of-hours services to seek help.¹⁸³ Like health-care professionals, some service users judge some age groups as more vulnerable, and therefore as ‘special cases’ who are more deserving of care.^157,184

Points of consensus around physiological symptoms as determining urgent and emergency need

Our literature review suggests that there is some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care, particularly around severity of symptoms and time frame. Much of the evidence from the provider perspective is drawn from the ED setting rather than from urgent care. A key distinction is made between emergency presentations and less urgent, non-life-threatening physiological presentations as the main determinant of appropriate service use, whereas users’ understanding of the seriousness of physiological symptoms draw on wider social and emotional factors that feed into their perceptions of urgency and time frame for accessing care.

Confusion about what constitutes urgent care

The terms urgent and emergency as categories of care are far from clear in the policy literature. The terms lack specificity, and it is difficult to discriminate between something ‘serious’, and appropriate for an UCC, WIC or minor injuries clinic, and something ‘more serious’ that requires the attention of an ED. There is a lack of consistency in meaning and messages across documents that note that people are confused about which services to use.^1–3,51,185 The health provider perspective examined in the research literature highlighted the variation in definition of ‘urgency’ or appropriateness and, at least in the context of the ED, an absence of consensus about ‘appropriateness’, the constitution of a ‘health emergency’ and what is ‘non-urgent’. From a service user perspective, conceptualisations of different services are shaped by perceptions of availability, accessibility and acceptability,¹⁸⁶ which, in turn, may influence whether something is categorised as ‘urgent’ rather than ‘routine’ or ‘emergency’. [For example, if a particular facility is not available in a particular area then an urgent problem may be effectively upgraded to an emergency. In the case of a broken bone, in physiological terms this may not be an emergency (serious, life-threatening) but if a local urgent care facility is not available or does not have radiography facilities, the injury will be treated in the ED and becomes conceptualised as ‘an emergency’ rather than urgent.]

Questions around terminology

Both the policy and the research literature use a wide range of terms to describe both emergency and urgent care. Urgency is often defined (particularly in the policy literature) in relation to emergency (e.g. less urgent, non-emergency). The public are expected to be able to make ‘appropriate’ choices about health services, but it is unclear how these terms are understood by service users.

Defining emergency and urgent is difficult because they are context-specific, dynamic concepts reflected in service users’ wide-ranging and fluid conceptualisations of urgent care. Although there is some recognition from policy and providers that service users’ evaluation of symptoms may vary from those made by clinicians, there is still an expectation that service users can and should make ‘appropriate choices’.

A significant proportion of studies included in the literature review are over 20 years old^{71,76,77,80,84,85,91,109–111,187,188} and so these earlier definitions of ‘emergency’ and ‘urgent’ may not reflect current service provision. Most of the evidence base that underpins conceptualisations of what counts as urgent or emergency is drawn from studies of ED use (particularly ‘non-urgent’ or inappropriate use). The extent to which these definitions transfer to urgent care settings is unclear. The generalisability of the findings from one location to a wider geographical area or population is limited. This literature is also drawn from a range of countries and there are difficulties in drawing international comparisons about conceptualisations of urgent care because of variations in definitions and differences in the organisation and delivery of health-care systems. For example, unlike some other countries where such research has taken place, the UK offers universal access to primary care services at no cost to patients.

Points of learning for the citizens’ panels and the interviews

Many of the papers in the review focus on particular groups of people (parents, older people, and people with asthma or chronic conditions) and other groups in the population may have different views about urgent care. The policy literature and studies of health providers suggest some narrow ways of thinking about urgent care, notably in relation to acuity of physiological symptoms, but service users also consider various emotional and social factors when deciding whether or not to use urgent care services. These findings prompted us to think about previously neglected population groups to include in the empirical work and to explore these broad conceptualisations of urgent care.

The literature review also highlighted that the language used by policy and professionals about urgent care is unclear. Urgent care is poorly defined, and often only in relational terms (i.e. contrasting with emergency need/care). This language may not be meaningful to or shared by service users. Urgent care policy definitions make a number of assumptions about what patients want, including care close to home, telephone access and self-care advice, and these needed to be tested in our empirical work. To this end we used the citizens’ panels and qualitative interviews to explore understandings of urgent (and emergency care) and people’s experiences of help-seeking, to fill some of the gaps in the literature.