Emergency Medicine at the Deep End

Back in March, the Scottish Deep End Project hosted the first meeting of EM at the Deep End for a roundtable discussion on the impact of health inequalities in emergency care. Read the summary here, and download the full report below.

Summary

Hosted by the Scottish Deep End Project, the Emergency Medicine at the Deep End group launched at a hybrid event online and in-person at the Clarice Pears Building in Glasgow on 12th March 2024. Twenty-five health and social care professionals, including emergency physicians and general practitioners from Deep End practices, sat alongside interested individuals from Public Health Scotland, Medics Against Violence and the Navigators programme, Community Links Worker programme, Infectious Diseases, Centre for Sustainable Delivery, University of Edinburgh Centre for Homelessness and Inclusion Health, and Scottish Government. Discussion focussed on the challenges faced in Emergency Departments due to health inequalities and what can be done to mitigate these problems.

The Challenge

People experiencing socioeconomic disadvantage have higher rates of emergency attendance across the spectrum of disease severity. (1) It is not merely a problem of frequent avoidable attendance; (2) the overall disease burden is significantly higher in socioeconomically deprived groups, with resultant high levels of premature, and excess mortality. (3) Patients from these groups are more likely to die from critical illness, regardless of severity. (4) This issue is pressing and urgent, not a niche special interest, and core to the work of Emergency Medicine. Addressing health inequality and the unmet need that drives people from less affluent backgrounds to access non-emergency care via the Emergency Department (ED) has the potential to both mitigate unjust health inequalities, and reduce the strain on a hospital system in crisis. Whilst many of these solutions will require increased investment and capacity building in primary care, including general practice, social care and the third sector, there are interventions that can be delivered within the ED that can ensure existing inequalities in health and healthcare are not worsened. (5)

The Scottish Deep End Project

Since its inception in 2009 the Scottish Deep End Project, a group of GPs from the 100 most deprived practices in Scotland, have made significant headway in raising the profile of inclusion health in general practice and have had a number of successes. Their activities have been targeted towards Workforce, Education, Advocacy and Research. Importantly, the model has been adopted internationally, with 16 Deep End groups operating in 7 countries. We propose that there would be benefit in adopting a similar approach in emergency care, and in working collaboratively alongside them. (6)

“The Inverse Care Law is not an immutable fact of life” 

The Inverse Care Law describes how the availability of good medical care tends to vary inversely with the need for it in the population served; (7) and efforts to mitigate these effects have been core to the work of the Deep End projects. The group recognises that the Inverse Care Law extends to the provision of emergency care, and that in Emergency Medicine, regardless of where we work, we are all at the ‘Deep End’ because of the breadth of the populations that we serve, and the fact that ED use is highly socially patterned.

Areas for Change

Intervention

Policy in emergency care has focussed on demand management, a strategy that has been established as ineffective. (8) Promoting an understanding of “unmet need” rather than “demand” better represents the reality of people who don’t choose to be in hospital, but attend because their needs aren’t met elsewhere. 

Social interventions in the Emergency Department do exist, and the potential for these has been demonstrated through initiatives such as the Navigator’s programme. (9) However, more work is required to sustainably integrate these programmes into emergency care, providing support at what might be an important, reachable moment for our patients, and making links to existing social supports in the community.

Research

While higher rates of Emergency Department use amongst communities experiencing the greatest deprivation is likely due to a complex combination of barriers to healthcare access elsewhere (e.g. Primary Care) and a higher burden of illness, more work is required to identify patterns of attendance and areas of intervention for marginalised groups. Research into what drives these findings could help to target effective change.

Advocacy

The Scottish Deep End Project has effectively campaigned for recognition of the impact of social deprivation on the delivery of general practice.  It is crucial that we are able to follow this example and effectively lobby for meaningful change at a government and policy level, including sharing experience and perspective to influence public opinion. Inclusion in, and collaboration with, groups and forums such as the British Medical Association, Royal Colleges, and all levels of government has allowed the Deep End project to disseminate the message, influence policy and contribute to meaningful change. The group has effectively harnessed media training to present their message more widely, which may be a helpful example for Emergency Medicine at the Deep End.

It was recognised that advocacy is required within Emergency Departments too. With evidence of socio-economic deprivation being an independent risk factor in acute and critical illness, work is required to better mitigate these harms more proactively and robustly consider the social environments to which we may discharge our patients.

Education 

Participants were in agreement that inclusion health needs far more visibility within education and training at all levels. This should include greater understanding of health equity, the social determinants of disease and training in trauma informed care. 

Next Steps

Challenges in implementing meaningful change at pace were understood across the attendees. However, the success, perseverance and collective voice of the Deep End projects has provided an example of what might also be possible in emergency care.

The immediate next steps identified for the project were:

Defining the Challenge

The next meeting of Emergency Medicine at the Deep End will be in the afternoon of Thursday 20th June on the theme of “Defining the Challenge”. The aim will be to widen the network, canvass the opinions of clinicians in emergency care across sites and interests, to define the challenges posed by health inequalities, and to focus the ongoing work of the group. 

Develop Research Portfolio

Work is already in progress to evaluate the impact of social intervention in the Emergency Department. Further projects, using the breadth of experience within the group and with collaborators, will be pursued.

Improving Intervention

Connections made during the launch meeting have facilitated discussion and collaboration in social intervention in emergency care and in the community (such as community link workers). Continued work will seek to improve these links, whilst recognising the need to grow capacity.

Integrate with Policy

There was a recognition that policy must acknowledge the needs of the most vulnerable groups presenting to emergency care. Working with Scottish Government to identify areas of policy the group may be able to contribute to, as well as collaboration with the Centre for Sustainable Delivery, where the group may lend its understanding to mitigate the effects of the Inverse Care Law in emergency care.

Providing a Toolkit

The meeting noted the success of groups such as ‘Green ED’ in raising the profile of environmental issues while also providing a practical toolkit for Emergency Departments to engage in change. This strategy may serve as an example for Emergency Medicine at the Deep End.

Education & Training Opportunities 

Improving education and training opportunities in inclusion health at both undergraduate, and postgraduate level. With a focus on developing an ‘Introduction to Inclusion Health’ training day for speciality Emergency Medicine trainees, as well as local induction resources and ongoing CPD opportunities.