95.The evidence submitted by Health Education England (HEE) offered an overview of the measures taken to improve staffing levels in emergency departments:
Working in close partnership with the College of Emergency Medicine since inception, HEE developed practical solutions to workforce pressures based on both current need and longer term sustainable solutions. These proposals include:
a)Additional ACCS-EM posts (more than 250 over three years);
b)Piloting and subsequent full adoption of a ‘run through’ training. This means those who enter ‘lower’ training do not need to compete to enter higher training, which enhances the attractiveness of the programme
c)Creation of the innovative Direct Route of Entry Emergency Medicine (DREEM) training pathway (above);
d)The “work, learn, and return” initiative whereby training places are offered to overseas doctors to develop emergency medicine skills and gain valuable clinical experience. The programme is up to four years, after which the doctor will return home to use their skills to care for patients and share learning with colleagues.
e)Rapid expansion of physician associates - a new group of staff to support the medical workforce in Emergency Medicine and other settings. […]
96.HEE’s submission claimed that there has been significant progress in the development of the emergency care workforce. The examples they highlighted included:
a)growth in the number of consultants has now been sustained at an average of 9% per year for more than a decade (compared with 3.7% average for all consultants);
b)the wider EM medical workforce (i.e. trainees and others) has grown at 3.7% per year compared with 2.4% for the wider medical workforce;
c)in 2004 consultants represented 15% of the EM medical workforce. In 2014 this was 23%.
97.Despite Health Education England’s claim that the expansion of the number of doctors has “relieved pressure on emergency departments”, measures to increase the complement of emergency care specialists have not kept pace with demand. In 2013, our predecessor Health Committee noted in its Urgent and Emergency Services report that “Only 17% of emergency departments in England are able to provide 16 hour consultant coverage during the working week”. Reporting on the situation three years later, the Royal College of Emergency Medicine said increased demand has further emphasised inadequate staffing levels in urgent and emergency care:
There are 176 type 1 Emergency Departments in England. Currently there are insufficient consultants in post to provide even one on duty in every department for even 16 hours per day.
Had staffing levels been adequate and kept pace with admissions by 2015–16 there would have been 2516 EM consultants in the NHS in England c.f. 1483. Had the workforce as a whole grown at a similar rate there would now be 8,074 doctors working in our emergency departments rather than, as now, 5,300.
98.It should not be assumed that an increase in the number of commissioned training places will automatically convert into an eventual increase in emergency care specialists. The British Medical Association’s evidence said:
We have concerns that there are a significant number of trainee vacancies across the UK. A recent survey of foundation trainees found that only 52% of foundation trainees in the UK were progressing directly into specialty training. Other research has revealed shortages in fill rates for higher specialty training in certain areas including emergency medicine and acute medicine.
The Royal College of Physicians’ evidence touched on this and said that 21% of consultants have reported ‘significant gaps in the trainees rotas such that patient care is compromised’. Royal College of Emergency Medicine concluded that “the attrition rate from UK training programmes has wasted our most valuable resource”.
99.The Royal College of Physicians’ written evidence stressed the impact that lack of staff will have on the flow of patients through the emergency department (the challenge of which is discussed in chapter 3 above). Their remarks particularly emphasised the impact on the patient experience:
The staffing crisis is impacting on physicians’ ability to swiftly assess patients after they present at A&E departments, to tailor their care plans and to achieve safe and timely transfers of care. This can negatively impact on patient experience and leaves wards unable to alleviate pressures on A&E departments. Targets on A&E waiting times are difficult to achieve unless there is enough staff to transfer patients or discharge them in a timely manner.
100.With emergency departments functioning under constant pressure the lack of 7-day 16-hour consultant coverage remains a major concern. Measures to improve patient flow, such as early senior review of patients, cannot be implemented if the requisite staff are not available.
101.There is no quick fix available to alleviate staff shortages. In 2013, our predecessor Health Committee’s report into Urgent and Emergency Services noted figures from the RCEM which showed that the 145 trusts in England with type 1 emergency departments were, on average, each spending approximately £500,000 per annum on locum costs for emergency care alone. In their written evidence to this inquiry the RCEM said that the figure now stands at £3 million per week for all trusts in England, which indicated that locum spend has more than doubled in three years. The RCEM, however, has now employed a new methodology for calculating how much acute trusts spend on locums. Their most recent assessment of the cost of temporary doctors in English emergency departments measured the total weekly spend at £13.5 million. This would indicate an average annual spend for each trust of over £4.6 million.
102.Dartford and Gravesham trust’s evidence illustrated the difficulties associated with recruitment and the particular challenges trusts are presented with by the agency spending cap and national policy direction which attempts to limit growing staff costs:
Medical staffing in A&E is proving especially difficult as some Trusts are not adhering to the agency caps and are able to outbid us for doctors. With a lack of A&E middle grades there is a seller’s market for A&E doctors and the lowest bidder can find themselves struggling to have enough doctors to meet the demand in A&E.
The long term growth in activity also means that this Trust has to increase its staffing levels in other groups, however this is contrary to the national messages requiring us not to do this. Without increasing staffing levels both during winter months and over the long term, safe staffing levels will not be achieved.
103.The growth in spending on emergency care locums runs contrary to the desire of the Government “to reduce the dependence on agency staff”. The Minister explained that permanent staff are more productive and “safer for the patient because they will understand the system better”. Lyn Simpson reiterated the argument that substantive staff “improve care to patients”. We are concerned, therefore, that in the last three years there has been significant growth in a workforce which is regarded by Ministers as sub-optimal in terms of patient safety.
104.We heard informally during our visit to Luton that successful trusts are often able to recruit because they are more attractive employers than neighbouring hospitals that may have poorer reputations. Ultimately, this can serve to reinforce the performance and financial problems struggling trusts often experience. Challenged that trusts are simply denying one another of necessary staff, Professor Willett said that local workforce action boards will sit under Sustainability and Transformation Plans and they:
will look at the workforce for the whole local health economy so that you will start to see some more sensible relationships develop, because it is right for the whole system not to be escalating prices through agencies, as perhaps happened before when people were competing, but, if we are going to work as a network and as a system of healthcare providers, we need to look at the workforce needs across everywhere. If there is one hospital that is really struggling with workforce, the impact on that hospital not performing well will be felt in the other parts of the healthcare sector. That is the approach.
Lyn Simpson, Executive Regional Managing Director for NHS Improvement, concluded that:
We need to work in partnerships with the other hospitals in a particular patch, rather than one organisation poaching or being able to attract staff greater than another, so that that partnership arrangement would benefit us all.
105.Professor Willett indicated that it will not be possible to meet demand by recruiting ever more emergency care specialists. Therefore, the model by which emergency departments provide care will have to change:
The original A&E departments, when I trained, had only just started to invent emergency medicine as a specialty. None of them had consultants. Over the years we have grown and grown that, but we have also tied that into saying that if you are an emergency department you have to have X, Y and Z behind it. That is where it becomes unsustainable, because we cannot do all those medical interventions in every hospital. You cannot attract the staff because there is not enough of it to keep the specialist skills up. […]
In the urgent and emergency care review, we are saying, right, this is not about isolated units any more. This is about the whole healthcare system working as a system, so that whether you are the paramedic at the scene or the GP in the home, whether you are the hospital, the urgent care centre, the minor injuries unit or whether you are the small hospital or the specialist hospital, you never have to make a decision in isolation. There is always someone in that system who will help you.
106.We are concerned that trusts informally acknowledge that those that are able to recruit often do so by depriving their neighbours of staff. Similarly, we are concerned at reports that the agency spending cap is being breached which consequently will distort the market for temporary staff. The market for emergency care specialists is failing and shortages of middle grade staff have become a particular problem. The long-term restructuring of emergency care may ultimately re-shape the provision of care and staffing requirements, but this will not address the problems facing emergency departments this winter.
107.The evidence from Health Education England said that additional numbers of physician associates will be available to the emergency care workforce. We also heard that trusts are beginning to recruit and train more staff in extended roles to bolster their emergency care teams. Importantly, the analysis by the Centre for Urgent and Emergency Care Research confirmed the positive impact staff in extended roles can have on patient care:
Controlled studies of the nurse practitioners, extended paramedic roles […] have shown that these are effective, leading to widespread implementation and clear benefit to patients and the NHS.
108.We are supportive of steps being taken by trusts to increase extended roles in emergency departments as part of the wider evolution of emergency care. These measures, however, will not help to alleviate additional pressure that may occur this winter. We are concerned that some emergency departments which are already falling short of the four-hour standard will enter winter with staff levels below those identified as necessary to provide the best possible care. We recommend that NHS Improvement consider the steps which can be taken this winter to ensure that all emergency departments, but particularly those which are currently performing poorly, are able to recruit the staff which they need to get their performance to an acceptable level.
109.In the longer term, we recommend that Health Education England look again at the measures needed to improve staffing levels in emergency departments, and redouble its efforts to ensure that the supply of such staff is sufficient to ensure safe and timely care. It is in everyone’s best interest for the prioritisation of the improvement of staffing levels to be the culture in every hospital.
110.The Government’s evidence outlined how the distribution of winter funding had been reformed with, they said, the purpose of encouraging better winter preparation. In 2014–15 £700 million additional funding was made available to sustain the urgent and emergency care system during the winter. It was this allocation that was incorporated in Clinical Commissioning Group (CCG) baseline funding for the following year. The Government’s evidence said:
Planning for 2015–16 was earlier in the year with resilience funding included in CCG baselines. One of the key barriers to success of resilience initiatives identified in previous years is funding being released to the system too late in the year, not leaving enough time for proper implementation. This early access means that local health economies can plan and implement initiatives far earlier as they know exactly what resources are available to them.
111.Discussing this reform, Lyn Simpson of NHS Improvement said that under the old system funding would often arrive too late to instigate programmes that could support the urgent and emergency care system during the winter and those reforms that were implemented were “fairly prescriptive and did not always meet the local need in how that funding would be spent”. Describing how the new mechanism has operated, Ms Simpson conceded that there had been difficulties in delivering the benefits expected of incorporating funding into CCG baselines:
We have seen a bit of a mixed bag across the country. Some organisations have come together with the commissioners, the providers, and said, “What do we need to put in now to prepare us for winter rather than doing it September/October time?”[…]
Where it has worked well, there has been a really good adult conversation about what we need to do. Where perhaps it is a bit patchy is that sometimes that conversation has not taken place; perhaps the provider has thought that, regardless of what has been said about it going into baselines, it will still appear late in the day to do some of the things that they have tried and tested.
112.Whilst the focus of NHS Improvement has been on local health economies planning early to use funding, the commentary received in evidence from providers expressed scepticism that, in reality, any further funding would be available to manage the expected increase in emergency admissions. NHS Providers emphasised that this funding was not ring-fenced and called in to question the effectiveness of working winter funding into CCG baseline allocations:
The inclusion of annual ‘just in time’ winter funding in CCG baseline annual allocations was intended to provide greater planning certainty for upfront investments, however, as this funding is no longer ring-fenced there has been a considerable reduction in transparency over how much money is invested in frontline U&EC services.
113.Notably, Morecambe Bay NHS trust said in its evidence that the money allocated to them in 2015–16 for winter resilience was less than in previous years when the allocation was made from the specific winter funding pot. Nottingham NHS trust’s evidence called into question the extent to which funding will be sufficient to achieve their objectives related to winter planning:
Whilst there is agreement around fast-track system resilience schemes, we are yet to be in a position to have confirmation on all funded and commissioned activities to support resilience over winter 2016–17. System resilience bids have been developed both independently and collectively by system providers. It is not yet clear whether the financial envelope will allow investment in schemes that will truly mitigate the anticipated pressures on our urgent care system.
They noted in their submission that no funding will be made available for additional bed capacity (the significance of which was discussed in chapter 3), whereas “in previous years this funding was substantial”. In the seminar we held in Luton with leaders of NHS acute trusts drawn from across England it was observed by one participant that funding for winter pressures ‘is not real’.
114.Our report, published in July 2016, which examined the impact of the spending review on health and social care concluded that there are “acute and increasing financial pressures” in acute trusts and any additional funding available is being used to tackle financial deficits. It is likely in our view that the funding designed to be used to manage winter pressure will have been absorbed in meeting the costs of core activity.
115.There is merit in providing funding for winter pressure much earlier in the planning cycle—but only if this funding is available to be used for the purpose intended. The incorporation of funding for winter resilience into CCG baselines without any form of ring-fence has made it impossible to track whether any additional funding will reach the front line to deal with the challenges that emergency departments and ambulance providers will face this winter.
116.On the other hand, ring-fencing can prevent available funding from being used where it is most needed or can be most effectively spent in a particular health economy. The incorporation of funding for winter pressures into CCG baseline funding not only enabled better long-term planning, it should also, as Lyn Simpson suggested, have enabled local areas to target the funding more effectively.
117.Rather than introducing a ring-fence on the winter resilience funding that is incorporated into the baseline allocation for CCGs, we recommend that NHS Improvement and NHS England take steps to ensure that there is transparency about the amount of funding which trusts and clinical commissioning groups direct to preparing for winter pressures. Thorough evaluation of the approaches to dealing with winter pressure will require transparency about how they are funded.
118.Visiting Luton we heard that the funding mechanism for urgent and emergency care underfunded treatment for those presenting with serious conditions whilst creating a financial incentive to treat minor conditions. We were shown that on an annual basis the Luton and Dunstable trust loses £3 million per annum through the provision of emergency care. It was noted that the patients with minor conditions which attract good remuneration relative to the actual costs of treatment are often sent to the co-located primary care service which is operated by a different provider, thus losing the trust income.
119.Whilst the Royal College of Emergency Medicine did not go so far as saying that emergency departments are paid too much for treating minor conditions, their evidence echoed the comments that were made by Luton and Dunstable trust:
Those patients requiring least intervention, investigation or treatment are remunerated at a rate that enables services to be maintained. However the maximum tariff for the most seriously ill or injured is less than £250. This ensures that treating the very patients emergency departments are established to treat is a loss-making endeavour for a hospital.
120.Professor Willett accepted that the existing tariff mechanism does not successfully reimburse trusts for undertaken urgent and emergency care. He described how each part of the system is remunerated through very different models which function inconsistently and said:
we have proposed a single payment method for the whole of the sector, which recognises the fact that an element is fixed, and we should not be arguing about that because that means that stops people being flexible.[…]
I think we will see over the next few years a very different funding model coming through, and, to be honest, the tariff argument, in my view, is a bit of a distraction at the moment because I do not think it actually plays out for an individual patient, which is what matters.
121.We are pleased that NHS England and NHS Improvement are pursuing a different funding model, but reform of tariffs should not simply be regarded as a technical long-term objective. Payment mechanisms should reflect the cost of providing care at each stage of the patient journey and incentivise ambulance and hospital trusts as well as community services to work together in the interests of patients. This means developing payment mechanisms which will suppress demand by encouraging prevention, facilitating early intervention, limiting the escalation of morbidity and helping to ensure that patients are seen by the most appropriate professional at the right time and in the right place. Tariff reform is long overdue and in responding to this report the Government should set out a clear timetable for it to be achieved.
122.The point was made in the course of the seminar we held with NHS trust leaders that there is a difference between performance management and performance improvement. It was generally felt that the emphasis within national organisations such as NHS England and NHS Improvement had been on daily performance management of trusts, rather than providing support and resources to trusts to improve performance. It was observed that substantial senior management time is lost in daily conference calls which, in the view of trust leaders, exist to give national officials and Ministers the impression that things are being done rather than to develop solutions to problems.
123.Homerton University Hospital Trust provided a considered view of the burden placed on trusts by these management demands. They said it is important for patient safety that trust performance is assessed against the four-hour standard, but argued that performance management of trusts should not become more intense just because hospitals are operating under pressure:
Close and frequent involvement of central bodies in the day-to-day operations of acute hospital trusts should cease. This can distract managers and takes them away from the actual task of managing their services at the busiest of times. The level of information reporting should revert to the same levels as routine business-as-usual periods. The combination of twice daily conference calls, 3+ times a day reporting and constant provision of minute detail often adds little value, can undermine managers and lead to little or no action or support from central bodies to assist with the challenges being faced.
We also heard a suggestion during the seminar we held with trust leaders that hospitals could be better helped to learn from their peers if NHS Improvement provided “brokerage of best practice” that could be easily accessed by trusts.
124.Pauline Philip, NHS England’s Urgent and Emergency Care Director, told us that NHS England and NHS Improvement were acting on these concerns and the system would function differently in 2016–17:
I think what has happened in the past is that we have been reactive. Basically, you hear the news reports and you read the newspaper. You see that the whole system appears to be in meltdown and people are then reacting to what has happened. We are trying to say through these local delivery boards that we need to be proactive and, instead of having all these calls in the evening and into the night, what we need ultimately is to accept that things will go wrong between emergency departments, but if we can work together in a way that we can support each other, then these types of calls, which were referred to, can become a thing of the past. We can have a new approach to escalation nationally and have some consistency in that, because there were different local approaches. From a provider point of view, my heart goes out to those organisations, because when you are trying very hard to manage a very difficult situation in your own hospital, the last thing you want to do is to spend hours on conference calls.
125.Describing how the central management system should operate in the coming winter, Pauline Philip said that there would be a focus from national bodies on providing assistance to trusts and local health economies as a whole:
We do understand that some delivery boards will still end up in a crisis situation during this winter. We are asking local delivery boards to work proactively with other local delivery boards so that we do not end up in an escalation situation whereby people are crying out for help at 10 o’clock at night; they work together all the time, but by having a new national escalation plan we have organised that in a fairly systematic way […]
That is a major focus over and above what has happened in previous years, but to try to support front-line providers in a way that they do feel, whether it is ECIP [Emergency Care Improvement Programme] that is coming in to support them or it is a CCG or a region that is having a dialogue with them, it is all joined up; we are not all asking them the same question and we are actually helping in a way that they can accept that help.
126.Trusts need year round support in redesigning their process both in terms of patient flow into the emergency department and eventual discharge into the community. Therefore it was encouraging that Lyn Simpson of NHS Improvement said:
This approach is different. It is about how we help organisations to help themselves. We need to differentiate what that improvement offer is to each organisation so that they really get what it is that they need rather than a universal offer. We have a segmentation process whereby we can look at the very best group perhaps but with people in the organisations that are struggling to share that good practice.
127.In addition, Pauline Philip said that NHS England and NHS Improvement will be given a baseline assessment of local provision by all A&E Delivery Boards which will tell them if trusts are using the five key interventions which are designed to improve patient flow. We regard this as a significant and positive step as there is significant variation in performance of emergency departments and their ability to manage similar challenges posed by demand, demographics, funding and staffing.
128.We are concerned about the level of variation in performance between trusts in managing urgent and emergency care. We recognise the pressures hospitals face but there is much that trusts can do to improve flows within their own systems and to learn from the best performing trusts. We support the steps taken by NHS England and NHS Improvement to try to tackle variation. We encourage them to roll out this process as quickly as possible so that other trusts facing similar challenges can overcome their problems.
129.It is encouraging that NHS England has said that new systems of management will change the demands on trust leaders. We were told that for those working on the frontline the current system appears designed as much to provide assurance to Department of Health ministers and senior officials at Richmond House as to help trusts improve their performance. We do not believe that the system of management has been designed for this purpose, but the frustration that is felt by so many illustrates its inherent flaws. Whether the mechanisms for managing trusts have evolved sufficiently will only become apparent once trusts and local areas begin to experience serious pressure. Performance management of trusts should not become more intense just because hospitals are operating under pressure. We recommend that the Department of Health should formally evaluate how the central management system which oversees performance against the four-hour target contributes to the maintenance of patient safety and the improvement of performance within trusts.
130.The challenges faced by the urgent and emergency care system are exacerbated by problem drinking. In October 2015, the Institute of Alcohol Studies reported the findings of a survey of emergency department consultants which found that “alcohol related incidents account for 25% of ED caseload”. In oral evidence Professor Keith Willett, National Director for Acute Episodes, NHS England, described the problems that emergency services can face:
As a clinician, the chronic use of alcohol and the drunk person creates a very difficult demand on emergency services. […] There are patient groups where alcohol is the primary problem—primarily they are drunk or they have an alcoholic disease problem—and there are those patients, which is a much larger proportion, where alcohol is part of the contributing element to their longterm illnesses, which obviously present as an acute component of that.
It has a significant impact on the services. We have to see this very much as a disease. We have to look at the public health issues behind it.
131.Professor Willett observed that caring for patients with alcohol problems can be very difficult for emergency department staff and affect their morale and the Institute for Alcohol Studies (IAS) research underlined this point. The IAS found that 43% of emergency department consultants had suffered injuries from intoxicated members of the public and 35% of consultants said they had been sexually harassed or assaulted whilst on duty.
132.In addition, during our visit to Luton and Bedford we were told that attendees at the emergency department have often consumed alcohol and, at weekends, this is the case for the vast majority of patients. This point was reinforced by those we met at the East of England ambulance service, who described extensive arrangements they have to make to deal with patients who, in many cases, are intoxicated to the state of unconsciousness. The Association of Ambulance Chief Executives said in their written evidence that for ambulance services dealing with alcohol related incidents is a standard part of managing the Christmas period.
133.Some work has been done to mitigate the effects of alcohol intoxication on the emergency services. The Centre for Urgent & Emergency Care Research described Alcohol Intoxication Management Services, which are an intervention designed to limit emergency department attendance:
These services are being piloted in a number of cities as a way of managing people with alcohol intoxication at times of peak incidence without transporting them to the emergency department.
Problem drinking continues to have a detrimental impact not only on accident and emergency departments, but elsewhere in the NHS and indeed wider public services. Winter pressures, especially over Christmas and New Year could be considerably reduced if staff were not having to treat the direct and indirect consequences of excess alcohol.
134.The impact that alcohol has on urgent and emergency care and other public services adds to the growing calls for effective cross-government action to radically upgrade public health and prevention. Our report of September 2016 on the funding, delivery and organisation of public health services concluded that:
Cuts to public health are a false economy. The Government must commit to protecting funding for public health. Not to do so will have negative consequences for current and future generations and risks widening health inequalities. Further cuts to public health will also threaten the future sustainability of NHS services if we fail to manage demand from preventable ill health.
135.Our report noted that the cost of alcohol related conditions to the NHS was £3.5bn per annum. Simon Stevens, Chief Executive of NHS England, said that the consequence of diminished public health services in relation to alcohol is that extra demand presents in the most expensive parts of the NHS such as emergency care.
136.Local authorities have a key role to play in managing problem drinking in their communities but they struggle to incorporate public health considerations into licensing decisions. As a consequence we urged the Government
to be bold, and make good on its commitment to health in all policies, by enshrining health as a material consideration in planning and licensing law.
137.Problem drinking is a significant contributor to the pressures in Accident and Emergency departments particularly at weekends and over holiday periods. The Government should take greater responsibility for policy decisions that would help to reduce the impact of excessive alcohol consumption on individuals, families and communities. Local authorities could be well placed to take action and we call on the Government to give them the levers to be able to do so by making public health and the impact on NHS services a material consideration in licensing and planning decisions.
122 Acute Care Common Stem training. ACCS is a three year training programme that normally follows Foundation Year 2. It is the only Core training programme for trainees wishing to enter Higher specialty training in Emergency Medicine ()
123 Health Education England () Para 14
124 , paras 14 - 15
126 Health Committee, Second Report of Session 2013–14,, HC 171, para 82
127 Royal College of Emergency Medicine () paras 12 - 13
128 British Medical Association () para 10
129 Royal College of Physicians () para 5
130 Royal College of Emergency Medicine () para 41
131 Royal College of Physicians () para 6
132 Health Committee, Second Report of Session 2013–14,, HC 171, para 82, Q 73
133 Royal College of Emergency Medicine () para 38
134 Royal College of Emergency Medicine submission to the House of Lords Select Committee: Long term sustainability of the NHS (NHS0029), para 45
135 Dartford and Gravesham NHS Trust () p 4
136 Q37 (Philip Dunne)
137 Q37 (Philip Dunne, Lyn Simpson)
138 Note of Committee visit to Luton and Bedford
139 Q37 (Professor Willett)
140 Q37 (Lyn Simpson)
142 Health Education England () para 14
143 Centre for Urgent & Emergency Care Research () p 1
144 HC Deb, 7 January 2015, [Commons Chamber]
145 Department of Health, NHS England and NHS Improvement () Annex A
148 NHS Providers () para 20
149 University Hospitals of Morecambe Bay NHS Foundation Trust () para 4.1
150 Nottingham University Hospitals NHS Trust () para 2
151 , para 4.3
152 Note of Committee visit to Luton and Bedford
153 Health Committee, , First Report of Session 2016–17, HC 139, para 168
154 Note of Committee visit to Luton and Bedford
156 Royal College of Emergency Medicine () paras 36-37
159 Note of Committee visit to Luton and Bedford
160 Homerton University Hospital NHS Foundation () p 4
161 Note of Committee visit to Luton and Bedford
166 Institute of Alcohol Studies, , October 2015, p 28
169 , October 2015, p 30
170 Association of Ambulance Chief Executives () para 4
171 Centre for Urgent & Emergency Care Research () p 3
172 Health Committee, Second Report of Session 2016–17, , HC 140, para 40
173 , para 35
174 , para 140
31 October 2016