Health CommitteeWritten evidence from the Department of Health, NHS England, and NHS Trust Development Authority (ES 01)

Summary of the Evidence

The challenges of urgent and emergency care

Despite the availability of excellent urgent and emergency healthcare, the system is under pressure and faces a series of long-term challenges. Demand on A&E and ambulance services continues to rise; recent performance in A&E has suffered; and recruitment of trainee doctors in emergency medicine is remains difficult.

The new health structure, mandate and outcomes framework, urgent care review

The Department is working with NHS England to address these challenges. NHS England is launching an immediate programme to recover standards and a medium term programme to ensure delivery over the next winter period. In the longer-term, as part of a new Vulnerable Older People’s Plan to be published in the autumn, NHS England’s Urgent and Emergency Care Review will look at how to deliver safe and sustainable services.

Evidence on the specific issues raised by the Committee

A system which includes primary and community models for providing urgent and emergency care would allow the range of patient needs to be met across different geographical locations.

We are seeing a move towards integrating some primary care services within A&E departments. Therefore, it is no longer representative of what is happening simply to speak of moving lower acuity facilities out of A&E.

Defining the role of an A&E Department by the cases it is expected to receive and the causal factors in presentations is becoming increasingly difficult.

There is potential to further reduce the number of patients transported to hospital by ambulances and to provide more efficient and local care.

The key benefit to the introduction of the NHS 111 service is to improve patient and public experience of the urgent and emergency care system by offering a free-to-call, easy-to-remember number to access urgent NHS services. Many of the NHS 111 sites that launched in February and March have failed to perform as expected. NHS England is working closely with providers and commissioners to resolve the outstanding issues.

The move to clinical quality indicators is intended to achieve a more balanced and meaningful view of performance for patients and the NHS in regards to quality and safety as well as time measures.

The situation regarding delays in handover from ambulance services is a complex one, and often reflects the pressure that is being placed on the whole system, including patient flow within hospital and delays in discharge to the community.

There is clear evidence of the benefit of centralising services and treatment for a number of defined urgent conditions such as major trauma, stroke and severe neurological disorders.

The Health and Social Care Act 2012 places strong requirements on the NHS England and clinical commissioning groups to make arrangements to involve users of services in the planning, development and decisions that would have an impact on the manner or range of health services available.

The details of the system of health scrutiny are set out in the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 (“the 2013 Regulations”). Under the 2013 Regulations, local authorities can review and scrutinise any matter relating to the planning, provision and operation of the health service in their area.

The Challenges of Urgent and Emergency Care

1. The current system of urgent and emergency care in England is under pressure. Patients are confused by the variability in opening times and services offered by unplanned care facilities, whilst they find it difficult to choose and access the right level of urgent and emergency care service. In the absence of advice and guidance, patients tend to go to the facility that offers the widest range of services. There is also poor sharing of information between different providers of urgent and emergency care.

2. A significant rise in attendances at A&E and associated facilities has taken place in the last decade. Demand on the ambulance service also continues to rise. The number of emergency patient journeys rose from 4.2 million in 2004–05 to 4.9 million in 2011–12, whilst the number of 999 calls rose from 5.6 to 8.5 million in the same period. Centralisation of services, which has proven beneficial for patient outcomes from some serious conditions and injuries, has added to the challenge of maintaining clinical skills and financial viability of smaller A&E units.

3. Long waiting times in A&E departments (often experienced by those awaiting admission and hence ill patients) not only deliver poor quality in terms of patient experience, they also compromise patient safety and reduce clinical effectiveness.

4. A&E departments have faced significant pressure over the last six months. In the last quarter of 2011/12, 47 out of 152 providers failed to meet the 95% standard for patients being seen and discharged within 4 hours. For the last quarter of 2012/13 this figure had increased to 94 out of 148 providers, double the previous number. Despite much analysis there is no single trend or factor to explain the deterioration but these include winter pressures and the increasing acuity of patients presenting at A&E. There remains a wide variation in performance both across the country and within the same areas where similar factors apply.

5. In recent years, poor recruitment of trainee doctors in Emergency Medicine (EM) has raised concerns within the specialty and the medical profession. The specialty in 2011 and 2012 has achieved a lower than 50% fill rate into higher training. The College of Emergency Medicine established the Emergency Medicine Taskforce in September 2011 to address workforce issues in EM. It found that fewer trainees are opting to choose EM due to concerns over the intensity and nature of the work, unsociable hours and working conditions (Emergency Medicine Taskforce Interim Report, 2012). The Interim Report is currently with Health Education England for further consideration. There are also significant manpower issues in Acute General Medicine, General Practice and mental health.

The New Health Structure, Mandate and Outcomes Framework, Urgent Care Review

6. The new health and social care system will ensure that all relevant parties can make the changes needed to the urgent and emergency care system to give it a sustainable future. The Department will work with NHS England, Local Authorities, Public Health England, Monitor, the NHS Trust Development Authority, and the Care Quality Commission to support continuous improvement in outcomes for patients. The Government’s Mandate to NHS England reflects principles in the form of objectives to be met year on year. The NHS Outcomes Framework also sets out the Government’s expectation that healthcare will result in better outcomes for patients.

7. The Mandate and NHS Constitution rights and pledges both set out an expectation on waiting times for patients. They include the following pledges concerning urgent and emergency care:

a maximum four-hour wait in A&E from arrival to admission, transfer or discharge;

all ambulance trusts to respond to 75% of Category A calls within eight minutes and to respond to 95% of Category A calls within 19 minutes of a request being made for a fully equipped ambulance vehicle (car or ambulance) able to transport the patient in a clinically safe manner; and

all ambulance trusts to respond to 95% of Category B calls within 19 minutes.

8. NHS England has been set up to support the commissioning of healthcare which will give the best outcomes for patients, involving them and the public in shaping and monitoring local services. Its role is to oversee the whole commissioning system and to ensure that, working in partnership with CCGs, patients receive the right standards and quality of care. NHS England will support Health Education England to ensure that the urgent and emergency workforce has the right values, skills and training to enable excellent care.

9. Resolving the current situation in urgent and emergency care will require the commissioning system to work with all key partners in hospitals, primary care, and local authorities to create a single national framework to ensure that we see rapid and sustainable improvement. The work needs to be considered in three phases:

An urgent recovery programme with significant attention given by local and national commissioners and providers to all factors which can help recover the standards, (including clear performance management).

A medium term approach to ensure delivery over the next winter period. This will include care system planning as well as a review of the levers and incentives in the system.

In the longer term, the implementation of the urgent care strategy in order to deliver safe and sustainable services.

10. In announcing its Review of Urgent and Emergency Care, on 18 January 2013, NHS England made clear its commitment to equip commissioners with the guidance and tools necessary to help them commission consistent, high quality urgent and emergency care services across the country.

11. NHS England’s Urgent and Emergency Care Review will form part of the Department’s Vulnerable Older People’s Plan, due to be published in the autumn. The plan will cover three areas: improving primary care; the care provided by hospitals, including the role of emergency care; and removing barriers to integration. We want to see real impact on the ground from 2015. We need to find a long-term sustainable solution to improve care for the most vulnerable, particularly the frail elderly and those with long-term conditions. In doing so, we will tackle one of the principal drivers of demand for A&E services, and ensure that the care people access suits their changing needs.

12. While enabling and supporting commissioning excellence is one of NHS England’s central functions, decisions on how services are configured and provided must remain a matter for the local NHS. An important purpose of the Review is to create clinical consensus on how urgent and emergency care services should be organised. It is then for commissioners to use those guidance and tools to commission for their own localities.

13. CCGs will be vital to this process, as they are responsible for commissioning the vast majority of urgent and emergency care services. NHS England will therefore ensure that the views of CCGs are central to any proposals for service design that come out of the Review.

14. The evidence provided here reflects the new system and coordinates contributions from the Department of Health, NHS England and the NHS Trust Development Authority.

Evidence on the Specific Issues Raised by the Committee:

The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas

15. A system which includes primary and community models for providing urgent and emergency care would allow the range of patient needs to be met across different geographical locations, including remote and rural ones.

16. NHS England’s Urgent and Emergency Care Review is considering the issues relating to access to primary and community care services and the consequent impact on ambulances and A&E departments. Primary care could more appropriately treat many of the patients that dial 999 for an ambulance. Until now urgent and emergency care has been fragmented and disconnected, as patients often do not know where they should go when they have an urgent care need that is not life threatening. This has led to inconsistencies in the responses and treatment patients receive. These include preventing cross referral, the need to re-triage at each step using different clinical assessment tools, patients being referred to services that do not have the skills they require or patients simply not knowing where and how they can access urgent care—and as a result dialling 999.

17. Evidence suggests that primary care could play a potentially important role in reducing the number of A&E attendances, for example by changing working practices and improving access. The Primary Care Foundation’s report Primary Care and Emergency Departments (March 2010) found that, when it used a consistent definition and a consistent denominator of all emergency department cases, the proportion that could be classified as primary care cases (types that are regularly seen in general practice) was between 10% and 30%. A&E Departments in rural areas tend to have lower numbers of primary care cases (approx. 10%), whilst those in urban centres have more (approx. 30%). However, it is not clear whether this is related to differences in the way primary care functions in rural and urban areas, the distance that patients have to travel to an A&E Department (ie the ease of access) or, most probably, a combination of the two.

18. Alcohol, depression and dementia related events can be key causal factors in emergency presentations. For mental health, there is a well-established, robust international evidence base about safe, cost effective alternatives to hospital care, which, if commissioned well, would reduce burden on the health care system, and on the workload of partners such as the police and community agencies. These also reduce suicides, homicides and deaths in custody. They are: crisis home treatment teams; assertive outreach teams; and alcohol community detoxification services. The Royal College of Psychiatrists and Royal College of General Practitioners have recently publicised evidence-based guidance to support commissioners. The unplanned care pathway for mental health has consistently been identified as one of the top four priorities for commissioning review by the mental health strategic clinical networks.

19. There is no “one size fits all” approach to the delivery of emergency healthcare and different models of care will be appropriate depending on several population factors, including the relative rurality of an area.

20. The key benefit to the introduction of NHS 111 service is to improve patient and public experience of the urgent and emergency care system, by offering a free-to-call, easy-to-remember number to access urgent NHS services. We also hope NHS 111 will be able to reduce inappropriate demand on emergency services, by giving patients an alternative route into NHS services.

21. Research shows that many patients are unaware of their GP out of hours service, or even that pharmacies can offer support without appointments, and a call to NHS 111 will get patients to the right place, first time. Information on the use of these services, collected through NHS 111, will be a vital tool in the commissioning of urgent and emergency care services for physical and mental health in future.

Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings

22. It is no longer representative of what is happening simply to speak of moving lower acuity facilities out of A&E. We are seeing a move towards integrating some primary care services within A&E departments. The Primary Care Foundation outlined in its report Primary Care and Emergency Departments (2010) that:

“Among respondents to our survey it appears that around two‐thirds of [A&E] services have primary care staff operating within or alongside the emergency department. This is not representative, as respondents are a self‐selecting group including more of those that have tried or adopted such a model. We estimate that around half of the services across the country have some form of primary care service working with the emergency department.”

23. The report also concluded that that if the 10% to 30% of A&E cases were treated elsewhere, A&E attendances could be reduced. However, it is relatively cost effective to treat lower acuity patients in a 24 hour facility. Furthermore, there is evidence that the creation of lower acuity facilities, categorised as “Type 3” (Minor Injuries Units, Walk in Centres; Urgent Care Centres), does not reduce the burden on neighbouring A&E departments.

24. Figures show that, between 2004 and 2013, attendances at Type 1 facilities (major A&E departments) rose from over 13 million to over 14 million, whilst attendances at Type 3 facilities rose from under 4 million to under 7 million.

25. Whether less serious cases are dealt with in separate Type 3 facilities or within A&E departments (possibly by primary care staff based there), the need to ensure that there is an integrated system with clear points of access is fundamental to the objectives of the Urgent and Emergency Care Review. Promoting self-care and publicising “phone before you go” will help to direct patients to the right course of action.

The range, severity and incidence of conditions that can be treated within an accident and emergency unit but not managed at an urgent care centre

26. The role of A&E departments is changing with specialist networks now in place for serious conditions such as stroke, heart attack, vascular surgery and the designation of major trauma centres. This adds to services already regionalised such as children’s intensive care, neurosurgery, and cardiac surgery. Defining the role of an A&E Department by the cases it is expected to receive and the causal factors in presentations is becoming increasingly difficult and advances in medicine, surgery and diagnostics are projected to increase specialist networks.

27. The Department of Health has defined the various types of A&E facility.1 If a unit is to receive unfiltered 999 blue light ambulances it must be capable of the resuscitation, diagnosis and immediate treatment of all acute illnesses and injuries in all ages. This will range from major haemorrhage from a stomach ulcer to an overdose in a patient with depression to a finger burn in a child.

28. Urgent Care Centres will vary in the patients they are able to manage, and will only accept ambulance borne patients to agreed protocols. They will also have in place protocols for the transfer of patients requiring inpatient treatment. The services they offer may overlap with traditional primary care, but those with x-ray facilities can deal with a wider range of injuries.

29. There is already a variation, in terms of facilities and staff, between different A&Es and in the pre-hospital triage used by the ambulance services to convey patients to the hospital most capable of treating the illness or injury. This is current best practice and patients transported by ambulance will “bypass” the nearest A&E if they need to access a more specialist centre. This occurs whilst there remains a public perception that any A&E can deal with virtually any condition. The reality is that patients who self-present at A&E may occasionally require transfer to a facility better skilled and better equipped to meet their needs ie a specialist centre or mental health specialist service.

30. The Urgent and Emergency Care Review will address how to design services that provide the range of appropriate care across localities, but it is important that it does not try to impose a view on which conditions can be treated by different types of facility. Care should be as close to the patient’s home as their condition allows, but where specialist care is required patients should be able to access this in a timely way. The object is to secure a consensus on service models that will ensure that urgent and emergency care is clinically safe, appropriate and accessible, no matter where you live, and delivered according to a national framework. It must remain a matter for local commissioners and providers to design a system which meets the needs of the local population.

The prospects for better integration of ambulance services with primary care under the new commissioning regime established in April 2013

31. The commissioning architecture, established by the Health and Social Care Act 2012, provides a unique opportunity for clinically-led commissioning at the heart of service planning and delivering. CCGs are responsible for commissioning the majority of urgent care services for their local population. In considering the most appropriate approach that responds to the needs of the local population, CCGs will be mindful of the opportunity that integrated services can provide.

32. This is particularly true as CCGs are clinically-led membership organisations, made up of GPs, who have first-hand experience of how services work for patients, both the limitations and the opportunities. CCGs are able to take their day-to-day experience and needs of their patients from their consulting room to the clinical commissioning board table.

33. The development of health and wellbeing boards brings all commissioners together to focus on doing the very best for a particular population and the opportunity to take a more system wide approach to commissioning these services. For example CCGs working in collaboration with colleagues from social care and health providers are able to review services in the round as part of the commissioning cycle considering the opportunity of integration, including closer working between health and social care professionals, as a way in improving outcomes for patients. 

34. NHS England will not mandate to a health community the approach it should take to commissioning services, but the support, development and assurance processes for CCGs being put into place by NHS England, aim to enable CCGs to become the best commissioners they can be, securing optimal outcomes for the population they serve. Where CCGs, working with co-commissioners, agree alternative approaches will provide the best outcomes for their patients they are able to commission different patterns of care, which may include integrated care.

35. The development of NHS England’s 10 year strategy, incorporating primary care and drawing on the work of the Urgent Care Review, will also contribute to enabling CCGs and their fellow commissioners in NHS England, to commission the most appropriate care for a population, improving health outcomes and decreasing inequalities. 

The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge

36. There is some potential to further reduce the number of patients transported to hospital by ambulances and to provide more efficient and local care. The number of calls to the ambulance services which are managed through clinical telephone advice has increased significantly over the last five years. Almost 90% of these calls result in no vehicle being sent to the scene (where clinically safe and appropriate). Compared to 1999/2000 levels, there are now 10 fewer patient journeys per 100 ambulance incidents, which reflects the increased use of “see and treat” and other efforts to provide levels of care that meet the clinical needs of the patient.

37. The ambulance service today is characterised by a highly skilled and qualified workforce able to respond to physical healthcare needs, that puts quality and appropriate clinical intervention at the forefront of care. This includes the move to more treatment over the “phone, at the scene and in patients” homes to better deal with the demand placed upon them.

38. Many Ambulance Service NHS Trusts have or are in the process of reviewing and changing the way they respond to emergency calls by broadening both their skill and fleet mix by introducing different types of response vehicle—motorbikes, rapid response vehicles, fully equipped ambulances etc. and by staffing those assets appropriately.

39. Taking Healthcare to the Patient (2005) stated that many 999 patients are still taken to hospital when they could safely receive advice, assessment, diagnosis, treatment and/or care closer to home or over the ‘phone. It identified the need to provide significantly more clinical advice to callers (“hear and treat”) and provide and coordinate an increasing range of mobile healthcare for patients who need urgent care (“see and treat”). This new model of care optimally addresses those in physical health crisis, but has had some consequences for those in mental health crisis. In parts of the country, police services and transport services staff are transporting up to 40% of all those presenting in mental health crises.

40. Two models of “see and treat” have emerged. Firstly, there are some Trusts with much larger numbers of Advanced Practitioners who require very little clinical field support and act as autonomous practitioners. Secondly, there is a mixed model where, particularly in urban areas (which often do not have good primary care services but greater numbers of acute trusts) existing Paramedics are used to undertake “see and treat” work and are supported by a network of clinical field supervisors.

41. Both models can work and a further assessment of their relative benefits will be needed. However there is still considerable variation in conveyance rates between ambulance services, and more could be done to develop and support ambulance clinicians.

42. In April 2012, the Department of Health published a currency for the contracting of emergency and urgent ambulance services, in order to allow locally appropriate ambulance care which may not involve conveyance, where such care is appropriate. The four categories are:

Urgent and Emergency Calls Answered.

Hear and Treat/Refer.

See and Treat/Refer.

See, Treat and Convey.

43. This currency was mandated for the 2011–12 reference cost collection and mandated for contracting in 2012–13. Prices will continue to be agreed locally for 2013–14. The four categories were developed and agreed with ambulance trusts and commissioners as the basis for payment.

44. The Urgent and Emergency Care Review will promote the commissioning of services which are better integrated and provide the right care in the right place at the right time. The King’s Fund recently published Urgent and Emergency Care—A review for NHS South of England, which identified a number of areas where change would lead to performance improvement. The NHS Trust Development Authority will incorporate the learning into its work with NHS Trusts to improve their emergency care performance.

Experience to date of the transition from NHS Direct to the NHS 111 service

45. In August 2011, the Department of Health and then NHS Commissioning Board, wrote to all SHA Chief Executives, asking them to confirm plans for the rollout of NHS 111 by April 2013. Responses were received in September 2011, showing that a vast majority of the country would be undertaking procurement exercises to determine the most suitable provider for NHS 111 locally. The plans also showed that contracts would vary between single-PCT/CCG geographic footprints, and larger region-wide footprints, and that a vast majority of sites would go live in February and March 2013.

46. The Department of Health developed a Service Readiness Testing process that each site had to pass prior to launch, including testing call handlers on a range of scenarios, testing the robustness of the clinical governance arrangements in each site, and testing the technical and interoperability processes between call centres, and other “end-points” (ie ambulance services, out of hours services etc.).

47. The Department also offered areas that needed it an extension of up to six months to the roll-out deadline of April this year. However, many areas did not take this offer up as their services were able to continue with their existing plans. Sites that launched prior to March 2013 performed well, mostly meeting the National Quality Requirements (NQRs) for calls answered in under 60 seconds (over 95%) and calls abandoned in over 30 seconds (under 5%). However many of the sites that launched in February and March 2013 have failed to perform as expected, with long delays for calls to be answered, and a high rate of abandoned calls. These problems were exacerbated by the long Easter weekend.

48. By 2 April 2013, 39 of the 46 separate NHS 111 sites had been launched—this accounts for around 89% of the population of England. The remainder had been delayed either due to planned late procurement processes, or inability of providers to mobilise in time. In most areas, NHS 111 has taken on calls from GP out of hours, and NHS Direct, in order to simplify routes into urgent care at all times of the day or night. A number of areas—particularly North West, West Midlands and Yorkshire & Humber, have had to switch GP out of hours numbers back on, in order to ensure the service providers could cope with the volume of calls. This has been caused principally by providers failing to deliver on staffing requirements for launch.

49. NHS 111 performance has now stabilized across the country, with all sites running well on weekdays. However several areas, including Kent, Surrey & Sussex, much of the south West of England, Norfolk, and Yorkshire and Humber are still struggling to perform at weekends, primarily because of short-staffing.

50. NHS England took a significant grip on the programme as soon as significant performance concerns were reported. This was just before the Easter weekend. Dame Barbara Hakin led daily SitRep calls with Regional Directors and colleagues from NHS England to monitor and mitigate performance issues. The actions taken quickly regained stability in the service and put in place further actions to improve performance.

51. Regional Directors and Area Teams of NHS England have been made fully aware of their roles in ensuring the service meets the highest possible standards at all times, and are supporting commissioners and holding providers to account to resolve issues.

52. A new comprehensive checkpoint system for sites yet to go fully live has been implemented, to ensure there is senior NHS England sign-off and confidence in each individual site before it proceeds to launch. NHS England has received updated plans from each of the 46 NHS 111 areas describing how the service will grow to full capacity in the coming months. Regional Directors and commissioners are working to ensure these plans are suitably robust.

53. NHS England is developing three workstreams to a) stabilise performance and ensure all future 111 launches are suitable and sustainable, b) review what has happened and what lessons can be learned from this experience, and c) look to the future—to ensure there are suitable processes and mechanisms for NHS 111 going forward, and to look at the future strategic direction of NHS 111.

54. It is too early to say what, if any, impact NHS 111 will have on A&E. The initial four NHS 111 pilot sites in County Durham & Darlington, Lincolnshire, Nottingham City, and Luton, were the subject of a formal independent evaluation by the University of Sheffield. This evaluation looked at the impact of introducing NHS 111 on the local urgent and emergency care system. However the small scale of the pilots, along with inconsistent control sites, and the short time frame that the evaluation was looking at, meant the conclusions were limited.

55. The evaluation found that, while there was a statistically significant change in calls to NHS Direct in pilot sites with reductions in three out of four sites, there was not a demonstrable impact on the rest of the urgent and emergency care system. While there were some instances of statistically significant changes in certain criteria in individual sites, these were sometimes in conflict with each other in different areas, and certainly not uniform across all four sites. The evaluation did find there had been a statistically significant:

reduction in urgent care attendances in one site (Luton).reduction in calls to NHS Direct in three of the four pilot sites associated with the introduction of NHS 111 (Durham & Darlington, Nottingham and Luton);

reduction in emergency calls in one site (Durham & Darlington) and increase in one site (Lincolnshire); and

increase in ambulance incidents in one site (Lincolnshire).

56. It is clear that the impact on the current urgent and emergency care system of NHS 111 will be different in different areas, and depends on a variety of factors, including how the Directory of Service has been populated, integration between NHS 111 and urgent care services (whether appointments can be booked for instance), changing demographic needs, and changes in patients’ expectations of what services should deliver.

57. The Minimum Dataset, published monthly by the Department of Health until April 2013, and now NHS England, also provides some information on system impact, presenting rises in A&E activity in NHS 111 sites in line with the national average (2%), and increases in ambulances arriving at scene above the national average (7% compared to 3%). A clinical panel advising the Evaluation reported a high level of agreement that the right dispositions had been reached by NHS 111 call handlers. This is corroborated by data that shows that around 75% of ambulances dispatched through NHS 111 result in transporting patients into hospital, demonstrating that it was appropriate for ambulances to be dispatched for these patients.

58. NHS England will continue to monitor the impact of NHS 111 on the urgent and emergency care system, and support commissioners in using NHS 111.

The implications of the shift away from determining the success of ambulance services via indicators based on response time to the new measures designed to assess clinical effectiveness

59. Clinical quality indicators aim to create a balance between quality and safety of care, service experience and timeliness. Professionals have told the Department that having time targets has in some cases distorted clinical practice. Quality indicators will help achieve a more balanced and meaningful view of performance for patients and professionals in regards to quality and safety as well as time measures.

60. In April 2011, a set of Ambulance Clinical Quality Indicators (CQIs) was introduced, which all ambulance services in England have been measuring and reporting against (See Annex A). These were developed to provide focus on the outcomes and quality of care delivered for all ambulance calls in response to concerns that a focus on response times alone had distorted clinical practice. This is particularly important for certain key interventions where time is a major determinant of outcome and requires rapid response by ambulance clinicians to the most serious cases. The Ambulance CQIs are thus intended to:

Encourage a continuous improvement approach in clinical outcomes and patient experience as no arbitrary targets are set.

Provide information that is easier to understand for patients.

Be used by commissioners and providers as a full set such that improvement action is focused against all CQIs rather than response times alone.

61. The measures compliment other measures of quality such as the NHS Outcomes Framework and National Institute for Health and Clinical Excellence (NICE) Quality Standards and reflect a whole system focus so that all members of the health economy have a role in the improvement of the patient pathway from prevention to definitive treatment and aftercare.

62. All ambulance trust are required to respond to 75% of Category A8 (immediately life threatening) calls within eight minutes irrespective of location. From June 2012, the Category A8 measure was split into two parts, Red 1 and Red 2. Category A8 Red 1 (immediate time critical calls) cover cardiac arrest patients who are not breathing and do not have a pulse, and other severe conditions. Category A8 Red 2 (serious but less immediately time critical calls) cover conditions such as stroke and fits. The splitting of Category A8 calls enabled the prioritisation of the most critical cases, and effective use of resources, reducing inappropriate and multiple dispatch of vehicles.

The causes of delays in handover from ambulances services to A&E or transfer between different levels of urgent care, and actions required to eliminate them

63. The situation regarding delays is a complex one, and often reflects the pressure that is being placed on the whole system, including patient flow within hospital and delays in discharge to the community. Any solutions require a whole system response, with all stakeholders committed to resolving the complex issues. The matter has recently been discussed by Monitor, CQC and NHS England using their “Duty of Co-operation” whilst local and regional summits were held in most ambulance trust areas. CCGs have a key role to play in co-ordinating discussions in the local health economy to find locally appropriate solutions, given that the causes of these delays can be different in different health systems.

64. Any delay in handing patients over from ambulances to A&E or in transferring patients between facilities is a cause for concern. Patients queuing to access space in A&E or awaiting transfers are subject to delays to care, however there is also a significant risk in those patients awaiting a 999 response in the community which cannot be sent due to ambulances being held up elsewhere. The issue also causes severe resource implications for ambulance trusts, which are then compromised in their ability to respond to 999 calls due to ambulances being delayed at A&E units.

65. The following key performance measures have also been developed within the NHS Standard contract 2013/14, to address inefficiencies in ambulance response times due to delays in the handover of patients from ambulance crews to A&E staff:

all handovers between an ambulance and A&E Department to take place within 15 minutes and crews should be ready to accept new calls within a further 15 minutes; with

a contractual fine for all delays over 30 minutes, in both situations, and a further fine for delays over an hour, in both situations.

66. These are counterbalanced by the simultaneous monitoring of hospital trusts in their ability of the hospital to perform timely patient handovers for patients arriving by ambulance (time to initial assessment) as part of the clinical quality indicators for A&E departments.

Clinical evidence about outcomes achieved by specialist regional centres, taking account of associated travel times, compared with more generalist hospital based services

67. Centralisation of services has proven beneficial for patient outcomes from some serious conditions and injuries.

68. The King’s Fund (2011) Reconfiguring hospital services document states that there are good evidence-based reasons why, in some services, larger units serving a wider catchment area produce better patient outcomes and are more cost-effective. It discusses the good reasons why consolidation of those services onto fewer hospital sites can be expected to drive up quality and drive down costs. The King’s Fund cites examples including A&E, maternity and neonatal services, hyper-acute stroke units and heart attack centres.

69. Evidence shows that if a patient enters a facility that is unable to provide the optimum care for their need, the time taken to obtain definitive diagnosis and treatment is significantly increased. This is because it takes time to recognise the severity of illness, confirm a diagnosis, arrange ambulance transportation and for the onward transfer. There are then a series of handovers and reassessments, all of which can delay the key interventions that will make a difference to outcome. A recent audit in Manchester identified transfer times of between 5 and 6 hours for patients needing urgent neurosurgery, but assessed in the wrong hospital initially.2

70. Delays of even an hour have a significant impact on the outcome for patients with time-critical conditions. A delay of 60 minutes in treating STEMI: (a common form of heart attack) means that between 1 and 2 people in every 100 who would otherwise have lived will die instead.3 Similar benefits are seen in stroke, with the odds of a favourable outcome halving if the initiation of treatment is delayed from 60 to 120 minutes.4 Furthermore, stroke patients become ineligible for the newest “clot-busting” treatments if they do not see a specialist and undergo CT scanning within 3–4 hours of symptom onset. Finally, in severe sepsis (infection) the importance of timely treatment is striking: for every one hour delay in starting antibiotics the chances of the patient dying are increased by 7.6%.

71. Trauma Services: There are approximately 20,000 major trauma cases in England every year. In 2012 a system of trauma care networks, including the development of 26 Major Trauma Centres at existing hospitals (including four children’s hospitals) was established across England. Major Trauma Centres have specialist medical teams which provide treatment for major trauma injuries 24 hours a day seven days a week and access to all necessary services on site for the optimal management of patients with severe multiple injuries; including neurosurgery and neuro intensive care , cardiothoracic, plastic and trauma surgery and trauma rehabilitation services. The National Audit Office estimated that this system of trauma care could save between 450 and 600 lives per year across England, and patients have a better chance of recovery from their injuries reducing the risk of serious disability; London, which set up its major trauma system in 2010, has already recorded fewer deaths.

72. Stroke Services: The radical restructuring of services in London has had a significant improvement on clinical outcomes while reducing costs. London hospitals had a model of provision of stroke care where all hospitals provided acute stroke care, however only a few hospitals were delivering high quality specialist care with access to the clot busting treatment (thrombolysis) 24 hours a day. The majority provided variable, often poor, acute stroke care. Service reconfiguration was implemented in 2010 reducing the number of hospitals providing immediate stroke care from around 31 to eight, maintaining access to hyper acute stroke services within 30 minutes for everyone in London. After implementation the proportion of patients taken directly to a hospital providing hyper acute stroke care increased from 39% to 69%, with a mean travel time from home to a hyper acute unit of 17 minutes.

73. London stroke survival is now higher than the rest of England; at 90 days after stroke there are 100 fewer deaths each year for an incidence of 6,400 strokes. There has been a reduction in average length of stay from 17 to 11 days between 2006 and 2012 with 40% of patients being discharged directly home from hyper acute care at three days. The London stroke model represents good value for money when costs and benefits beyond 30 days are accounted for, reducing net costs by £33.5m per year.

74. Cardiac services: Patients with a heart attack should be taken to a specialist centre, and undergo immediate coronary angiography from a specialist cardiac team; appropriate intervention should be completed within 4 hours from first contact.

75. Important differences in services between specialist centres and district general hospitals (DGHs) have been demonstrated. In London in 2008, the mortality rate from heart attack was 5% in specialist centres and 12% in DGHs. Length of hospital stay was ten days in a DGH, but only four in a specialist centre.5

76. Best practice models of care provide clear evidence of a direct causal link between adoption of best practice and markedly improved patient outcomes. If best practice is adopted, fewer patients die, more patients make a quicker, fuller recovery, and the patient experience is improved.

Aspects of care which are likely to improve by being located in regional specialist units and the risks associated with removing services from existing A&E provision

77. There is clear evidence of the benefit of centralising services and treatment for a number of defined urgent conditions:

major trauma;

brain injury;

chest injury;

heart and lung injury; and

major abdominal, pelvic, spine and limb injuries.

Stroke;

heart attack;

major vascular (blood vessel) rupture or blockage;

severe neurological disorders; and

severely ill children.

78. As outlined in the previous section, the regionalisation of services has led to improved clinical outcomes and reduced costs. The smaller number of hospitals in London providing specialised stroke care, for example, has resulted in a much better survival rate for stroke in London compared to the rest of the country.

79. The urgent conditions listed above constitute a small percentage of the current case mix of a general A&E department. However, by doing the right thing for the outcomes of these patients ie by networking and centralising services, the resulting reduced number of challenging critically ill patients in some units is likely to be less of a draw to retaining and recruiting the required number of staff.

80. According to the King’s Fund, achieving the best patient outcomes and patient experience, and narrowing the quality gap between the best and worst performers, is best achieved by designing reconfiguration to drive accelerated adoption of best practice models of care in as many services as possible. This in turn is best achieved by designing reconfiguration along patient pathways involving specialist/tertiary hospitals, district general hospitals (DGHs) and primary care providers. It requires a significant change in the way emergency and network services are currently provided. Recent successes by PCTs in reconfiguring stroke and trauma services highlight the potential of strong commissioning to bring about markedly improved patient outcomes.

81. It is possible that smaller A&E departments would become less clinically sustainable. Hospital trusts have important interdependencies of services for critical care, radiology, pathology and acute bed numbers. Removing certain groups of patients can therefore reduce the need for these interdependent services. Given the current shortage of medical staff in acute and emergency care, recruitment and retention may also become difficult for smaller units, as staff move towards the larger centres where better care can be delivered. Therefore, any decision to centralise services needs to take into account issues of equality and health inequalities, so that no individuals or groups are disproportionately disadvantaged by the relocation of service and that the benefits of any service change are experienced by whole populations.

82. Delineating and agreeing the optimal model of care for those who present with mental health or behavioural health (substance misuse) unplanned care events, either as the underlying cause of the presentation or the key presenting factors, will also have an important impact on the volume of work in A&E and unplanned care centres.

83. The emergence of networks (hub and spoke) with larger A&E departments working with local urgent care centres is one of the emerging solutions.

The effectiveness of the existing consultation process for incorporating the views of local communities in to A&E service design

84. Through the Health and Social Care Act 2012, the Department has introduce new and stronger requirements on local commissioning organisations to make arrangements to involve users of services in the planning, development and decisions that would have an impact on the manner or range of health services available to those users.

85. Where commissioners are considering a change to services, it is good practice that they involve service users early in the design of proposals, so that these can be shaped by patient insight and feedback. Where commissioners want to seek views on a specific set of configuration proposals, it may be sensible to hold a formal publication consultation in order to gather public opinion on different options. However, it is important that any involvement activity is tailored and proportionate to the nature of the issue under consideration, and that involvement is an on-going activity throughout the lifecycle of a service redesign programme or reconfiguration and that commissioners use a spectrum of involvement activity, rather than only defaulting to formal public consultation exercises.

86. The Department’s policy is that any changes to services must be clinically-led, have a clear clinical evidence base and deliver an improvement in the quality and sustainability of services received by patients and the public. When developing proposals, commissioners should assure themselves, and the communities they represent, that there is strong clinical evidence supporting any change. This would include, for example, being able to demonstrate that safety and clinical outcomes will be improved by relocating services. Commissioners will want to consider a range of evidence and advice including that available from NHS England’s clinical directorates, clinical senates and networks, NICE and Royal Colleges. In reviewing the evidence and the case for change, commissioners will need to consider how high quality and sustainable services are secured in a way that aligns with the principles and values of the NHS Constitution.

87. Reconfiguration is about modernising the delivery of care and facilities to improve patient outcomes, develop services closer to home and most importantly—save lives. The Government’s reforms have put local doctors and other healthcare professionals at the heart of the NHS, making sure that patients receive the very best and safest care. If clinical evidence supports a change in services, it is right that healthcare professionals are empowered to look at how care and treatment can be improved. Any proposed changes to hospital services must involve patients from the start and demonstrate a clear improvement to services and be subject to a transparent and rigorous public consultation exercise.

88. These principles are further enshrined in the Government’s four tests for reconfiguration, which are that local reconfiguration plans must demonstrate:

(a)support from clinical commissioners;

(b)strengthened public and patient engagement;

(c)clarity on the clinical evidence base; and

(d)support for patient choice.

89. There are times when difficult decisions have to be taken. But the Government has been very clear that any such decisions must have a clear clinical evidence base and patients and the public must be involved in that process, regardless of whether a local case for change concerns A&E or any other clinical service.

The ability of local authorities to challenge local proposals for reconfiguration under the revised oversight and scrutiny powers included in the Health and Social Care Act 2012

90. Local authority health scrutiny is a mechanism for ensuring the health service is genuinely accountable to patients and the public, and it helps to bring local democratic legitimacy into the process of service changes. The details of the system of health scrutiny are set out in the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 (“the 2013 Regulations”).

91. Under the 2013 Regulations, local authorities can review and scrutinise any matter relating to the planning, provision and operation of the health service in their area. This includes NHS and public health services commissioned by NHS England, clinical commissioning groups and local authorities, including those provided by NHS bodies as well as by providers from the private and voluntary sectors (such a body or provider being referred to in the 2013 Regulations as a “responsible person”).

92. Substantial service change might be proposed by a number of players in the new system such as a commissioner or provider of NHS-funded health services. Generally, such “responsible persons” are required in the 2013 Regulations to consult with the local authority on proposals for a substantial development of the health service or for a substantial variation in the provision of such service. The local authority might also offer advice on how the responsible person could shape any subsequent public engagement.

93. It is a requirement in the 2013 Regulations that the responsible person, when consulting the local authority, provides the authority with, and publishes, dates against which the responsible person will decide whether to proceed with the proposal and the date by which they require the local authority to provide any comments on the proposal.

94. NHS England’s position is that effective early and on-going dialogue between NHS commissioners and local authority health scrutiny functions is an important element of good partnership working, and builds on the wider constructive relationships developing between the NHS and local government through health and wellbeing boards. Early engagement of health scrutiny can help to build local consensus on a case for change, and in refining any wider public engagement plans. It is equally important that both the NHS and local authorities are able to provide and review collectively the evidence for change.

95. In the same vein, the Department and NHS England expects commissioners to be able to present strong evidence, it is its view that local authorities have a responsibility to provide robust evidence in case of disputes. Where disagreements occur, it is preferable these are resolved locally without recourse to referral to the Secretary of State—as referral in many ways represents a break down in effective local partnership working. However, the right of referral remains an important part of the wider democratic and accountability framework under which the NHS and local government operates.

May 2013

Annex A

CLINICAL QUALITY INDICATORS, AMBULANCE WAITING TIME COMMITMENTS

The Ambulance Clinical Quality Indicators listed below together with the response times measures form the basis of how Ambulance Trusts are monitored in their performance by commissioners.

1. Outcome from acute ST-elevation myocardial infarction (STEMI)

STEMI is an acronym meaning “ST segment elevation myocardial infarction”, which is a type of heart attack.

2. Outcome from cardiac arrest—return of spontaneous circulation

This indicator will measure how many patients who are in cardiac arrest but following resuscitation have a pulse/heartbeat on arrival at hospital.

3. Outcome from cardiac arrest—survival to discharge

Following on from the second indicator, this one will measure the rate of those who recover from cardiac arrest and are subsequently discharged from hospital.

4. Outcome following stroke for ambulance patients

This indicator will require ambulance services to measure the time it takes from the 999 call to the time it takes those F.A.S.T-positive stroke patients to arrive at a specialist stroke centre so that they can be rapidly assessed for treatment called thrombolysis.

5. Proportion of calls closed with telephone advice or managed without transport to A&E (where clinically appropriate)

This indicator should reflect how the whole urgent care system is working, rather than simply the ambulance service or A&E, as it will reflect the availability of alternative urgent care destinations (for example, walk-in centres) and providing treatment to patients in their home.

6. Re-contact rate following discharge of care (ie closure with telephone advice or following treatment at the scene)

If patients have to go back and call 999 a second time, it is usually because they are anxious about receiving an ambulance response or have not got better as expected. Occasionally it may be due to an unexpected or a new problem. To ensure that ambulance trusts are providing safe and effective care the first time, every time, this indicator will measure how many callers or patients call us back within 24 hours of the initial call being made.

7. Call abandonment rate

This indicator will ensure that we and other ambulance services are not having problems with people phoning 999 and not being able to get through.

8. Time to answer calls

It equally important that if people/patients dial 999 that they get call answered quickly. This indicator will therefore measure how quickly all 999 calls that we receive get answered.

9. Service experience

All ambulance services will need to demonstrate how they find out what people think of the service they offer (including the results of focus groups and interviews) and how we are acting on that information to continuously improve patient care.

10. Category A 8 minute response time

This indicator measures the speed of all ambulance responses to the scene of potentially life-threatening incidents and measures that those patients who are most in need of an emergency ambulance gets one quickly.

11. Time to treatment by an ambulance-dispatched health professional

It is important that if patients need an emergency ambulance response, that the wait from when the 999 call is made to when an ambulance-trained healthcare professional arrives is as short as possible, because urgent treatment may be needed.

Mandate, NHS Constitution and ambulance waiting times

1. The Mandate and NHS Constitution rights and pledges both set out an expectation on waiting times for patients. These include specified standards in ambulance call response times that all ambulance trusts must meet. Commissioners are supported to manage the delivery of these standards through the NHS standard contract, NHS England’s planning guidance for commissioners Everyone counts: planning for patients 2013/14. It is one of the factors that is considered when determining Quality Premium payments for clinical commissioning. Ambulance trusts are also additionally held to account by the NHS Trust Development Authority and Monitor through governance and risk assessment frameworks where response time standards are part of the suite of quality indicators.

2. On the basis that faster response times improve health outcomes and experience for patients with immediately life-threatening conditions, all Ambulance Trusts are required to respond to:

75% of Category A8 (immediately life threatening) calls within eight minutes, irrespective of location. This is divided into subcategories- Category A8 Red 1, Category A8 Red 2, defined below.

95% of Category A calls within 19 minutes of a request being made for a fully equipped ambulance vehicle (car or ambulance) able to transport the patient in a clinically safe manner

3. From June 2012, the Category A8 measure was split into two parts, Red 1 and Red 2. Category A8 Red 1 (immediate time critical calls) cover cardiac arrest patients who are not breathing and do not have a pulse, and other severe conditions. Category A8 Red 2 (serious but less immediately time critical calls) cover conditions such as stroke and fits.