1 Oversight and responsibility for
urgent and emergency care |
1. On the basis of a report by the Comptroller and
Auditor General, we took evidence from the Department of Health
(the Department) and NHS England about emergency admissions to
hospitals in England.
The number of emergency admissions continues to rise at a time
when NHS budgets are under significant pressure. Between 2000-01
and 2011-12 the rate of increase has been much higher in England
than in Wales, Scotland and Northern Ireland. In 2012-13, there
were 5.3 million emergency admissions in England, an increase
of 47% over the last 15 years. These admissions accounted for
around 67% of hospital bed days in England, and cost approximately
2. Patients may be admitted to hospital as an emergency
through various routes, including from: major A&E departments;
single specialty A&E departments, minor injuries units or
walk-in centres; referrals by GPs or other health professionals;
and referrals following outpatient appointments. In 2012-13, 71%
of emergency admissions came via major A&E departments and
almost all of the increase in emergency admissions has come through
3. The services which make up the urgent and emergency
care system are delivered through a wide range of local bodies
and organisations. When
the health system is working effectively, only those with a genuine
urgent need to be treated in a hospital should be admitted for
emergency care. For everybody else, there should be appropriate
services based in primary care or out in the community that help
to keep people well, or treat them away from hospital if they
do become ill. All parts
of the health system including ambulance services, A&E
services, other departments within hospitals, primary and community
health services, and social care services have a role to
play in managing emergency admissions by preventing patients from
being admitted to hospital when they do not need to be, making
sure those who are admitted stay no longer than is necessary,
and ensuring that they are treated in the most appropriate setting.
4. When health and social services are not working
effectively the pressure is usually felt by A&E departments
having to deal with more patients.
Approximately one-fifth of emergency admissions to hospital are
avoidable, and many patients stay in hospital longer than is necessary.
Poor quality access to primary care can lead to more people attending
A&E rather than going to their GP surgery.
Shortcomings in social care, primary care and community care can
also put pressure on A&E services by delaying the discharging
of patients which places more pressure on bed availability.
The fragmented delivery of urgent and emergency care services
can result in duplication of activities, such as the condition
of patients being assessed twice.
5. It is crucial to have clear accountabilities in
a devolved delivery chain like the NHS. The Department told us
that it retains overall responsibility for the urgent and emergency
care system in England, but it discharges its duties through a
large number of arms-length bodies.
For example, NHS trusts are accountable to the Trust Development
Authority; NHS foundation trusts are accountable to Monitor; and
both are accountable to the Department. NHS England is accountable
for the commissioning and performance of the NHS, including holding
clinical commissioning groups to account for the commissioning
of local services.
Foundation trusts are also individually accountable directly
to Parliament. However, the Department and NHS England
could not clearly explain to us who is accountable for ensuring
A&E services are delivered efficiently and how particular
failings in local services would be effectively challenged and
addressed. In particular,
the Department struggled to convincingly set out for us which
body a citizen should complain to about a failing local urgent
and emergency care service, and what would be done about that
6. The Department said that urgent care working groups
had been established to bring together the statutory bodies (clinical
commissioning groups, NHS England and local authorities) responsible
for the delivery of health and social care services with local
care providers to create more accessible and integrated local
urgent and emergency care systems. However, while the Department
asserted that these groups exert significant influence, it accepted
that they had no powers to deliver services and instead operated
as a network that relied on the good will of all those parties
7. The Department told us that a tripartite group,
accountable to the Department and comprising NHS England, Monitor
and the Trust Development Authority, would oversee the urgent
care working groups. However, neither the Department nor NHS England
could clearly explain under what circumstances the tripartite
group would step in and who will drive change when local urgent
and emergency care systems were not working effectively together.
8. The main financial incentives to reduce emergency
admissions sit with hospitals, despite all parts of the health
and social care system having a role to play. Currently, local
clinical commissioning groups pay hospitals a tariff for each
patient that they treat. Since 2010-11, commissioners have set
limits on the level of emergency activity that they will pay hospitals
at full tariff, based on the number of emergency admissions at
each hospital in 2008-09. When emergency admissions exceed this
level the commissioners only pay the hospital 30% of the tariff.
NHS England told us that the savings made from the remaining
70% of the tariff were supposed to be reinvested in out-of-hospital
care to reduce admissions, but until recently commissioners were
often spending the savings on other aspects of care. This
equated to removing about £250 million a year out of the
acute care system. Since 2011-12, commissioners have also not
paid hospitals a tariff for patients who are readmitted to hospital
within 30 days of being discharged.
9. Since 2011-12 there has been some attempt to expand
the range of incentives, when the new GP contract started to include
payments for GPs to review and reduce local emergency admissions
levels. From 2013-14 NHS England introduced a 'quality premium'
for clinical commissioning groups to reduce avoidable emergency
admissions. However, there are still no financial incentives for
community and social care services to reduce emergency admissions.
10. A new 'year of care' funding model is being piloted
in eight areas 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. NHS England intends that this will encourage
hospitals to take a holistic approach to caring for such patients,
and it plans to roll-out this funding model in 2015-16.
- In addition, starting from April 2015, the £3.8
billion Better Care Fund aims to ensure better integration between
health and social care, particularly in out-of-hospital care.
Local health and wellbeing boards will be responsible for allocating
this fund. The fund
will comprise £1 billion that the NHS already transfers to
local government, £800 million from the Department, and £2
billion that will need to come from additional NHS savings, mainly
in the acute care sector.
NHS England told us that this will be a massive challenge, as
these savings are on top of the 4% efficiency savings that the
NHS already needs to make in 2015-16.
1 C&AG's Report, Emergency admissions to hospital:
managing the demand, HC 739 Session 2013-14, 31 October 2013 Back
paragraphs 1, 1.9 Back
C&AG's Report, paragraph 1.11 Back
C&AG's Report, paragraph 1.3 Back
Qq27, 72; C&AG's Report, paragraphs 2 & 3 Back
C&AG's Report, paragraphs 1.3 & 1.4 Back
Qq 36, 47; C&AG's Report, paragraphs 11, 22 Back
Qq71-72, 75-76; C&AG's Report, paragraph 2.12 Back
Q27; C&AG's Report, paragraph 15 Back
Qq42, 45, 102-103, 113 Back
Qq1-3, 12 Back
Qq2-3, 8, 44, 48, 52 Back
Qq42-43, 45-47, 52; C&AG's Report, paragraph 3.6 Back
Qq42-48, 52 Back
C&AG's Report, paragraph 2.23 Back
Qq152-153; C&AG's Report, paragraph 2.24 Back
C&AG's Report, paragraphs 3.8, 3.9 Back