Emergency Admissions to hospital - Public Accounts Committee Contents

2  Meeting demand for urgent and emergency care

12. NHS England agreed that it was essential to have a clear understanding of demand, activity and capacity across the urgent and emergency care system in order to manage the system effectively and to recognise where the bottlenecks are within it.[25] NHS England now publishes a winter health check every week that brings together a range of information from across the system, including: A&E attendance and emergency admission numbers; performance against the four-hour A&E waiting time standard (which requires 95% of patients attending A&E to be seen, treated and either discharged or admitted within four hours of arrival); ambulance handover delays; bed occupancy rates; and delayed discharges from hospital.[26] NHS England has also started to publish more information about the quality of GP services on its website. [27]

13. However, performance management has been hampered by shortcomings in the data.[28] The NAO reported concerns about the suitability of the current measure for the delayed discharge of patients from hospital, and NHS England acknowledged that the measure may underestimate the scale of the problem. NHS England said there were also some issues about whether ambulance handover times— the time it takes from when an ambulance arrives at an A&E department to when the patient is handed over to the care of A&E staff— are reported consistently. There is a need for a cohesive and harmonised dataset that brings together the various indicators for a particular local area and presents the full picture of what is happening across local urgent and emergency care systems. This would allow both MPs and the public to make comparisons and to hold their local organisations to account.[29]

14. The urgent and emergency care system comes under particular strain in winter, and in 2013, as in previous winters, the Department and NHS England put additional money into the system to help alleviate this added pressure. In September 2013, £250 million was allocated to help 53 struggling urgent and emergency systems prepare for winter. An additional £150 million was announced in November 2013 to help other health systems prepare for winter. In previous years, this allocation had normally taken place in December.[30]

15. The Department said that this extra money was not intended to reward failure, but that it was difficult to assess which parts of the country have the most significant challenge, and therefore need extra support.[31] The timing of these payments, so close to winter, does not enable hospitals to plan ahead sensibly and is likely to lead to the use of more expensive temporary or agency staff to meet demand.[32] The Department and NHS England acknowledged that this situation was not ideal and that this money should be allocated earlier. The Department confirmed that it aims to release the £250 million winter fund for 2014-15 in the first quarter of 2014-15.[33]

16. The allocation of additional seasonal monies is a short-term measure. To tackle the underlying problems more fundamental changes are needed. We welcome NHS England's proposed shift to seven-day working in hospitals and the positive changes that this is likely to bring, including reduced weekend mortality rates and more efficient use of NHS assets and facilities.[34] NHS England said that achieving seven-day working in urgent care will involve meeting ten clinical standards, which broadly amount to greater availability of diagnostic facilities and better access to senior decision-makers, such as consultants, at weekends. It also explained that not all services will be open seven days a week in every hospital; instead hospitals will work in networks or federations that mean that communities have access to all services seven days a week. [35]

17. NHS England said that the introduction of round-the-clock consultancy care would start with A&E services, and that it aimed to have at least the first phase in place by the end of 2016-17. To achieve this, NHS England plans to use a number of levers to ensure the necessary changes are made, including clauses in commissioning contracts, the publication of progress in meeting the clinical standards, amendments to training contracts, and the renegotiation of the consultants' contract. However, NHS England was unclear how much the move to seven-day services in hospitals will cost the NHS. It said that early evidence from eight hospitals that had started to introduce seven-day services suggests that the shift will increase hospital running costs by up to 2%, but recognised that more work is needed to better understand the costs. NHS England also said that an organisation called NHS Improving Quality planned to work with 13 early adopter communities to carry out additional economic modelling.[36]

18. A significant part of the costs will depend on the outcome of the ongoing renegotiation of the consultants' contract. NHS England said that negotiations were underway between the British Medical Association and NHS Employers to reset the consultant's contract with a view to setting the time consultants must work before they qualify for overtime and removing their right to refuse to work at weekends. Following our hearing the Department sent us a note stating that Government had mandated these negotiations in October 2013, and that the target was to have a phased implementation of the new contracts from 2015. However, NHS England told us that neither it nor the Department were directly involved in these negotiations.[37]

19. The move to seven-day working not only requires changes to consultants' working practices, but also that enough consultants are in post to deliver services seven days a week. There is still a shortage of A&E consultants, despite a 70% increase in A&E consultants over the last ten years.[38] In 2011-12, 8% of consultant posts in emergency departments were vacant and 9% were filled by locums.[39] There are also major problems in training sufficient numbers of doctors in emergency medicine. In 2012, only 18.5% of ST4 (first year of higher training) posts were filled.[40] The Department agreed that these vacancies and shortfalls mean that there is too heavy a reliance within hospitals on temporary staff to fill the posts.[41]

20. The Department acknowledged that struggling hospitals, such as those placed in special measures, find it even harder to attract and retain candidates for vacant consultant posts. There are currently no mechanisms in place to make working in these hospitals a more attractive prospect, such as providing incentive payments to work there. We raised with the Department the possibility of paying consultants more to work at struggling hospitals.[42]

21. The Department told us that it is working with Health Education England, the College of Emergency Medicine and the trade unions to examine both short- and long-term options to address the shortage of consultants and trainees. The Department said it was looking at how to make the emergency medicine profession a more attractive option for doctors in the long-term. Both it and NHS England were considering a number of options, including adjustments to annual leave or pensions, examining whether intensive roles need a different structure to achieve a better work-life balance, and making better use of a hospital's entire consultant body to alleviate the pressure on emergency medicine. After our hearing the Department sent us a note expanding on the work to be undertaken by an Emergency Medicine Workforce Implementation Group, which is jointly chaired by Health Education England and the College of Emergency Medicine. However, the Department and NHS England failed to outline a convincing strategy or vision for tackling the immediate or longer term shortage of A&E consultants.[43]

25   Qq30-31, 84; C&AG's Report, paragraph 3.7 Back

26   Qq32-35, Winter Health Check Reports http://www.england.nhs.uk/category/winter-hcr/ Back

27   Q114 Back

28   C&AG's Report, paragraph 3.7 Back

29   Qq33-35; C&AG's Report, paragraph 1.24 Back

30   Qq85-86, 158-164; C&AG's Report, paragraph 17 Back

31   Q164 Back

32   Q158; C&AG's Report, paragraph 17 Back

33   Qq158, 163 Back

34   Qq94-95, 97 Back

35   Qq95,167 Back

36   Qq94-95, 119-122 Back

37   Qq95-96, 98-101; Ev. 20 - note from the Department of Health to the Public Accounts Committee, 15 January 2014, p.5 Back

38   Qq16, 25; C&AG's Report, paragraphs 1.18 & 3.18 Back

39   C&AG's Report, paragraph 3.18 Back

40   Q18; Briefing from the Royal College of Surgeons, http://www.rcseng.ac.uk/policy/documents/RCSbriefingonemergencyadmissionsforPAC18December.pdf Back

41   Qq21, 23 Back

42   Qq16, 20, 22-23, 165-166 Back

43   Qq18, 21-22, 24-26; Ev. 20 - note from the Department of Health to the Public Accounts Committee, 15 January 2014, p.3 Back

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Prepared 4 March 2014