The guideline committee made the following recommendations for research. The evidence reviews contain the methods and evidence that were used to develop these recommendations, and a summary of the guideline committee's reasoning for making the recommendations. Each recommendation includes a link to the relevant evidence review on the NICE website.
Is extended access to GP services, for example during early mornings, evenings and weekends, more clinically and cost effective than standard access?
Continuity of care improves patient experience, aids clinical decision‑making and could reduce hospital admissions. GPs' knowledge of patients enhances trust and promotes patient-centred care, especially when dealing with complex conditions. Currently, outside of standard GP hours (Monday to Friday, 08:00 to 18:30), people who need urgent primary care are triaged and treated by an out-of-hours GP provider and will usually be seen by a primary care clinician who is not familiar with them or their history, and who might not have access to their complete clinical records. Extended weekday and weekend access to their usual primary care team might reduce people's unscheduled use of secondary care emergency services. It might also increase opportunities to prevent exacerbations of chronic disease and thus reduce emergency hospital admissions. There is also likely to be less movement to secondary care if there is greater access to usual primary care because GP surgeries are often more conveniently located than more distant out-of-hours centres. Many extended access schemes currently in operation for general practice are for prebooked appointments only and do not provide emergency care. The focus of this research recommendation is on extending opening hours of practices for the full spectrum of GPs' clinical work. [See the evidence review on GP extended hours.]
What is the clinical and cost effectiveness of providing extended access to social care services, for example during early mornings and evenings, and 7 days a week?
A person with social care needs is defined as someone needing personal care and other practical assistance because of their age, illness, disability, dependence on alcohol or drugs, or any other similar circumstances. This is based on the definition of social care in section 65 of the Health and Social Care Act 2012.
At present access to social care differs throughout the country. Some areas have access to all social care services whereas others have very limited access. When social care services are substantially reduced, such as during weekends, collaboration and multidisciplinary planning between hospital, community health services and social care is difficult to achieve. This increases the number of avoidable hospital admissions and readmissions, and delays discharges.
NHS England has stated that community care services in hospitals, primary care, community care and mental healthcare must be available 7 days a week. This will support people to stay in the community and allow those in hospital to leave earlier. Extended access to community care has a direct impact on bed occupancy rates. Current figures suggest that 22% of hospital patients are waiting for a social care assessment so that they can be discharged. Extended access to social care would play an important role in alleviating this problem, particularly for the frail elderly. [See the evidence review on social care extended access.]
What is the clinical and cost effectiveness of having GPs within or adjoining emergency departments?
Royal College of Emergency Medicine survey data suggest that around 20% of people who attend emergency departments could be treated by GPs. Extended access to GPs in their surgeries is a requirement of current health policy, but the impact of such provision on reducing emergency department attendances of people with acute illnesses is unknown. An alternative approach, proposed in a joint report from the Royal College of Emergency Medicine, Royal College of Paediatrics and Child Health, Royal College of Physicians, and Royal College of Surgeons, is that every emergency department should include a primary care out-of-hours facility. This approach deserves systematic research evaluation focused on the specific impact of GPs on secondary care and the wider urgent and emergency care system. [See the evidence review on GPs within or on the same site as emergency departments.]
What is the most clinically and cost effective way to configure services to assess frail older people who present to hospital with a medical emergency?
Older people are more likely to be admitted for medical emergencies, and to stay longer in hospital, than younger people. This is because there is more multimorbidity, frailty and polypharmacy in older people. Hospital services have adapted to the growing population of older patients by introducing liaison services such as Frail Older Persons' Assessment and Liaison (FOPAL) services. These are now widespread, and share characteristics such as medication reviews and the use of comprehensive geriatric assessments.
However, it is not clear whether there are additional benefits from admitting older people with multimorbidity and frailty to a specialised elderly care assessment unit or an acute frailty unit. Theoretical advantages could include better planning of investigation and diagnosis, multidisciplinary working, dedicated discharge teams, and direct links with community and social care. The question is important because of the potential for large reductions in length of hospital stays and readmissions, and improved quality of care. New units with varying designs are emerging throughout the NHS but there is currently no strong evidence for their effectiveness. [See the evidence review on admission through elderly care assessment units.]
What is the clinical and cost effectiveness of different methods for integrating patient information throughout the emergency medical care pathway?
Good clinical decision-making depends on the provision of accurate information at the point of care delivery. Paper-based information systems cannot adequately serve the complex needs of people with frailty or multimorbidity. However, the experience of the NHS National Programme for IT has shown the need for an evolutionary and evidence-based approach to developing electronic systems with the capacity for clinical decision support. Examples of where such an approach could be used include managing cognitive impairment, polypharmacy, caring for people with multidisciplinary or complex care needs, and recognising a person's preferred place of death in palliative care. In many locations around the country, web-based patient information systems integrated between primary and secondary care are currently being set up. This research recommendation aims to ensure that where information systems are developed they undergo systematic parallel research evaluation. [See the evidence review on integrated patient information systems.]
What is the most clinically and cost-effective use of clinical call handlers in a telephone advisory service in terms of i) the ratio of clinical to non-clinical call handlers and ii) point of access to clinical call handlers in a telephone advisory service pathway? [See the evidence review on non-emergency telephone access and call handlers.]
Are paramedic remote decision-support technologies clinically and cost effective? [See the evidence review on paramedic remote support.]
Which primary care-led models of assessment of people with a suspected medical emergency in the community, such as GP home visits, are most clinically and cost effective? [See the evidence review on GP-led home visits.]
What is the clinical and cost effectiveness of providing GPs with access to plain X‑ray radiology or ultrasound with same-day results? [See the evidence review on GP access to radiology.]
What is the clinical and cost effectiveness of providing extended access to community nursing, for example during evenings and weekends? [See the evidence review on community nursing.]
What is the clinical and cost effectiveness of limiting emergency department opening hours, and what effect does this have on local healthcare provision and outcomes for people with medical emergencies? [See the evidence review on emergency department opening hours.]
Is a minor injury unit, urgent care or walk-in centre clinically and cost effective i) as a stand-alone unit and ii) when located on the same site as an emergency department? [See the evidence review on minor injury unit, urgent care centre or walk-in centre.]
What is the optimal configuration in terms of clinical and cost effectiveness of hospital diagnostic radiology services to support 7-day care of people presenting with medical emergencies? [See the evidence review on 7-day diagnostic radiology.]
Are standardised criteria for hospital discharge clinically and cost effective in specific medical emergencies? [See the evidence review on standardised discharge criteria.]
What is the clinical and cost effectiveness of providing 'physician extenders' such as advanced nurse practitioners, 'physician associates' and advanced clinical practitioners in secondary care? [See the evidence review on physician extenders.]
What is the clinical and cost effectiveness of post-discharge early follow-up clinics for people who have had a medical emergency and are at risk of unscheduled hospital readmission? [See the evidence review on post-discharge early follow-up clinics.]
Which components of a hospital escalation policy to deal with surges in demand are the most clinically and cost effective? [See the evidence review on escalation measures.]