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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 171 - i

House of COMMONS

Oral EVIDENCE

TAKEN BEFORE the

Health Committee

emergency services and emergency care

Tuesday 21 may 2013

Mike Farrar, Dr Patrick Cadigan and dr mike clancy

Evidence heard in Public Questions 1- 95

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Oral Evidence

Taken before the Health Committee

on Tuesday 21 May 2013

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

Grahame M. Morris

Andrew Percy

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston

________________

Examination of Witnesses

Witnesses: Mike Farrar, Chief Executive, NHS Confederation, Dr Patrick Cadigan, Registrar, Royal College of Physicians, and Dr Mike Clancy, President, College of Emergency Medicine, gave evidence.

Q1 Chair: On behalf of the Committee, I welcome all three witnesses. This is our first evidence session on this inquiry into urgent and emergency care, which is a subject that the Committee has received a number of approaches on, both through our constituencies and as a Committee. It is very topical. We are looking forward to what you have to say. Could you briefly introduce yourselves to get the session under way, please?

Dr Clancy: I am Dr Mike Clancy. I am President of the College of Emergency Medicine.

Dr Cadigan: I am Dr Patrick Cadigan. I am Registrar of the Royal College of Physicians, London.

Mike Farrar: I am Mike Farrar, Chief Executive of the NHS Confederation.

Q2 Chair: Thank you very much. You are all very welcome. You will be aware, I am sure, that David Prior, the new chairman of the CQC, has lost not very much time in declaring that the pressure in A and E departments, in his words, is "unsustainable" and "out of control". Do you agree with that analysis and, if you do agree with it, what do you think are the principal causes? Let us get the discussion under way and start with Dr Clancy.

Dr Clancy: I think a multitude of factors has led to the deterioration in the performance of type 1 emergency departments, which have been under sustained pressure for a long time and in fact have reached the limits of their compensatory capacity. There is a major workforceworkload imbalance within emergency departments and an inability of the whole system at the moment to meet the demand. What is happening in emergency departments reflects the performance and difficulties of the whole NHS as well as within the emergency department.

Looking at the factors that contribute to that, I would like to clarify the issue of increasing attendances and to distinguish between attendances in the system overall and type 1 emergency departments in particular. If we take all of the urgent care services-emergency departments, minor injuries units and walkin centres-there has been a 50% increase between 2001 and 2011. For type 1 emergency departments, that has risen by 17% from 2003 to 2011. From the latest data from the A and E statistics website of the Department of Health, the change between this year and last year is a quarter of a million new attendances.

It is helpful if we talk about raw figures as well as percentages. A quarter of a million is five new emergency departments each seeing those patients. So the numbers themselves do not tell the whole story. The numbers are increasing; but, just as those are averages, some departments are reporting substantial increases in attendances. What is happening is that the work load of out-of-hours services is increasing. There is clear evidence that attendances after midnight and at weekends are substantially increased and that more patients are being admitted. Over this year compared with last year, there were 142,000 more admissions. As to patients waiting in emergency departments, there were 152,000 patients waiting more than four and less than 12 hours last year. That is a 34,000 increase. Those are big numbers.

Along with that, more elderly patients are attending, so in the order of more than a quarter of a million more people over the age of 70 are attending who have greater needs. It is also helpful to point out to the Committee that, although winter pressures are a frequently used term, the variation in attendances between quarters is minimal. Therefore, this is a continuous, not a single, problem.

There are other problems beside numbers. There is a lack of clear alternatives to emergency departments that patients trust and want to use. That means that 10% to 30% of patients could be cared for in an alternative setting to the emergency department. Emergency department staff shortages are particularly acute, especially out of hours, and this exacerbates the situation because it is particularly difficult to staff departments out of hours. The locum and vacancy rates combined for key decision makers are in the order of 20% and for consultants in the order of 17%. The lack of bed capacity, with occupancy running typically at 100%, means it is difficult to get patients into hospital at this time. The inability to discharge patients means it is harder to get them in and that has led to substantial overcrowding. If you look at the numbers of people multiplied by the length of time they spend in emergency departments, that is what is increasing substantially. Overcrowding of emergency departments is one of the major challenges that we face. You should know that that is dangerous: there is an associated mortality and morbidity associated with overcrowding. We know that and are doing our best to control it. Getting rid of overcrowding is one of the challenges because it is something that we know is a substantial risk. Thank you.

Q3 Chair: That is a barrage, if I may say so, of statistics and evidence. Can I start by dwelling on the rise in attendances? I think I am right in saying that you said 250,000 year-on-year total attendances across the full range of emergency departments-this year on last, a 250,000 increase. Did I hear that right?

Dr Clancy: That is for type 1 emergency departments. For emergency departments that are not minor injury units or walkin centres, it has increased by a quarter of a million from last year.

Q4 Chair: Could I ask you to reconcile that? I know there are figures around that suggest that yearonyear attendances are down a fraction and with those numbers you are stating they are up. Both propositions cannot be true.

Dr Clancy: Sure. These figures are from the Department of Health’s A and E statistics website that we can all visit and were there, updated, on 17 May. It is because of this ambiguity around numbers that I thought it was important to draw your attention to that. The big increase in numbers is of the whole system combined. Within emergency departments, there has been less of an increase, but nevertheless a substantial increase. That is where percentages can be misleading. We are working with a system that is at the limits of its tolerance and small changes can make big differences to how it functions.

Q5 Chair: That is understood, but can I push you on this? Where does the figure come from that suggests there has been a 1.7%-I think it is, but I do not know the absolute number-decline in attendances year on year for the first quarter of this year?

Dr Clancy: It may be a function of when you choose to measure it-if you are combining quarters in a different sequence, for example-but I have taken the four quarters that constitute 201213 against 201112.

Mike Farrar: Just for clarity, the 1.7% reduction I think is a comparison of the previous full quarter against that same quarter a year earlier. In aggregate, the total number has been increased over the 12 months, but actually a quarter comparison of the last quarter compared with the year before in that quarter shows that 1.7% rise.

Q6 Chair: So the 250,000 is a fullyear number.

Dr Clancy: Yes, absolutely.

Q7 Chair: Taking fullyear numbers and accepting that there is not a major seasonal variation, it is a rising trend.

Dr Clancy: Yes.

Q8 Chair: I want to clarify this as the starting point because there has been some discussion about whether the demand pressures are continuing upwards or edging downwards. I want to be clear what the answer to that question is.

Dr Clancy: What I have tried to say is that the numbers per se do not tell the story. It is the case mix, the age and so on, and the time they are attending, so more people out of hours, more after midnight, more by ambulance and more of the elderly.

Q9 Chair: I understand there are several other factors. I am trying to dwell for a second on the numbers in order to try to get that straight. Can I bring in our other two witnesses?

Dr Cadigan: My understanding is that there has been some difficulty in interpreting the figures on the basis of the last 10 years since changes were made in the way they were analysed. The inclusion of emergency care centres’ figures, together with A and E departments, has made it difficult to understand, and I gather there has been some debate about whether the inclusion of followup visits has made the figures difficult to understand. Local information from trusts that I am familiar with over this last critical period is that there has been, in the last few months, an increase in the order of 2% to 3% in attendances. At the same time, there has been an increase in length of stay, and it is flow out of the emergency department that is one of the crippling factors. That is something in which our college, responsible for most of the conditions that provoke emergency admissions, is particularly interested.

Chair: Thank you.

Mike Farrar: It is really important to understand what the figure that people are pointing to is describing. This is the number of people in A and E departments who are waiting longer than four hours to receive treatment and be effectively managed. That figure really points to the flow of patients through the system. So, while over the last decade we have seen increases in numbers of people attending, and indeed numbers of admissions, the NHS has, largely, been able to handle that flow. In fact, for the vast majority of the last decade, you saw improvements in the speed at which people were being managed through A and E departments. Over the last couple of years, that has plateaued and is now effectively decreasing in terms of the flow of patients. There are causes within the system as to why we might be seeing that: the inability to return people home into independent living and the inability to keep people well, which means more people presenting by default at the place of last resort, which accident and emergency departments are. We cannot avoid some speculation that the NHS has largely performance-managed this particular target quite heavily for certainly five of the last seven years, but that has lost traction over recent years. In fact, the key thing about this performance-management culture, which people often say has been brought into disrepute, is that it also had preventative aspects. When you saw performance deteriorating around A and E, you were able to put in extra resources to support that. It was not all about saying, "There is a big stick." There were also some opportunities for support and that system leadership has disappeared.

Of course we are also aware-and we do not have data on this, but I am worried-that the resources available through social care support, which very often might have been low-level family support such as respite care, are the kinds of things that were keeping people staying at home longer and may well have been lost with some of the resource cuts to social care. While they are still funding packages on discharge, the loss of preventing people arriving in a state of poor health may well be driving some of this additional acuity when people arrive at A and E services and need admission. So it is multifactorial, but it is a measure of flow. That is important because, if we are going to find solutions, it is not about fixing one bit of it; it is about getting the balance of investment across the system-primary, community, emergency medicine at the front door, general physicians in hospital, general practitioners out in the community. It is about flow and balance of resources.

Chair: That gives us an overview of the issues we are grappling with. Barbara, do you want to lead off on the fourhour wait?

Q10 Barbara Keeley: Yes. First, I am surprised that you are as tentative as you are in saying that it may well be cuts in resources for social care. There have been 27% cuts to local authority budgets. My local authority has moved to "substantial" from "moderate". I would put it stronger than that. I do not know why we are tiptoeing around this issue. That is an enormous cut to resources, which, as you say, is keeping people out of hospital. So we might as well be a bit more straightforward about it.

There are other things too, if I can just reflect, and I am not sure how common this is. Other cuts that were being made in my area were, for instance, to close two walkin centres and an active case management pilot for people with longterm conditions. They are all things that might have kept people out of A and E. The reason that the two walkin centres were closed was that they were not judged to be keeping people out of A and E, but in fact the one in my constituency was seeing 2,000 people a month. Those people do not go away, do they? If they are not able to go to the walkin centre, they are going to go somewhere. It may be that some of these shortterm decisions have had those sorts of repercussions. If that sort of decision is multiplied up and down the country, we have gone for the very short-term solution.

Let us go back to the waiting time target. We have already covered quite a lot of the ground, but 94 out of 148 providers are failing to meet the target of 95% of patients seen within four hours. Are we at the point where, just having that as a measure-if that is the measure-it is failing almost right across the system? There have been other factors introduced by Dr Clancy, things like overcrowding, which itself is dangerous. Are we now at the point where there are other measures that are needed to reveal the performance and quality of care within A and E, or do we still rely on that because the fourhour time limit is important in itself?

Dr Clancy: The deterioration in fourhour performance-which is a process measure and not a quality measure-has reflected the pressure the system is under. Organisations are now focusing more on how many people are waiting up to 12 hours and have, in a sense, parked the fourhour target because it is so difficult to manage. That is a reflection of the pressure the system is under. The problem with the fourhour target is that it is convenient but it falsely localises the problem-we have already said that it is a systemwide problem-and organisations such as Monitor have focused on that because it is a convenient thing. But there is a suite of seven other indicators, which have not been adopted, that allude to quality as well as process, and could reflect the quality of care and give a more even representation. Nevertheless, for all its faults, the fourhour target does reflect the problem, which is that it is a system under severe pressure that is struggling to perform.

Q11 Barbara Keeley: What are the other indicators?

Dr Clancy: I am happy to share those with you, but they include, for example, people who reattend, people who left without being seen, patients whose cases have been reviewed by consultants prior to discharge, and also trying to get a handle on patient experience, which is a really important aspect that we have found difficult to do well on up to now but do have as a priority.

Dr Cadigan: The merits and demerits of the fourhour target were debated in the medical community when it was introduced. The sceptics have had to face up to the fact that it has improved the standard of care in A and E departments up to the point where it reached the buffers in capacity. At the point where there is inadequate capacity and where the right thing to do is to hang on to someone for a little longer in the A and E department, the fourhour target forces you to move them-and forces you to move them to an inappropriate place-when it is clinically inappropriate.

Q12 Chair: That’s gaming, not care.

Dr Cadigan: Yes. It is clinically inappropriate. Of course if the patient moves to the wrong ward and is looked after by the wrong team, they are then handed over to another ward, and every handover loses you one and a half days in length of stay. So a target that is inflexible can be damaging. One good thing about the fourhour target, of course, is that it is the measure that has revealed finally, publicly, the extent of the problem, and the reason I suspect we are here today is that the fourhour target has failed in 90% of trusts.

Mike Farrar: I would echo what Mike and Patrick have said. However, it is a useful indicator, but there is a difference between an indicator and a target. The indicator gives you some sense of the flow through a system. In clinical terms, obviously, if you present with severe chest pain, waiting for three hours and 59 minutes is not right. So differentiating between the clinical triaging and making sure the right people get treated quickly within that is more important at one level than saying, "How is our system working?" But it tells you something about how patients are able to be admitted and the capacity of the hospitals. It also gives you a bit of insight into how many people are presenting, which we have discussed. It is a useful indicator, but I am clear that it is not a relevant clinical target-particularly now when demand is clearly outstripping supply-in the sense that it would be wrong to make sure that everybody got care within four hours but actually the people who need immediate clinical treatment are then being stretched in their time. It is more about getting that right, I think.

Q13 Barbara Keeley: The next point is this. We have covered some of this ground, and clearly we have the increases in demand there, but we have the other factors-more elderly people, out of hours, after midnight and by ambulance. You may not have data on this, but to what extent is the failure to meet that fourhour target demand and how much is it other factors? So many things have changed, haven’t they? Is there a feel for 70% of it being demand and 30% of it being something else?

Mike Farrar: It is worth being quite academic about this. It seems to me that there was a great absorption of increased demand for the vast majority of that first bit of the decade that did not impact on this target. In fact, on that target, we were getting better: the number that was ratcheted up at one time was 90% within four hours and it got to 95%, and that was while demand was increasing. To try and understand what will happen you need to look at, and be clear about, what has happened since we hit our high watermark. There is a resource issue here. At the heart of all this, the NHS has the increasing demand, but for the vast majority of the first part of that decade we were able to put resource across the whole of the system. We were increasing the resource available in line with demand. What has really happened since then is that demand has continued to increase but the resource available to increase supply has reduced. This, of course, brings us back to the great conundrum, which this Committee has sat looking at many times: the only way you were going to continue to be able to meet that demand was actually spending your money more wisely and investing in services that prevented demand. What you are seeing now is an indication that we have simply not been able to do that. My fear is that, because we are still struggling to do that, there is the potential for these figures to get worse. I am sure in the short term there will be a push to put more resources into this particular bit of the system, to look at this particular indicator, but the truth is that that inability to transform the way we provide care is really stretching waiting times.

We will see, I think, elective waiting times struggle as well because a lot of this emergency capacity has taken away the opportunity that the trusts had to do their elective work, which was all about the 18week target. Also, because financially trusts benefit more from their elective work than they do from their emergency work, it will have a knockon impact on the finances of the trust. So it is pointing to that inability, that we have had to transform the service and we have had more demand and less resource.

Dr Clancy: The demandflow equation probably varies in each system. There has been an increase in demand but it is not just the numbers; it is the complexity of these patients. They are more time-consuming to sort out because of the nature of their problems. The flow is a big problem because, if you have 10 patients waiting for six hours, that is 60 hours of patient care. You could have theoretically got through a lot more patients in that time but you still have to get through your patients plus look after these people who are there. The reason we are struggling is partly flow and partly increased demand, but also the time when that demand is made is when it is hardest to provide the service, which is out of hours.

Q14 Barbara Keeley: A point I have made on other occasions is that it is possible to look at the impact that changes in social care resource are having. Because we had 152 different social care systems up and down the country, it would be possible to locate a few where perhaps the changes had been biggest and judge what impact they were having on their local acute services. I do not know why we keep missing the opportunity to do that.

Dr Cadigan: I do not think we have data on that. You are absolutely right to talk about health and social care needing to work very closely together in solving some of the flow problems, both in preventing patients coming into hospital and expediting their discharge. It would be foolish not to face up to the demographics, which I am sure this Committee has heard about on many occasions, that there will be a 50% increase in patients with three or more conditions at the same time by 2018, and by 2030 the number of patients over 85 will have doubled. These patients consume a large number of occupied bed days with high average lengths of stay, so it would be foolish not to look at that demographic and consider the implications for social services as well as medicine.

Q15 Barbara Keeley: But it is possible, it seems to me, to isolate some of the changes that have occurred over the last year or two and say, "This local authority did this; what impact did it have on A and E and acute services?"

Dr Cadigan: I do not have data on that.

Barbara Keeley: No, but I am saying we should be doing so.

Chair: Dr Clancy wants to come in.

Dr Clancy: One of the problems is trying to understand the system, which is complicated, fragmented and with no requirement to report all of its new initiatives. So trying to understand the consequences of these changes and learn from them is quite problematic.

Q16 Grahame M. Morris: With all due respect, Dr Cadigan, you are missing the point. We understand the demographics. What has changed is the resource issue for local authorities. In most cases, they have changed the eligibility criteria so people who would have been supported through the social care system are presenting to A and E. We think that that may be a factor and should be further investigated.

Dr Cadigan: With respect, I do not think I am totally missing the point in that one of the difficulties with very elderly frail patients is making sure that you adequately meet their medical needs. There is a tendency-and it is sometimes a tendency among doctors-to regard these patients as "not coping", when there is actually a serious medical problem. We need to build in structures to make sure these patients have a proper assessment medically and socially. But I agree with you entirely that, without the social dimension being present, the system will fail.

Q17 Dr Wollaston: I have a point of clarification. Barbara referred earlier to the closures of walkin centres pressing up and increasing the numbers of attendances in A and E. Am I right in thinking that in fact walkin centre attendances and minor injuries units are included in the figures for A and E?

Dr Clancy: Would it be helpful to repeat the figures?

Chair: Not all of them.

Dr Clancy: No. If we combine the whole system together-emergency departments, minor injuries units and walkin centres-from 2001 to 2011, they went up 50%. That is the headline going from 10 to 20-

Q18 Dr Wollaston: But is it not the case that walkin centres and minor injuries units were only included in the figures from 200304?

Dr Clancy: Yes.

Q19 Dr Wollaston: So should we just take the figures from that time onwards?

Dr Clancy: Yes. It would not be dissimilar from what I have described. There has been a substantial increase when you take all of those combined. That has to be contrasted with type 1 emergency departments, where there has been an increase but it is of a lower order-say about 17%.

Q20 Dr Wollaston: In the CEM report you suggest bringing more GPs into A and E departments to deal with that. But isn’t the danger there that you just end up attracting even more people to attend an inappropriate location?

Dr Clancy: If we were a business, we would have been extraordinarily successful with the numbers that we were treating.

Q21 Chair: That is assuming you were being paid for them.

Dr Clancy: Yes. The fourhour target has attracted people. The issue is with finding a viable attractive option for patients who could be looked after in an alternative setting to the emergency department. Our challenge is to provide something, working with patients, that they would want to use. The trouble is that emergency departments are a highly identifiable brand with a guaranteed service. We need the alternatives to be equally visible, available and desirable. That is a challenge. At the moment, the initiatives of working with primary care, which are a key component to all of this, are to get the work force to deal with these patients. But in the longer term those patients that are best cared for out of hospital should be cared for out of hospital.

Q22 Dr Wollaston: My point is that you then facilitate it and make it an even more attractive offer by putting more GPs within a casualty department, but would it not be better to put those GPs out in the community so that people are drawn to the correct location? Aren’t you going to create an even greater pull factor?

Dr Clancy: We would be delighted if primary care and the components of that were able to attract patients out of emergency departments to be looked after by them. What you have are these shortterm fixes for a severely pressured system. The longer-term strategy is that patients who do not need the resources of an emergency department-it does not serve them or us well-should be looked after in the community.

Q23 Dr Wollaston: I am sorry to press this point, but, if as a shortterm fix you put more GPs into casualty departments, aren’t you going to exacerbate the problem? You are going to have even more people attending. It is not a shortterm fix at all surely.

Dr Clancy: It means that you get more people attending the same location but looked after by a different and appropriate professional group, which I think is helpful. The longer-term strategy should be about that care being provided in an alternative to an emergency care hospital setting for those patients who need that.

Q24 Dr Wollaston: But, if there is a shortage of GPs and you put them in a casualty setting, you are just going to end up reinforcing the wrong pattern.

Dr Clancy: Yes, that is one of the challenges that we face, which is that emergency departments are the mat upon which everything else that does not quite work well falls. We need to hold all those other parts to account to make sure that they work properly; if they are working properly, those patients do not need to be there. We would welcome a system that is joined up, works together and is transparent and accountable. As to patients who come to us who could have been looked after by another group, we could work with that group to help them look after those people.

Mike Farrar: To add a supplementary, one of the issues about outofhours services is that you do not have the full range of professionals available to you that you have during inhours services. At one point the view was that if you were not treated by a doctor you could not be managed, but we have gone way beyond that and many multiprofessional interventions take place during the day. But when we go to the outofhours period there is much less availability of a multidisciplinary team. That is one of the problems. If you are trying to find solutions, more and more GPs spending more time out of hours dealing with problems that could be dealt with in a more lowlevel and caring way is not a sustainable solution either. So there is something about getting the 24/7 nature of healthcare right but seeing that as multidisciplinary, not just about more doctors.

Dr Wollaston: Thank you.

Dr Cadigan: That is absolutely right. I agree with both my colleagues that one of the big challenges here is outofhours care. The problem, as Mike Clancy says, is that A and E is the recognisable brand. That is where patients will go because they know they will see someone who is expert-who will see them, often within four hours, and they will receive treatment. Patients will go where the lights are on. In many of these alternatives, the lights are not on after five o’clock in the evening or at weekends. We have to face up to the fact that services other than an A and E department are often run on a ninetofive and elective basis. So the challenge to the entire service-and I think this is a problem for all of us primary and secondary care managers-is to say, "How can we deal as a whole service with this challenge and do we prioritise it? Do we move people resource into that area?"

We have a view that we will have to change the way that physicians work. We have a project called the Future Hospital Commission, which will look radically at the way physicians work to improve patient flow. The challenge to primary care-and we must ask representatives of primary care to talk about this-is what contributions they will make to solving this problem.

Chair: I have a lot of colleagues wanting to come in. Andrew wants to come in and then Virendra.

Q25 Andrew Percy: I want to come back in on the social care issue. I was concerned that there seemed to be a casual link being made between the two, but actually there is no evidence to support it at all because it is important to stress that eligibility criteria for social care services for the last decade have been getting downgraded. I was on a local authority for 10 years and we downgraded the social care services a number of years ago. In my own local authority we took the decision not to downgrade from "substantial" to "moderate", but we have still seen this huge spike in A and E. It is important to stress that and to tease out from you, which is what I think you have said in your evidence, that there has not been any piece of work done around this, has there? There is no evidence to support the fact that social care service changes and the changing of the thresholds has so far impacted, given that a lot of local authorities have made the decision but have not actually implemented it yet?

Dr Cadigan: I do not know of any evidence of that.

Q26 Andrew Percy: That leads me on to there being other factors at play here. In my own constituency, the biggest issue for people is not accessing GP services out of hours. We all know the history of that. I am wondering whose job it is to take the lead, particularly around this issue of what impact the social care changes will have, because there are statements made around the table about this having such a huge impact but there has not been any study done of this or any evidence to-

Dr Cadigan: The only indirect bit of evidence I know of is that health economies that have a large population of elderly people living in them have better hospital avoidance rates and lower hospital admission rates than other health economies. That suggests to me indirectly that, if you have built up a lot of services for elderly people, then that may work. But I cannot break that down into health and social care.

The other thing to say-and again it is harking back to the outofhours issue-is that, if an elderly person has a crisis in their home, a fall at the weekend or out of hours, it is very difficult to access social services, primary care and a number of very good things that you can access Monday to Friday, and patients come to A and E. Without a system in place at A and E for accessing intermediate care, for example, those patients will be admitted to an acute bed by default. A and E is the default position.

Mike Farrar: Can I pick up on this point? In terms of changes to eligibility criteria, that is just one element of this. What I was referring to, which is harder to demonstrate, is the community support organisations that are absolutely vital in working with our services to keep people living independently. That is one of the factors.

You point, quite rightly, to the fact that you say, "Eligibility criteria over a decade have seen improvements even while they have been tightening." But I would say the same of GP out-of-hours services, that, since the changes were made in 2004, the first seven years of that saw improvements in this measure about whether or not people were flowing through the system even after those changes.

The key reason why both the Conservatives in 1990 and the Labour Party in 2002 took decisions on GP out-of-hours services was because you could not recruit GPs. The biggest barrier to recruitment, people said, was the outofthehours commitment, the outofhours responsibility. In our strategic aim of the NHS, which is to create more primary community social care and avoid our hospital services being used, if you cannot recruit GPs, then you are in real trouble. So the outofhours changes are a bit of a red herring in some way when we are looking for the significant issues. Improving outofhours care is significant and looking at the wide range of services available through social services is a big issue. Eligibility criteria may be a more specific issue and up till recently we have managed to absorb those changes, but now, when there is less resource available overall, we are facing real problems.

Q27 Grahame M. Morris: On that subject, because I think it is really important, Mike you told us earlier that the causes of the increase in attendances are multifactorial-there are a number of aspects to it-but the Secretary of State has said several times in debates, in Health questions, that he pinpoints the prime cause as being the change in the outofhours GP contracts. There are other issues around the new 111 service, our concerns about the change in eligibility criteria putting further pressures on the service, but could you focus in on the Secretary of State’s position in respect of the change of outofhours contracts, and perhaps Dr Cadigan and Dr Clancy might have a view on that as well?

Mike Farrar: I remember outofhours care before the 2004 change and, basically, the big change that people remember was the one where GPs themselves stopped doing their own outofhours care-the image of "Dr Finlay’s Casebook" was there. That was a change in the 1990 contract. After that point, GPs did not have to provide their own outofhours care but were clinically responsible for the quality of care of the deputising arrangements, and, as you know, at that point GPs either did their own deputising through GP coops or they had commercial deputising organisations. There was a high level of complaints about outofhours care compared to inhours care, as you can imagine, and that has continued over the last two decades.

In 2002, the contractual changes at that point said that GPs no longer had to be responsible for the clinical quality of the deputising services. In practice, not much changed other than we paid more because PCTs, who were supposed to commission then a wider range of services, would commission the primary care outofhours service in the same breath as A and E departments, walkin centres and NHS Direct. The idea was that you had a more coherent strategy for outofhours care, but in fact PCTs rolled over previous contracts and just had to pay more because GPs were not obliged to do it. From 2004 to 2010, although that change was in place, improvements in the flow of patients through A and E were going up, with the high watermark being 200910, I think, when 95% of patients were going through in four hours. So the question is what has happened since then. I do not think there have been any discernible structural changes to GP out-of-hours services since then.

So I would say-and I think there is room for improvements in every service-that the evidence of a direct correlation between GP outofhours care contractually being the requirement of GPs and the A and E performance is not necessarily proven by those statistics.

Q28 Mr Sharma: Thank you very much. We heard evidence that primary care is also struggling under demand pressure. Is it the case that there is more demand across the board, and pressure in A and E is not the direct result of patients staying away from primary care? Can I add to that, does this indicate that there are simply more people presenting to NHS services all across the emergency and primary care system?

Dr Cadigan: I cannot speak authoritatively for primary care, but I know that there has been an increase in the rate of general practice consultations year on year, up from something like-I may not have this right-an average of three to an average of five over the last five years. But there has been an increase in consultations and I do not think anyone is disputing that general practice is working very hard.

There is evidence that general practice behaviour can influence hospital admissions. There is evidence that continuity of care with a GP is correlated with reduced referral rates to hospital. There is also evidence of very different performance across the primary care system, with some primary care functioning extremely well but with a variability of that quality. That quality is seen-and again I do not have the figures-in that, with out-of-hours care, I think there is a factor of 10 variability in the rate at which patients are referred to hospital via outofhours primary care organisations. That may reflect the availability of other services. What I am certain is-and I cannot speak for primary care-that they should be involved in this discussion as key partners in finding the solution.

Q29 Mr Sharma: What do you say, Dr Clancy?

Dr Clancy: Just to come back to the contribution of out-of-hours care, I am unaware of any evidence that it has fundamentally changed over the last few years and the deterioration in performance has not corresponded with an alteration in the way out-of-hours care has changed, so its contribution to the present problem is not obvious to me. What I would say, however, is that its contribution to the solution of this problem is very obvious in that they can make a major contribution in looking after patients where they can provide an alternative to emergency departments.

Q30 Grahame M. Morris: Can I ask a very short supplementary? There was previously a commitment to the delivery of an appointment with a GP within 48 hours, which has been quietly dropped. Do you have any evidence or have you quantified what impact that has had in terms of patients who say, "Well, I cannot get in to see my GP till next week. I know I will be seen at A and E," so they present there instead?

Dr Clancy: There is a review of the evidence by the urgent and emergency care review, which is in draft form at the moment. I think we are all wary of commenting on another professional group, but there are relationships between availability or performance of appointments and whether people attend emergency departments, as well as social deprivation and other factors. Reference to that document may be helpful in answering that question more comprehensively. But, as to the notion of availability of appointments and their relationship to the use of emergency departments, I think there is evidence to support that.

Mike Farrar: Can I come at this from a slightly different angle, because it is illuminating? Work has been done by a group called Patient Access. Rather than coming at, "Where are the big problems in this?", they looked at practices-this was largely around Leicestershire and the east midlands-which seemed to have the lowest number of A and E attendances. What they found for some of the top performers-not uniquely, true-was that they have moved from an immediate access, a facetoface consultation, in general practice to an immediate telephone consultation with a GP. They found that the cutoff was 30 minutes. So, if you got a telephone consultation with GPs in 30 minutes, it had a big impact on the facetoface consultations in general practice. It reduced it by something like 40%. But even though that measure was taken to support primary care work load, it was having a corresponding benefit in A and E. They had not intended that. So, if you come at this from an appreciative inquiry of, "What is happening in those places that are having low A and E attendances?", it does seem to point to immediate access to medical advice being very helpful in reducing your need then to go to A and E. But you could not do that if it was based on a similar basis of facetoface consultations because of the available slots. So, one of our solutions has to be about this opportunity around using technology and immediate access.

What we found in the middle of the last decade with some A and E performance in the past was that, if you had a more junior sort of triaging upwards, then you built in a lot of delay, whereas, if you could get access to more senior opinion sooner, you could discharge, take responsibility and then people’s use of the services could be diverted to the right place quicker. I very much support Mike’s point about whether the outofhours arrangements and the sort of access issues in play outside of hospitals are material to the solution? I think they are, but it comes back to whether we could we use our technology-things like telephone or online consultations-much better. Of course you can do online consultations through the night, and there is a whole set of reasons why you can deal with some problems that way.

Q31 Grahame M. Morris: Didn’t someone introduce NHS Direct following that philosophy?

Mike Farrar: But NHS Direct was nurse-led. NHS 111 is protocol-led and it still takes a while to get to the doctor. That is one of the points I made about having senior decision makers at the earliest point. It seems to have a good impact.

Q32 Barbara Keeley: It is that point, really. In Manchester, we have had total collapse of NHS 111. It suggests it is going to lead very directly to a whole load of people who cannot get access to that medical advice and it is not nurse-led any more so people would not have the confidence in it. It seems to me that it is possible-we have raised the point about looking at places where social care changed a lot and clearly the collapse of NHS 111 in Manchester when it was first introduced-to work out the impact of these things. It seems strange that we have a national picture presented to us and yet we have had examples where things have really gone wrong. The same is true in commercial outofhours services in certain parts of the country, where the commercial provider that was brought in has not done a good job, not such a good job as a GP cooperative, and those arrangements have collapsed and caused lots of problems. There should be some case studies on these things to work out the impact they are having. I am surprised that we have this national picture and are not looking at these very specific examples that would suggest what goes wrong. When NHS 111 is introduced and then falls over, what impact does that have? Was there a spike in the A and E figures?

Mike Farrar: I could not disagree with the proposition that we should have more data to understand the consequences, but there is considerable variability. We are talking about case studies and it is often difficult to generalise. We try and present this aggregate figure and give general trends, but it-

Q33 Barbara Keeley: It is not helpful when so many things have changed.

Mike Farrar: No, and certainly I think you can look at case studies such as I have described. It is not just where it is failing, but understanding what is going right that points to what the future might be. Certainly we try to do that with our members and I know others are trying to do that, but we could and should do more.

Dr Cadigan: I think a very important principle was raised by Mike with "early senior review". Wherever it has been looked at-in whichever setting, in the A and E department, the acute medical unit or in general practice-the fact that you have a senior decision maker available to assess patients and advise them at the point where admission is being considered has proven both to facilitate appropriate admissions and to prevent inappropriate admissions. That senior decision maker in the community could well be a general practitioner, and it would be very important that that general practitioner had access to complete records about the patient and any care plan decisions that had been made. That theme of continuity of care via continuity of information is an important one that we might want to explore when we talk about how the system works, but, if a general practitioner were in that role, then they could certainly function as a senior decision maker. The telephone experience that Mike is describing has the principle called "Doctor First", where patients have access to a conversation with a doctor first, and that seems to work.

Dr Clancy: I find trying to understand the performance of 111 very difficult because I have not seen nationally collated figures of how the whole system is performing. Therefore, trying to get a balanced picture-such as whether Manchester, for example, is representative of the rest of the country-is problematic.

Q34 Barbara Keeley: I mentioned that because it collapsed when it was first introduced. The complete absence of NHS 111 probably has statistical significance. It might provide a case study.

Dr Clancy: I think the notion of patients having access to a telephone to get advice and guidance is a good one that should not be abandoned because of the difficulties we are experiencing at the moment. Patients have to have access to a resource that tells them what they need to do. It is our responsibility, as a health service, to deliver that.

Q35 Barbara Keeley: There is a question, surely, of whether that has to be a senior decision maker. We do not even have nurses any more on this service.

Dr Clancy: There is recurring evidence that the more senior the input and the earlier it is in the patient journey, the better the patient journey. If you choose alternatives to that, then you have to compensate by having people behind them to pick up the decisions.

Q36 Valerie Vaz: I am seriously concerned about what you are saying about patients having to speak to a doctor. You are sitting there as professionals, but the average patient probably would not know what to say and what to ask. As to this idea that you just ring up a doctor and tell them about your symptoms, I thought medicine was based on observation. I have had exactly the same experience and I have a degree in biochemistry and am a lawyer so can actually articulate it, but the average patient probably would not know what to ask, would they? Do you seriously think that is a good way for patients to be seen?

Mike Farrar: All I can do is rehearse with you the evidence from those practices in terms of the acceptability to patients of speaking to doctors on the phone, the evidence from some of the early telehealth studies where people have been seen on the line, and the fact that in those practices they have reduced the number of people who get facetoface consultations and it does not seem to have any detrimental impact on outcomes. It is very difficult to generalise about patients. While you might say, "Can the average patient articulate their problems?", we also have GPs who say the average patient comes in with reams of internet-printed script that they understand far better than they do and how can they possibly keep up with the evidence? Generalising about patients is a problem, but in those practices the evidence seems to be that patients like it and that there is no deterioration in their care as a consequence of getting a telephone consultation within 30 minutes.

Q37 Valerie Vaz: With the greatest respect, you are generalising and saying, "Patients like it"; and you have just based this on-what-the evidence of two practices? I can tell you that I do not like it.

Mike Farrar: Aren’t we both generalising?

Q38 Valerie Vaz: I don’t like being turned away from a surgery.

Mike Farrar: I was pointing to some practices that have actually done this.

Q39 Valerie Vaz: But I am saying we should be very careful and I do not accept what you say, that patients want to speak to a doctor, because you are putting the onus on the patients having to understand what they are being asked and not everyone would know that spewing up, or coughing up, green sputum is a bad thing.

Dr Cadigan: What I would say is that doctors spend a lot of time talking to patients, get pretty good at extracting relevant information and deciding whether that needs to be taken any further by perhaps asking the patient to come in to be examined. Of course what you lose is the facetoface contact. You lose some of the way you can use your antennae in that way and the ability to examine patients, but, provided you are aware of those limitations, you can behave safely and usefully.

Q40 Valerie Vaz: You could not do that with an elderly patient, who maybe has complex needs, could you? I don’t know.

Dr Cadigan: Ideally that elderly patient with complex needs would have been assessed and you will have access to the information about that assessment. We might come on to that later.

Chair: We have a long list of questions in front of us. Mr George wants to come in and then I am going to move to David Tredinnick.

Q41 Andrew George: I want to pick up on Dr Clancy’s earlier comment that the sooner a patient can be seen by a senior clinician, a doctor, then the sooner the issue can be resolved. In my own area in Cornwall last year, the outofhours GP service began using the NHS Pathways telephony logarithm system and it immediately produced a spike in, or larger numbers of, patients coming to the emergency department of the local hospital. It appears from that-and it is backing up a lot of what you are saying-if you use a system with clinicians who don’t know the patients and telephonists who are not clinically trained using that system, that it is more risk-averse and seems to produce more patients coming into emergency departments, clogging those departments up. Aren’t there lessons to be learned from that and from a lot else that you are saying, that you need to introduce more familiarity, early intervention of clinicians into the system?

Dr Clancy: What we are saying is judgment versus an algorithm and I think experience and judgment can trump an algorithm. The algorithms are risk-averse because, rightly, we do not want to get it wrong. It is a big responsibility for the people who are taking those calls, and that is why it is set in that way. One of the consequences of having that approach is that the referral rates, I suspect, will increase. One of the values of having an experienced clinical judgment at the beginning is that you can add more to the judgment than an algorithm.

Mike Farrar: It is important to qualify, from our perspective, that the importance of clinical judgment at an early stage is for those for whom there is a serious clinical condition that needs to be managed. There is a place for 111 but it needs to be in the context of other services. Equally, there is a significant place for keeping people well that avoids them having to look for advice and immediate assessment. Patrick’s point about the role of primary care being proactive in terms of managing people with known and chronic problems is the ultimate strategic position that you want to find rather than saying part of the way that we deal with this current crisis is to spend more time on very senior doctors being more available to people who have fairly minor needs. But for the group where there is a likely potential of admission, the access to a senior person sooner is where it is critical. Certainly, the amount of risk that a senior clinical perspective is prepared to manage compared to a junior view is significant in terms of the number of admissions that we have seen.

Q42 David Tredinnick: Specifically on the subject of risk, do you think that clinicians generally have become more risk-averse, particularly since the Francis report, in decisions relating to admissions and discharge? Do you think this could have contributed to the pressures on the system resulting in more trusts missing their fourhour targets?

Dr Cadigan: We are meeting in the shadow of the Francis report and we have been talking, I suppose, more about quantity than quality of care, but it is a very serious issue. Have people become more risk-averse since the Francis report? I do not know of any evidence about that, but the evidence that senior doctors admit fewer patients to hospital probably suggests that there is a confidence factor involved in discharging people. One of the disadvantages of having very junior doctors responsible for those decisions-and that still happens in some trusts-is that they will be very risk-averse and will admit first of all. So managing uncertainty and risk is part of the essential professional skills, and that develops with time.

Dr Clancy: It is really hard to isolate, but people are more comfortable and confident around moving patients when it is to their benefit. As to the gaming issue and the pressures people are under, which we should not underestimate-units are under severe pressure to meet these targets-clinicians, nurses and doctors should feel more empowered and comfortable that, when they witness something that they do not think is right, they do not allow that to happen. That has been something that all of the colleges have encouraged and I know that Parliament has as well. That does translate into a different practice, but I do not believe it is a contributor to the present performance issue.

Q43 Barbara Keeley: Pressure to achieve cost savings has led elsewhere to a reduction in bed numbers, with the consequent impact on the ability of A and E to process patients. You talked a lot about flow issues, but at the same time there seems to be this increased demand for acute admissions, in that you said patients are more ill and more likely to need admission. Is there not a simple thing there, that part of this problem in A and E stems from a reduction in bed numbers? What is the evidence that that is a factor?

Mike Farrar: Bed numbers have reduced, but so has length of stay. Bed numbers are not the greatest guide. It is more about the use of beds and how hospitals are working. I would be very cautious about saying that the only solution to this is about creating more capacity. One of our problems at the moment, when we are trying to invest more in primary, social and communitybased services to prevent people from needing hospital, is that the resource we need is very much tied up in our current expenditure in hospital. If anything, despite the fact that our strategy has been to invest more in primary and community, we have been, in percentage terms, putting more money into more hospital capacity and more hospital care over the recent decade than we have been putting into primary and community care; RCGP figures demonstrate that. So it is a great challenge. The challenge, in talking about bed numbers, is more about the flow of patients who need hospital getting really good quality care-getting the best care when they are in there so that they don’t have to be readmitted-having proper discharge planning when they arrive so that they can go out smoothly and getting the balance of investment in social care right so you are not waiting for access. But I think bed numbers per se is not a great number, and we would have problems if we started to have a political debate in this House that said we are protecting the NHS because we are keeping the bed numbers high. It is not about input; it is about the use of those beds.

Q44 Barbara Keeley: My question was opposite to that. There has been a reduction in bed numbers and now you have-clearly, because you have an increased number of more elderly, more ill patients who need admissions-an issue in that they are getting stuck in A and E because you cannot admit them. It is more that than the other way round. I am not suggesting-

Dr Cadigan: I think that is right and there is an ambition to reduce the number of hospital beds.

Q45 Barbara Keeley: But is that the right ambition given that we now have an issue in A and E?

Mike Farrar: It is part of that flow.

Dr Cadigan: So the number of acute beds has gone down by something like 10% in the last 10 years. We have compensated for that by reducing length of stay. If you look at the lengthofstay graph, that has now started to plateau, so we are struggling to-

Q46 Barbara Keeley: But the link I am trying to chase is the link to the process and flow problem you have in A and E in that, if you cannot admit them, they are going to stick there in A and E until you can.

Dr Cadigan: Yes, and there are figures from local trusts showing that, this winter, length of stay went up. That is because it becomes more difficult to use that smaller number of beds efficiently. Because occupancy rates are very high, patients are in the wrong ward and they move ward four times, and it is difficult to deal with them in terms both of quality and efficiency of care when the number of beds is small.

Q47 Barbara Keeley: So there is a link.

Dr Cadigan: The more you reduce the number of beds, the more difficult it is to cope with variations and fluctuations.

Q48 Barbara Keeley: Obviously, so there is a link to this A and E problem, to the reduced number of beds.

Dr Cadigan: There probably is a minimum number of beds that we can manage with. The demographics of the ageing population suggest that we will have to maintain a certain number of beds. What that number is I do not think anybody knows, but it would be naive-and this was said by the national clinical director for elderly care-to believe that any time soon there will be a reduction in the rate of acutely ill elderly patients coming to hospital.

Dr Clancy: When you are running occupancy close to 100% or more, it is incredibly hard to get patients into hospital. If you do not have some capacity, the turn-around times for these patients becomes more problematic. I am not an expert at flow, but about 85% occupancy, as I understand it, is the ideal level. Once you start operating at a much higher level, it is very difficult and we do not have that headroom to get these patients in and out of the system. That is where, with the bed reduction, in my view-and I have much sympathy for Mike’s argument about increasing capacity-there is some sense of having reached a ceiling here. If you cannot get the patients in easily and it is taking till four o’clock in the morning to solve these problems, do we need more capacity than we presently have?

Q49 Valerie Vaz: The majority of admissions at The Manor hospital seem to be elderly people. Would one of the solutions be a proper, integrated look at elderly people going straight to a specialist ward, rather than coming through A and E?

Dr Cadigan: There have been many such solutions tried. Could I point you to the work that has been done in Leicester, by Dr Simon Conroy particularly, where a geriatrician is based in the A and E department and that geriatrician has access to a number of different facilities that can be used-access to intermediate care beds, elderly care psychiatry and to a frail elderly assessment unit? That is a point where you have a senior decision maker, responsible for that particularly difficult and challenging group of patients situated in a place where they can take a decision, and where they have access to alternatives to acute admission. That is a model that has been shown to work, has been shown to reduce admissions and to increase the quality of care. Of course, part of the work we are doing in our Future Hospital Commission is to go round the country looking at units like this. That work is being replicated and trialled in many other parts of country, so I think people are groping their way towards these solutions and might need some help to push it on.

Q50 Valerie Vaz: Where would they get that help from? Who gets a grip of all this? Where do they get that help from?

Dr Cadigan: How is it paid for?

Q51 Valerie Vaz: No, who gets a grip of it? You said people are going round and there is information swirling around. Someone has to get a grip of all that information. Please don’t say it is the NHS Commissioning Board.

Dr Cadigan: We are collecting some of that information.

Q52 Valerie Vaz: Right. Are you feeding it into somewhere?

Dr Cadigan: Indeed. We have a project at the moment called the Future Hospital Commission.

Q53 Valerie Vaz: I know about that and have met representatives, but who would get a grip of all this information in the Department of Health?

Dr Cadigan: The national clinical director for elderly care would be a good person to look at and there are publications from the Department on this, but I cannot tell you where they are at the minute.

Q54 Grahame M. Morris: I have a question about the kind of multifaceted nature of the increase in demand, but, just to go back to an earlier question, there is something I should bring to your attention, which I am sure you are aware of. We shouldn’t characterise all the increase in demand as being frail elderly. There are 500,000 disabled people under 65 who are falling out of the social care network who develop to a crisis point and need admission. So the debate on how we address this should not be focused exclusively on the frail elderly. I wanted to ask you about how we are tackling this, because it is multifaceted. It is not about changes to GPs’ outofhours contracts. It is not exclusively about the operation of NHS Direct or the 111 service. There is no magic bullet. We need a broad-spectrum antibiotic, don’t we, to tackle it on a number of fronts? What is the role of the Urgent Care Boards? Are they helpful as a mechanism for addressing this multifaceted problem?

Mike Farrar: It is a good move because, effectively, it is trying to replicate someone. It comes back to the point that was raised before about who has a grip on these things. If these things are multifactorial and relate to all bits of the system, then a systemmanagement approach, where you have somebody who can take that overview, is really important. In the latest reform to the NHS, those kinds of systemmanagement roles have been structurally removed so the only way that you recreate them is by volition, where you create something like a board where the parties can come together and actually identify-and it will be different in different parts of the country in different places-where the particular investment or problem is.

I welcome the urgent and emergency care boards. I think it is a good move. They need to be able to look perhaps broader than just the individual localities. There is a risk that you create a large number of very small ones, when actually most of these systems work around conurbations; things like 111 are a Greater Manchesterwide service. So I think there is a view that perhaps the urgent and emergency care boards need to be bigger than individual districts. But I do welcome it and it does replace that system leadership thing that is now-I think detrimentally-missing in the new system.

Q55 Grahame M. Morris: Can I ask your colleagues to reply as well? Could you also give us your thoughts on whether it is best to have a local solution in devising a recovery plan or whether there is undue influence from the centre, from NHS England?

Dr Cadigan: Another easy question. As to the Urgent Care Boards, we welcome them, but cautiously, because to hand over the most difficult problem in the NHS at the moment to an immature organisation that is working under the aegis of several immature organisations is potentially hazardous. That being said, the idea that commissioning should drive this is an important one. To put the clinical commissioning groups at the centre of it seems to me a key. One of our hopes for the emergence of clinical commissioning is that it would allow sensible conversations between commissioners and providers in solving these sorts of problems. It is very interesting, again, that those trusts that have succeeded best in reducing hospital admissions have been trusts with a single commissioner, so the development of a relationship between a trust and a commissioner, which is capable of constructing perhaps new ways of working financially. Many of the successful projects that have achieved this have dismantled payment by results. It is interesting that Monitor is looking at payment systems at the moment. Collaboration between clinical commissioning groups and local providers with the right clinical advice has the potential for solving this problem. The difficulty is that they do not have any more levers than we do at the moment and no more money.

Q56 Grahame M. Morris: It is another layer of bureaucracy when part of the concept was a simplification of structures and bureaucracy, yes. I am not putting words into your mouth; it is just a thought.

Dr Clancy: I think the Urgent Care Boards are welcome. They are a recognition of the problem, but we have to ask ourselves why they have had to be formed when there is a group already responsible for the delivery of that care. This means that it is a very difficult problem to solve. The clinical care groups may well be the mechanism, but the responsibility and oversight of this whole problem, in my view, has to be central. It is a risk if we devolve this to local responsibility. We have many options, which may or may not be supported by the evidence, to explore. What is clear is that people are seeking guidance as to how to solve this problem because it is a very difficult problem. Unplanned attendances relate to a third of the health service’s activities and half of their budget. To allocate this to embryonic structures that are struggling with a very difficult problem, to me, seems not to be the safest way forward.

Q57 Chair: Do we have any idea, purely as a question of fact, how many Urgent Care Boards are envisaged? What is the process from where we are now?

Dr Cadigan: I understand from the documentation I have read that there will be one related to each A and E department.

Dr Clancy: I don’t know. I have the document somewhere.

Q58 Chair: Did you say one related to each A and E department?

Dr Clancy: It may be each commissioning group, but there is a document from the Department.

Chair: I think it is something about which we might seek guidance from the Department.

Q59 David Tredinnick: On these boards, it seems as if you-and I listened to Mr Farrar-were suggesting that these are almost mini-strategic health authorities, and that you lament the fact that we no longer have that oversight. They are certainly smaller, but-I am just trying to work out-I do not think they are quite as small as has just been suggested. Do you think that is fair?

Mike Farrar: I would not want to call them mini-strategic health authorities because it is around a particular function. If this is a wholesystems issue and if we have fragmented budgets, which we do-so the spending of money in primary care, social care, community and hospital care, for specialist services and on prevention is all in separate pots with separate budget holders-and if you are trying to fix these things locally, I do not see any other way around getting a group of people who control those budgets together to look at how are they spending them with synergy to get a better service. I am not a great fan of saying you have to have committee structures to do it-I should not say that to a committee, should I?-but the reality is, to align those budgets and get a common purpose around what the solutions are, that you do need to bring people together. If the mechanism in the short term is Urgent Care Boards, then fine. Do they need to be a fixture for ever and a day? Hopefully not, but I think you do need to get them together to resolve it and I do not see any other way around that at the moment.

Q60 David Tredinnick: I have one other question on this, unless anyone else wants to come in through you, Chair. What do you think of the King’s Fund’s suggestion of urgent care networks, please?

Dr Clancy: These suggestions, to my knowledge, are evidence-light and we have been subjected to repeated experimentation. I would ask that we do not adopt new things until we know they work. The urgent care centres were an experiment. We do not know whether they worked. They do not uniformly deliver the same service and so on. So I think we really need to ask the question, "Are these good things to do?" before we do them.

Q61 David Tredinnick: This is not strictly related to this, but it came up in earlier questioning. Why do you think there are so many more A and E admissions after midnight?

Dr Clancy: It is a mixture of things. There is the issue of what society expects as well as what the patient needs. The concept of discharging somebody who has fallen over, who is elderly and on their own at night and who comes to your department, to send them back to their home with an element of uncertainty about how they will do, is not acceptable in society. The alternatives-

Q62 David Tredinnick: It is a cultural change, is it? Is it, going back to Francis, a riskaverse society that is now overloading the system?

Dr Clancy: That is not necessarily related to Francis and was so before that.

Q63 David Tredinnick: It is health and safety. We were always talking about health and safety. Is it now that we have become so risk-averse that this is actually impinging on A and E’s capacity?

Dr Clancy: The problem is that the options to discharge, for example, elderly falling patients in the middle of the night are negligible. The services that you can use to make sure that they go back safely are hard to assemble at night. Also, I believe that there were directives that we should not be moving around or discharging patients after midnight as well. So there are demands upon us that society expects of us as well as the clinical needs of the patient.

Q64 Valerie Vaz: I want to ask you, Dr Clancy, something you mentioned in your written evidence about rising demand. You also said "the lack of staff recruitment ensures that the ratio of doctors to patients has steadily worsened." Do you have a figure for a safe ratio?

Dr Clancy: I can tell you that we are seeing about 15 million patients and that there are in the order of 1,400 consultants. That works out at about just over seven consultants per department. We have grown from four or so in 2007, so there has been an expansion, but there are not enough trained emergency physicians to deliver the care that the public expect. The recommendation of the college was a pragmatic one, which was, "How many consultants do you need to deliver a 16hour presence"-in other words, up to midnight-"in a department?" The minimum number for that was 10. We are well short of that, but we had made substantial progress. That is not the major concern. The major concern-and this Committee really should understand this-is that junior doctors are choosing not to do this kind of work. This is difficult, unsociable, intense work. The fill rate into our higher training programme is half what it was and we have lost 200 future consultants because of that failed recruitment. The need to recruit more consultants is very evident. We know that, if you have consultants, associate specialists and other trained doctors, the quality of care improves.

My major concern for the future of the emergency care system is that not enough doctors want to do this work. I am talking about the emergency departments, but the same arguments apply in the acute medical unit and to the general practitioner at two in the morning in a tower block. The challenge that we face is: how do we value this work more highly than we do now and how do we ensure that we attract doctors into this work, which is difficult and hard, in a career that is sustainable? We are asking doctors to work till they are 67. This is tough work that many doctors migrate away from because it is hard. So one of the challenges is that we need-and we have talked about joinedup systems and thinking differently-to enable emergency work to be as valued as much as elective work and not seen as some annoyance to the hospital system that ruins their income generation. You may well come on to the funding of emergency care and the way in which it is inadequate and unfair, but the fundamental challenge that we face is that the future work force is not sufficient to deliver the care that the people of this country expect. The lag time to sort that out is about 10 years and it is not for lack of saying that.

Q65 Chair: I do not think there will be any disagreement in the Committee about the importance of that. Could I ask you for a checklist of three priority areas to address the lack of attractiveness of emergency medicine to young wouldbe consultants?

Dr Clancy: There would be a sense of commitment and a clear vision to address this problem so that people who are interested in this area could see that there is an intention to sort the problem out. By sorting the problem out, the circumstances under which they work become better because overcrowding starts to be addressed. We need to give them a worklife balance that is achievable. There is a remuneration issue to this, as there is in many walks of life, but we need to recognise the intensity and unsociability of this work to encourage doctors to join us. At the heart of this is a commitment and vision to sort the problem out. That requires a clear expression by all the trusts, Urgent Care Boards and whoever else, that they will solve this problem. If we cannot see the prospect of a solution, then attracting the good and best able doctors-my specialty is the most exciting, as you would expect me to say-will be difficult. The issue is the sustainability of doing this job and we need to look at how we can attract more people into it. It is about worklife balance, intensity, recognition and valuing emergency care more highly.

Q66 David Tredinnick: I find this a really extraordinary response, I have to say. I was lucky enough to be at a dinner last year at the Royal College of Surgeons and they were saying that surgeons who had gone out to Iraq and worked in emergency care regarded that as a huge benefit because they had learned so much in such a short time. I find it extraordinary that junior doctors would not see A and E as a terrific opportunity to improve their skills and actually to be in an extremely exciting place. I do not know what has happened to your marketing, but it seems very strange.

Dr Clancy: I would like to answer that comprehensively. You are absolutely right that this is an attractive, rewarding specialty. We attract our full quota into the training programme; the first three years are fully subscribed. After three years of exposure to this kind of work, half of them elect not to continue with it because of its intensity, its unsociability and the difficulty of delivering highquality care in the system in which we work. There is no doubt about its value and its value to juniors. The issue is, "How do I carry on working like this in this area for the rest of my life?"

Dr Cadigan: If I may back Mike up, exactly the same is starting to apply to acute medicine, the stage when the 50 patients that have passed through Mike’s department are admitted, acutely ill, to the medical specialties. Recently, we have done a survey of our registrars and the junior doctors at the grade below registrar. The most junior doctors say they look up at their seniors and regard their work load as unmanageable: 80% regard it as unmanageable and they vote with their feet and go into other specialties, specialties with a more pastoral view of life. It is not because the work is not exciting, challenging and professionally rewarding if it is done in the right way, but no doctor finds satisfaction in working in an environment where you cannot behave professionally. If we come back to the Francis inquiry, many of the difficulties doctors had in behaving professionally were because of the working environment, overwork and lack of nursing support.

Q67 Dr Wollaston: I want to clarify something, going on from that. Do you think there is too great a pull factor in some other branches of medicine in that they are more remunerated from, say, the opportunities for private income and the opportunities not to do out-of-hours work? Do you think we need to be much clearer about how we are guiding junior doctors through the system? We are overtraining some specialties and that is hugely wasteful for the NHS as well, isn’t it?

Dr Cadigan: Part of the solution to the problem with acute medicine-and I am not going to talk about A and E at the moment but about acute medicine-is to try and make it an attractive specialty. How do you make it enjoyable for people to do? It has never been a glamorous specialty, whereas specialties like my own-cardiology-have had a certain glamour over the years. It is not just glamour; it is about the quality of life and the quality of work.

If you are a specialist, you tend to work in a specialist unit: you work in an enclave that you can protect in terms of the sorts of patients you accept into that unit; you work with a consistent team; you work on a group of patients that you know you can deliver good results to. When you move outside that specialist environment into the general medical wards, the wards into which patients are admitted if they do not have a very specialist need, such as a heart attack or a stroke, you find a very different environment where you cannot control the patients coming in; where you do not work with a consistent team and you may be working with a different group of doctors every day; where neither the doctors nor the patients benefit from continuity of care; and where, because of the pressure on beds, patients may move from ward to ward four times within the first 48 hours. That is not a professionally rewarding, safe or educationally good environment. So there are big contrasts between the life you have in a specialty unit and the life you have in the general hurlyburly of the medical wards and the A and E department. We would like to do some work to change that and we have a number of ideas of how it could be done.

Chair: That is a subject, if I may say so, for another day, otherwise we are going to be here till supper time.

Q68 Dr Wollaston: Dr Clancy, if I may, how much of an A and E consultant’s time is spent actually seeing patients? I know across the board in the NHS that very many senior consultants end up spending a huge amount of time actually doing paperwork and relatively little time in facetoface patient contact? How big an issue is that for A and E?

Dr Clancy: It is not a model I recognise. That was a criticism a decade ago. All the consultants are paid to deliver direct clinical care. The supervision and performance of these departments is very closely monitored and the clinicians are accountable for their performance and where they are. I believe that the consultants are out there seeing patients. That is certainly where I would expect them to be and that is what they are paid to do.

Q69 Dr Wollaston: I have one final point, if I may. In your estimation, how much is the problem with access and waiting times due to the impact of things like alcohol, say, on a Friday and Saturday night in A and E? How big an issue is that?

Dr Clancy: Alcohol is a big issue-it is a contributor-and it varies from inner city to rural areas. The estimates vary from 20% to 30% in some units at particular times of the day, so overnight, for example. Alcohol is a significant contributor to attendances, but it is no worse now than it has been over the past few years. I would draw one thing to your attention, which is about consultant presence-what you rightly asked me about. At the moment, with the number of consultants we have, we are able to deliver a 12hour presence 77% of the time on weekdays but only 30% of the time at weekends. The challenge for us is how we get that presence there when patients need it. This can be simplistically reduced to doctors working at the wrong time, not doing the thing patients need. What we need to do is shift when we work and what we do to address the pressures that the patients are making very clear to us they want addressed.

Q70 Chair: Why is that simplistic?

Dr Clancy: Because there are many factors at play. I think it is a professional challenge as well. As Patrick alludes to, trying to move things around is challenging, and that comes back to our point, which is that we have to make this work-the thing to do for the future that people want to do-to move those curves over to where they need to be.

Q71 Chair: I agree but I was just picking up your word "simplistic". It struck me that you used the word "simplistic" and then went on to describe precisely what most of us, including, I suspect, you, would want to see happen.

Dr Clancy: Okay, fine.

Q72 Dr Wollaston: Just simply, if you make more doctors work those hours to provide that cover, you are going to have even fewer people wanting to go into A and E. Is that the challenge that you mean?

Dr Clancy: If we ever get to the situation where we do not need any more people, that is fine, but we are so far away from that. Trying to solve this problem at the rate we are solving it is going to take 17, 18 or 20 years.

Q73 Valerie Vaz: Do you have a percentage of locums in A and E?

Dr Clancy: Yes. There is a survey document, which we will make available to you, that shows that in the key decision makers the vacancy and locum rate, other than consultants, is about 20% plus and the vacancy in locum rate for consultants is about 17%. Trusts at the moment are spending, on average, per trust £500,000 per annum in locum costs for emergency departments. That is a resource that really should be allocated in the future for substantive, trained doctors who want to do this work.

Chair: We need to move on to money.

Q74 Grahame M. Morris: I know there are lots of questions around these issues that you have touched on and in fact I think Dr Cadigan mentioned his concerns about these immature organisations, or the embryonic organisations that Dr Clancy mentioned, the Urgent Care Boards. But just in terms of the money and the suggestion that 70% would be retained from the excess urgent care tariff and somehow used to reduce pressure on A and E departments, NHS England-the commissioning board-is saying that should inform its decision making. What are your thoughts, quite quickly, because I know we do not have a lot of time?

Mike Farrar: Very quickly, the history of that split was that there was a view, probably three years ago, that part of the reason for that demand in A and E going up was supply-induced demand, that trusts got paid more because of the people who came through. The idea was trialled, effectively-and I think it has been, although it has stuck-that the primary care trusts would pay 100% but only 30% of that would go to the provider. The 70% would go to the strategic health authority-now to NHS England-and the idea was to try and change the incentives around not treating people. The baseline was set at the 2009 level, so anything over and above that contractually was eligible for these arrangements. It is patently clear that supplyinduced demand is not the driver here because trusts are now losing significant sums of money on people, but that rule is still in play.

There are two ways you could change that. One would be to scrap it, so trusts get 100% of any payments for people over the 2009 baseline. If you do that, obviously the trusts will be in a better financial position but it may not do anything about changing the direction, the flow, of patients into those services. The alternative is to say, "Well, that 70% that is available should be used to redirect the work. It should be used to redirect patients by providing better services away from the hospital." That is quite an interesting debate about whether you simply accept it has not worked, put all the money still available into the hospital sector-in other words, money follows the patient-or do you try and put the money where you want the patient to go by putting more of that 70% into alternatives to hospital care? I certainly would favour the second, but certainly the way it is working at the moment is that the hospitals are getting the worst of all possible worlds because they have the patients and they are not getting the money. That is not sustainable and it is now punitive.

Dr Cadigan: It is demoralising as well. In addition to the 30% rate, we have the question of ambulance fines. There is a fine if you keep an ambulance waiting for a certain length of time. It is proposed in the latest NHS England document that there should be a fine for keeping patients in A and E more than 12 hours. These are matters that are often outwith the control of the trust and the A and E department that are trying to deliver the care. It would be helpful to have a more constructive look at the way finance is used. I am not a financial expert. It would be really helpful, though, to see us incentivising programmes that, for example, reduced length of stay. If those incentivised programmes were integrated and integrated health and social care, that would be a really interesting thing to do.

Q75 Chair: Is there not a problem with this argument that it assumes the 70% is somehow in a bank somewhere and nobody is spending it? It is actually currently being used to pay for other services.

Mike Farrar: It is and you cannot predict it, of course, because it fluctuates quarter on quarter. So, in terms of planning to invest that in alternative services, it is much more difficult. What is absolutely vital is that that money is still available in the local system.

Q76 Chair: It is being used in the local system.

Mike Farrar: It is money that is allocated to the local system. A commissioner in their budget will have a certain amount of resources that they think they have contracted for with the acute provider. If they go over and above that contract, they now pay 30% across and have 70% that is effectively given to NHS England. So it is money that you can deploy but you cannot plan it. It is very difficult to plan it because it depends on contractual performance. This is why there was a big debate about how much actually that money is, whether it is the £70 million to £80 million, which I think NHS England described. But there was a view at one point that it was £300 million to £400 million.

Q77 Chair: The HSJ thinks it is £400 million.

Mike Farrar: It is very difficult to say that we will take that and spend it on a recurrent basis on alternatives. There are things you could do with that money inside as well as outside the hospital to try and move the work through.

Q78 Barbara Keeley: We are moving on to ambulance services now. There has been increased pressure on ambulance services. I suppose that is not surprising given what you have said about increased demand. The number of emergency and urgent calls has increased by 4% every year since 200708. So I guess it is just a question of what weight we should give to some of the other things we have talked about, the problems with NHS 111 and the fact that patients do not seem to have the confidence they might have in outofhours services. Or is this just a straightforward increase in demand, as you have talked about? Is that the issue? It is the case, I think, that six ambulance trusts failed to achieve the standard of 75% emergency response within eight minutes for the category A calls.

Mike Farrar: First, we have a very narrow window of assessing whether ambulance services are good, which is one very small target, which largely relates to if you have a cardiovascular sort of emergency. Our ambulance service is the best in the world compared with anybody else’s, so we should not forget that.

The second thing is that they have had to cope with an additional demand but they have also been modernising. The interesting figure with ambulance services is the conveyancing rate. That is effectively the ability for ambulance services to deploy a paramedic who can immediately treat, support and avoid people coming into A and E. There is quite a good deal of variability in conveyancing rates between ambulance services. The ambulance services sit right at the heart of this and they could be very much part of the solution, but we need to strengthen and support them in this. I am sympathetic to ambulance services who find their capacity tied up sat outside A and E departments. It is not a great place for patients to be, but we also have to support our ambulance services to be a part of the service provision rather than just seeing them as a mode of transport. We can do better in that respect.

Q79 Barbara Keeley: The point of my question is how much is increased demand just straightforward increased demand? Are other factors playing into it such as problems with NHS 111 and lack of confidence of patients in outofhours services? Do you think it is pure demand?

Mike Farrar: This is an odd thing to say, but one of the ambulance trust chief executives who talked to me recently said, "Of course, in recessions, calls to 999 go up because it is the only free number you have on your phone." I do not know whether that was anecdotal or whatever, but I think 999 is a convenient route. That is why I think 111 is part of the solution, if we can get it right. This line of demand around ambulance services has been fairly constant and has not changed much for quite a while now.

Dr Clancy: There is quite a clear relationship between overcrowding and how long ambulances have to wait to offload. Therefore, if you sort the overcrowding out, you sort the offloading out. It will be possible for us to answer this question-between 111 performance and ambulance demand-because those figures will become available in the future and we should be able to correlate the referral rates between the two.

Dr Cadigan: The other way to think about this might be constructively to look at what the ambulance service could contribute in the future in the way perhaps of managing demand sensibly. That difference in conveyance rates is very important because some ambulance services clearly feel supported in taking clinical decisions and offering other solutions. They must have those other solutions available. So if an ambulance crew has access to primary care, intermediary care or some agency that is familiar with the patient’s care plan and the decisions that have been made, that is very important. I would point you to a project that has been running in London to make sure that the ambulance service has information about endoflife care decisions that have been made by patients. If patients make decisions about endoflife care, what they wish and do not wish to have, it is very helpful if those are shared by all parts of the health service and they have now been shared with the ambulance service so that inappropriate actions are not taken. That is a model for the whole system-responding to knowledge of a patient’s condition, diagnosis and the care plan that has been made-that could be extended to other groups of patients. I would target perhaps patients in care homes, the elderly frail and the sort of patients that we know with longterm conditions that we can identify and develop care plans for.

Q80 Andrew Percy: I am interested in this comment from the NHS Confederation in particular about the fourhour target not being particularly helpful. It concerns me as a Member of Parliament representing a constituency that is very rural, but also as a first responder myself with Yorkshire Ambulance Service-I do a Friday and Saturday overnight-that, if we lost that target, patients in rural areas would be seriously disadvantaged. At least at the moment there is a requirement for them to put resources into trying to hit that target. We struggle already and have had to wait 20 or 25 minutes for an ambulance at a cardiac arrest on more than one occasion. If we lost that fourhour target, what would the impact be on rural areas, do you think?

Mike Farrar: First of all I was not suggesting that it was unimportant. I think I said the fourhour indicator is a really good indicator of flow, but it is not clinically relevant. If you have a heart attack, you need to be seen much quicker than that. That is the point I was trying to make. As to the eight minutes-75% within eight minutes, which I was talking about for immediate response-

Q81 Andrew Percy: I am sorry, that is what I was thinking of, not four hours. I meant the eightminute thing; I was miles away on something else and, in my defence, I am ill.

Mike Farrar: That is an important indicator and for many patients there is the clinical-my colleagues here will know-validity of the eightminute standard for people who have heart attacks. But eight minutes is not necessarily, again, clinically relevant for everybody; it is particularly key for certain conditions. I am not advocating getting rid of that standard as a way of assessing people. I was saying that there has been a perception that ambulance services in this country are not very good because a number have struggled to hit that 75% target. I was making the point more charitably-and I think quite rightly-that our ambulance services are the best in the world when you take their performance in the round.

Q82 Andrew Percy: I understand. I just worry that, if we lost the eightminute target, the first thing that would happen is that resources would be moved back to urban areas because that is where the call demand is. The only thing that keeps ambulance trusts maintaining the resources they do in our rural areas is the fear of not hitting the 75%, which my trust, Yorkshire Ambulance Service, has not done. That is about the only thing that has encouraged them to keep resources out in our rural areas.

I am also interested in what ambulance services can practicably do to assist with this A and E demand issue. I have been at lots of jobs over the last few months and they are only red 1 or red 2; so I understand they are very serious calls, with the potential of risk to life and all the rest of it. But in pretty much every circumstance, even when it has been perfectly clear that a patient is not particularly ill, because of perhaps being risk-averse and all the rest of it, the first thing that happens is that the person is bundled into an ambulance and taken off to A and E, some 30 miles away in some cases. I wonder what can be done practicably. What is the role for an ambulance service in a rural area like that where there is nothing else for them to be transferred to? How do they contribute to alternative pathways? Is there any good work around the country?

Mike Farrar: Again, colleagues will add their bit, but I think the conveyancing rates vary. Different ambulance services have different services available. In rural areas it may well be that A and E is a very sensible place to take people. The ability to discharge from A and E on arrival, if they are stabilised well at immediate point of treatment or indeed to reduce the length of stay because of any complications that might emerge, can be massively affected by the immediate response. As a first responder, all the evidence is showing that the investment in ambulance services, in having good qualified paramedic support on ambulances, is helping to relieve pressure on both attendances and potential length of stay for people with conditions if they are admitted. So there is evidence around that, and it may well be that we could get our ambulance service organisations to give you some of the emerging data about the level and availability of paramedics as having an impact on improving outcomes in emergency care and indeed tackling some of these issues on A and E attendances.

Q83 Andrew Percy: Following on from that, an issue in my area at the moment is that, unfortunately, it is not always paramedics who are part of a doublecrewed ambulance. In fact, it is emergency medical technicians, who may have had only six to nine weeks’ training. It would be great if there was always a paramedic available, but that is not the case. The trend seems to be going in the opposite direction, where, while we do have plenty of paramedics-no doubt about that-we are now getting doublecrewed ambulances where it is emergency medical technicians and there is not a paramedic in sight attending lifethreatening red 1 and red 2 calls. I understand the role they can play, but I fail to understand why-with what is happening in terms of how ambulances are crewed, but also with there being a lack of any alternative location for patients in my area to go-there do not seem to be any other pathways. We are just going to see this continued demand on our ambulance services to the point where the patient is not benefiting and we see a failure year on year to hit the target.

Dr Clancy: What we are saying is: how do we give ambulance staff the skills and resources to make a judgment about nonconveyance and how can we help them with that? There are examples in the east midlands where ambulance crews have been trained to look after patients who have fallen over and they make a judgment about whether or not they need transfer. It is also about access to other resources, of help and advice that can be networked so that you can speak to somebody and seek guidance about that. This is a great opportunity for us to augment the ambulance service by increasing their skill set because they are at the front line of this patient group. What is clear is that not all of these patients need ambulances to come to hospital and, therefore, if we augment that group in any way we can, that will probably help the whole system.

Dr Cadigan: The broader theme is that, faced with a medical manpower crisis, we should use every opportunity of using other healthcare professionals to help out, skill them up and train them as appropriate.

Q84 Barbara Keeley: I do not represent a rural area-I represent part of Salford-and I think there is really quite a heavy load now put on first responders. Andrew talked about that and clearly they do have a role to play in rural areas, but talking to one of the first people trained as a first responder in Salford I am amazed at how much she gets called. That is a thing to be careful of-that people like that and people like Andrew are being called on really quite substantially, to very serious calls, and they are volunteers. We need to be careful that they are not being overused. They are not a substitute for paramedics, nor should they be.

Mike Farrar: On that point of the growth in paramedics, there was a big push throughout the early part of the last decade around getting the numbers of paramedics available through ambulance services increased. I suspect that has levelled off with the resources. Again, looking at solutions for the ambulance service, recruitment of paramedics may well be a wise and sensible investment for trying to tackle some of the problems.

Q85 Chair: I want to probe you on this question of differentiated response-time targets. Do you have any formulation that you think would be more appropriate than the 75% within eight minutes?

Mike Farrar: It is worth talking to the experts about the conditions where the eightminute standard is absolutely about saving lives and others where it is not. Obviously there is the triaging done on the phone in the first instance, about the dispatch of the ambulance, but within the eightminute frame I have to defer to my colleagues here, I think.

Dr Clancy: I think I know where I can find the evidence for you, but it would be wrong of me to portray it.

Q86 Chair: If you have thoughts on the question of a more refined version of what good looks like in emergency response times for ambulances, the Committee would like to see it.

Dr Clancy: I will try and find that.

Q87 Andrew Percy: On that point about paramedics, I am not saying that the eightminute target is necessarily perfect. I had a paramedic who said to me once, "If we turn up in seven and a half minutes and they die, that is okay, but, if we arrive in nine and they survive, we are still penalised." So it does seem a bit wrong. I want to get your opinion on the use of minor injuries units, which are quite important in rural areas. The conveyance rate for ambulance services to minor injury units is incredibly low because of this risk-averse nature, I think, of actually taking someone to an MIU where it may be nurse-led; fortunately, in my town it is doctor-led. It seems to me-and I can only say this from the experience of the many calls I have been to-that there is a fear of taking them anywhere other than A and E, because, if something goes wrong, it is the ambulance service that would be liable. I am not convinced that the training, the pathways or even the processes are in place to support ambulance crews and paramedics in making a decision other than, "We will transfer to A and E." Minor injuries units seem to be coming under attack at the moment because a lot of trusts are looking at them and saying, as to the figures they present you with, "Oh, well, they are not very well used. Look at these rates overnight." It seems to me that they should be part of the solution to this, but more and more of them are being downgraded from doctor-led to nurse-led or being closed overnight. Do you have a view on that at all?

Dr Clancy: The point about a wider work force delivering clinical care over a longer period of time is really important. This is another example of getting the right patient to the right service. There are a number of patients that could be very successfully looked after in minor injuries units that are transferred to emergency departments. That is about holding the system to account. It is that accounting process that, maybe, we do not have developed well enough at the moment. If, for example, patients were unnecessarily transferred to the emergency department, at the moment I do not have any obvious way of feeding back that that could have been looked after at a lowercost institution, for example; I just carry on and get on with it. It is that lack of joinedup responsibility and sharing of what is happening and how we can improve it that is missing from the system at the moment.

Q88 Andrew George: But you have protocols to deal with this.

Dr Clancy: Yes, there are protocols, but they involve a degree of judgment as well and also there is an overwhelming pressure on paramedics not to get it wrong-and I acknowledge that fully. I am very sympathetic to the choice of going to a higher level of care. We need to support them is what I am saying.

Q89 Mr Sharma: My question was partially answered, and you both used the response that more skills and resources need to be given to the ambulance crews so that they can provide the service. Do you think that the commissioning of ambulance services can play a part in redesigning to make them more adept at reducing A and E attendances and to bring their incentives and priorities in line with those of other providers?

Mike Farrar: Commissioning has a really important role to play when you have a series of pathways that cross different bits of the system. What commissioning should and could do very well is help coordinate the different responses at the different times and get the investment right. Part of the secret of really good strategic commissioning-and I am a big fan of clinicians having a bigger responsibility around commissioning and I take the point that commissioning groups are immature-is about saying: where do you get the best results clinically for your investment? So when you look at urgent and emergency care as a wholesystem response, having clinicians say it is really important that we have more senior decision makers at this point in the system and more paramedics at this point in the system, and that it is important overall that we are seeing this shift of resource towards avoiding people ending up in hospital who do not need to be, that is a massive role for commissioners and I really welcome clinical commissioning groups being able to do that. They need a chance to get their feet under the table to have a look at that. Commissioning ambulance services is quite challenging for them, of course, because ambulance services cover big geographies and commissioning groups cover little geographies. So one of the challenges is getting a commissioning system for ambulance services that makes all of the clinical commissioning groups get the kind of right local service they need. That is a logistical challenge in the system.

Q90 Chair: It might be a job for a larger Urgent Care Board.

Mike Farrar: It could be, couldn’t it?

Q91 David Tredinnick: I have some quick questions about influence pre and post the recent reforms. Do you think the new commissioning structures enable the clinical commissioning groups to have greater influence on design and clinicians than the old primary care trusts, under the old arrangements? Do you think the Health and Social Care Act has made a dramatic difference or not? It is a pretty soft question.

Mike Farrar: I am sure Patrick and Mike will have views themselves. One of the big risks-one of the reforms I have already mentioned, so I will just mention it briefly again-is this. I worked for many years to try to unify budgets and all the evidence, I think, of how you get best value out of budgets is that you have a unified budget which you can deploy flexibly to the right areas. I worry enormously that one of the things we have structurally built into the new system is different budget holders for different bits of the budget, social care, particularly primary care, separate from hospital and community budgets, and specialist services. If we are being really strategic, the health improvement spend in another place as well is a big risk. In terms of the new system, I am not worried about clinicians having a greater responsibility-that is a great step forward-but the deployment of fragmented budgets worries me a lot.

Dr Cadigan: It is very difficult to say yet whether it has worked or not, but from conversations with colleagues around the country there are good examples of cliniciantoclinician conversations resolving some difficult problems. As I said earlier, one of the things that is done in successful groups that have achieved integrated care-and I think integrated care is going to be part of the solution to the sort of problems we are talking about-is that they have reached mutual arrangements to dismantle standard payment by results and gone for shared financial incentives and shared financial risk solutions. That seems to be a model that is going to have to be fostered.

Dr Clancy: The college has done a survey recently that was undertaken last year and a third of emergency departments reported that they weren’t directly involved in any discussions with their commissioning groups. Patrick makes the point that when there is good engagement there is progress, but when there is no engagement that could be an impediment. Engagement with those people who deliver the care is of paramount importance and I think that these groups should be mandated, or that involvement of the people who deliver the care should be insisted upon. It should not be an option whether they are engaged or not. A concern for our specialty is that we are not getting the engagement that we need.

Q92 David Tredinnick: If the Health and Wellbeing Boards are anything to go by-having attended a local one in Hinckley, in my constituency-we are getting a huge level of cooperation between county council, borough council, doctors and all the other associated people there; it is quite an impressive result.

Mike Farrar: I think Health and Wellbeing Boards could have a really positive effect on the preventative element as well, supporting people around avoiding lifestyle problems.

Chair: Sarah wants the last word.

Q93 Dr Wollaston: Before I ask the last question, I will state for the record that I am married to an NHS consultant psychiatrist. We have touched on commissioning services that avoid cases arriving in casualty in the first place, but do you think there is a greater role for commissioning services that act as a diversion once people are there, so, for example, liaison psychiatry, I am referring to, specifically in the role that has in reducing readmissions, services for dual diagnosis once people are in casualty, that kind of area? How important a role is that for us to look at in the throughput through casualties?

Dr Clancy: Mental health is the big neglected area. That plays itself out in emergency departments where it is not easy to get the resources that you need to look after these patients. Mental health crosses not only those who are mentally ill but many other patients as well. It is well recognised that that is a serious area where there is inadequate provision. In many ways, emergency departments are not the best location for patients who are psychiatrically unwell to be cared for but they end up there because there is no better alternative. I think we need to recognise that the provision of help for the mentally ill is inadequate.

Mike Farrar: There is a specific scheme that was developed around the West Midlands mental health service called RAID. It is a particular model with protocols, which has been seen to be very successful in helping to manage patients with mental illness who appear in emergency departments.

Q94 Dr Wollaston: I have seen some figures from RAID looking at up to 30% of reattendances being prevented.

Mike Farrar: "Avoided", but, basically, for the people for whom this is a relevant service-that is, people with mental health and physical problems-this is a very effective way of avoiding them ending up in hospital, yes.

Q95 Dr Wollaston: So why are we so poor in the NHS at rolling out successful projects?

Mike Farrar: The holy grail.

Chair: Shall we address that on another day? Thank you very much. It is surprising, but then again perhaps not surprising, that almost whatever the inquiry we conduct we end up needing more integrated services. That is one of the strong messages that I think we all take away from what you have said this morning. Thank you very much.

Prepared 29th May 2013