Health CommitteeWritten evidence from the NHS Confederation (ES 09)

Executive Summary:

Pressures on A&E services reflect pressures being experienced across the whole system. It is imperative we share understanding of the problem and avoid one part of the system blaming another for strains on emergency services.

Years ago we warned that the biggest concern facing the NHS would be to sustain massive improvements in reducing waiting times for care, as demand outstripped the funding available to the NHS. We have now reached a point where the cracks are beginning to show and some services are reaching capacity. Swift action must be taken to slow down the trend of over-burdened urgent and emergency care, as demographic pressures mean this is a something which is here to stay.

There are myriad reasons why A&E departments are buckling under the strain. The rise in demand is particularly concentrated on those with less serious conditions and those over the age of 85. Cuts in social care, under investment in primary and community care and perverse financial incentives in the system are all contributing factors to the rise.

An overhaul of financial flows in the system to incentivise and change the status quo is long overdue. Our members have particular concerns regarding the marginal tariff for non-elective work. This tariff, while good in intention has not tackled increased demand. We therefore welcome the review currently being conducted by Monitor and NHS England into this matter.

NHS out-of-hours care is not fit for purpose and successive Governments have so far failed to address this problem. Local NHS organisations now need to look at how they can provide services which are available 24 hours a day, seven days a week. However, this requires a change in working patterns—recognising weekends and evenings as normal working times—and service delivery planning. It is a shift which needs to be driven by quality and safety in patient care, and not overtime rates. Equally, this should not be the responsibility of one profession—out-of-hours care needs to be provided by multidisciplinary services.

The introduction of the NHS 111 has been problematic in many areas. We fully back the principle of a single portal for people to access healthcare to address the confusion felt by many about where to access care, but we believe so far the 111 service has been a missed opportunity. There are currently significant problems with the service in that it is not properly connected to hospitals and does not have an online counterpart. These issues need to be addressed swiftly if the benefits of the service are to be realised and the public’s trust is to be gained. We understand from NHS England that recent figures show there are some signs of improvement.

As part of the need to integrate different parts of the system and to relieve burdens on urgent and emergency care, we fully support the objective of using a person’s unique NHS number across health and social care. This would want to give people greater ownership of their number so they can use it to link information to their records and allow the NHS to make targeted interventions aimed at reducing demand.

Tackling the issues in emergency care will require political courage. We are arguing for more investment in primary, community and social care—as well as a concentration on how to reorganise services so that they are more joined-up and organised around an individual’s needs. We also need to see a change in culture that makes tackling demand a top priority for all parts of the NHS.

1. Demographic Change and Increased Demand

1.1 The NHS and improvements to public health have ensured that people are living longer and diseases which were once fatal can now be managed for longer periods of time. For example the population of over 65s is projected to grow by 50% over the next two decades. While these improvements should be celebrated the increase in the number of people living with multiple, long term conditions has led to increased demand being placed on the health service.

1.2 The effect of lifestyle choices, including smoking, alcohol abuse and obesity, on public health and wellbeing have also increased pressures on the NHS. The cost for treating diseases associated with these lifestyle choices is estimated at a cumulative £17.9 billion each year—almost a fifth of the annual NHS budget.1 They have also led to an increase in some long-term conditions, for example the rising rate of diabetes—expected to double in the UK by 2025.2

1.3 These changes have led to increasing demand for NHS care. Emergency and urgent care is the point where pressure is most intensely felt. For example, total annual attendance at accident and emergency departments in England increased from just over 14 million in 2000/01 to just over 21 million in 2010/11, a 50% increase in over 10 years.3 The increase in breaches of targets which is happening in some areas, such as the 4 hours target in accident and emergency is reflective of increasing pressure elsewhere in the system, rather than within emergency services alone. In addition to this, it is estimated by groups including the National Clinical Advisory Team that around 30% of people attending emergency departments could have been treated elsewhere.

1.4 The demographic changes outlined above combined with the funding pressures on local government have also led to increased pressures on social care. When people’s needs are not met by the social care system they turn to the NHS, which experiences the increased demand for emergency and unplanned work, and delay in discharging people from hospital. Delayed transfers of care already cost the NHS £545,000 per day (approximately £200 million per year). The number of emergency admissions among patients aged 75 and over has increased by 18% between 206/07 (1.231 million) and 2010/11 (1.453 million). These pressures will increase without action to ensure a sustainable funding solution for social care.

1.5 More work is needed to understand the demand for urgent and emergency services. The way the NHS measures activity has changed in recent years and we need to look at demand in urgent settings (such as minor injury units or walk in centres) as well as emergency departments in order to get a full understanding of the picture. According to NHS England there is a general rising tide with 5.9% more attendances in 2012/13, than in 2009/10. However, we need to recognise that if demand continues to rise emergency and urgent care will reach capacity.

2. A System Wide Approach

2.1 Emergency care is a fundamental issue for all parts of the NHS. To tackle this system wide problem we need a system wide solution. The NHS must avoid one part of the system blaming another for pressures on emergency services. System leadership which brings together all of the parts of the local NHS will be vital to responding to the pressures on emergency services. Currently much of the focus is on the acute and ambulance trusts. However, emergency care is an issue for all parts of the NHS so any approach will need to involve commissioners, as well as acute care, primary care and community services providers. This will require risks and rewards to be shared and organisational interests set aside, for the greater benefit of the local health economy.

2.2 The new commissioning system, and Clinical Commissioning Groups (CCGs) in particular, will have a key leadership role in this, particularly as CCGs are effectively made up of GPs as commissioners who also deliver primary care services. However, it needs to be recognised that CCGs are very new to their role and will need support from the Clinical Support Units and NHS England’s Local Area Teams to do this.

2.3 The new health and wellbeing boards could also play an important role in facilitating this sort of joint approach. However, though significant advances have been made at this early stage of the Boards’ development, there remain considerable challenges to realising this potential. Board members will need strong communication and political skills. While most boards already have a partnership of shared respect and understanding, they will need to go beyond this to become a cohesive, unified body in which overall strategic priorities are put above personal or organisational interests.

2.4 The issue of ambulances handing over patients to hospitals is one example of where a system wide approach is vital to managing the pressures faced by emergency departments. Ambulances stacked up outside of hospitals waiting to handover patients is something which should never be acceptable in the NHS but has become a problem in some areas in recent years. Our report Zero tolerance: Making ambulance handover delays a thing of the past4 recommends that as delays in handovers are symptomatic of wider pressures, a wider response is needed to tackle them. This involves considering “downstream” issues like timely discharge from hospital to free up beds for emergency admission. It also recommends close working with primary and community care providers, to ensure their critical role in managing urgent and emergency care systems is better understood and developed.

3. Managing Demand: Services Reconfiguration and Cultural Change

3.1 The NHS needs to do more to manage the demand facing the NHS in order to lessen the pressures on the service. We need a change in culture that makes this a top priority for all parts of the system. A key part of this will be greater investment in prevention and early intervention services, which could also be achieved through service reconfiguration, specifically through integration between primary, secondary and social care. While local authorities now commission most public health services, there is still a role in this for the NHS.

3.2 This needs to be a whole system effort, where proper management of unscheduled episodes happens along the whole continuum of care, and thus implying well developed communication channels among all the parts of the system. Information gathering and sharing across the system is thus paramount, especially along those fault lines where different parts of the system interface.

3.3 For example, A&Es admission rates are affected by limited access to out-of-hours primary care services and management of patient referrals/transfers between acute, primary and community care. This goes hand in hand with a reduced availability of senior acute clinical staff at night and during weekends, with an impact on hospital mortality rates, which are 10% higher at weekends.5 Providing services available 24 hours a day, seven days a week, throughout the system can help in reducing attendance to emergency departments.

3.4 However, it requires a change in working patterns—recognising weekends and evenings as normal working times—and service delivery planning. It is a shift which needs to be driven by quality and safety in patient care, and not overtime rates. Investing in good-out-of-hours services will help this.

3.5 Another example is the positive impact of proper discharge planning, involving different parts of the system—internal hospital teams, ambulance services, social care and family carers. This has also shown to reduce the risk of re-admission within 30 days following discharge. For example, some NHS organisations, such as in Torbay, have employed a discharge manager who has specific responsibility for ensuring discharge of patients is done as safely and as smoothly as possible.

Case study: Integrated care, Southern Health NHS FT.

The trust is responsible for delivering community and mental health services to 1.2 million people in Hampshire. Operating on a block contract—£350m, 9000 staff—the trust aims to reduce costs, delivering more services for less money; improving clinical outcomes for patients and their families; and improving patient and carer experience.

The focus has been placed on supporting frail elderly people in the community, through creating single Community Care Teams (CCTs), including different levels of care and based around a general practice, serving approximately 30,000 people through 3 sub-teams. Through collaborating with primary care, the FT developed a new, integrated workforce which assesses and proactively plans to meet the needs of vulnerable patients. With acute providers, the FT is creating integrated acute & community elderly care services to reduce emergency admissions and length of stay.

The model showed a certain reduction in A&E admissions of frail elderly throughout the past 5 years of implementation. A key barrier to be broken was the resistance to the cultural shift which achieve integrated care required. Behaviours had to change, in order to enable cooperation through partners that were not necessarily under the same management lines. This shift of relationships across the system, and developing a new set of values, is key in delivering a unified response to urgent and emergency care.

3.6 Significant initiatives led by both NHS providers and commissioners have also strengthened early intervention efforts in areas such as psychiatric liaison, alcohol and falls prevention. We are calling for the introduction of services which aim to take a whole person and community approach to improving health. These could for example include a combination of smoking cessation, weight management, or psychological well-being interventions such as stress management. NHS organisations and local authorities should also work together through health and wellbeing boards to provide wellness services which take a whole person and community approach to improving health. To support this sort of approach, NHS England should design a payment mechanism specifically to support coordination of these sort of services.6

3.7 However, our members have clearly stated this sort of work has often been driven by certain individuals and it is not yet something built into the NHS system. We must ensure these initiatives become the norm across the health service.

4. NHS 111

4.1 Another tool to effectively manage the demand for urgent and emergency care, creating a unique contact point and enabling admission triage, is NHS 111. The different points to access urgent and emergency care, such as walk-in centres, and minor injury units can, create confusion in patients, rather than helping to ensure they are treated in the right place. Having one telephone number as single entry point to the health service would certainly help address these concerns.

4.2 While we understand from NHS England that there have very recently been improvements, there are clearly significant problems in some areas of the country as 111 has been rolled out. We have warned in the past about the way that the service were being procured in some areas. However, these problems should not lead to the service as a whole being dismissed. National bodies, particularly NHS England, will need to act to ensure that these problems are overcome and 111 successfully implemented. The roll-out is clearly very variable across the country and does not seem to be related to type of provider. It will be important to analyse the differences between the good and the bad and learn from that analysis.

4.3 National bodies, along with commissioning support units and NHS England’s local areas teams will need to provide support to commissioners in implementing the service. It is concerning 111 has no online counterpart and in many places is not well connected enough to hospital services. It is paramount for 111 to have systems in place to gather and share information among local care providers and commissioners, including an up to date directory of local services which call handlers can use to help patients makes the right choices about the care they receive.

5 The Role of Ambulance Services in Managing Demand

5.1 NHS ambulance service account for 1.5% of NHS spend but the consequences of their decisions impact on 20% of NHS activity. Ambulance trusts have already been playing a greater role in reducing demand as well as meeting the QIPP saving challenge. For example, our Ambulance Service Network’s document Falls prevention: New approaches to integrated falls prevention services7 sets out benefits, including in terms of making savings, resulting from a falls prevention strategy.

5.2 Non-conveyance of patients, by ambulance crews (ie the decision not to move a patient to an emergency department but to give them alternative treatment more appropriate to their needs)has proven key in managing demand and improving care. Practical solutions, such as improving training for paramedics and providing them with the support needed for making non-conveyance decisions, will promote a culture questioning about whether a hospital is the best place to treat the patient, rather than simply taking them there by default. When redesigning local services, commissioners will also need to find ways to incentivise non-conveyance.

5.3 There is wider scope for better integration of ambulance services with primary health care and community services, particularly for screening, and notifying, people at risk of admission in the community. To both enable this and to enable ambulance services to continue meeting the increased demand for unscheduled care, better information gathering and sharing is particularly important. For example better data can allow the NHS to target frequent attendees in emergency departments and examine if they can receive more appropriate care in a different setting. We need to enable the use of the NHS number as the unique identifier across the health and care system to facilitate this approach.

6. Alternatives to Urgent and Emergency Care

6.1 Properly coordinated, person-centred services can better care for the health of people, rather than dealing with the sickness of patients when they arrive at a hospital. Some progress has been made on transferring care into the community but more must be done. We welcome Bruce Keogh’s review into this issue. There needs to be renewed efforts at national level to enable services other than emergency departments to better deal with unscheduled care episodes, locally and safely. This includes fundamentally reviewing how we organise and fund our services outside traditional hospital settings, the way staff work throughout the whole week, and how we provide effective alternatives to hospital-based emergency care.

7. The Role of Primary Health Care and Community Services, in Relation to Urgent and Emergency Care

7.1 We need to see better utilisation of community care and primary care to take the pressure off emergency departments, making sure people can be treated safely in their own home and avoid unnecessary visits to hospital.

7.2 According to the King’s Fund,8 the prevalence of unscheduled hospital admissions for conditions that could be prevented suggests that there is potential to manage patients better in primary care. Primary care needs to work with the rest of the health and social care system to manage the demand on urgent and emergency care. Specifically, limited access to GP’s out of hours and variability in quality is a contributing reason for greater demand on emergency services. In some places there are attempts to address these variations, in order to find innovative solutions that suit local needs. In particular, there is a need to find better ways of sharing and using data to highlight and address variations, especially to better manage the health of patients with long term conditions in primary care. The below example highlights this.

The Pan London General Practice—A London Strategy to improve quality, access and patient experience in general practice.

The initiative addresses significant variation in quality across the English capital through:

1.Provide clinicians with the data and information they need to identify and prioritise areas for quality improvement

2.Share this transparently at a local level peers to engage general practice in driving care improvement.

The project aims at achieving transparency in data at a local level for patients, the public and professional peers through public facing launch of the standards on a web based platform that includes:

Intuitive dashboard to present the outcome standards.

Public Health Observatory Health Profiles that describe the health of the local population.

Practice voice.

A patient feedback mechanism.

A range of tools and applications for general practice, eg survey templates for achieving DES requirements for patient participation.

As a result, general practitioners took ownership for the quality improvement agenda and delivered a step change in performance for London. Also, unwarranted variations reduced and efficiency savings delivered, contributing to meeting the QIPP challenge by 2014/15.

7.3 As outlined in our 2013 briefing on the role for community healthcare in transforming local care,9 the community health sector is already driving the transformation of local care systems. Innovative community healthcare providers, including stakeholders such as charity and social enterprises providers are enabling people to stay healthy and independent and avoid crises that lead to unplanned hospital admissions. They enable staff to develop a holistic view of the needs of each individual and provide personalised continuous, rather than episodic, care. This sort of care is much better for the growing number of people with long term conditions and can help better manage those conditions, which in turn will help reduce unnecessary hospital admissions.

7.4 Central to the community health model are prevention, early intervention and enabling timely discharge or transfer from hospital to improve recovery. Community health is moving the focus away from traditional models of healthcare in acute settings to nurse-led rehabilitation in, or closer to, peoples’ homes, the provision of “hospital at home” services such as diagnostics and chemotherapy, and community-based end of life care. Below is an example of where community services have been used to reduce the pressure on urgent and emergency care.

Case study: Birmingham Community Healthcare NHS Trust

Birmingham Community Healthcare NHS Trust has developed a model of care that enables rapid, 24-hour access to community services to reduce emergency hospital admissions. It has established a 24/7 single point of access for urgent and non-urgent referrals, which aims to signpost patients to appropriate care. For urgent care, a rapid response and advanced assessment at home is delivered within two hours. For non-urgent care, multi-disciplined teams respond and manage between four and 48 hours.

A clinician-led telemonitoring service has also been expanded across the city, which allows patients to self-monitor vital health indicators that are automatically relayed, monitored and recorded. This new model of care has allowed 97% of referrals to be responded to within two hours, resulting in a 12% reduction in GP-referred medical admissions to the local hospital. The telemonitoring has facilitated a reduction in emergency admissions of up to 70%, saving an estimated £250,000.

7.5 While there are good examples of innovative initiatives across the NHS more needs to be done to ensure best practice is widely adopted. In order to see this much needed shift toward more care in the community and better utilisation of primary care, NHS organisations will need to redesign services so they better meet the needs of local people and tackle the pressure being felt on urgent and emergency care. Government and national NHS bodies will also need to examine how we pay NHS organisations for their activity to ensure that the necessary large scale change needed is incentivised and adopted at scale and pace across the system.

8. Redesigning Incentives

8.1 Our members have particular concerns regarding the marginal tariff for non-elective work. This was introduced with the intention of penalising acute trusts by paying them a reduced rate (30%) of tariff, (ie the mechanism for paying trusts for their activity) for a rise in non-elective admissions in order to encourage finding ways to reduce demand. While the intention of this was welcome, in practice this policy has not tackled rising demand. What it has achieved is to substantially increase the already intense financial pressures on acute trusts with emergency departments. Furthermore, the marginal tariff has in practice transferred the risk to providers and has not created a shared imperative for commissioners to actively engage with this issue and make changes to the local health service which will tackle rising demand.

8.2 We welcome the review of the marginal tariff by Monitor and NHS England which recognises these concerns. It is vital that the 70% saving from the tariff remains with clinical commissioning groups so they can invest it in changes to local services that will tackle rising demand. This investment must not return to national bodies, the Department of Health or the Treasury, as has happened in the past.

8.3 On a larger scale, more needs to be done to ensure that the right incentives are in place across the system. We need to incentivise better joint working, more focus on intervention and greater investment in community services, all of which would relieve the pressures on urgent and emergency care. The various payment systems, such as tariff, currencies and payment by results, have often been developed in an ad hoc way to address various issues and plug particular gaps across the system.

8.4 While this is understandable, we believe that the new NHS system which came on line in April 2013 represents an opportunity for Monitor and NHS England to take a more of strategic approach toward incentives in the NHS as a whole. We urge them to develop incentives which will facilitate risk sharing across the system. As part of this, Monitor and NHS England will need to ensure that local leaders are given the freedom to assess what is needed in their area and the flexibility to develop local incentives.

Case study—The North West London Integrated Care Pilot (ICP)

The North West London Integrated Care Pilot (ICP) was launched in June 2011 and brings together more than 100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age UK and Diabetes UK) to improve the coordination of care for a pilot population of 550 000 people.

The ICP was developed in response to variations in the quality of care and a rising deficit across the local health economy. The clinicians involved decided two areas of focus for integrated care: people older than 75 years and those with diabetes. These groups were experiencing a high level of avoidable admissions and variable care, there was known best practice and improved outcomes would be measureable.

The ICP developed a unique model of clinicians working together in multi-disciplinary groups within a multi-disciplinary system. The multi disciplinary group (MDG) risk stratified the patients identified for the pilot, developed shared protocols for care across organisations, discussed these protocols and developed care plans with patients, mapped available care and addressed gaps in provision, introduced case conferences for patients with particularly complex needs or significant problems, and reviewed overall performance of the pilot.

£7m investment was provided by London SHA channelling the funds from the 30% marginal tariff on “excess” emergency admissions to hospital. This provided for an operational team, an information tool (to support risk stratification, care planning, sharing of medical information and evaluation), care coordination and incentive for providers to save.

Some benefits have been seen relatively early in the pilot, though it is anticipated the full benefits would become apparent over a 5–10 year timescale. Based on analysis of the impact to date, the ICP hopes to reduce emergency admissions for people over 75 with diabetes by 10%. Patients are also experiencing better coordinated care across different providers. The aspiration for the pilot is to scale up to the whole local population, focusing on the 20% that drive 80% of cost.

9. Redesigning Services

9.1 If we are to invest more in prevention and in services closer to home then NHS organisations will often need to redesign local services. In places it will be necessary to close some services or even possibly whole hospitals, with associated staff deployment, retraining or redundancy. In some cases evidence shows that concentrating certain services in specialist centres, such as stroke services in London, significantly improves safety and outcomes for patients. Again this may necessitate the closure of some local emergency departments. The NHS Confederation will shortly be publishing a report which will set out the reasons behind redesigning services and how we can overcome the obstacles to making the right of changes for patients. Below is a case study highlighting the value of centralising certain services.

Case study: Improving quality, safety and outcomes in stroke care

The London Stroke Strategy replaced 32 stroke units across the capital with eight hyper-acute stroke units as the first destination for anyone who has a stroke in the capital. After an initial 72 hours of specialist care, patients are transferred to their local hospital specialist stroke unit. Quality criteria apply to all of the stroke units in London, with the HASUs having to meet specific quality standards associated with delivering 24 hour emergency stroke care.

The model did require extra investment, but that investment has resulted in a reduction in overall costs across London as the average length of time patients stay in hospital has gone down. Early findings show impressive improvements in stroke care across the city, with an increase in the use of thrombolysis to a rate higher than any other major centre in the world and an overall fall in mortality rates across the capital.

9.2 We understand how important accident and emergency services are to local people so it is essential that patients, local communities, and their representatives—including local and national politicians—are properly engaged in this debate. Currently many people are sceptical that they will receive the same quality of care in the community as they will in their local hospital. We are calling on the Government, politicians and national NHS bodies to set out a vision for the future of community care. They must demonstrate how patients with continuing conditions can benefit from being treated in a more convenient location and how this will take the pressure off urgent and emergency care.

9.3 The public are often only aware of the closure of hospital services and not of the subsequent investment in community services or at centralised specialist centres. They need to see that reconfiguration should be about moving care to the most appropriate setting, not cutting services. We recommend NHS organisations have the resources to run services alongside one another in the short term. This will allow patients to be gradually moved from hospital to a community setting.

9.4 Redesigning services requires investment. With central Government funding unlikely to significantly increase in coming years, the NHS will need to make best use of the money already available to it in order to invest in redesigning services. NHS organisations will need to consider redistributing existing funds (for example the 70% saved from the emergency tariff). They should also consider using some of the money currently held in contingency funds. NHS organisations will need to carefully balance the potential risk resulting from decreasing these funds against the urgent need to invest in better patient care.

9.5 Currently the way the health system is organised restricts the ability of local organisations to redesign services. NHS acute trusts are paid for their activity through the tariff while primary care and community care are paid through block contracts, which disincentivises activity. This difference in incentives is an obstacle to redesigning care which urgently needs to be addressed when Government and national bodies redevelop incentives as we outline above.

9.6 A period of stability in the NHS will be crucial in allowing local communities to come together, build strong relationships and develop sound, evidence-based proposals for change. We must avoid another disruptive, structural reorganisation of the health service and we strongly recommend a cross-party agreement on this issue, to ensure a significant period of stability in the future.

10. Legal Challenges Against Reconfiguration Proposals

10.1 There are many legal requirements governing how a reconfiguration should be carried out. It is right to ensure that a strong, transparent process is in place. The rigorous scrutiny from this can be helpful in strengthening proposals. This needs to be balanced against the potential loss of momentum, if changes are stalled at a later stage by legal review. Our recent work on reconfiguration has shown that there is generally good guidance available for many of these obligations, but that strong project management by NHS organisations conducting reconfigurations is important to keep on track of them all. It is important for local NHS organisations to develop strong relationship with relevant bodies throughout the process to help deal with uncertainties at as early a stage as possible.

10.2 Following the implementation of the Health and Social Care Act 2012, and the introduction of health and wellbeing boards, the role of local authority Overview and Scrutiny Boards in scrutinising reconfiguration proposals is unclear. We recommend NHS England issues guidance to provide clarity on this.

11 Challenges for Emergency Departments in Rural Areas

11.1 There are particular challenges for rural areas where the quality of urgent and emergency services vary. Again, lessons need to be learned from the good practice which exists across the country so these innovations can be more widely adopted by commissioners. Similarly community services and primary care (such as community pharmacies) can play a greater role in ensuring the health needs of rural communities are better met. In rural areas in particular it will be important for hospital trusts to link their work with local councils, whose public health role can help in managing demand.

11.2 There are also particular issues around staffing emergency departments in rural areas. Staff often cluster around large teaching hospitals and it can be difficult for NHS employers to attract and retain staff. This situation can impact on costs, with some rural services relying on expensive locums, and in turn this can make recruitment even harder. There is no silver bullet to this issue—solutions will need to be found which are appropriate to local areas.

About us

The NHS Confederation represents all types of organisations that commission and provide NHS services. It is the only membership body to bring together and speak on behalf of the whole of the NHS.

May 2013