NHS Accident and Emergency Departments in England
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NATIONAL AUDIT OFFICE REPORTBY THE COMPTROLLERAND AUDITOR GENERAL NHS Accident & Emergency Departmentsin England ORDEREDBY THEHOUSEOFCOMMONS TO BE PRINTED 15JULY1992 LONDON:HMSO 158 f7.15 NET NHS ACCIDENT & EMERGENCY DEPARTMENTS IN ENGLAND This report has been prepared under Section 6 of the National Audit Act, 1983 for presentation to the House of Commons in accordance with Section 9 of the Act. John Bourn National Audit Office Comptroller and Auditor General 8 July 1992 The Comptroller and Auditor General is the head of the National Audit Office employing some 900 staff. He, and the NAO, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources. NHS ACCIDENT & EMERGENCY DEPARTMENTS IN ENGLAND Contents Page Summary and conclusions 1 Part 1: Introduction 4 Part 2: Management and organisation of Accident & Emergency departments 6 Part 3: Planning and strategic issues 17 Appendices 1. Developments in Accident & Emergency services since the 1960s 25 2. Accident & Emergency departments, health authorities and professional organisations consulted; bibliography 27 3. Primary care research project 29 4. Planning for hospital Accident & Emergency services 30 5. Performance and quality indicators for Accident & Emergency services 32 Glossary of terms 34 NHSACClDENT&EMERGENCYDEPARTMENTSINENGLAND Summary and conclusions 1 About 11 million people a year seek medical attention in Accident & Emergency departments in England, and members of the public often gain their first impressions of National Health Service (NHS) hospitals on visits to Accident & Emergency departments. 2 Patients attend Accident & Emergency departments with a wide variety and range of illnesses or injuries. Only a small proportion are seriously ill or severely injured, but these patients require immediate attention from highly skilled medical and nursing staff. In order to deal with the full range of demands placed upon them, but especially the needs of those who are seriously ill or severely injured, the departments must have skilled staff and essential equipment available at all times. 3 This report gives the results of a National Audit Office examination of Accident & Emergency departments in England. A companion report deals similarly with the departments in Scotland. Wales has not been included in this examination, but many of the National Audit Office’s findings and conclusions may be relevant to purchaser authorities and provider hospitals in the principality. Main findings and On management and organisation of Accident & Emergency departments conclusions 4 The National Audit Office concluded that, allowing for constraints outside the departments’ control, the Accident & Emergency departments they visited were being well run on a day-to-day basis. But the examination also pointed to opportunities for more positive management, which would be assisted by: . stronger representation of Accident & Emergency departments in hospital management (paragraph 2.4); . much more flexible and capable computerised management information systems (paragraph 2.10 and Figure 3); l measures to improve management of the departments’ rising workload (paragraph 2.24, Figure 4 and paragraphs 3.8-3.14); . consistently better use of nurses’ skills (paragraph 2.32 and Figures 5 and 6); . monitoring the adequacy and timeliness of support to the departments from other specialties and services (paragraphs 2.46-48); . better communications with general practitioners (paragraph 2.55): l development of systematic clinical audit (paragraph 2.61). Of these, better management information would pave the way for objective assessment of the efficiency and effectiveness of the departments’ work. 1 NHS ACCIDENT & EMERGENCY DEPARTMENTS IN ENGLAND Extra resources would be required for the implementation of some of the measures listed above; additional resources need to be assessed at local level against the longer term benefits resulting from implementation and alternative uses. On planning and strategic issues 5 Some of the measures need to be supported by action involving regional health authorities and, as purchasers, district health authorities. For example, regions need to develop policy frameworks (eg for location of Accident & Emergency departments) and purchasers need to continue to develop quality standards linked to contractual targets (paragraphs 3.2-3.7 and Figure 9). 6 Numbers of new attendances at Accident & Emergency departments have continued to rise, currently to more than 11 million a year. Concerted action is needed to ensure that patients receive the most appropriate health care and that the departments are not overloaded with patients who might be better treated elsewhere (paragraph 3.11 and Figure 11). While some departments have made good progress in reducing numbers of return attendances, these could be further reduced in some places (paragraph 3.14). Medical staffing 7 Towards the end of the National Audit Office examination, the Joint Planning Advisory Committee (which advises the Secretary of State for Health on the numbers of doctors in training) recommended that there should be an increased number of doctors in training in Accident & Emergency departments. This was intended to meet forecasts of appointments of an additional 72 Accident & Emergency consultants in England in the three years to the end of 1995. In May 1992 the Department of Health asked regions to provide details of their plans for implementing the increased numbers of training posts, which would have to precede increases in numbers of consultants. 8 The expected increase in numbers of Accident & Emergency consultants is consistent with National Audit Office findings that experienced medical staff in Accident & Emergency are often overstretched. Health authorities and providers need to consider how quickly they can implement the planned increases,whilst taking account of othercalls on their resources. They should ensure that new posts are deployed to achieves the greatest benefits to quality of service for patients (paragraphs 3.15-3.21). Severe injuries 9 In 1988 the Royal College of Surgeons urged action to improve the care of patients with severe injuries, a view which professionals in Accident & Emergency have strongly endorsed. Taking account of these views and their own findings, the National Audit Office concluded that: l early and continuing improvements are needed to ensure uniformly good provision for care of all severely injured patients (paragraph 3.32 and Figure 13); . the Department of Health and the NHS should consider how trauma audit should be carried forward (paragraph 3.38). 2 NHS ACCIDENT & EMERGENCY DEPARTMENTS IN ENGLAND General 10 Accident & Emergency departments have been undergoing a long process of conclusions development, gradually moving away from the outdated concept of casualty departments. There has been good progress over the last 30 years, and the expected increases in numbers of experienced medical staff in Accident & Emergency departments should now pave the way for further substantial improvements. The National Audit Office examination suggested that potential benefits of the increased staffing include better training and supervision of inexperienced doctors. Other measures leading to improved quality of service to the public depend on better information systems and planning. While the implementation of some improvements will be subject to assessment of local priorities for Accident & Emergency services, and the competing claims of other specialties and services, purchaser/provider contracts offer a focus for agreeing priorities for action. 3 NHS ACCIDENT & EMERGENCY DEPARTMENTS IN ENGLAND Part 1: Introduction 1.1 The primary task of Accident & Emergency 1.4 There has been considerable progress in departments is to care for and treat ill or developing hospital Accident & Emergency injured people, quickly and at any time. This services over the last 30 years. Appendix 1 includes minimising numbers of deaths and summarises developments since 1962, when degrees of disabilities. Patients comprise: the Platt report found that casualty departments, as they were then called, were those with life-threatening illnesses or inadequate and largely unmanaged. The injuries, who require immediate medical report drew attention to the need for assessment and may need resuscitation; substantial changes, including renaming those with serious illnesses or injuries them as Accident and Emergency who require admission to hospital; departments in order to emphasise that they were not intended for casual attendance. those with minor illnesses or injuries, who can often be quickly discharged after treatment. Scope of National Audit Office The departments require 24 hour, 7 days a examination week medical and nurse staffing, and prompt support from other hospital specialties and 1.5 Against this background, the National Audit services. The Accident & Emergency service Office examined the management and must be available to all patients who need to organisation of Accident & Emergency use it. departments, and relevant planning and strategic issues. They carried out their main 1.2 There are swne 235 main Accident & Fieldwork and discussions between May and Emergency departments in England December 1991, undertaking detailed (Figure l], but there is no