House of Commons - Public Accounts

Select Committee on Public Accounts Sixteenth Report

3 Improving the integration of emergency care services

19. Under its 2001 Reforming Emergency Care strategy the Department established the principle that all services must be designed from the point of view of the patient and their needs should be met by the professional best able to deliver the service. The Department therefore recommended the integration of the system of emergency care providers, including the development of Emergency Care Networks to promote and co-ordinate cross-boundary working between primary care trusts, acute trusts, social services, local authorities, ambulance trusts, pharmacies, mental health trusts and voluntary organisations. The Department also proposed that healthcare professionals should be trained and empowered to use their competencies and skills to practice autonomously, so that for emergency conditions which are not life threatening a single practitioner would manage the patient throughout their journey.[20]

20. To reduce delays further, acute trusts need to look wider than A&E departments and the Department has assisted trusts to identify 'bottlenecks' in the patient journey and develop solutions (Figure 5). Primary care trusts, which allocate financial resources for emergency care services, have however found it difficult to remove these chokepoints because of funding constraints. The Department acknowledged that the partly historical basis of NHS finance meant allocations to some primary care trusts were probably lower than they should be, but the Secretary of State wanted to address this issue over the coming years.[21]

21. Although the NHS has developed new types of provider and co-located services to improve access to emergency care, the National Audit Office found that by and large the public continued to expect provision of emergency treatment through A&E departments. The acute hospital system could therefore become blocked, and capacity could be released if patients were treated in alternative ways. The level of public knowledge about the availability and services of the different types of providers is not sufficient for them to consistently make informed decisions about accessing emergency care. The Department agreed there was confusion and said it would consider renaming services to reflect their function. A good public education policy was needed to ensure patients knew what services were available to them, but it was no longer policy for patients to be educated to go to the "right place" for treatment.[22] Figure 5: Potential bottlenecks around an A&E Department

Source: National Audit Office

22. The ambulance service is not a free taxi service, and the Department was challenging the perception that an ambulance should always take a patient to A&E. Advertising campaigns about 999 calls have been used, for example in London and Lancashire, and the Department said that public behaviour could be expected to change with experience of being treated at home or being provided with different care pathways by emergency care practitioners, instead of being transported to A&E. The Department was not aware of any direct interventions by trusts, such as letters to inform members of the public about inappropriate use of the ambulance service.[23]

23. Although the Department promoted the idea of Emergency Care Networks as the means of achieving its targets for emergency care in 2001, the National Audit Office still found that many of these cross-organisational and multi-disciplinary networks were still in their infancy (Figure 6). Structural reform, organisational boundaries, conflicting performance indicators, and availability of funding and the way it is allocated were obstacles to improved joint working. In its 2004 report, Transforming Emergency Care in England, the Department identified strong partnerships as the key to the issue of waiting times. The National Director for Emergency Access believed that if Emergency Care Networks were charged with commissioning all emergency services for a locality, including social service support, improvementswould be possible.[24]

24. The Department believed that the move to a single telephone call access system would provide a more patient-centred response to requests for emergency care. Originally it had envisaged that all services would be linked through a single point of access - NHS Direct - and that a 'navigator' would provide assistance to get the patient to an appropriate service as quickly as possible. It remained committed to providing this simple local access to emergency care through one national telephone number, but the organisation to which the enquirer was connected would depend on the locality, and could for example be an ambulance service, a GP co-operative, or NHS Direct. It was also the Department's intention that Walk-in-Centres, Minor Injury Units and Urgent Care Centres should be integrated with the out-of-hours service. GPs would continue to be rostered, but the talents of nurses and paramedics will be utilised to a greater extent than currently.[25]Figure 6: Emergency Care Networks in Strategic Health Authority Areas are at different stages of development

Source: National Audit Office

25. The development of emergency care and emergency nurse practitioners has been an important change in the way emergency care is delivered. They are trained to diagnose, treat and discharge patients whose condition is not life threatening, and they are able to determine the most appropriate care pathway for the patient without reference to a medic. The National Audit Office found the skill content was not consistent, and the length of courses varied before the trainee could begin the role. The Department assured us that it was working on agreeing some overall educational standards for competence and skills and a set curriculum for local universities.[26]

20 Transforming Emergency Care in England: A report by Professor Sir George Alberti, Department of Health, October 2004 Back



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