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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