Conclusions and recommendations
1. Demand for emergency care continues to
rise. Emergency Care
Networks should be given responsibility for reviewing local patterns
of demand compared to supply, and emergency care services should
be commissioned accordingly.
2. The Department is to be commended for expanding
access to emergency care through the establishment of new providers,
but there is a lack of knowledge about the relative unit costs
of these services. The Department should
clarify the methodology for computing costs so that strategic
planners for emergency care services can estimate the relative
unit costs of the different providers and assess the impact on
existing organisations if changes in service provision are made.
3. As a consequence of the Department actively
managing trusts' performance, the percentage of patients being
discharged or admitted from A&E in under four hours has risen
from 77% in September 2002 to 94.6% in September 2004.
After the maximum total time ceases to be a national target there
is a risk that high level attention to performance in A&E
Departments will diminish. To avoid this risk the Department should
continue to monitor performance closely and provide support to
NHS acute trusts to identify bottlenecks in their systems and
help them develop practical solutions.
4. Four hours is too long for the treatment
of many patients with minor injury or illness, and the proportion
of older and vulnerable patients who spend longer than four hours
in A&E remains disproportionately high.
The Department should make data available to all emergency care
providers so that they can benchmark their performance and monitor
their processes to ensure patients spend no more time in A&E
than is clinically necessary. In collaboration with other National
Directors, particularly the Older People's Czar, the National
Director for Emergency Access should promote action to identify
ways of reducing the need for crisis emergency care for the elderly
and those with mental health problems.
5. Treatment would be improved by more efficient
use of or investment in diagnostic services, more effective bed
management and timely access to specialist opinion.
To reduce variations in patients' experience of A&E services,
NHS acute trusts should draw on approaches used by the highest
performing departments and hospitals. These include widening staff
responsibility for initial interpretation of x-rays, and using
up-to-date equipment in diagnostic services, and making use of
Departmental checklists for bed management and access to
specialist opinion.
6. The work on constructing quality standards
for emergency care and national clinical audit tools is welcome
but overdue. The National Director for
Emergency Access should work with expert groups, such as the Faculty
of Accident and Emergency Medicine, to test the reliability, validity
and responsiveness of the 36 quality of care indicators which
have been proposed. Once a range of performance measures have
been agreed the Department should make the data available for
patients, clinicians and managers so that they can benchmark the
standards of care being provided.
7. The current absence of integrated patient
records is an acknowledged risk to patient safety. To
prevent the collection of duplicate information and reduce the
risk to patient safety the Department should clarify where the
responsibility for inputting particulars collected at each stage
of the emergency patient's journey will lie. Pending integrated
care records which allow emergency healthcare professionals to
audit clinical outcomes by tracking patients' progress, the Healthcare
Commission should develop more audit tools which allow clinicians
to measure the quality of care and benchmark performance across
all emergency providers.
8. Delivery of high quality care in a timely
manner depends on having enough skilled staff 24 hours a day.
The Department should amend its A&E
workforce planning model, in light of feedback from its own trials
and the recommendations of the British Association for Emergency
Medicine, and make the tool available to all A&E service managers.
The workforce development confederations of strategic health
authorities should then agree regional strategies to address any
identified shortfalls in skilled staff.
9. Patients are confused by the variety of
different emergency care providers. Strategic
health authorities, working with Emergency Care Networks, should
rationalise the system of names used for emergency care services
so that the purpose of each type of organisation is clarified
and standardised across the country.
10. Patients need to understand the circumstances
in which an ambulance should be called,
when ambulance personnel should and should not be expected to
provide a transport service to A&E, and that minor injuries
and illnesses can be treated efficiently at emergency care providers
other than major A&E departments. The Department should engage
in a public education campaign, drawing on best practice from
other organisations such as the UK Fire Service,
11. The emergency care services of some acute
and ambulance trusts are commissioned by more than one primary
care trust. The current method of funding
is not flexible enough to deal with differences in strategies
to address local health needs or with variations in demand. The
Department should evaluate the potential for making Emergency
Care Networks responsible for allocating funds for emergency care
services in their locality. It should draw on the knowledge and
experience gained from Cancer Networks in performing this function.
12. The Department's vision for simple local
access to emergency care through one telephone call is laudable
but staff need sufficient clinical experience and training and
local knowledge to provide a safe service.
The Department should expedite its discussions with NHS Direct,
the Ambulance Services and GP Out-of-Hours Service providers and
conclude on how to handle initial requests for help via the proposed
single national telephone number for emergency care. It should
also publicise the evaluations of the Out-of-Hours Exemplar Programme
to ensure that Emergency Care Networks can adapt best practice
to fit the situation in their localities.
13. Increasingly, emergency care practitioners
and emergency nurse practitioners are becoming responsible for
the treatment of patients, but there is no standard training or
job description for these roles. To provide
much needed national consistency, and in accordance with ideals
of the NHS Knowledge and Skills Framework, the Department should
clarify the skills and competencies that a person needs to be
effective in these posts and define the minimum content for the
education curriculum.
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