Urgent and emergency services - Health Committee Contents


5  Improving A&E performance

The four hour standard

65. The four hour waiting standard requires all A&E departments to see 95% of attending patients within four hours of their arrival at A&E. It was the deterioration in performance against this standard which prompted NHS England to launch a recovery programme for emergency care. In evidence no witnesses argued that the four hour target should be scrapped. Dr Clancy told the Committee that it was a "process measure and not a quality measure"[59] and that other quality indicators were more useful in explaining how well emergency departments are performing.[60] Mike Farrar explained that whilst the four hour standard was not "a relevant clinical target" it remained a useful indicator of overall performance.[61] Mr Farrar said:

    The indicator gives you some sense of the flow through a system. In clinical terms, obviously, if you present with severe chest pain, waiting for three hours and 59 minutes is not right. [...] But it tells you something about how patients are able to be admitted and the capacity of the hospitals. It also gives you a bit of insight into how many people are presenting.[62]

Dr Cadigan sounded a note of caution, pointing out that the target was prone to 'gaming'. He said when considering the care of a patient in an emergency department:

    At the point where there is inadequate capacity and where the right thing to do is to hang on to someone for a little longer in the A and E department, the four hour target forces you to move them—and forces you to move them to an inappropriate place—when it is clinically inappropriate.[63]

66. In Chapter 1 we identified rising admissions to hospital from the A&E department as a key indicator of the changing nature of the workload of the A&E department. In this chapter we examine how the flow of patients through a hospital can adversely affect the work of an emergency department. In oral evidence Dr Gerada linked these two factors and the issue of emergency department staffing (also discussed in this chapter), arguing that the four hour waiting target could drive unnecessary admissions. Dr Gerada said:

    With the four-hour target, there are what we call zero-hour admissions, especially children or the elderly, who are so-called admitted but not really admitted. [...]The problem is zero-hour admissions either for observation or because there is not somebody senior enough to make the decision whether or not to discharge. That comes back to the original premise of the College of Emergency Medicine: there are not enough senior doctors in the emergency department to make decisions, hence you are clogging up.[64]

67. In a well-functioning health system the four hour waiting time standard would be met as a matter of course rather than as an objective of policy. The four hour standard retains its value as a basic measure of performance but it does not provide a full measure of service quality. It is prone to gaming and the key indicators of hospital performance should be based on a broader assessment of patient outcome and experience. Waiting times are certainly part of this, but not the whole of it.

Patient flow

ASSESSMENT OF PATIENTS

68. In publishing the evidence base for the Emergency and Urgent Care Review, NHS England specifically acknowledged that:

    Timely access is required from supporting specialties to enable appropriate admission and transfer of patients to improve patient flow within A&E departments.[65]

Further information detailed within the evidence base published by NHS England demonstrates the scale of the challenge that they and the Department face in achieving this objective.

69. The Committee notes the case study of the South Warwickshire NHS Trust which participated in the Health Foundation's Flow Cost Quality improvement programme and reported in April 2013. The trust decided to analyse the flow of patients from A&E through the hospital after examining the care of one patient who spent an eight day stay in hospital. In this patient's case they discovered that only 18% of his time in hospital had added value to treatment and the rest of the time in hospital was regarded as wasted.[66] The trust undertook a programme of substantial data analysis in attempt to understand why the flow of patients was so inefficient and to uncover the root causes of the problems. They found that:

    As in many hospitals, most emergency patients faced delays waiting for an initial assessment by a junior doctor. Once assessed, they then had to wait for input from a senior medic. There was also a lot of duplication (and therefore waste) in the current system. Patients coming through A&E would be seen by a junior doctor first, then by a registrar and sometimes by an A&E consultant. This would often trigger a referral to a specialist team.[67]

70. The analysis found that there was a four-hour delay between a patient arriving at A&E and then arriving at an assessment unit or ward:

    The consequence is that although two-thirds of patients arrive during working hours (when senior decision-making staff are available), they are not in the 'right' place by the time the senior staff leave the hospital at 6.00pm. [...]

    As a result of existing work patterns (8am to 6pm, Monday to Friday), on-take physicians and surgeons saw only around a third of patients before 6pm on the day they presented.[68]

71. In order to resolve this the team in charge of reviewing patient flow hypothesised:

    that if they placed senior clinical decision-makers in the MAU (medical assessment unit), when patients presented, they could improve the system dramatically. Having senior medical staff available to assess patients earlier would get patients onto their right care plan more quickly and efficiently.[69]

    The specialists also recognised that if they visited the assessment units after their morning ward rounds (at which time they would have discharged patients), they could 'pull' patients from the MAUs to their specialist wards while beds were available.[70]

72. The new system was trialled amongst cardiologists, who discovered immediate benefits, and it has been extended to other specialities including elderly care. In order to make the new system work consultants had to accept extended evening and weekend working. The presence of senior medical availability until 8pm instead of 6pm:

    ensured that patients were being assessed and put on the right care management plan on the day they presented. It took major delays out of the process and, crucially, avoided the need to 'store' patients overnight on the MAU.[71]

73. The King's Fund analysis in southern England supports the conclusions of the South Warwickshire study by emphasising the importance of access to senior medical staff. They found:

    In future rapid access to a senior opinion will need to be the norm. Many hospitals are now developing Acute Medical Unit (AMU) consultant job roles; specialists in assessment and early treatment; networkers across the hospital to conduct patients to the right speciality; and a source of advice to community based clinicians to prevent admission.

    In some AMUs the acute consultants are increasingly used by GPs to provide advice on seriously ill patients, developing closer working with the community. For example, in one trust the AMU consultant on call takes GP referral calls directly, preventing 40% from being admitted.[72]

74. The written evidence of the Royal College of Physicians emphasised the principle that early senior review could improve diagnoses, eventual patient outcomes and relieve pressure within emergency departments. They said:

    emergency departments should consider implementing a rapid assessment and treatment (RAT) model in order to provide early senior review for informed expert assessment, diagnosis, care planning, end-of-life discussions, etc. Senior triage of GP referrals to acute medicine has also been shown to be effective; acute medicine consultant triage of GP phone referrals and the introduction of medical ambulatory care pathways has seen a reduction in community admissions by 37% in the areas served by Royal Derby Hospitals area.[73]

75. The evidence appears to be strong that quick access to a skilled clinician, rather than laborious 'triage' through an ascending hierarchy, delivers care that is both better and more economic.

76. We recognise, however, that in practice there is a difficult balance to draw, particularly when staffing pressures are particularly acute in emergency medicine.

77. Acute trusts must learn from best practice in the NHS. Patient flow studies by the Health Foundation have found that pressure on emergency departments can be relieved by restructuring the assessment of patients and changing working patterns. The management and boards of Acute Trusts should take responsibility for examining their own procedures and identifying whether they are in line with established best practice. In evidence Professor Willett told us that UCBs could help to examine best practice models.[74] We agree that UCBs are well placed to undertake this role; successfully disseminating best practice across emergency and urgent care would help to establish the value of UCBs.

78. Accessing early senior review of cases can reduce duplication and accelerate the path of a patient through the system. Senior clinicians are better able to balance risk and make key decisions. We therefore recommend that trusts assess the viability of implementing a rapid assessment and treatment (RAT) model. Additionally we recommend that Acute Trusts operating emergency departments explore the value of effective acute medical units (AMUs) which are designed to incorporate rapid access to senior specialist assessment and the swift development of care plans including a plan for discharge.

Staffing

79. The fifth system design objective of the NHS England Urgent and Emergency Care Review is to improve the patient's experience and outcomes by "ensuring early senior clinical input in the urgent and emergency care pathway."[75] Improving access to senior clinical opinion can be achieved, in part, by reforming staff rotas and reorganising the operation of emergency departments. Nonetheless, the ability of emergency departments to provide swift senior assessment is fundamentally related to overall staffing levels.

80. The CEM argued in both written and oral evidence that emergency departments do not have sufficient specialist consultants to sustainably meet demand. The CEM's written evidence states that:

    Workforce recruitment is in crisis. 3 successive years of only 50% fill rates for Emergency Medicine trainees has resulted in a 'lost cohort' of over 200 potential consultants. This loss is permanent and irredeemable. In consequence all UK departments have a significant shortfall in senior trainees, this is compounded by hundreds of vacancies for other middle grade and consultant posts. This shortfall affects service delivery and patient safety on a daily basis. The College has called for a minimum of 10 consultants per Emergency Department and 16 in larger units.

    The pressure on those in post is relentless and demoralising. Trainees and Consultants alike struggle to maintain morale when forced to work within and deliver care on the very margins of safety. This creates a vicious circle of recruitment and retention failure.[76]

81. The Emergency Medicine Trainee Association observed in their written evidence that recruitment problems are also the result of "a failure to retain quality EM (emergency medicine) doctors at the middle grade level."[77] Dr Clancy went on to explain in oral evidence the relationship between patient numbers and consultants:

    we are seeing about 15 million patients and that there are in the order of 1,400 consultants. That works out at about just over seven consultants per department. We have grown from four or so in 2007, so there has been an expansion, but there are not enough trained emergency physicians to deliver the care that the public expect.[78]

82. The CEM's position is that a minimum of 10 consultants are required in order to deliver a 16 hour presence in emergency departments.[79] Dr Clancy told the Committee that existing staffing levels allow for a 12 hour presence 77% of the time on weekdays but only 30% of the time at weekends.[80] Only 17% of emergency departments in England are able to provide 16 hour consultant coverage during the working week.[81] In order to fill the gaps in staffing rotas emergency departments are making use of locums. Dr Clancy said that:

    in the key decision makers the vacancy and locum rate, other than consultants, is about 20% plus and the vacancy in locum rate for consultants is about 17%. Trusts at the moment are spending, on average, per trust £500,000 per annum in locum costs for emergency departments. That is a resource that really should be allocated in the future for substantive, trained doctors who want to do this work.[82]

83. In regard to the future sustainability of the system Dr Clancy added that:

    My major concern for the future of the emergency care system is that not enough doctors want to do this work. [...] The challenge that we face is: how do we value this work more highly than we do now and how do we ensure that we attract doctors into this work, which is difficult and hard, in a career that is sustainable? We are asking doctors to work till they are 67. This is tough work that many doctors migrate away from because it is hard.[83]

Referring not only to A&E consultants but acute medicine in general, Dr Cadigan said that the specialty is not seen as being glamorous because:

    If you are a specialist, you tend to work in a specialist unit: you work in an enclave that you can protect in terms of the sorts of patients you accept into that unit; you work with a consistent team; you work on a group of patients that you know you can deliver good results to. When you move outside that specialist environment into the general medical wards, the wards into which patients are admitted if they do not have a very specialist need, such as a heart attack or a stroke, you find a very different environment where you cannot control the patients coming in; where you do not work with a consistent team and you may be working with a different group of doctors every day; where neither the doctors nor the patients benefit from continuity of care; and where, because of the pressure on beds, patients may move from ward to ward four times within the first 48 hours. That is not a professionally rewarding, safe or educationally good environment.[84]

84. Earl Howe commented that recruitment and retention of trainees is a concern as "the lifestyle is pressurised and there are fewer opportunities for private work."[85] His view is broadly in line with that of the Emergency Medicine Trainee Association who described "brutal working patterns" and reported that:

    It is still not uncommon for some juniors to work seven straight nights in EM usually under intense pressure due to the high volume of patients in the department. It is clear that these rotas are not sustainable over the long term and this is a major reason for many excellent EM trainees are choosing other specialties. [...]It is not uncommon for many ED junior doctors to work through an entire shift without a rest break due to the service pressures or having to cover due to gaps in the rota.

They argued in their submission to the Committee that the specific circumstances of emergency medicine demanded a review of the junior doctors' contract to improve their terms and conditions:

    the new junior doctor's contract has to recognise that the needs of acute specialties are very different from the non-acute specialties and that 'a one size fits all' approach will be disastrous for the specialties such as EM. We believe that special attention should be paid in defining these needs in terms of workable terms and conditions as well as appropriate remuneration. Junior doctors working in EM currently get the same banding as other specialties who do not work under the same intensity or pressure as those working in EM.

85. In evidence Sir Bruce Keogh agreed with the contention that the existing training regime attracts trainees to sub-specialities which are of less value to patients and the NHS than emergency care. Neither Earl Howe nor the Secretary of State would commit to reforming training in order to drive trainees away from more fashionable sub-specialities and into emergency care, and the Secretary of State was more circumspect than Sir Bruce Keogh, saying:

    I am not aware that we are training too many doctors in particular specialties. We need more doctors, full stop. We need them in most specialities because of the increase in demand across the system.[86]

The Secretary of State said that it was Health Education England's job "to make sure that we have the right number of doctors and nurses with the right skills in the right areas".[87]

86. There is a crisis in the recruitment and retention of trainee emergency department consultants. At present trusts are recruiting too many expensive locums at all levels of seniority. The Department of Health, Health Education England and NHS England must work together to address the concerns of trainees and make a career in emergency medicine an attractive option for more young clinicians.

87. The Committee does not believe that attracting and retaining trainees is simply a question of improved remuneration. Trainees will only join a specialty if they are convinced that it offers the prospect of a career that is both professionally and personally rewarding. It is important that Health Education England and Local Education and Training Boards address these issues in order to make emergency medicine an attractive career option.

Delayed discharge

88. In April 2013, the Health Foundation reported on a programme implemented by Sheffield Teaching Hospital NHS Trust which had been designed to improve the flow of elderly patients through the hospital. The report highlighted the problems associated with failing to discharge patients at the earliest opportunity:

    A consultant analysed the notes of 23 of the 100 patients with the longest lengths of stay. This review highlighted the difference between 'possible' length of stay (based on the first definitive note by a geriatrician that the patient was medically fit to be discharged) and 'actual' length of stay. The notes revealed multiple points when the patients could have been discharged. Opportunities were missed partly because the services involved in discharge were unable to respond quickly enough, as a consequence of a mismatch between capacity and varying demand.

    As a consequence of delayed discharge, some frail patients deteriorated while others were transferred to other parts of the hospital. These transfers sometimes resulted in vital information being lost, resulting in further deterioration, re-work and delay. On average, patients spent four times longer in hospital than was initially estimated by consultant geriatricians involved in their care. It is estimated that these 23 patients received approximately £471,960 of hospital care that could potentially have been better spent on more appropriate care in their own homes, or on residential or nursing care.[88]

The case study reached the clear conclusion that delays in discharge not only incurred unnecessary cost but could also result in poor patient outcomes. Commenting on the pressures in the system which have resulted in some emergency departments failing to meet the four-hour target, Dr Cadigan said "it is flow out of the emergency department that is one of the crippling factors."[89]

89. In oral evidence Mike Farrar told the Committee that achieving smooth patient flow in hospital was dependent on good discharge planning.[90] The NHS England A&E improvement plan acknowledges that problems in A&E may the result of failing to discharge patients because of lack of available community and social care services.[91] Indeed, UCBs have been tasked with working with local authorities to ensure that early discharge options are available.[92]

90. The King's Fund does not believe that delays in discharge are entirely attributable to lack of available social care provision, but they observe that:

    Local authorities have tried to protect social care budgets, but net expenditure on adult social care has fallen in real terms for the past two years. The number of people receiving publicly funded social care through local authorities has also continued to fall - by 7 per cent in 2011/12 and by 17 per cent since 2006/7. Over the same period, the number of people aged 85 years and over has risen by more than 20 per cent. A recent survey of Directors of Adult Social Services by the Fund found that transferred NHS money is being used to promote the closer integration of care but in many cases it is being used to offset general service pressures and councils are finding it much harder to find savings that do not impact on the quality or quantity of care (Appleby et al 2013).[93]

The King's Fund do not, however, present evidence that the challenges facing social care have directly resulted in reduced availability of social care places to which patients can be discharged.

91. The Foundation Trust Network presented anecdotal evidence from its members of the problems facing acute trusts in this regard. The FTN identified the relationship between delayed discharge, reduced bed capacity and a lack of flexibility in hospitals. They said:

    Many hospitals are also facing an urgent and growing problem of not being able to discharge patients in a timely and effective way because of problems in social care stemming from funding cuts due to reduced local authority budgets. FTN members report problems with 'hospital back door' discharge, leading to longer stays and higher bed occupancy rates. This rapidly leads to problems coping with 'hospital front door' A&E admissions as beds are not available. Small increases in patient acuity - such as a 1% or 2% annual rise - can lead to increased admission levels that hospitals find it very difficult to absorb when they are running at or close to capacity.[94]

92. Andrew Webster, Associate Director Integrated Care at the Local Government Association (LGA), however, challenged the notion that delayed discharges in relation to the availability of social care were a major factor in the pressures afflicting emergency departments. He told the Committee that:

    Many people focus on the issue of whether people are getting stuck in hospitals—what are described as delayed discharges. Those are actually going down, and those that are attributable to social care are going down faster than those that are attributable to things in the health system.[95]

Additional written evidence submitted by the LGA bears out this claim. They quote statistics published by NHS which show that:

    In 2012/13, the daily average number of delayed transfers of care per 100,000 population (aged 18+) was 9.5, which compares to 9.7 in 2011/12.

    On delays attributable to local government going down

    In 2012/13 the daily average number of delayed transfers of care attributable to social care per 100,000 population was 3.3, which compares with 3.7 in 2011/12.[96]

93. Earl Howe told the Committee that:

    about 3% of total bed days are due to delayed discharges, with approximately 2% of occupied beds being delayed. So the long-term trend has reached a plateau. It is sticking at around the level of 2,000 acute patients. Before, it was around 7,000.

We, nevertheless, find the disparity between the anecdotal evidence of health professionals and the formal statistics striking. The Secretary of State conceded as much in oral evidence and he observed:

    when you talk to chief executives of hospitals and to A and E departments and ask, "What is the biggest single pressure that is a worry for you in terms of hitting your 95% target?", they say it is the lack of availability of beds in the hospital to admit people who need admitting. In the last few months, nearly all the chief executives have said that they have approximately two wards full of people who could be discharged but they are not able to discharge.[97]

94. The national data available on delayed discharges contradicts the evidence of clinicians and managers across the acute sector. The Committee believes that the data is incredible and we recommend that Ministers swiftly investigate the method of data collection in order to understand whether the available figures genuinely reflect the situation on the ground.

95. More important than national data collection is the delivery of accurate information to local system managers. The Committee received strong evidence to suggest that delayed discharges were a significant threat to patient flow, and therefore to care quality. We recommend that NHS England should require each area's Urgent Care Plan to include an assessment of the impact of delayed discharges on patient flows and a plan to address the issue.

Tariffs

96. The NHS Confederation explained in written evidence that the rationale for the 70-30 tariff split was to provide acute trusts with an incentive to discover new ways to reduce demand.[98] Mike Farrar described this as having failed because it was "patently clear that supply induced demand is not the driver here".[99] The NHS Confederation argued that what the marginal tariff has achieved is to:

    substantially increase the already intense financial pressures on acute trusts with emergency departments. Furthermore, the marginal tariff has in practice transferred the risk to providers and has not created a shared imperative for commissioners to actively engage with this issue and make changes to the local health service which will tackle rising demand.

The Shelford Group observed in their submission to the Committee that the problems associated with the marginal tariff were compounded for the largest specialist hospital in a health community. This is because patients in emergency departments "can often by-pass other more local providers to receive care."[100]

97. Discussing the way in which the tariff paid to hospitals operates, Professor Willett told the Committee that:

    At the moment, we pay a hospital by the admitting diagnosis of the patient and the reference cost set by the average length of stay across the country in previous years. The difficulty is that [...] if the admitting diagnosis happens to be a urinary infection but they have rheumatoid arthritis and had a stroke last year and so on, what determines how long they stay in hospital is not the fact they came in with a urinary infection but that their dependency is much greater than someone who came in who just had that infection.[101]

The College of Emergency Medicine expressed frustration with the existing arrangements noting that "resuscitation is remunerated at a lower value than a routine out-patient attendance."[102] The NHS Confederation was critical of the way in which payment systems have been developed and said that tariffs must be reformed to:

    incentivise better joint working, more focus on intervention and greater investment in community services, all of which would relieve the pressures on urgent and emergency care.[103]

They concluded that:

    The various payment systems, such as tariff, currencies and payment by results, have often been developed in an ad hoc way to address various issues and plug particular gaps across the system.[104]

98. Dr Cadigan noted that that there are examples of single commissioners successfully working with providers to reduce admissions. He said that those that have achieved this "have dismantled payment by results."[105] Further to this Dr Cadigan explained that:

    one of the things that is done in successful groups that have achieved integrated care [...] is that they have reached mutual arrangements to dismantle standard payment by results and gone for shared financial incentives and shared financial risk solutions.[106]

99. The current arrangements for remunerating A&E departments with only 30% of the tariff for activity over 2008-09 levels is no longer viable. The baseline is five years old and does not account for, or reflect, the pressures that hospitals face. As part of its review of the marginal tariff, Monitor should seek options which minimise the twin dangers of perverse incentives and excessive complexity. Incentivising all providers to direct patients to the correct treatment option, however they come into contact with the NHS, should be the over-riding priority.


59   Q 10 Back

60   Ibid Back

61   Q12 Back

62   Ibid Back

63   Q 11 Back

64   Q 194 Back

65   NHS England, June, 2013, p 12 Back

66   Ibid, p 4 Back

67   Ibid, p 5 Back

68   Ibid, p 6 Back

69   Ibid, p 9 Back

70   Ibid Back

71   Ibid Back

72   The King's Fund, March 2013, p 26 Back

73   Ev 90 Back

74   Q 278 Back

75   NHS England, June 2013, p 6 Back

76   Ev 92 Back

77   ES 21, written evidence from the Emergency Medicine Trainee Association, page 1 Back

78   Q 64 Back

79   Ibid Back

80   Q 69 Back

81   NHS England, June 2013, p 51 Back

82   Q 73 Back

83   Q 64 Back

84   Q 67 Back

85   Q 287 Back

86   HC 119-iii, Q 278  Back

87   Ibid, Q 281 Back

88   The Health Foundation, Improving the flow of older people - Sheffield Teaching Hospital NHS Trust's experience of the Flow Cost Quality improvement programme, April 2013, p 3-4 Back

89   Q 9 Back

90   Q 43 Back

91   NHS England, May 2013, p 2 Back

92   Ibid, p 7 Back

93   ES 28, written evidence from the King's Fund, para 14 Back

94   ES 37, written evidence from the Foundation Trust Network, para 33 Back

95   Q 167 Back

96   Ev 112 Back

97   HC 119-iii, Q 240 Back

98   Ev 100 Back

99   Q 74 Back

100   ES 40, written evidence from the Shelford Group, para 19  Back

101   Q 281 Back

102   Ev 95 Back

103   Ev 101 Back

104   Ev 101 Back

105   Q 55 Back

106   Q 91 Back


 
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Prepared 24 July 2013