3Maintaining patient flow this winter
Increasing bed capacity
42.The relationship between demand, bed capacity and emergency department performance is at the heart of the Royal College of Emergency Medicine’s concerns:
The increase in attendances in the last 5 years is equivalent to the workload of 10 medium sized departments in England alone–none of which have been built. Moreover, during the last 5 years the number of beds available for admission of acutely ill and injured patients has continued to fall and we now have the lowest number of beds per capita in Europe and England has the lowest number within the UK.58
43.In practice, the College argued that the consequence of limiting bed capacity has been a growth in general and acute bed occupancy from 86.3% in 2010–11 to 91.2% in 2015–16.59 The College’s evidence, however, noted that:
This is the figure recorded at midnight—daytime occupancy rates frequently exceed 100% in many hospitals. Such occupancy levels mean there is no surge capacity, rendering hospitals hostage to fortune.60
The British Medical Association (BMA) noted that:
[figures] from January–March 2016 showed the average occupancy rate in acute and general hospitals was 91.2%, with 20% of trusts averaging 95% or above, leaving very little flexibility in the system to cope with a seasonal spike in demand.61
University Hospitals of Morecambe Bay NHS Foundation Trust’s evidence illustrated the pressure that trusts are operating under:
Medical bed occupancy has been increasing in the last 6 months—as illustrated in the chart below—reaching well over 100% with escalation beds open and outliers spilling into surgery.62
During our visit to Luton we heard that the first step taken by Luton and Dunstable trust to improve its performance in 2010 was to increase its bed capacity.
44.The Nuffield Trust has assessed the merits of increasing bed capacity to improve patient flow, ease pressure and improve the performance of emergency departments:
One possible solution would simply be to increase the number of beds to return acute wards to a level of acute bed occupancy more conducive to faster flow. Our analysis has shown that this increased capacity accounted for by far the largest proportion of the £650m in additional winter funding money given to the NHS […] in 2014–15.
However, this did not result in enough capacity to meaningfully reduce occupancy. The issue is in any case increasingly a year-round one. The current strain on NHS finances, particularly capital funding, make it highly unlikely that a large number of new beds will be constructed in the near future.63
45.The analysis that there is little respite in the spring, summer and autumn is generally consistent with the figures provided by Morecambe Bay NHS trust. Nonetheless, the peak period for occupancy was during the winter months of 2015–16, which indicates that the growth in admissions during the winter will create additional demands for beds. Whilst year round pressure is now a commonplace feature of the system, for many trusts winter remains the greatest challenge.
46.Comments made in oral evidence by Lyn Simpson, Executive Regional Managing Director for NHS Improvement, reinforced the position portrayed by Morecambe Bay. She told us that there is now very little bed capacity within acute trusts that could be brought to bear this winter:
There is not a bed stock that is ready to just switch on because it is unused. In previous years, we have been able to flex the use of beds and bring some additional beds into play for the winter period. This year we have been thinking about how we can use the current bed stock more efficiently. If you look at benchmarking data and efficiencies, there is scope to do more with what we currently have, rather than to bring more into play. There is a lot of good will, as well as reciprocal arrangements, across health economies. If an organisation is feeling under pressure, there is the ability to work closely with a partner and to flex across the system. The old idea of having beds that are mothballed and then brought back into play for periods of time is something that we should avoid and we should use the current bed stock more appropriately.64
Funding & staffing additional capacity
47.Whilst Ms Simpson, like Professor Willett, characterised the challenge facing acute hospitals as being one of making more efficient use of resources, this was not entirely reflected in the evidence we received from trusts. Nottingham University Hospitals NHS Trust said it does not believe it will have the funding in place to increase capacity this winter in the same way it has done in previous years.65 Similarly, the evidence submitted by Dartford and Gravesham trust highlighted the pressure they face, but they too said it is a lack of funding, rather than the inability to handle a change in approach, that will prevent them from increasing capacity:
The Trust had the third highest level of occupancy of General and Acute beds of any Trust in England in Q4 15–16. The significant rise in population will increase the use of escalation beds over the longer term as there is currently no funding available to increase the inpatient capacity to properly meet this demand. During winter months the impact of the increased demand for beds means that the Trust faces specific capacity problems that manifest themselves primarily on A&E performance.66
48.Perhaps most significantly, however, Morecambe Bay NHS trust said that, rather than increasing bed numbers to keep pace with demand, they would have to reduce them because of insufficient staffing:
the Trust has had to take the difficult decision to reduce its medical bed capacity in several ward areas for safety reasons because it cannot achieve the appropriate ward staffing ratios.67
49.Another trust described in its evidence plans to free bed capacity during the winter by reducing elective activity. St Helens and Knowsley Teaching Hospitals NHS Trust said that increased non elective activity during the Christmas holiday period was planned for by reducing elective activity. They said that in 2015–16 NHS England:
requested a plan to demonstrate a reduction in the elective programme in order to free up an additional 20% bed capacity for NEL [non-elective] demand. This was submitted and achieved.68
However, in the seminar we held with leaders from NHS Trusts it was noted that a consequence of this policy is that patients who have had elective procedures postponed during periods of peak demand will, in some cases, present at the emergency department as non-elective cases.
Community provision
50.Whilst increasing bed capacity is not regarded as a viable option by the Nuffield Trust, their evidence identified further utilisation of capacity within the community as being a mechanism for easing pressure in acute trusts. They said that “investment in new rehabilitative ‘step-down’ beds, where patients can recover outside hospital, could deliver substantial gains”.69 It was therefore encouraging that the Minister said in evidence that as part of the process of developing sustainability and transformation plans:
we will see the whole healthcare economy players look to develop a more integrated pathway and rehabilitation beds. Intermediate care beds, I am sure, will form part of that.70
During the seminar we held with national policy experts the point was made that there is often an emphasis on community rehabilitation beds to enable discharge from acute hospital. There is, however, less attention paid to the ‘step-up’ element of community provision which can prevent emergency attendance and admission.71
Conclusions
51.The acute bed ratio was 3 per 1,000 people in 2013 compared to 4.1 per 1000 in 2000.72 We note that ongoing pressure in emergency departments has worsened as the bed per person ratio in the NHS had deteriorated. England has the lowest bed capacity in Europe and our method of counting bed occupancy at midnight provides false assurance. This only serves to widen the gap between Ministers and officials’ perception of pressure in hospitals and the reality facing clinicians at the front line of acute care struggling to find beds for their patients.
52.Acute trusts which host emergency departments are now running too hot. Whilst it may be a practical short term measure given the available resources to postpone elective activity to create capacity for non-elective admissions, the detrimental effect on patients should not be ignored. Postponing elective activity means postponing patient care and results in longer waits for treatment. Furthermore, trusts should heed the warning that in some cases the underlying medical problem for elective patients may deteriorate and they may re-present in emergency care and experience worse outcomes or require more interventions than if treated at an earlier stage. Delaying treatment in order to flex capacity does not necessarily represent an efficient use of scarce resources.
53.Investment in ‘step-up / step-down’ community rehabilitation beds helps to relieve the pressure on NHS beds and can help to flex capacity at times of especially high demand. Nevertheless, acute trusts need to plan effectively for sufficient acute beds as well as access to community beds to improve patient flow.
A&E infrastructure
54.As noted above, the Royal College of Emergency Medicine’s evidence pointed out that “the increase in attendances in the last 5 years is equivalent to the workload of 10 medium sized departments in England alone—none of which have been built”.73 Furthermore, the College noted that emergency departments were designed to accommodate far fewer patients.74 Torbay and South Devon NHS Trust’s written evidence explained the limitations that an outdated emergency department can place on patient care and the ability of a hospital to implement practical changes within their departments that could improve patient flow:
The Emergency Department is not fit for purpose; the design limits flexibility and does not have sufficient cubicle space to meet demand during busy periods. There are limited facilities for children and for the safe management of people who present with a mental health need. There is also limited opportunity to extend ambulatory care pathways for people who are able to be assessed, treated and discharged home on the same day.75
55.Emergency department infrastructure must be capable of accommodating the growth in patients and allowing the implementation of practical guidance such as streaming patients to ambulatory care. Simon Stevens, Chief Executive of NHS England, acknowledged this in his evidence to us in July 2016:
It is certainly the case, by the way, that many A&Es have to deal with many more patients than they were originally designed or built for, which is part of the reason why some infrastructure investment would be so welcome as a way of improving those services.
56.Our report, published in July 2016, which examined the impact of the spending review on health and social care reported a reduction in the capital funding available to the NHS:
Capital spending will, however, remain flat in cash terms over the spending review period, at £4.8bn each year. That represents a real-terms reduction of 9% from 2015–16 to 2020–21.76
In addition our report concluded that transformation funding which should be used to support the ambitions of sustainability and transformation plans will not be available. We noted that this funding is “being used largely to ‘sustain’ in the form of plugging provider deficits rather than in transforming the system at scale and pace”.77
Conclusions
57.As identified by NHS England’s chief executive, emergency departments will struggle to manage demand unless additional infrastructure funding is made available. Whilst this would not result in necessary new infrastructure in time for this winter, it would allow the service to improve overall performance and to manage ever increasing background demand as well as predicted spikes in future winters.
58.It is essential that the Government ensures that sufficient capital funding is available for trusts to develop the infrastructure that will enable them to meet performance levels demanded by Ministers. The first step will be an assessment of the infrastructure investment required to ensure that type 1 emergency departments are fit for purpose, which should be completed through the Sustainability and Transformation Plan process. Once that assessment is complete, NHS England and NHS Improvement will need to ensure that the available capital funding is directed accordingly—we call on the Government to review the real terms cuts to NHS capital budgets in the Spending Review and to protect the transformation element of the Sustainability and Transformation Fund. We emphasise the importance of evaluation of completed projects in order to guide future investment and identify and share best practice.
Supporting adult social care to maintain patient flow
Availability of adult social care
59.As described in Chapter 2, safely discharging patients without delay when they no longer require in-patient treatment is an important step in managing patient flow through a hospital and underpins good patient experience and safe performance in the emergency department. It is for this reason that “[increasing the] proportion of patients receiving […] rehabilitation, recovery and reablement care outside hospital in home or community settings [and] mandating ‘Discharge to Assess’ and ‘trusted assessor’ type models” is a central element of the guidance designed to improve patient flow.78
60.In their written evidence the United Kingdom Homecare Association argued that some discharge to assess schemes have already begun to reduce the length of hospital stays.79 In addition they said that an evidence base is now developing to support the application of reablement programmes:
Investing in short-term community reablement services can prove to be a cost-effective way of facilitating a timely discharge from hospital and minimising the potential for readmission. HSCIC have reported that 81% of people aged 65 years or over who had received a reablement/rehabilitation package upon discharge had not been readmitted after 91 days at home.80
61.Chapter 2 described how some trusts support patient flow out of their hospitals by creating their own services that provide social care in people’s homes. These initiatives, however, have a limited scope and much of the evidence we received emphasised the desire amongst witnesses for greater support to be made available to local authorities for the commissioning of all forms of adult social care.
62.Written evidence submitted by Morecambe Bay NHS trust said that the inability to discharge medically fit patients means that delayed discharges average 120 across each of their hospital sites per day.81 The trust concluded that the Government could support trusts with type 1 emergency departments by better supporting adult social care as:
it is clear that adult social care funding and social care capacity—packages of care, long term residential and nursing care–and in particular EMI [elderly mentally infirm] nursing care—is woefully short.82
The British Geriatrics Society echoed this view, reporting in their evidence that:
The King’s Fund briefing Deficits in the NHS 2016 provides an up to date analysis which shows that despite transfers of NHS budget to social care it has not kept pace with the increase in demand, and the fall in social care spending between 2010–15 has led to two issues: i. people being unable to access the care they need leading to poorer health outcomes and an increased likelihood of presenting at A&E, and ii. people remaining on an acute hospital ward for longer than necessary, again with an impact on A&E departments, and most critically a negative impact on the health of older people with frailty which deteriorates with every additional day spent on an acute ward. For an older person with frailty the loss of skeletal muscle strength resulting from a hospital stay can make the difference [between] being able to rise independently from a chair or bed and being dependent.83
63.Homerton University Hospitals Trust’s evidence outlined some of the more localised and specific consequences of limited funding and a shortfall in resource:
Delays in social care assessments were seen due to vacancies and the difficulty in recruiting substantive staff. Agency staff were often used however their skill mix was poor. Limited suitable care home capacity also led to delays in discharging patients.84
Cost of delayed transfers of care
64.It is not only patient well-being and flow through hospital which is undermined by an inability to discharge to adult social care. The BMA’s evidence reported the National Audit Office’s assessment of the financial cost of delayed discharges:
The National Audit Office estimates that around 2.7 million of hospital bed days are occupied by older patients no longer in need of acute treatment which equates to a £820m gross cost to the NHS.85
65.In our report examining the impact of the spending review on health and social care we explored the relationship between the NHS, adult social care and the financial rationale for further investment in adult social care provision. We concluded that:
We are concerned about the effect of reduced access to adult social care as a result of the cuts to funding and the impact of this on the NHS. Given the evidence of the linkages between health and social care, we were concerned that none of the senior officials giving evidence from the Department of Health, NHS England or NHS Improvement were able to quantify the financial cost of one of the most visible interfaces between health and social care, namely delayed transfers of care as a result of not having adequate social care packages in place. […]
We recommend that the Government urgently assess and set out publicly the additional costs to the NHS as a result of delayed transfers of care, and the wider costs to the NHS associated with pressures on adult social care budgets more generally. That assessment should be accompanied by a plan for adult social care which demonstrates that the Government is addressing the situation in social care and dealing with its effect on health services.86
Conclusions
66.Ensuring sufficient capacity within community services and adult social care to enable timely discharge is a central element of maintaining flow out of an emergency department and through the hospital. It was encouraging, therefore, that Pauline Philip, Urgent and Emergency Care Director at NHS England, confirmed that this one area where there is potential to improve performance in the coming months:
one of the pieces of work […] that we are doing as part of the A&E improvement plan is looking at this whole issue of discharge and patients who are occupying beds in acute hospitals who do not need to be in acute care. Clearly, there is a significant opportunity there. By working within the local delivery boards, this is one of the first issues that they are addressing, looking at the numbers of patients who are occupying beds in each hospital, who are not just in the original detox category but in the wider medically fit category, and then looking at capacity within the wider health economy, whether it is bed capacity or care capacity. That is probably the opportunity that we would be looking towards this winter.87
67.As outlined above, additional funding may not realistically be available to facilitate additional bed capacity in trusts in the short term, but it could be used to increase the availability of adult social care. The NAO’s analysis has delivered an economic rationale for providing additional support to adult social care. The Care Quality Commission’s (CQC) report examining the state of care in England made the case in terms of quality. The CQC concluded that hospitals will find it “increasingly difficult” to improve their urgent and emergency care services “unless they are able to work more closely with adequately funded adult social care […] providers”.88
68.Better local planning through A&E delivery boards, integrated to work closely with local authorities may help to limit delayed discharges in some cases but we do not believe that on its own this will sufficient to address the scale of the problem. We recommend that the Government should provide additional funding to increase adult social care capacity. This could substantially relieve pressure on trusts as exit block is a key contributor to winter pressures in areas lacking sufficient adult social care provision.
69.Discussing the challenges facing trusts of delayed transfers of care, Pauline Philip added that following the national benchmarking exercise that was due to take place in September 2016, A&E delivery boards will have achieved “an understanding and a grip of how big the problem is within their patch”.89 The national benchmarking exercise that has been undertaken by A&E delivery boards should inform an assessment of the impact that cuts in adult social care have had on the performance of trusts. We reiterate our frustration that the Department of Health has yet to undertake this assessment and consider it is vital that it does so at the earliest opportunity, particularly given its impact on the performance of the urgent and emergency care system.
70.Delayed discharges cause exit block in hospitals, which in turn hinders the flow of patients through hospitals and the performance of emergency departments. This has worrying implications for patient safety. We believe that adult social care is underfunded and this is having an impact on the NHS. The performance of the NHS and social care cannot be viewed in isolation. Adequate funding of social care and appropriate development of the social care workforce are worthy objectives in their own right, but the urgency of action on those two objectives is thrown into even sharper relief in the context of their contribution to the improved performance of the urgent and emergency care system.
Utilising primary care to reduce demand
Case-mix
71.The Royal College of Emergency Medicine’s evidence revealed a degree of scepticism about initiatives to extend access to existing primary care services to reduce demand in emergency departments. The College noted that admissions have increased at faster rate than attendances and consequently:
We are not dealing with ‘more of the same’. The case-mix has shown a significant rise in the proportion of patients whose care cannot be delivered outwith the acute hospital setting.90
72.Outlining how demand may be limited at emergency departments over the winter months, the Government’s evidence highlighted its expectation that primary care will make an important contribution:
Last year, the concern was that where there were extra general practice services in place—they were not advertised early enough to alert people so people still went to A&E. The wider winter planning communication that will go out to the system setting out expectations around a number of areas such as bank holiday planning, elective breaks, marketing campaigns, escalation and, primary care etc will be used to stress the message of better and earlier advertising of available services needed and explore ways for local systems to promote these services more widely. This will also be picked up through assurance of preparations for winter.91
73.In their evidence a number of trusts said the availability of primary care will influence how hospitals manage during the winter. Dartford and Gravesham noted that community based services including primary care can influence patient demand in a way which can “confound planning”.92 Morecambe Bay NHS trust said that one of the biggest challenges they face in their areas is that services close during the Christmas holiday period and the Government should “encourage and incentivise 7-day working by all partners over the festive period”.93 Evidence from St Helens and Knowsley trust outlined a scheme they will operate which intends to redirect patients into primary care.94
74.As noted above, the Royal College of Emergency Medicine (RCEM) has questioned this approach. The Nuffield Trust’s analysis has found
relatively little evidence that factors traditionally thought to increase attendances are linked to the recent deterioration in A&E performances[…] While there is evidence that the availability of GP appointments can reduce A&E attendance, the direct connection to performance against the four-hour target is weak.95
75.Addressing the RCEM’s concern that primary care will not be caring for the patients who require admission and are most likely to breach the four-hour standard, Professor Willett, NHS England’s National Director of Acute Episodes of Care, told us that a multi-faceted approach is required to address demand in emergency departments.96 Professor Willett said that managing the demand placed on the service from those patients that require admission needs a different approach, but the growth in attendances has been driven by self-referral patients with less severe conditions.97
76.Professor Willett argued that limiting pressure in emergency departments can only be achieved by making improvements across the entire urgent and emergency care system:
There is not a silver bullet. […]
it is very easy to try to simplify it and say, “This is what we should do,” but the reality is that we have to do everything within the system(.98
Extended hours
77.Addressing the specific concern of some trusts that primary care will simply be unavailable during Christmas the Government’s evidence described the extended hours schemes provided by hubs through the Prime Minister’s access fund programme.99 Philip Dunne, Minister of State for Health, outlined in more detail the Government’s initiative to extend GP opening hours:
We are now rolling out greater opening hours for GPs. It is at their own initiative where and when they do it, but certainly in my own area we now have GPs 8.00–8.00 on Saturdays, which is an innovation in the last year. That will start to take off across the country and we will see more primary care involvement throughout the year, six days a week.100
78.We published a report on primary care in May 2016 which investigated the extended hours projects in detail. Whilst improving access to primary care is an important objective we concluded that demand for the type of routine service described by the Minister was limited and that there were potential unintended consequences if the development of extended opening hours undermines the ability to staff existing urgent out-of-hours provision. GPs may not be available to provide the services required in places which are conveniently accessible by patients in rural areas.101
Conclusions
79.There is little evidence that previous attempts to divert patients away from emergency departments and into primary care have been successful. As we approach winter, primary care will only play a limited role in addressing acute winter pressure, as the challenge for the system is managing complex patients that require admission to hospital. We would like to see further evidence that the Government’s proposals for extended GP hours will limit the demands placed on emergency departments.
80.Our report of May 2016 described a future primary care system based on practices working in networks and federations, accommodating multi-disciplinary teams made up of GPs, advance nurse practitioners, physician associates, pharmacists and physiotherapists.102 It was encouraging that Lyn Simpson stressed the importance of different health professionals developing wider skill sets in primary care as this will be central to the new primary care team.103 In the long term enhanced and properly resourced primary care shaped around the recommendations we made in our report of April 2016 on primary care will be crucial in helping to prevent the escalation of illness to an extent where emergency admission to hospital is required.
Co-location of primary care with emergency departments
81.Although the RCEM argued that pressure in emergency departments cannot easily be relieved by enhancing primary and urgent care services, the College does believe that co-located services could limit demand in emergency departments. They said in their written evidence that a model should be developed in which the emergency department sits at the centre of a hub and co-located urgent care could deflect cases away from the emergency department.104 The rationale for this is that redirection and re-education strategies aimed at patients have failed and therefore services should be based around emergency departments.105
82.The RCEM said that “more than a third of attendances could be managed without input from an EM doctor”106 and noted that:
The lack of other services for urgent care needs leads to clinically improbable spikes in attendances at weekends and bank holidays. Establishing an A&E hub model of service provision would ensure that up to a third of patients (almost 5 million per year) were seen by more appropriate providers/services thereby decongesting the emergency department and improving the care delivered to those most in need of ED clinicians.107
83.Visiting Luton and Dunstable trust we heard that the development of co-located primary care allowed patients that did not require care in the emergency department to be streamed to a more appropriate service.108 The primary care service at Luton hospital remains subject to the four-hour waiting time standard and was regarded as central to delivering good performance and patient care.
84.In 2013, our predecessor Health Committee said that it “welcomes the development of Urgent Care Centres on hospital sites and accepts the evidence that these units can improve the quality and efficiency of emergency care”.109 The arguments of the RCEM and the practical effect of this measure witnessed in Luton are convincing, but the submission to this inquiry by the Centre for Urgent and Emergency Care Research called into question the evidence base for this practice:
Co-location of these centres with emergency departments has been proposed as a way of reducing the burden of primary care attendances on the emergency department. Our systematic review of 20 studies (Ramlakhan 2016) found little evidence to support the implementation of co-located urgent care centres. Provider-induced demand may lead to a paradoxical increase in attendances. The evidence for improved throughput is poor and any savings may be overshadowed by the overall cost of introducing a new service. A robust evaluation of proposed models is needed to inform future policy.110
Conclusions
85.‘A&E’ is a widely recognised and attractive brand. Patients understand that if they attend they will be cared for there and then. Meeting national policy experts in Luton we learned that patients are particularly drawn to A&E if they have experience of other countries’ healthcare systems where this is the normal route for out-of-hours care or they have previously encountered problems accessing emergency GP appointments or GP-out-of-hours care.111 Co-located primary care is subject to the four-hour standard—whereas directly accessed primary care is not.
86.Co-location of primary care with emergency departments is theoretically attractive in diverting patients who arrive in A&E who would be more appropriately seen in a primary care setting. This approach may have the unintended consequence of attracting more people to attend A&E in the future rather than contact their primary care service directly. We agree with the Centre for Urgent and Emergency Care Research that a robust evaluation is needed of proposed models of co-located of primary care with emergency departments. Further research is required to understand the impact on patient behaviour, emergency department attendance and patient outcomes. In particular there needs to be much greater investigation into the risk of creating supply-induced demand. Given the shortfall in GP numbers, it is unlikely to be sustainable to operate several parallel systems for out-of-hours GP access and it is important that commissioners to consider the wider impact on primary care provision for patients as well as for A&E.
87.Equally, NHS England should be aware that co-location may not be a solution which enhances access in rural areas, and some trusts may simply not have the capacity to accommodate such a service or the capital resource to create it. Models will need to adapt to local circumstances and must be robustly evaluated.
The ambulance service
Potential of paramedics
88.In both their written submission and their contribution to our seminar with national policy experts, the Centre for Urgent and Emergency Care Research told us that there is good evidence that paramedics are able to reduce hospital transfers and admissions through a ‘see and treat’ approach at home:
Emergency care practitioners or paramedic practitioners have extended roles that allow them to treat patients without transporting them to hospital. Our review of seven systematic reviews and 12 primary studies (Turner 2015) found that these roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital. Our primary studies of paramedic practitioners (Mason 2007) and emergency care practitioners (Mason 2012) confirm these findings in the NHS.112
Professor Willett, the National Director of Acute Episodes of Care, summarised the potential of the paramedic workforce by saying that “they are probably the area of healthcare that has the greatest opportunity to manage demand for the rest of the health economy”.113
Delayed handover of care
89.Too often, however, paramedics’ specialist expertise is being wasted as a result of delayed handover of patients at emergency departments. The Association of Ambulance Chief Executives (AACE) noted in its evidence that “The most important issue ambulance services face from acute trusts is that of ambulance handover delays at Emergency Departments (EDs)”.114 The Centre for Urgent and Emergency Care Research reported that in “the year 2015–16 the 10 regional ambulance services in England lost a total of 407,000 hours through handover delays at ED”.115 Providing the perspective of ambulance trusts, the AACE said:
As an example, one English ambulance trust loses approximately 700 hours every week due to this issue; for some trusts, the loss of hours is greater. […]
Nationally and regionally, it is worthy of note that there is significant variance between acute trusts in terms of ambulance handover delays. Acute trusts that do not experience as many ambulance handover delays have a distinct ‘zero tolerance’ approach with clear ownership of the issue across the trust, not just within the ED.116
90.The comments we heard when visiting the East of England Ambulance Service in Bedford reflected the frustration expressed by the AACE. We heard from East of England Ambulance Service of ambulances waiting for unacceptable periods outside emergency departments and also of huge variation within their geographic footprint between the length waits and procedures for handover.117 The consequence of delayed handovers of care is that poorly performing trusts tie up ambulances and their crews in their specific area thus reducing the availability of paramedics and vehicles further afield. This is not consistent with the system-wide, place-based approach to managing demand in emergency departments that is being encouraged by NHS England and NHS Improvement.118
91.Pauline Philip’s commentary on the challenge of delayed handover reinforced the notion that responsibility for avoiding delays rests with acute trusts. Ms Philip told us that handover delays can be avoided by trusts ensuring they have the correct processes in place and make optimal use of the space available to them:
Time and time again, when we come across the issue of these ambulances outside a hospital, it tends not to be about the number of staff within the emergency department but how the emergency department is being organised, the processes that exist—very simple things—and the capacity. We meet departments all the time that do have staff standing there, but they do not have enough trolley space.119
92.The incentives created by the four-hour waiting time standard do not necessarily encourage trusts to make best use of their space and prioritise swift handover. The clock for the four-hour standard begins at handover or 15 minutes after the ambulance arrives at the hospital.120 From the perspective of a trust that is struggling to meet the four-hour standard, whether a patient waits in an ambulance for 5 minutes or for two hours is immaterial as long as the patient does not suffer any adverse consequences and is eventually admitted, transferred, or discharged within 3 hours and 59 minutes. It underlines the pressure some hospitals are facing that valuable ambulance crews and vehicles can, in some cases, be treated by trusts as an extension of their emergency department.
Conclusions
93.Acute trusts must take responsibility for patients arriving by ambulance so that handover is not delayed. As outlined by the AACE this is dependent upon the entire trust taking responsibility for addressing the problem and speaks to the development of the positive cultural approach described in chapter 2. We heard in Bedford that there are some trusts that will not acknowledge their responsibilities even when a patient is in an ambulance parked on the ramp of the emergency department. NHS Providers’ submission pointed to practical steps that trusts can take to minimise handover delays:
The London Ambulance Service has worked with local London trusts to improve ambulance handovers to emergency departments by employing Hospital Ambulance Liaison Officers (HALOs). HALOs act as an initial point of contact for ambulance crews and receive early indications of incoming ambulance cases so appropriate resources can be identified to minimise handover delays and ambulance turnaround times.121
94.Delayed ambulance transfers are an unacceptable waste of valuable paramedic resources and disadvantage patients living in neighbouring areas who may experience longer waits if vehicles are tied up elsewhere. NHS England should urgently address the level of variation to ensure that there is a timely handover of patients.
64 Q27
70 Q26
71 Note of Committee visit to Luton and Bedford
76 Health Committee, Impact of the Spending Review on health and social care, First Report of Session 2016–17, HC 139, para 2
86 Health Committee, Impact of the Spending Review on health and social care, First Report of Session 2016–17, HC 139, paras 53, 54
87 Q25
88 Care Quality Commission, State of Health Care and Adult Social Care in England 2015–16, HC 706, October 2016, p 4
89 Q57 (Pauline Philip)
96 Q6
97 Q6
98 Q51
100 Q18 (Philip Dunne)
101 Health Committee, Fourth Report of Session 2015–16, HC 408, Primary care, para 28
102 Health Committee, Fourth Report of Session 2015–16, HC 408, Primary care, paras 103–106
103 Q21
108 Note of Committee visit to Luton and Bedford
109 Health Committee, Second Report of Session 2013–14, Urgent and emergency Services, HC 171, para 114
111 Note of Committee visit to Luton and Bedford
113 Q38
117 Note of Committee visit to Luton and Bedford
118 Q17
119 Q32
120 NHS England, Emergency Care Weekly Situation Report, Definitions and FAQs, April 2014
31 October 2016