Winter pressure in accident and emergency departments Contents

Conclusions and recommendations

Evolving demand

1.We are very concerned about the decline in performance of major emergency departments in England. We recognise that hospitals are managing ever growing demands, but the performance of emergency departments against the four-hour waiting time standard is a marker of much wider system pressure. (Paragraph 12)

Early senior review of patients

2.Both the Nuffield Trust’s and the Health Foundation’s research support the case for early senior review of complex cases. The systematic review cited by the Centre for Urgent & Emergency Care Research, however, reported limited cost and patient outcome benefits from routine use of early senior review of patients. When redesigning systems and processes with the intention of improving patient flow trusts should assess how they are applied and whether they are effective in their local context. (Paragraph 22)

National policy interventions

3.It is welcome that the interventions designed for use by A&E Delivery Boards and individual trusts focus on the practical aspects of patient flow throughout a patient’s stay in hospital. We support the whole system approach to providing a better experience of care to patients in the right setting at the right time. (Paragraph 27)

4.Ministers and senior officials should acknowledge the reservations expressed by the Centre for Urgent and Emergency Care and re-examine the evidence base for the initiatives being applied within emergency departments. (Paragraph 29)

Practical improvement

5.We recommend that NHS England and NHS Improvement set out how they intend to formally evaluate the effectiveness of the interventions that they have mandated and how they will be encouraging trusts to do likewise. Data collection and evaluation should be built into future programmes from the outset to improve research into the most effective interventions. (Paragraph 30)

6.The ongoing decline in performance of type 1 emergency departments against the four-hour target should be regarded as a matter of patient safety rather than a failure to meet a bureaucratic objective. (Paragraph 32)

7.Through the improvement work they are undertaking with trusts, NHS England and particularly NHS Improvement should facilitate the development of the cultural approach we witnessed in Luton, where waiting times in A&E are seen as everyone’s responsibility. (Paragraph 33)

Flow & delayed transfers of care

8.It is an indictment of the existing state of adult social care provision that some acute trusts are having to establish domiciliary care services in order to improve patient flow through their hospitals and ease pressure in their emergency departments. This only serves to underline the perilous state of adult social care in England and the fundamental inadequacy of provision in some parts of the country. The Government should undertake an urgent review of the state of adult social care and its impact upon the NHS and the most vulnerable individuals who depend upon both. (Paragraph 41)

Increasing bed capacity

9.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. (Paragraph 53)

10.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. (Paragraph 58)

Supporting adult social care to maintain patient flow

11.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. (Paragraph 68)

12.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. (Paragraph 69)

13.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. (Paragraph 70)

Utilising primary care to reduce demand

14.We would like to see further evidence that the Government’s proposals for extended GP hours will limit the demands placed on emergency departments. (Paragraph 79)

15.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. (Paragraph 80)

16.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. (Paragraph 86)

17.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. (Paragraph 87)

The ambulance service

18.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. (Paragraph 94)


19.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. (Paragraph 108)

20.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. (Paragraph 109)


21.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. (Paragraph 117)

22.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. (Paragraph 121)

Management of the system

23.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. (Paragraph 128)

24.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. (Paragraph 129)

Demand driven by alcohol consumption

25.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. (Paragraph 137)

Four-hour waiting time standard

26.We support retaining the four-hour waiting time standard in emergency departments. We recommend, however, that evidence-based standards of performance should be developed which allow for a better assessment of the performance of the wider health and social care system in relation to urgent and emergency care. (Paragraph 143)

Ambulance service targets

27.Reform of the existing target regime for ambulance providers in combination with tackling handover delays should be prioritised by NHS England. This would help to remove the practical barriers that limit the ability of ambulance providers to ‘see and treat’ patients without having to convey them to hospital. (Paragraph 148)

31 October 2016