Conclusions and recommendations
1. In 2012-13, there
were 5.3 million emergency admissions to hospitals, an increase
of 47% over the last 15 years. Two thirds of hospital beds are
occupied by people admitted as emergencies and the cost is approximately
£12.5 billion. NHS trusts and NHS foundation trusts, primary,
community and social care and ambulance services work together
to deliver urgent care services. Since April 2013, A&E services
have been commissioned by clinical commissioning groups, which
are overseen by NHS England. However, it is the Department of
Health (the Department) that is ultimately responsible for securing
value for money for this spending.
2. It is not clear who is accountable for
the performance of local urgent and emergency care systems, and
for intervening when local provision is not working effectively.
The Department accepts that it has overall responsibility for
the urgent and emergency care system. But it discharges its duties
through various arms-length bodies, and both the Department and
NHS England struggled to explain to us who is ultimately accountable
for the efficient delivery of local A&E services and for intervening
when there are problems. Delivery is fragmented, and the health
sector does not consistently work together in a cohesive way to
secure savings, better value and a better service for patients.
Urgent care working groups, which have been established to create
better integration, have no powers and are overly reliant on the
good will of all those involved. A tripartite group, accountable
to the Department and comprising NHS England, Monitor and the
Trust Development Authority, is intended to oversee the performance
of various aspects of the urgent and emergency care system, including
urgent care working groups. However, it is unclear under what
circumstances the tripartite group would intervene at a local
level.
Recommendation: In
response to this report, we expect the Department to:
- Confirm that it is responsible for the
overall performance of urgent and emergency care; and
- Set out how it will challenge local performance,
step in when this performance is substandard and enforce beneficial
local changes to save money and provide a better service when
local agreement cannot be reached.
3. Financial incentives across the system
are not aligned, which undermines the coordination of care across
the system. All parts of the health system
have a role to play in reducing emergency admissions, including
providers of social, community, primary and secondary care. However
the financial incentives to limit A&E admissions are not working
across the whole system. Hospitals get no money if patients are
readmitted within 30 days and a reduced rate if they admit patients
above an agreed limit, but there are no financial incentives for
community and social care services to reduce emergency admissions.
A new 'year of care' funding model is being piloted that aims
to promote the integration of services for patients with long-term
conditions by providing funding per head of population for the
totality of their care, both in and out of hospital. From April
2015, the £3.8 billion Better Care Fund is intended to ensure
better integration between health and social care. However, £2
billion of this funding will have to come from additional NHS
savings, mainly in the acute sector, on top of the 4% savings
the NHS already needs to make in 2015-16.
Recommendation: The Department, NHS England
and Monitor should review the overall system for funding urgent
and emergency care, including the impact of the 'year of care'
funding, to ensure that incentives for all organisations are coherent
and aligned.
4. Neither the Department nor NHS England
has a clear strategy for tackling the chronic shortage of A&E
consultants. Many hospitals, and especially
those facing the greatest challenges, struggle to fill vacant
posts for A&E consultants. There is too great a reliance on
temporary staff to fill gaps, which is expensive and does not
offer the same quality of service. The Department told us that
it was working with the College of Emergency Medicine and Health
Education England to increase the supply of emergency medicine
doctors. Solutions may include the greater use in A&E of consultants
from other departments, mandating that all trainee consultants
spend time in A&E, making A&E positions more attractive
through improved terms and conditions, and providing financial
incentives for consultants to work in more challenging hospitals.
But we are not convinced that the Department has a clear vision
of how to address either the immediate or longer term shortage
of A&E consultants.
Recommendation: The
Department and NHS England should urgently develop and implement
a strategy which considers all available options and addresses
the immediate and longer term shortages of A&E consultants.
5. We are not convinced that additional funding
from the Department to support A&E services during winter
has been used to best effect. Trusts receive
additional funding from the Department to support the additional
workload they face in winter. The Department allocated £250
million to help 53 struggling urgent and emergency care systems
prepare for winter in September 2013, and further funding of £150
million was announced in November 2013. The Department acknowledged
that the allocation of this funding so close to winter was not
ideal as it means that hospitals cannot plan ahead and instead
resort to more expensive temporary solutions, such as engaging
agency staff to meet demand. The Department plans to release the
£250 million winter fund for 2014-15 in the first quarter
of that year. However, the Department said it was difficult to
assess where the money could best be allocated to address real
need rather than rewarding failure.
Recommendation: The
Department should evaluate promptly the impact of additional winter
pressure money allocated for 2013-14 and the timing of when the
money became available, and use this analysis to inform the early
and effective allocation of this fund in 2014-15.
6. We welcome the proposed shift to 24/7 consultant
cover in hospitals, but are concerned about the slow pace of implementation
and the lack of clarity over affordability.
The introduction of round-the-clock consultancy care will start
with A&E services, but will not be in place before the end
of 2016-17. Round-the-clock hospital services are intended to
reduce weekend mortality rates and make more efficient use of
NHS assets and facilities. However, its implementation will rely
on the British Medical Association and NHS Employers negotiating
a more flexible consultants' contract, and neither the Department
nor NHS England has direct control over the timescale or details
of these negotiations. The Department and NHS England are also
uncertain about the likely costs of moving to 24/7 consultant
cover, which early evidence suggests could increase hospital running
costs by up to 2%.
Recommendation: The Department should act
with urgency to establish the costs and affordability of this
measure and develop a clear implementation plan.
7. Commissioners and urgent care working groups
lack the quality data needed to manage the emergency care system
more effectively. Those who manage urgent
and emergency care services need a clear understanding of demand,
activity and capacity across the system. However, performance
management is hampered by poor quality data. For example, the
NAO reported concerns that the current measure for delayed discharges
from hospitals to social care does not accurately reflect the
scale of the problem, and figures for the time spent by patients
in ambulances upon arrival at hospital before being handed over
to A&E departments are not reported consistently. In addition,
information across local urgent and emergency care services is
not available in one place so that the public can easily make
comparisons and hold their local organisations to account.
Recommendation: NHS
England should ensure that reliable information is available across
the urgent and emergency care system and that local information
is published collectively in one place.
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