The Committee visited Luton and Dunstable University Hospital NHS Foundation Trust (L&D) and the East of England Ambulance Trust (Bedford) on Tuesday 6 September 2016.
Committee members present: Dr Sarah Wollaston MP (Chair); Julie Cooper MP; Dr James Davies MP; Andrea Jenkyns MP; Maggie Throup MP; Dr Philippa Whitford MP.
Representatives of the L&D included: Pauline Philip, Chief Executive, Luton & Dunstable Hospital Trust; David Carter, Managing Director; Mr Dave Kirby, Consultant in Emergency Medicine and Medical Director for Operations & Performance.
Pauline Philip and Dave Kirby provided an overview of Luton & Dunstable’s approach to the delivery of the 4hr standard and the systems and processes the Trust had put in place to manage capacity and demand. The Committee was then escorted on a tour of the emergency department (ED).
The Committee heard that there is a little seasonal effect in Luton and peak periods of demand do not necessarily happen in winter. Equally, attendances fall at certain periods during the summer as Luton is not a tourist destination and the local population decreases as summer holidays are taken. It was explained that a process had been set in train in 2010 to achieve good performance in the emergency department and this is subject to constant evaluation and development.
The L&D said that they had increased bed capacity to improve patient flow but other reforms centred on the management of the emergency department and the organisational culture. A system of streaming patients between the ED and a primary care service had been established. The basic principle that is applied is that if a patient walks into the department, can talk in full sentences and has no obvious condition which requires urgent attention then they will be directed to the co-located primary care service. A small number of risk factors are excluded from the streaming process. This service is not accessible from the street and can only be accessed via the ED. GPs in the primary care service have the same access to services as those in the wider community. Originally, the co-located service had dealt with minor injuries but the ED found that this provided little benefit as a significant number of patients would end up being sent back to the ED. The L&D said that the primary care service, however, had helped reduce congestion in the ED and there is no evidence that the co-located service has increased demand.
Once a patient is in the ED early senior review of complex patients means that it can be quickly decided (within an hour) if a patient will require admission. This does not mean that a final diagnosis is reached within this timeframe but the point was made that this is not required to know whether a bed will be needed or not. The L&D emphasised that developing this system had required investment in a sophisticated IT system, and the staff to use it. The system allows for anticipatory planning of bed requirements and maps the movement of patients through the hospital.
The cooperation of other specialties within the hospital has been seen as central to maintaining good performance against the four-hour standard. Early on in the process of improvement an agreement was reached with consultants that patient lists would not be cancelled at late notice if they agreed to help in the ED at periods of peak demand. All teams within the hospital recognise that meeting the target is a matter of patient safety rather than a bureaucratic objective. In practice this means that staff can be re-allocated from wards to support the short-term use of escalation wards to increase capacity. The application of IT means that there is a predictive capability to help plan for peaks in demand.
Good performance has been supported by an integrated health and social care team. However, the L&D said that the one aspect of care that they can’t plan or adapt for is the lack of adult social care and this posed a major threat to the performance of the ED and hospital. Concern was also expressed about the performance of out-of-hours primary care and the difficulty in accessing alternative urgent care services. It was observed by the L&D’s representatives that the performance standards in other urgent care services do not match that of the ED where patients know that they are likely to be seen within four hours. The L&D said that an integrated urgent care service routed through the 111/999 integrated access hub is required—their own audit of attendances had shown that only 58% of patients would attend the ED if there was proper integrated urgent care with a comprehensive service directory.
The Committee was told that the provision of urgent and emergency care is a loss-making activity for the L&D. Overall, the emergency department loses £3 million per annum. The L&D said the tariff system pays EDs too much for simple cases but too little for complex patients in the ED. It was also noted that the co-located primary care service is operated by a different provider so the tariff for those cases does not reach the L&D.
The Committee held a seminar with a range of national policy experts. Attendees were: Dr Clifford Mann, President, Royal College of Emergency Medicine; Anthony Marsh, Chief Executive, Association of Ambulance Chief Executives; Dr Tom Downes, Consultant Physician and Geriatrician, Clinical Lead for Quality Improvement, Sheffield Teaching Hospitals NHS Foundation Trust and Health Foundation Quality Improvement Fellow; Professor Steve Goodacre, Professor of Emergency Medicine, Centre for Urgent & Emergency Care Research, University of Sheffield; Professor Sue Mason, Professor of Emergency Medicine, Centre for Urgent & Emergency Care Research, University of Sheffield; Corrine Eastes, Emergency Care Improvement Manager, NHS Emergency Care Improvement Programme; Sasha Karakusevic, Senior Fellow, Nuffield Trust.
The seminar opened with a general discussion about performance of the urgent and emergency care system. The point was made that last year the weather was relatively good and the flu vaccine proved effective, but despite this many trusts struggled. It was observed that it has proved possible for some trusts to replicate good practice from elsewhere. Concerns were expressed, however, that short-term decision making can drive actions for the medium and long-term and too much emphasis had, in the past, been placed on improving performance by reforming commissioning processes rather than focusing on service delivery.
The effect of the four-hour waiting time standard was assessed by the policy experts. The Committee was told that there is little evidence of active ‘gaming’ of the system. In the early days of the target gaming did exist but it is much reduced now. The target is not thought to particularly drive clinician behaviour but it was observed that nurses are under pressure to make swift decisions.
The Committee heard that very few patients are admitted to hospital unnecessarily and even if a patient does not eventually stay overnight in hospital that did not mean that admission was not required when the patient attended the emergency department. There was a discussion about what happens to patients after they are admitted with the point being made that before admission the system is heavily regulated in terms of time but after admission patients can enter a ‘black hole’. Countering this, the Committee heard that good clinical practice means that in reality the approach to patient care does not alter once patients are admitted and the four-hour target is met.
Looking at how the system could be improved, it was observed that quite small differences in operational performance can make the difference between a successful and a failing organisation. The importance of community resources was emphasised and the Committee was told that often the discussion around community beds focuses on ‘step-down’ rehabilitative care with little attention paid to ‘step-up’ services which can limit demand for emergency care.
Examining patient behaviour, the Committee was told that in some areas migrant communities will disproportionately use A&E as they have little knowledge or experience of primary care in their countries of origin. It was observed that growing numbers of ambulatory patients are being referred to A&E by other health professionals and problems with out-of-hours services can drive patients to emergency departments. For example, some out-of-hours services will not liaise with paramedics about patient care.
The Committee was told that at present the urgent and emergency care system is defined by managing crises rather than avoiding them. Demand for beds will grow by 9,000 by 2020 so the approach has to change. The Committee heard that the capacity of the system to absorb demand is limited by the available workforce and that patients with complex needs (a group which is expanding rapidly) absorb the most staff time. Moreover the interface between health and social care is ‘forming a dam’ of patients. It was noted that including a new metric of daily discharge ratios in the Carter review emergency medicine dashboard may have a positive impact.
The Committee met senior representatives of acute trusts drawn from across England all of which host type 1 emergency departments. Attendees were: Kate Slemeck, Chief Operating Officer, Royal Free London NHS Foundation Trust; Nick Hulme, Chief Executive, The Ipswich Hospital NHS Trust & Colchester Hospital University NHS Foundation Trust; Libby McManus, Chief Executive, North Middlesex University Hospital NHS Trust; Rob Cooper, Acting Director of Operations and Performance, St Helens and Knowsley Teaching Hospitals NHS Trus; Liz Davenport, Chief Operating Officer, Torbay and South Devon NHS Foundation Trust; Jenifer Rossall, General Manager for Acute Medicine, Nottingham University Hospitals NHS Trust.
The seminar began with a description by one trust leader of the specific challenges they face. The trust in question has an ageing population, a significant tourist population and in addition 22% of local children live in poverty. The Committee was told that major problems with emergency care had started to be alleviated by increased recruitment but the fundamental problem faced by the trust was the size of its emergency department. There simply is not the space to accommodate the average number of daily attendees.
Another trust described the challenge of working with three different Clinical Commissioning Groups, all of which have different policies for discharging patients. The trust representative told the Committee that they experienced a 6% annual increase for elective procedures which left them 30 – 60 beds short. Previous winter resilience schemes had focussed on limiting elective activity during periods of peak demand but it was found that some of these cases re-presented at the emergency department.
The Committee heard from a representative of a trust that has encountered very serious problems in the performance of its emergency department. It was noted that some problems were specific to the trust such as poor rotas of middle grade staff and an inefficient layout of the emergency department. The trust said that their attendances were disproportionately high and attributed this to a lack of GP and community provision.
The Committee heard that the consequence of poor performance is that staff begin to give up on ever performing well and a ‘culture of hopelessness’ can prevail. In the following discussion it was observed that Chief Executives in some cases have to tell the staff in poorly performing trusts that they all have to do better.
Although this may be necessary it was acknowledged that it could be high risk. It was agreed that the cultural differences between successful and unsuccessful trusts—and the behaviour and expectations of the staff—are very striking.
One trust leader described an initiative that had been launched whereby the trust would provide a domiciliary care service. This, the Committee was told, was to make up for a lack of adult social care and because the cost of keeping patients in hospital exceeded the cost of providing care to the same patients in their own homes. Local authorities are reluctant to commission trusts to provide this service as they immediately classify it as an NHS service. Even without local authority commissioning, however, the Committee was told that the service still makes economic sense for the trust. The Committee heard that recruiting staff to this service was easy as the NHS brand is hugely attractive to workers in the care sector. In one area, local authority funded homecare services were described as being ‘on their knees’.
The Committee heard a number of observations in relation to staff from various attendees. The point was consistently made that in some areas it is almost impossible to recruit middle grade doctors and that workforce planning has to apply to entire areas rather than just individual trusts. The Committee was told that the limited supply relative to demand of nurses means that they can carefully choose where they work—they often don’t choose the ED because of the stress associated with it.
Primary care was not seen as contributing greatly to efforts to manage winter pressure. The Committee heard that primary care doesn’t change its offer in relation to winter and doesn’t react to the Christmas and new-year bank holidays when demand can transfer to the ED. The Committee was told, however, that some preventative measures have been introduced such as prescribing prophylactic antibiotics for people with respiratory conditions. This could make a significant difference as 80% of admissions at certain winter periods in one area are for respiratory illness.
The management and resource available to the urgent and emergency care system was discussed with the Committee. The attendees agreed that there had been excessive micro-management of trusts in previous years and the system appeared designed to provide assurance to the centre as opposed to solving problems. It was noted that hours of leadership time spent participating in conference calls during periods of pressure contributed very little to the practical resolution of problems. The Committee was told trust leaders should be able to go to NHS Improvement with specific problems and receive advice on how other trusts had managed to solve the problem that had been identified. This, in essence, would be brokerage of good advice by NHS Improvement.
Funding was said to be very limited and one attendee said that incorporating winter allocations into CCG baseline funding meant in practice that the funding ‘isn’t real’. The Committee heard that even if extra funding was provided to open additional beds it would achieve little as there is no more bed capacity to be used.
The Committee visited the East of England ambulance centre in Bedford. The Committee was given a tour of the control room and representatives of the East of England Ambulance Service Trust (EAST) discussed the challenges that the ambulance service has to face. Attendees from EAST included: Sarah Boulton, Chair; Robert Morton, Chief Executive; Kevin Brown, Director of Service Delivery; Tracy Nicholls, Head of Clinical Quality; Sandra Treacher, Emergency Operations Centre Clinical Lead; Nikki Ward, Head of Business Development.
The trust told the Committee that they had initiated a process to ‘hear and treat’ a greater proportion of patients which would reduce the need to dispatch vehicles. The Committee heard that all ‘green’ calls are now triaged this way and that they had doubled the proportion of patients being triaged to ‘hear and treat’. The ambition of the trust, they said, is for 10% of patients to be managed by ‘hear and treat.’
A substantial portion of the discussion examined the problems associated with the existing target regime for ambulance services. The Committee heard that the 8 minute response time was clinically appropriate for some calls but not others and that this can create perverse incentives. In addition the necessity of instantly responding to the target means that crews are regularly despatched and then recalled. The demands of the target, EAST said, mean that behaviour is driven by making time rather than clinical need. EAST argued that targets could be better applied if they covered the totality of care for specific conditions.
It was noted that other parts of the UK such as Wales have different target regimes. In Wales 10% of calls require an ambulance within eight minutes but in England it is 50%. The Committee was told that there may be a capacity gap that is being driven by excess demand. Ireland was cited as an example because it has half the number of calls to the ambulance service per 1,000 people than the East of England. In addition it was noted that in some systems 40% of patients do not require conveyance to hospital because of ‘see and treat’ by paramedics. The Committee was told that transport has traditionally defined the ambulance service but it should be only one consequence of the service provided.
The problem of handover delayed was addressed by the representatives from EAST. The Committee was told that there is very significant differences between trusts in the time taken to transfer patients from ambulances to emergency departments. EAST said that at some hospitals delays of over an hour were a common occurrence and waits of more than two hours were not uncommon. The consequence of the delays is that vehicles and crews are unable to respond to emergencies elsewhere and waiting in an ambulance substitutes for waiting in hospital.
31 October 2016