Health CommitteeWritten evidence from the Royal College of Physicians (ES 06)

The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing almost 28,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare. Our primary interest is in building a health system that delivers high quality care for patients.

The RCP welcomes the opportunity to respond to your Inquiry on emergency services and emergency care.

Summary of the RCP’s Response

At the start of 2012, the RCP launched the Future Hospital Commission1 to review the organisation of hospital care for adult inpatients with medical illness. In September 2012, the RCP released Hospitals on the edge? The time for action.2 The report sets the scene for why we must radically review the way we design and deliver acute services for patients. It sets out in stark terms the scale of the challenge facing acute hospitals. The Commission will publish its report in September 2013.

There are many compounding factors that affect emergency services and emergency care, which includes rising demand and the changing needs of an ever ageing population.

Further challenges include:

Lack of comprehensive, effective alternatives to admission across seven-days.

Complex discharge issues.

Handover and flow.

Recruitment into emergency medicine.

The RCP does not believe there is a “silver bullet” solution to the challenges currently facing emergency care services. The challenges facing Emergency Departments are the most visible manifestation of the pressures facing the system as a whole. As such the solutions lie across health and social care. One of the biggest challenges to emergency services and emergency care is the issue of “exit blocks”. This occurs when patients who could be discharged are not discharged either due to lack of appropriate services to discharge them to, or due to the lack of seven-day capabilities to discharge. In turn, this can lead to patients who need to be admitted facing delays getting on a ward, or being care for in overcrowded conditions, increasing the pressure on “front door” services.

The RCP believes the following fundamental “whole-systems” principles are integral to overcoming the pressures on emergency care services:

A focus on capacity within the hospital to meet demand. Capacity includes not only beds, but adequate staff levels and appropriate levels of access to diagnostics and treatment.

Supported early discharge (including adequately equipped and resourced services in the community over seven days, and strong links between in-hospital and community teams across primary, secondary and social care).

The availability to provide care and discharge on a seven day a week basis.

Better integration and collaboration within secondary care to ensure smooth flow of patients within the hospital.

Early senior assessment and review.

A focus on ambulatory care where appropriate.

National support for the structured expansion of the physician associate grade.

In our response we have covered:

1.Increasing clinical demand, and the general pressures on emergency services.

2.Compounding pressures on emergency services and emergency care.

3.Whole-system approaches to relieve the pressure on emergency care services.

Increasing Clinical Demand

1. The population of Great Britain has changed substantially since 1948. There are 12 million more people now, living longer, with life expectancy at birth around 12 years longer. People aged 60 or over make up nearly a quarter of Britain’s population,3 and half of those aged over 60 years have at least one chronic illness.4

2. Unsurprisingly, the demographic of hospital inpatients has also changed substantially. An increasing number of patients are older and frail, and around 25% of inpatients have a diagnosis of dementia. At the same time the number of general and acute beds has decreased by a third in the past 25 years, yet during the past 10 years there has been a 37% increase in emergency hospital admissions and a 65% increase in secondary care episodes for those over 75 in the same period (compared with 31% increase for those aged 15–59).5 The RCP highlighted this in our publication, Hospitals on the edge? The time for action, in September 2012.

3. Addressing the unrelenting rise in emergency hospital admissions is one of the major challenges facing the NHS. This was further highlighted in the House of Lords Committee on Public Service and Demographic Change which warned that the government and our society are woefully underprepared for ageing.6 Given the continued increase in emergency admissions, the RCP is calling for a radical review the organisation of hospital care if the health service is to meet the needs of patients.7

Compounding Pressures on Emergency Services and Emergency Care

4. There are a number of compounding pressures on emergency services and emergency care. These can be split into short-term “episodes”, and longer-term factors or “trends” which have been developing over a period of time. Taken together these factors highlight the breakdown in a whole system of care rather than just in emergency departments.

5. Some of the short-term episodes include:

(a)Extended winter period—the long winter and cold March in 2013, increasing cardiac and respiratory illnesses

(b)System transition—it is vital that there is strong leadership with clear accountabilities, especially at a time of transition.

6. In addition to this there are a number of long-term factors, or “system-wide trends”, which have been emerging over time. These include:

(a)Out-of-hours care breakdown—emergency activity at the weekend is around a quarter lower than during the rest of the week.8 Patients admitted at the weekend do not get diagnostic tests as quickly as those admitted during the week, there are significant falls in the number of procedures performed at the weekend, including emergency procedures, and fewer people are discharged. This suggests that patients are being “pushed” into the following week. Analysis of “system stress” (when admission to hospital exceeds discharge) shows a progressive rise from Sunday to Wednesday and “recovery” (discharges exceeding admissions) from Thursday to Saturday.

(b)Handover and flow—the main cause of delays in ambulance handovers are delays in patient flow through the hospital; which relates to workforce and demand issues at the “front door”, and capacity/flow issues internally through the hospital. The concept of “flow” is a pre-requisite to efficient, safe and effective care of patients in emergency departments and acute medical units. If patients who require further in-patient care are unable to be transferred out of an emergency department or acute medical unit after their condition has been stabilised both they and subsequent arrivals may be disadvantaged.

(c)System fragmentation and lack of alternatives to hospital admission—despite the high cost of hospitalisation, the NHS has been slow to develop comprehensive, effective alternatives to admission. Patients become acutely ill 24 hours per day, seven days per week. The current drive to seven-day working patterns in secondary care must continue.9 This drive towards seven day services is not matched in the community. Out-of-hours (OOH) GP coverage has become more fragmented and is supplied by agencies more commonly since the introduction of the new contract in 2004.10 This compromises efforts to avoid out-of-hours hospital admissions and prolongs the length of stay for inpatients unable to access pathways out of hospital seven days per week, disrupting the capacity to manage new admissions. Integration of primary and social care and primary and secondary care have both been shown to reduce hospital admissions.11

(d)Complex discharge issues—the successful discharge of frail older people following an emergency admission to hospital relies on effective joint working between NHS, social care partners and the independent sector. In organising discharge pathways, a “whole systems” approach is important. To deliver this, links between primary, secondary and social care must be improved, with greater collaboration in care planning and supported discharge, and better sharing of good practice where this is already happening.

(e)Financial—acute trusts have often targeted acute and geriatric bed closures12 resulting in the UK having lower numbers of emergency beds than other western health care systems to meet savings targets. There is a risk that reducing admissions and beds will lead to a small bed base with high occupancy rates which cannot respond safely to fluctuations in demand.

(f)Confusing system for patients requiring access to services—the number of unscheduled care services available may be adding to the confusion experienced by patients when seeking appropriate emergency care. Evidence also suggests that the increase in the supply of newer types of emergency care facilities appears to have led to increased patient demand.13

(g)Recruitment and staffing—recruitment into emergency medicine is becoming increasingly difficult, with gaps in training schemes, an increasing reliance on locums, and unfilled consultant posts. In addition to this, three successive years of only 50% fill rates for Emergency Medicine (EM) trainees has resulted in a “lost cohort” of over 200 potential consultants.14 In consequence all UK departments have a significant shortfall in senior trainees which affects service delivery and patient safety on a daily basis.

7. To conclude, we see a number of compounding factors that have created pressures on emergency services and emergency care. What is clear to us is that problems in emergency care services are the most visible manifestation of a “whole system failure” (across primary, community, secondary and social care—and within the hospital itself), and that the solutions must lie across the system.

Whole-System Approaches to Relieve the Pressure on Emergency Care Services

8. There is an urgent clinical need to redesign acute services primarily to drive up quality, as well as to deliver effective and efficient services. Problems with emergency services and care are the most visible manifestation of a whole system failure. Solutions to the issue require integration of working (between primary, secondary and community care), but also a more collaborative working approach within the hospital itself. This issue is being addressed by the RCP’s Future Hospital Commission, which reports in September.

9. System-wide solutions include:

(a)Early senior review—emergency departments should consider implementing a rapid assessment and treatment (RAT) model in order to provide early senior review for informed expert assessment, diagnosis, care planning, end-of-life discussions, etc. Senior triage of GP referrals to acute medicine has also been shown to be effective; acute medicine consultant triage of GP phone referrals and the introduction of medical ambulatory care pathways have seen a reduction in community admissions by 37% in the areas served by Royal Derby Hospitals.15

(b)Focus on supported discharge on a seven day a week basis—prioritisation of discharge activities can improve flow in the ED. There is evidence to support the development of generic and disease specific early discharge schemes16 that should rapidly respond to patients being designated medically fit, seven days a week.17 Effective discharge planning can reduce length of stay and readmission, therefore it is a vital element of an effective emergency care process. However, the discharge process has become complex, with patients often requiring a social care assessment, capacity assessment, mental health assessment, best interests assessment and subsequent actions. The current system means that patients are kept in acute hospitals as a “place of safety” while all of these assessments are completed. This could be provided by community services supervised by primary care. A supported discharge relies on effective systems and appropriately resourced services within primary, community, secondary and social care services.

(c)A focus on ambulatory care services—the underlying principle of ambulatory emergency care (AEC) is that a significant proportion of emergency adult inpatients can be managed safely and appropriately on the same day, with follow-up for diagnostics and/or treatment, without admission to a hospital bed. Effective ambulatory emergency care is a whole systems approach that is only achieved by re-organising the working patterns of emergency care and diagnostic services. Robust community services are imperative to provide a safety net system for AEC.

(d)Targeted programmes for community services—although there is weak evidence for the efficacy of broad admission avoidance programmes,18 targeted programmes for nursing and residential home residents with advanced care plans, the frail elderly at home, terminally ill people and some long-term conditions (notably heart failure) may be effective. These require senior decision makers and the capacity within community services to provide immediate care for these groups of patients on a seven-day a week basis.19

(e)Use of acute medical units (AMUs)—evidence supports the effective use of AMUs to improve the care of patients admitted in an emergency;20 ensuring rapid, senior, multi-professional assessment and treatment of patients admitted in an emergency, seven days a week is a key principle of AMU care, which is supported by a number of publications from the RCP and Society for Acute Medicine.21

(f)Emergency care boards—that promote clinical conversations to create shared ownership of emergency pathways and collective problem solving.

(g)Staffing—in order to overcome some of the pressures on emergency services staffing, we would recommend an increase in physician associates (previously assistants) who have a shorter training scale (two years), and can offer continuity of care in emergency care services and on wards.

10. There are a number of strategies available to those involved in the planning and provision of emergency services. Often these deal with redesign to the emergency service at the hospital “front door”. However, these redesigns will fail to achieve any improvements in services in emergency departments if wider changes across the system are not also made. This whole system approach must include: a focus on capacity within the hospital to meet demand, supported early discharge (including adequately equipped and resourced services in the community, etc), and the availability to provide care and discharge on a seven day a week basis.

11. Hospitals must deliver consistent, high quality 24-hour services, including a consultant-led service seven days a week. The workforce challenges associated with this are a further driver for reconfiguration.

Concluding Remarks

12. Given the pressures on emergency services require a whole-systems approach, the RCP recommends:

(a)A focus on capacity within the hospital to meet demand. Capacity includes not only beds, but adequate staff levels and appropriate levels of access to diagnostics and treatment

(b)Supported early discharge (including adequately equipped and resourced services in the community over seven days, and strong links between in-hospital and community teams across primary, secondary and social care)

(c)The availability to provide care and discharge on a seven day a week basis

(d)Better integration and collaboration within secondary care to ensure smooth flow of patients within the hospital

(e)Early senior assessment and review

(f)A focus on ambulatory care where appropriate

(g)National support for the structured expansion of the physician associate grade.

13. The RCP’s Future Hospital Commission will make recommendations relating to many of these areas and will report in September 2013. The RCP will ensure the Committee is kept informed as work progresses.

May 2013