Urgent and emergency services - Health Committee Contents


Conclusions and recommendations


Growing demand

1.  The Committee was surprised by the lack of clear evidence about trends in the level and nature of demand for urgent and emergency care. There is a pressing need for clearer information to be produced which can detail where urgent care cases present across the system and the case mix of urgent patient presentations; it is also important to monitor waiting times for urgent and emergency services in order to ensure that services are accessible to patients in urgent need of care. The Committee recommends that NHS England should ensure this data is collected and reported on a consistent basis across the country. (Paragraph 24)

Root cause analysis

2.  The emergency and urgent care functions of the NHS are undoubtedly working under stress and there is insufficient resilience in the system. Availability of a hospital bed when required is a fundamental part of an emergency care system. Successful delivery of this basic requirement is, however, dependent on the ability of the system to understand the demands made upon it and to deploy its resources in the most effective way. Rising demand for hospital admissions may be as much a symptom of system failure (for example, failure to provide timely care in a patient's home) as it is of an underlying rise of demand. Until these systems failures are addressed, hospital managements need to ensure that there is sufficient bed capacity available to meet current demand. (Paragraph 29)

3.  The system cannot accurately analyse the cause of the problem, still less resolve it, if it continues to "fly blind". More accurate information about the causes of rising service pressures is not simply a management convenience; it is fundamental to the delivery of high quality care. (Paragraph 30)

Fragmentation

4.  The successful provision of emergency and urgent care is a matter of life and death and therefore clarity in commissioning is vital. The Committee is concerned that the lines of responsibility and accountability for funding and managing services have been blurred. The Committee notes the concept of UCBs putting local clinicians and commissioners together to make practical changes and plan service improvement, but it is concerning that new structures are required so soon after the establishment of CCGs and Health and Wellbeing Boards. Health and Wellbeing Boards have made an uncertain start but retain broad support and they are structured to bring all parts of the system together. The current problems should, theoretically, have provided them with an opportunity to develop their functions, but they appear to have been superseded by UCBs. (Paragraph 36)

Simplifying commissioning

5.  We recommend that CCGs and Health and Wellbeing Boards explore the benefits of establishing single commissioning teams for out of hours care, ambulance services, 999, and NHS 111. A single commissioner can lead across CCG boundaries in the case of services which are most appropriately commissioned on a regional or sub-regional basis. Fragmented commissioning and provision results in a situation where patients are unaware of many available services or are unsure of the most appropriate service. The single commissioning teams for urgent care should take responsibility for signposting patients to available services. (Paragraph 39)

Funding

6.  The Committee was disappointed with the evidence that was presented about the creation of UCBs. Ministers are relying on UCBs to implement short-term practical changes to improve hospital performance, but the composition, responsibilities and authority of UCBs remain unclear. There is little evidence that any form of national strategy exists beyond the creation of UCBs, and senior figures in NHS England could not tell us precisely how many UCBs have been established. (Paragraph 54)

7.  The evidence presented to the Committee did not persuade us that the structures existed to enable UCBs to implement reforms or influence local commissioning arrangements. The Committee believes that Ministers need to seek much greater clarity from NHS England about its plans for UCBs and ensure that they, or Health and Wellbeing Boards, are required to account for an Urgent Care Plan for their area in the winter and spring of 2013-14. The Committee recommends that NHS England should ensure that these Urgent Care Plans are prepared and agreed before 30 September 2013. (Paragraph 55)

8.  It is concerning that UCBs appear to have been created without any senior figure in NHS England being clear whether they are intended to become permanent features in local health systems. We agree with several witnesses that UCBs meet an urgent need to introduce "system management into the system" If that is to be their role, we do not believe it should be regarded as either voluntary or short-term. (Paragraph 56)

Specialist centres of care

9.  The Committee accepts that a strong case has been made for the centralisation of some aspects of acute emergency care in regional specialist emergency units on the basis that substantial clinical benefits are delivered by focusing skills and resources in single locations. We are, however, concerned that this evidence is not abused; each proposal for service redesign should be reviewed on the basis of the evidence so that centralisation is justified only when the evidence supports it, not as an end in itself. For example, in rural areas the benefits of centralising care for some serious conditions could be negated by increased transport times. (Paragraph 62)

The four hour standard

10.  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. (Paragraph 67)

Assessment of patients

11.  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. 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. (Paragraph 77)

12.  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. (Paragraph 78)

Staffing

13.  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. (Paragraph 87)

Delayed discharge

14.  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. (Paragraph 94)

15.  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. (Paragraph 95)

Tariffs

16.  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. (Paragraph 99)

Primary care

17.  The Committee strongly believes that primary care has an important role to play in delivering accessible, high quality urgent care. However the service structure required to deliver this objective is different from the structure required to deliver 'care to patients with complex needs and deal with uncertainty in acute conditions'. The Committee does not favour a single blueprint from the Department or NHS England. The Committee recommends that NHS England (as the commissioner of GP services) should seek innovative proposals for the development of community-based urgent care services in each area. These proposals should include consideration of step-up and step-down care and they should be properly integrated into the rest of the urgent care system in that area. NHS England should be open-minded about how such a service should be provided. (Paragraph 108)

Urgent Care Centres

18.  The Committee welcomes the development of Urgent Care Centres on hospital sites and accepts the evidence that these units can improve the quality and efficiency of emergency care. We recommend that UCBs should actively consider the development of such centres on acute hospital sites where there do not currently exist, although we accept Professor Willett's warning that they can be a variety of reasons why the model does not fit every circumstance. (Paragraph 114)

19.  The Committee also accepts that the warning of the College of Emergency Medicine that patients will continue to find the organisation of urgent care baffling if similar phrases mean different things in different places. Extensive application of the principles of Urgent Care Centres need to be backed up by clear objectives, clearly communicated. (Paragraph 115)

NHS 111

20.  The decision to roll out NHS 111 was made before any evidence had been gathered to assess the strength of the service it could deliver. The service was shaped on patchy evidence despite the results from a small number of pilots questioning the ability of the service to divert demand away from urgent and emergency care services. The Committee concludes that the national deployment for NHS 111 was undertaken prematurely and without a sufficiently sound evidence base. (Paragraph 122)

Assessment

21.  The Committee is concerned that NHS 111 did not apply the principle of seeking early engagement by a senior clinician, with the result that many calls took longer than necessary and some patients were advised to attend A&E but did not, in the event, need to be there. We recommend that, as part of its workstream examining the future strategic direction of NHS 111, NHS England attributes a higher priority to the principle of early clinical assessment. (Paragraph 125)

22.  The Committee accepts that a recognisable telephone led non-emergency service is useful but it is not yet convinced that the balance between "triage" and early access to a senior clinician is right. The Committee recommends that this balance should be actively reviewed by NHS England as part of the ongoing development of NHS 111. (Paragraph 127)

Ambulance services

23.  Ambulance services must demonstrate a commitment to establishing a ratio of paramedics to technicians which ensures that ambulance crews are able to regard conveyance to an emergency department as only one of a range of clinical options open to them. We recommend that NHS England undertakes research to establish the precise relationship between more highly-skilled ambulance crews and reduced conveyance rates. (Paragraph 139)

Developing the functions of ambulance services

24.  There is still a considerable variation in conveyance rates across ambulance trusts. NHS England should take the lead in reviewing the various staffing models used by different trusts to help understand which structures are most effective in reducing conveyance rates and putting patients on the correct pathway. This should establish an evidence base for both urban and rural settings to help ambulance trusts determine how they organise their resources and workforce. (Paragraph 147)

25.  Ensuring that all ambulance crews have access to national patient data would increase the patient information available and allow for better decisions to be made regarding conveyance and care. The Committee recommends that UCBs take the lead in assessing access to the National Spine for all key parties in the delivery of emergency care and coordinate plans to ensure that the minimum patient record is made available. (Paragraph 148)

Incentives

26.  The Committee believes it is vital that commissioners successfully introduce tariffs which encourage ambulance providers to 'hear and treat' and 'see and treat' patients. Such encouragement would provide ambulance trusts with further incentives to develop a skilled workforce predominantly made up of paramedics. This would be of particular benefit to patients in rural areas who have only limited access to services. (Paragraph 151)

27.  A service that is paid to transport patients will employ technicians to facilitate this; one that is paid to treat patients will invest in recruiting and training paramedics. The Committee therefore urges NHS England to closely monitor the relationship between the use of the new tariffs, conveyance rates and the balance between technicians and paramedics in ambulance trusts. (Paragraph 152)


 
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Prepared 24 July 2013