Health CommitteeSupplementary written evidence from the Department of Health (ES 01A)
I presented oral evidence on the 25 June at the Health Select Committee’s inquiry into emergency services and emergency care, alongside from NHS England, Dame Barbara Hakin, Professor Keith Willett and Professor Sir Bruce Keogh.
During my oral evidence session, I promised to write to you on a number of areas and Committee members requested further clarification on some issues.
I have set out as far as possible to answer the Committee’s points of clarification and to provide further detail on where I agreed to write to the Committee in Annex A. At Annex B I have included a series of tables and charts to provide further detail to the information provided in Annex A.
I hope this reply is helpful.
Earl Howe
5 July 2013
Annex A
URGENT CARE BOARDS
1. During the initial stages of the evidence session, questions were focused on short term measures to drive improvements in A&E, and the development of urgent care boards. In May 2013 NHS England, the National Trust Development Authority and Monitor published plans to strengthen performance in urgent and emergency care, which led to the establishment of urgent care boards in many areas. Further information on this work is accessible from the NHS England website at: www.england.nhs.uk/2013/05/09/sup-plan/.
Bed Numbers, Occupancy Rates and Other Factors and Their Effect on A&E
2. Members of the Committee asked me to write to them with facts and figures on factors such as bed numbers, occupancy rates and their impact on the pressures in A&E departments.
Bed numbers
3. The average number of daily available beds has been reducing since 1987. However, while bed numbers have fallen, the bed occupancy rate (for all beds open overnight) has remained relatively stable, rising in the winter months, as we would expect, but remaining between 84 and 88% since 2000. (See Table 1 in Annex B).
4. NHS hospitals need to manage beds effectively in order to cope with peaks in demand. There are higher occupancy rates in winter, when demands are at their greatest. Bed availability fluctuates, but the NHS has practice and experience in managing capacity to cope with both routine and emergency care.
Length of stay
5. The Committee asked for clarification on how increasing reports of older, sicker patients staying longer in hospital could be reconciled with overall reported shorter stays in hospital. There may be local evidence to suggest that some people, after being admitted to hospital following presentation at A&E, are staying longer than average. Where this phenomenon occurs it is largely due to demographic changes, such as the increase in the population of frail and elderly people and the fact that many patients’ needs are now more complex; it may be also be a result of delayed discharge because of issues accessing community services. Nevertheless, the national average length of stay in hospital following an emergency admission has decreased.
6. We do know that many patients admitted are now assessed and treated much quicker than in the past. The latest data shows that, for 50% of emergency admissions, patients are being discharged from hospital the following day or earlier. For those emergency admissions not discharged the same day, the mean length of stay has steadily decreased over the past 5 years. The number of patients treated as day cases has been rising steadily since 2003/04, and now stands at just under 80% of all inpatient activity.
Cancelled operations
7. The statistics for 2012/13 show that the number of cancelled elective operations is broadly low and stable at 0.9% of all elective activity (the same as 2009/10). There were 19,968 cancelled operations in Quarter 4 2012/13, 1.1% of elective activity. The increase in this period is due to seasonality but at just above one%, cancellations remain very low compared to the total number of elective operations carried out. Hospitals should do everything they can to keep last minute cancellations of operations to an absolute minimum.
8. The number of cancelled urgent operations remains very low in the context of the millions of operations performed in the NHS each year. In April 2013, 401 urgent operations were cancelled and 7 urgent operations were cancelled for the second or subsequent time.
9. The Handbook to the NHS Constitution includes a pledge that all patients who have operations cancelled, on or after the day of admission, for non-clinical reasons should be offered another binding date for their operation within 28 days, or their treatment should be finished at the time and hospital of the patient’s choice.
Impact on A&E
10. Overall, we are looking at the relationship between A&E pressures and elective care. Preliminary analysis of historical data suggests that there are no obvious correlations between A&E waits and performance against the referral to treatment waiting time standard for admitted patients.
Delayed Transfers of Care
11. I will now to turning to questions raised by Committee members about delayed transfers of care. In terms of a definition, a delayed transfer of care from acute or non-acute (including community and mental health) NHS care occurs when a patient is ready to depart from such care and is still occupying a bed. A patient is ready for transfer when:
(a)
(b)
(c)
12. While the figures I quoted to the Committee in terms of total bed days due to delayed discharge and occupied beds delayed (3% and 2% respectively) may be small in the context of a system as large as the NHS, this still translates as 2,000 people every day who are in a hospital care when they would be better receiving care elsewhere and 2,000 beds that could be occupied by someone who is waiting for hospital treatment.
13. The latest available data on delayed transfers of care was published on 28 June 2013. The published data includes a snapshot of the number of patients delayed at midnight on the last Thursday of the month, and the total number of delayed days for all patients during the month.
14. The data shows that, at the end of May 2013, there were 4,200 patients delayed, of which 2,592 were acute patients. There were 120,233 total delayed days during the month, of which 74,324 were in acute care. Sixty-seven% of all delays were attributable to the NHS, 27% were attributable to social care and the remaining six% were attributable jointly to the NHS and social care.
15. The main reason for NHS delays was “patients awaiting further non-acute NHS care”, this accounted for 32% of all NHS delays. The main reason for social care delays was “patients awaiting a residential home placement or availability”, this accounted for 28% of all social care delays. Where both the NHS and social care are attributable, the major reason for delay was “patients awaiting completion of assessment”.
16. The distribution of delays has been changing gradually over the past 12 months. Delays attributable to the NHS now account for 67% of all delays compared to 64% in May 2012, with a similar fall in the proportion of delays attributable to social care.
17. Last week we announced, in the Spending Review, that we have set aside a £3.8bn pooled budget for better integration between health and social care services, with strict conditions that ensure the money is spent where it is needed the most. Better integrated care should improve the transition between health and social care and over time reduce the level of delay transfers of care.
Workforce
18. Turning to questions raised about the emergency medicine workforce, I hope it is helpful if I clarify that Health Education England (HEE) is a new arm’s length body responsible for the education, training and personal development of NHS staff. It has a £5billion budget and its remit includes addressing workforce shortages in the short and long term.
19. In September 2011, the Department along with the College of Emergency Medicine established the Emergency Medicine Taskforce to address workforce issues in emergency medicine. HEE has set up the Emergency Medicine Workforce Implementation Group to develop the recommendations made by the Taskforce. The group is planning to set up a number of pilots relating to education and training of emergency department staff.
20. On the issue of attrition rates, the notion of ‘attrition’ is not clear cut in emergency medicine (or in other medical specialties). HEE is currently developing, with its Local Education and Training Boards, a methodology for assessing attrition from medical training. Results will be available later in the year.
21. On the Working Time Directive (WTD), classifying all resident time as working time can mean that immediate compensatory rest is required. However, this aspect arguably has less impact on emergency medicine than on any other specialty, because emergency medicine is the specialty most suited to round-the-clock shift working and handovers are more straightforward and less likely to overrun.
22. The other key aspect is the 48 hour cap on average hours and the impact of the cap on hours (to 56 hours) of the junior doctor’s contract. This has commonly meant that since each doctor’s hours are reduced, more doctors are needed. It also reduces the time available for training and can mean dilution of training opportunities, although the Temple report suggests this should be manageable within the 48 hour limit and other studies agree with this.
23. However, training has not appeared to be a particular issue for emergency medicine, because A&E departments have less down time and the opportunity to make better use of the out of hours period than most other specialties. However, where a specialty has staffing difficulties, they will obviously have more problems with the need for additional doctors.
24. Overall, we would not regard the shortage of emergency doctors as an WTD problem. However, the impact of the WTD restrictions is heightened by the shortage of EM doctors.
NHS 111
25. Committee members also raised questions about NHS 111. I hope it is helpful if I set out for the Committee the history of the introduction and implementation of the NHS 111 service. On the issue of senior official responsibility for NHS 111 services, prior to November 2012, Mark Britnell and Jim Easton held responsibility respectively for NHS 111 services. Ian Dalton took the lead in NHS England in November 2012 and Barbara Hakin took on the lead at the end of March 2013.
26. The Department of Health started work in 2008 on scoping the introduction of a single number to access NHS urgent healthcare services. This included carrying out research with the public that found there was overwhelming support for such a service in particular with a ‘999 style’ memorable number. Research was also conducted to identify which of the available three-digit numbers the public preferred, 111 was by far the most popular.
27. Following this work, the Department asked Ofcom to designate a three-digit number for this purpose. Ofcom launched a public consultation in July 2009 and, following a positive response, announced the designation of 111 as the three-digit number for NHS urgent healthcare services on 18th December 2009.
28. The Coalition Government stated its commitment to a national roll-out of the new NHS 111 service as part of an integrated 24/7 urgent care service in The Coalition: our programme for government and the White Paper Equity and excellence: Liberating the NHS, both in 2010.
29. The Department of Health worked with the Strategic Health Authorities in England to develop the NHS 111 service. Four pilot areas were chosen to initially launch the service in 2010 and to be independently evaluated by the University of Sheffield. Each of these NHS 111 pilot areas developed different operational models for the service, to provide the broadest evidence base possible for the construction of the national service.
30. The Secretary of State for Health, Andrew Lansley, officially launched the first of these NHS 111 pilots on 23 August, in County Durham and Darlington. The service was subsequently launched in Nottingham City, Lincolnshire in November and in Luton in December 2010.
31. In August 2011 the Department of Health and NHS England wrote to all Strategic Health Authority Chief Executives asking them to submit their firm plans to complete the roll-out of the NHS 111 service by April 2013. Responses were received by the Department from each of the SHAs in September 2011.
32. On 1 October 2011 the Prime Minister and the Secretary of State for Health, Andrew Lansley announced that the NHS 111 service would be rolled-out across England. In summer 2012 the Department and NHS England jointly wrote to the NHS offering an extension of up to six months where it was deemed necessary. This offer was only taken up by four areas.
33. The University of Sheffield carried out the evaluation of the pilots, the final report of which was published in August 2012, this can be found at:
34. www.sheffield.ac.uk/polopoly_fs/1.227404!/file/NHS_111_final_report_August_2012.pdf
35. The final report of the University of Sheffield’s independent evaluation of the first year of live operation of NHS 111 in the four original pilot areas was published on the 25th October 2012. The report found that overall the new service achieved its goal of getting patients to the ‘right place, first time’ and had high satisfaction levels among users. The detailed findings of the report show that 93% of callers questioned felt that the advice given was helpful and 86% said they followed the advice they were given. In addition, 86% said that they were ‘definitely clear’ about when to use 111 and 86% said they would use 111 again for a similar problem. The evaluation report also indicated that the introduction of NHS 111 had yet to have an impact on the demand on urgent care services although in one of the pilots there had been an increase in ambulance incidents.
Paramedics
36. Finally, on the issue of paramedics, in 2012, of the 32,076 ambulance staff in 2012, 11,954 were paramedics. Please see table 8 and 9 for current and comparative data on ambulance workforce numbers and for information on paramedics in training.
Annex B
Table 1
AVERAGE AVAILABLE AND OCCUPIED NHS OVERNIGHT BEDS 1997–98 ONWARDS ENGLAND
Source: NHS England KH03
|
Period |
Total Available Beds |
Total Occupied Beds |
Occupancy Rate |
|
1997–98 |
193625 |
156549 |
80.9% |
|
1998–99 |
190006 |
156669 |
82.5% |
|
1999–00 |
186290 |
154137 |
82.7% |
|
2000–01 |
186091 |
156290 |
84.0% |
|
2001–02 |
184871 |
157330 |
85.1% |
|
2002–03 |
183826 |
156933 |
85.4% |
|
2003–04 |
184019 |
157862 |
85.8% |
|
2004–05 |
180966 |
154215 |
85.2% |
|
2005–06 |
175436 |
148465 |
84.6% |
|
2006–07 |
167019 |
141133 |
84.5% |
|
2007–08 |
160891 |
135799 |
84.4% |
|
2008–09 |
160254 |
136860 |
85.4% |
|
2009–10 |
158461 |
135009 |
85.2% |
|
2010–11 Q1 |
144455 |
122551 |
84.8% |
|
2010–11 Q2 |
141477 |
119298 |
84.3% |
|
2010–11 Q3 |
141630 |
121497 |
85.8% |
|
2010–11 Q4 |
142319 |
123279 |
86.6% |
|
2011–12 Q1 |
137354 |
116452 |
84.8% |
|
2011–12 Q2 |
138525 |
116372 |
84.0% |
|
2011–12 Q3 |
137963 |
117708 |
85.3% |
|
2011–12 Q4 |
140454 |
122105 |
86.9% |
|
2012–13 Q1 |
137287 |
118064 |
86.0% |
|
2012–13 Q2 |
135559 |
115730 |
85.4% |
|
2012–13 Q3 |
136111 |
116854 |
85.9% |
|
2012–13 Q4 |
138239 |
121067 |
87.6% |
Table 2
DAY CASE RATES
Eletive G&A FFCEs, England, 2003-04 to 2012-13
Provider based
|
Year |
G&A Day case FFCEs |
G&A Ordinary FFCEs |
G&A Total FFCEs |
Day case rate |
|
2003-04 |
3,775,621 |
1,774,096 |
5,549,717 |
68.0% |
|
2004-05 |
3,823,067 |
1,706,601 |
5,529,668 |
69.1% |
|
2005-06 |
4,052,576 |
1,709,709 |
5,762,285 |
70.3% |
|
2006-07 |
4,285,945 |
1,578,464 |
5,964,409 |
71.9% |
|
2007-08 |
4,741,728 |
1,748,601 |
6,490,329 |
73.1% |
|
2008-09 |
5,071,361 |
1,674,292 |
6,778,017 |
74.8% |
|
2009-10 |
5,275,248 |
1,628,113 |
6,951,646 |
75.9% |
|
2010-11 |
5,588,136 |
1,593,215 |
7,211,772 |
77.5% |
|
2011-12 |
5,868,139 |
1,598,851 |
7,466,990 |
78.6% |
|
2012-13 |
6,004,064 |
1,535,703 |
7,539,767 |
79.6% |
Table 3
LENGTHS OF STAY
Average length of stay, England, 2000-01 to 2011-12
|
Year |
Mean length of stay (days) All episodes |
|
2000-01 |
8.2 |
|
2001-02 |
8.1 |
|
2002-03 |
7.9 |
|
2003-04 |
7.4 |
|
2004-05 |
7.1 |
|
2005-06 |
6.6 |
|
2006-07 |
6.3 |
|
2007-08 |
5.7 |
|
2008-09 |
5.7 |
|
2009-10 |
5.6 |
|
2010-11 |
5.5 |
|
2011-12 |
5.3 |
Table 4
Table 5
Table 6
CANCELLED URGENT OPERATIONS AUGUST 2010 TO APRIL 2013
|
Month |
Urgent operations cancelled |
|
August 2010 |
172 |
|
September 2010 |
185 |
|
October 2010 |
173 |
|
November 2010 |
211 |
|
December 2010 |
322 |
|
January 2011 |
222 |
|
February 2011 |
248 |
|
March 2011 |
237 |
|
April 2011 |
219 |
|
May 2011 |
205 |
|
June 2011 |
251 |
|
July 2011 |
203 |
|
August 2011 |
254 |
|
September 2011 |
310 |
|
October 2011 |
301 |
|
November 2011 |
419 |
|
December 2011 |
389 |
|
January 2012 |
322 |
|
February 2012 |
352 |
|
March 2012 |
282 |
|
April 2012 |
229 |
|
May 2012 |
283 |
|
June 2012 |
229 |
|
July 2012 |
250 |
|
August 2012 |
238 |
|
September 2012 |
244 |
|
October 2012 |
301 |
|
November 2012 |
299 |
|
December 2012 |
220 |
|
January 2013 |
316 |
|
February 2013 |
272 |
|
March 2013 |
355 |
|
April 2013 |
401 |
Table 7
DELAYED TRANSFERS
Delayed Transfers of Care
|
May-12 |
March-13 |
April-13 |
May-13 |
|
|
Patient Snapshot |
3,857 |
4,052 |
4,043 |
4,200 |
|
Total Delayed Days |
119,331 |
118,186 |
112,994 |
120,233 |
Table 8 and 9
CURRENT AND COMPARATIVE DATA OF NUMBERS OF TRAINED PARAMEDICS NATIONALLY, PROPORTION THEY REPRESENT OF AMBULANCE STAFF AND NUMBERS IN TRAINING FOR FUTURE
|
NHS Hospital and Community Health Services: |
||||||||||
|
Qualified ambulance service staff and support to ambulance service staff |
||||||||||
|
|
|
|
|
|
|
|
Headcount |
|||
|
2006 |
2007 |
2008 |
2009 |
2010 |
2011 |
2012 |
||||
|
Total ambulance staff |
28,648 |
28,471 |
30,518 |
32,284 |
33,163 |
32,902 |
32,076 |
|||
|
Qualified ambulance staff |
16,176 |
17,028 |
17,451 |
17,922 |
18,450 |
18,687 |
18,645 |
|||
|
Manager |
614 |
598 |
685 |
692 |
696 |
700 |
657 |
|||
|
Emergency care practitioner |
438 |
646 |
705 |
750 |
780 |
770 |
742 |
|||
|
Paramedic |
8,222 |
8,241 |
9,203 |
10,089 |
10,678 |
11,368 |
11,954 |
|||
|
Ambulance technician |
6,902 |
7,543 |
6,858 |
6,391 |
6,300 |
5,853 |
5,295 |
|||
|
Ambulance personnel (old definition) |
.. |
.. |
.. |
.. |
.. |
.. |
.. |
|||
|
Support to ambulance staff |
12,472 |
11,443 |
13,067 |
14,362 |
14,738 |
14,238 |
13,451 |
|||
|
Ambulance personnel (new definition) |
4,630 |
4,537 |
5,438 |
6,347 |
6,444 |
6,398 |
6,290 |
|||
|
Trainee ambulance technician |
1,829 |
1,147 |
1,258 |
1,415 |
1,481 |
1,193 |
875 |
|||
|
Trainee ambulance personnel |
.. |
.. |
.. |
.. |
.. |
.. |
.. |
|||
|
Clerical & administrative |
3,247 |
3,340 |
3,882 |
4,161 |
4,384 |
4,303 |
4,382 |
|||
|
Estates (maintenance & works) |
205 |
166 |
220 |
189 |
226 |
232 |
237 |
|||
|
Healthcare assistant |
834 |
992 |
845 |
936 |
960 |
958 |
980 |
|||
|
Support worker |
1,727 |
1,261 |
1,424 |
1,314 |
1,254 |
1,162 |
695 |
|||
|
|
|
|
|
|
|
|
|
|
||
|
Paramedics |
|||||
|
Commission Group |
Actual 09/10 |
Actual 10/11 |
Actual 11/12 |
Actual 12/13 |
|
|
Commission |
486 |
633 |
549 |
466 |
|
|
Starters |
468 |
520 |
570 |
501 |
|