Urgent and Emergency Services

House of Commons Health Committee

Urgent and emergency services

Second Report of Session 2013–14

Volume II Additional written evidence

Ordered by the House of Commons to be published 16 July 2013

Published on 26 July 2013 by authority of the House of Commons London: The Stationery Office Limited

The Health Committee

The Health Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Department of Health and its associated bodies.

Membership Rt Hon Stephen Dorrell MP (Conservative, Charnwood) (Chair)1 Rosie Cooper MP (Labour, West Lancashire) Andrew George MP (Liberal Democrat, St Ives) Barbara Keeley MP (Labour, Worsley and Eccles South) Charlotte Leslie MP (Conservative, Bristol North West) Grahame M. Morris MP (Labour, Easington) Andrew Percy MP (Conservative, Brigg and Goole) Mr Virendra Sharma MP (Labour, Ealing Southall) David Tredinnick MP (Conservative, Bosworth) Valerie Vaz MP (Labour, Walsall South) Dr Sarah Wollaston MP (Conservative, Totnes)

Powers The Committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the Internet via www.parliament.uk.

Publications The Reports and evidence of the Committee are published by The Stationery Office by Order of the House. All publications of the Committee (including press notices) are on the Internet at www.parliament.uk/healthcom.

The Reports of the Committee, the formal minutes relating to that report, oral evidence taken and some or all written evidence are available in printed volume(s).

Additional written evidence may be published on the internet only.

Committee staff The staff of the Committee are David Lloyd (Clerk), Martyn Atkins (Second Clerk), Stephen Aldhouse (Committee Specialist), Frances Allingham (Senior Committee Assistant), and Ronnie Jefferson (Committee Assistant).

Contacts All correspondence should be addressed to the Clerk of the Health Committee, House of Commons, 7 Millbank, London SW1P 3JA. The telephone number for general enquiries is 020 7219 5466. The Committee’s email address is [email protected].

1 Mr Stephen Dorrell was elected as the Chair of the Committee on 9 June 2010, in accordance with Standing Order No. 122B (see House of Commons Votes and Proceedings, 10 June 2010).

List of additional written evidence

Page 1 Dr John Wright Ev w1 2 Healthcare Audit Consultants Ltd Ev w2 3 South Western Ambulance Service NHS Foundation Trust Ev w7 4 NHS Benchmarking Network Ev w10 5 Miss Beverley Griffiths Ev w13 6 Pharmacy Voice Ev w14 7 North East Ambulance Service NHS Foundation Trust Ev w16 8 Royal College of Surgeons Ev w19 9 Priority Dispatch Ev w22 10 Royal College of Nursing Ev w23 11 The Royal College of Radiologists Ev w27 12 College of Paramedics Ev w28 13 Board of Directors of University Hospitals Coventry and Warwickshire NHS Trust Ev w31 14 Emergency Medicine Trainee Association Ev w33 15 Janet Egan Ev w36 16 UNISON Ev w38 17 Carers UK Ev w41 18 The Medical Care Research Unit, School of Health & Related Research, Ev w44 University of Sheffield 19 British Medical Association Ev w45 20 London Ambulance Service NHS Trust Ev w50 21 The King’s Fund Ev w52 22 Nuffield Trust Ev w55 23 Dr Timothy Whelan Ev w57 24 NHS Direct NHS Trust Ev w59 25 Myasthenia Gravis Association Ev w73 26 Centre for Public Scrutiny Ev w74 27 Unite Ev w78 28 NHS Clinical Commissioners Ev w82 29 Royal College of Paediatrics and Child Health Ev w83 30 Foundation Trust Network Ev w85 31 Dr Daniel Albert Ev w92 32 Parliamentary and Health Service Ombudsman Ev w94 33 The Shelford Group Ev w97 34 Circle Healthcare Ev w102

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Written evidence

Written evidence from Dr John Wright (ES 02) Summary — The number of patients attending the Newcastle ED (RVI) has increased by 100% in eleven years. — The situation changed with the change in general practitioner responsibilities for on call in 2004. — The 4-hour target for EDs compounded the situation by making the ED the number one choice for out of hours care for many patients. — Stafﬁng changes and efﬁciency improvements meant our staff could keep pace with the increased numbers until 2010–11. — For the past twelve to eighteen months there has been unprecedented demand for ED services and any reserve in the system has now been depleted at the busy times. — Trainees are shunning our specialty because of excessive work pressures and unsocial hours, there are subsequently gaps in trainee rotas. — The solution is to have one single point of access to unscheduled care: the ED. — The ED needs to be better resourced, but if it is, unscheduled care could be better than the model in operation up to 2004.

Emergency Care in Newcastle ED (RVI) 1. My name is Dr John Wright. I am an Emergency Medicine consultant in the Royal Victoria Infirmary in Newcastle-upon-Tyne. I have been a consultant for twelve years, and a doctor for twenty five years. I am submitting this evidence as an individual. Any comments I make do not necessarily reflect any opinion from within my trust (Newcastle Upon Tyne Hospitals NHS Trust), other than my own. 2. For anyone interested in the background of individuals submitting evidence, I trained in Dundee University and did most of my postgraduate training in Glasgow before returning to my home city of Newcastle. I have worked in twelve UK hospitals and have practised medicine in seven countries. 3. A colleague sent the link to this Select Committee to me and suggested I might want to comment. Having witnessed a recent deterioration in the quality of service we are trying to provide due primarily to increased volume of demand I decided it was important to make members of the Committee aware of the local situation here in Newcastle. 4. When I started working as a consultant in 2001 our ED saw 59,000 patients that year. In 2012 our ED saw 120,000. That is a 100% increase in attendances in eleven years. Newcastle in general has a static population, but our case mix has changed, with increasing numbers of sick elderly patients with multiple pathologies, increasing numbers of children with minor illness and increasing numbers of patients in their twenties and thirties who bypass general practice completely. 5. The situation changed significantly from 2004 onwards when general practitioners were allowed to opt out of on-call duties. In addition, around the same time the GP contract changed, the way they were remunerated for visiting elderly patients in care homes changed (meaning after this point such patients didn’t always get the high quality service they were receiving beforehand). The Out of Hours general practice services that were set up to replace the previous system of GPs covering their own patients was inadequately funded nationally. Instead of having approximately 20–30 GPs on call for a city the size of Newcastle, the number of on-call GPs seemed to decrease to approximately four–five, with individual doctors having a much larger geographical area to cover. This of course meant patients found it increasingly difficult to get a timely response by a quality on- call doctor. It didn’t take patients (especially young adults) long to realise that they would get a quicker response by going to the local ED. To compound matters, the government of the time introduced the four-hour target for EDs, meaning in hospitals like RVI that hit this target, excessively long waits became a thing of the past for the vast majority of patients attending. 6. For about seven years after 2004 we experienced steady and sizeable annual increases in attendances, but we managed to cope by becoming more efficient and also developing rapidly and by becoming a quality specialty. Our ED doctors now equal or better the quality of emergency medicine practitioners in any other advanced country. Between 2004 and 2010 in Newcastle we increased consultant numbers from six to ten, middle grade numbers remained static and the numbers of the most junior doctors (F2s, also still called “SHOs”) were increased from twelve to seventeen. Nurse numbers increased by about 10%. 7. Unfortunately for the past twelve to eighteen months conditions in our ED have deteriorated due to unprecedented demand with limited access from the ED to inpatient beds. It is my opinion that any reserve in the system had gradually been eroded up to 2010–11 when unexpectedly we started receiving even more patients and many more unwell patients. The capacity in our hospital is limited like all others in the NHS and this means we now frequently have to hold patients in a crowded ED while waiting for a bed. Our hospital never closes to ambulances but recently we have started accepting ambulance patient diverts (on occasion) cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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from three or four of the other local hospitals because they have filled all their beds. The reasons are multifactorial, but include poor social and medical care in nursing homes, an increasing elderly population with multiple morbidities, younger patient choosing to bypass general practice for themselves or their children because they perceive a better service in the ED, and NHS Direct inappropriately triaging patients to our ED (colloquially known as “NHS re-Direct”- we must hope that “111” proves to be a better system.). 8. A massive knock-on effect of the increasing pressures on ED doctors is that there has been a sharp decline in the number of trainee doctors wishing to work in our specialty. Why should they wish to work in such an unpleasant working environment as a crowded ED serving a hospital that has run out of capacity? In a recent specialty application round only 50% of posts were filled nationally. Our department currently has three of seven senior trainee posts unfilled, and six of the seventeen “SHO” posts unfilled. 9. Most ED doctors love their specialty; we deal with patients with undifferentiated illness or injury, diagnose and treat or reassure. Our breadth of knowledge has to cover the whole spectrum of medical illness and it is often an exciting and rewarding profession. Nearly all our patients are very grateful for the help they receive and they make sure we are aware of their gratitude. However, more and more shifts are becoming increasingly unpleasant for both staff and patients alike. Nobody wants to see themselves or their loved ones waiting in busy, cramped situations in what can appear to be a frightening and chaotic environment. Patients hate this, staff hate this. In addition there is plenty of evidence that shows quality of care decreases in these situations. 10. There are two possible solutions: 1. Return out of hours care for patients to their own GPs. This will require a large increase in resources because 2013 is not the same as 2004 for many reasons. This move will also be met be resistance by our GP colleagues now that the “genie is out the bottle”, and who can blame GPs for wanting to avoid this? 2. Locate all out of hours care in the ED. This has the potential to create an emergency care system better than what existed before 2004. Local Out of Hours GPs can work under the umbrella of Emergency Medicine in a secure working environment with access to the requisite investigations and IT systems etc. Patients will rapidly realise that there is a single point of access to the NHS unscheduled care system, removing confusion. The current plethora of services offering additional care to general practice or the ED (Walk-in Centres, Minor Injuries Units, Urgent Care Centres) should be located beside or within the ED. The single access point, which should always be controlled by the ED clinicians and GPs should never be controlled by a Clinical Commissioning Group. The experiment has proved that the additional services offered have not decreased general practice or ED demand. 11. In order to fulfil solution 2, the ED needs to be recognised as “special”. Staff working in the ED system should be rewarded by having a lot more colleagues working alongside them on each shift—this will attract the medical and nursing staff currently leaving. The environment needs to be pleasant for patients and this will naturally ensure the working environment for staff is pleasant and rewarding. Staff need access to the appropriate investigations at all times, and central government needs to address the significant problem of hospital overcrowding. The current way of working cannot go on for much longer, everything and everybody is creaking and groaning! April 2013

Written evidence from Healthcare Audit Consultants Ltd (ES 03)

Summary 1. Claims that large proportions of A&E activity (as much as 50%) can be absorbed into the community and that it will be any cheaper to do so are not based on sound evidence. 2. Claims that the quality of care in A&E departments will be improved by restricting access and capacity within A&E are not based on sound evidence. 3. Most reconﬁgurations of services are likely to be costly, risky and ineffective in achieving their goals. 4. There must be more rigour in reviewing business cases for reconﬁgurations of emergency services. 5. The interests of local people should not be overridden. Defences against the abuse of professional self- interest must be strengthened.

1 Introduction 1.1 Much of the rhetoric around changes to the emergency care system takes as a given the beneﬁts of closing A&E departments throughout the country. But in theory and in practice there is almost no evidence to support this position. This paper provides a brief critique of the attempts to reorganise the emergency care system in England in recent years. It points to shortfalls in three crucial areas of evidence: demand for A&E services will be reduced by investment in out-of-hospital care; centralisation of services will result in improved quality and lower costs; and, how the latest reforms will affect the interface between ambulance services and out-of-hour services. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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1.2 Finally the paper considers some of the factors behind the drive to close A&E departments at a time when there is evidence of increased pressure on existing departments, and the need for more open and honest consultation with the public.

2 Reductions in Demand for A&E services 2.1 The crucial assumption justifying the reduced provision of A&E services and hence savings in capacity and staffing is that investment in out-of-hospital care will reduce demand. But the evidence for this does not stand up. Indeed there is some evidence to the contrary: for example readmission rates significantly increased for older patients with a mixture of conditions who were allocated to hospital-at-home services (Purdy et al. 2012, p89). 2.2 As Professor Alan Maynard (2013) argued recently there is no compelling evidence for claims that A& E flows can be directed into community care as a cheap substitute rather than, as seems to be the case, an expensive complement to acute care. 2.3 Carson et al. (2011, p19) found no direct link between A&E attendance and hospital admission, and moreover diversion schemes were generally found to be ineffective. They state (our bold), There is some evidence that when A&E departments become overwhelmed junior staff will admit more people—the primary failure is in the A&E system not the volume presenting. There are a number of key factors driving hospital admission numbers. These are: the number of individuals referred by GPs, 999, 111 and NHS Direct staff and out-of-hours services (which are all influenced by access to GP urgent care), and the efficiency of the process in A&E and acute medicine, including the availability of senior staff. There is little or no evidence for the effectiveness of diversion schemes on admissions; some have had serious safety questions raised; while diversion schemes tend to focus on people who were never likely to be admitted because all they needed was advice or more basic care. 2.4 Carson et al. (2011) also found that when a consistent definition of primary care is used and a consistent denominator of all emergency department cases, the proportion of A&E cases that could be classified as primary care was between 10% and 30%. Not the 50% or more as claimed by rationalisation zealots. 2.5 Carson and colleagues state, Whilst it is undoubtedly true that primary care clinicians can relearn the skills needed to deal with the minor injuries that were excluded from the definition of primary care cases, there seems little value in this when A&E nurses already do this work well. 2.6 Carson et al. (2011, p22) also examined the use of urgent care centres and walk-in clinics, and found that, There is a lack of published evidence to support the hypothesis that urgent care centres and walk-in centres will reduce attendances at emergency departments; in contrast, indications suggest they increase total burden on the NHS. Where the vision of the urgent care centre is that it is fully integrated part of the A&E service … it will take time to establish and much longer for the relationships and mutual trust to grow so that the centre functions with full effectiveness. 2.7 There has been considerable investment in urgent care centres and walk-in-centres over the last ten years and yet overall A&E attendances have continued to rise as Figure 1 shows. Although most of this increase reflects attendances at urgent care centres and walk-in centres, there has also been an increase in the number of people seeking care at their local A&E departments (see Boyle 2011, p250, for a detailed discussion). cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Figure 1: A&E ATTENDANCES IN ENGLAND, 1991–2—2012–13

2.8 The College of Emergency Medicine has recommended that urgent care centres should be complements to existing A&E departments not substitutes. So much for the argument that urgent care centres will replace A&E departments with unsubstantiated claims that over 50% of attendances will divert from A&E to urgent care centres. 2.9 Recommendation 1: further investment in community facilities should be put on hold until there is an independent review of the impact of investment to date in such facilities to establish that these provide a cost- effective and high-quality alternative to A&E services.

3 Centralisation of Services 3.1 Local acute hospitals in their current form cannot continue to exist without the provision on site of A& E services and corresponding emergency surgery. The safe provision of so much else depends on this. 3.2 It is taken almost as an article of faith now that centralisation of health services—whether emergency services, maternity, or paediatric—will result in reductions in costs to the system and better quality healthcare. Yet this is based on virtually no evidence. The best systematic appraisal of the evidence on hospital reconfigurations and the development of out-of-hospital care certainly does not support the headlong flight towards so-called rationalisation that we are witnessing today. 3.3 Looking first at the efficiency arguments, recent research undermines the case for simple economies of scale in hospital reconfigurations. Thus, in a Nuffield Trust report, Hurst and Williams (2012, p59) concluded, There is also a large literature on the effect of changes in size on unit costs in hospitals. Reviews suggest that cost per case declines as hospitals increase in size to about 200 beds. There appear to be roughly constant returns to scale between 200 and 600 beds; however, above approximately 600 beds diseconomies of scale seem to set in, possibly because larger hospitals become more difficult to manage. 3.4 In London, the region with the highest costs in the country, it seems perverse that rationalisation of emergency services is promoting super hospitals of well over 1,000 beds. A prime example is East London Hospitals Trust with a turnover of £1.25 billion and 15,000 staff. How can such rationalisation be regarded as promoting efficiency when the super hospitals that remain are often the most expensive, the most subsidised and those hospitals with the lowest productivity. 3.5 Looking at the quality issue, in research from the King’s Fund, Harrison concluded (Harrison 2011; 2012), We have argued that volume and outcome studies do not provide, in themselves, an adequate justification for centralizing hospital services. Further studies focusing purely on hospital or surgeon volumes will not advance understanding of why quality of outcome varies between hospitals, why some small units seem able to produce the same quality as much larger ones, why large units sometimes perform badly or on the circumstances which determine whether the hoped for gains from centralizing services are actually achieved. 3.6 In the case of emergency care, Harrison went on to point out that centralisation may have a negative impact with mortality increasing the greater distances that have to be travelled, cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Even if gains in outcomes are achieved by centralization, the longer journey times that it entails for some patients may offset them to some extent. One study of stroke care found that the clinical risks of longer journeys outweighed the beneﬁts of centralization. Nicholl et al. found that for every mile a seriously injured person had to travel to hospital, the risk of death increased by one%. Other work has found that the longer journeys discouraged use of health-care services.

3.7 Harrison also pointed out, Most studies have focused on a narrow range of procedures, usually surgical interventions. They take no account of the implications for both the losing and the receiving hospitals of the effects of moving services between sites. Implicitly such studies assume that the higher-volume hospitals can absorb extra activity and maintain their supposed higher-quality levels. But stafﬁng and physical constraints may make that impossible or if possible, very slow to realize.

3.8 A further clinical issue is that the unintended costs to hospitals adversely affected by the withdrawal of services have not been identified or calculated. This is supported by for example the experience of Queen Mary’s Hospital, Sidcup which entered into a spiral of decline following the loss of A&E facilities and larger than predicted loss of income as patients and staff withdrew support. 3.9 What is often seen to be the overriding driver toward centralisation of A&E services is the claim that there is a shortage of suitably qualified medical staff as a result of the need to implement the European Working Time Directive (EWTD). This has been cited in many of the cases for reconfiguration referred to the Independent Reconfiguration Panel (IRP), and continues to be cited in the current climate. But the conclusion of the outgoing chairman of the IRP was (Barrett 2012, p5), With the benefit of hindsight, I think it is fair to say that the EWTD did not turn out to be the insurmountable obstacle it was originally perceived to be. Instead, in many cases it forced the NHS to think more imaginatively about how best to utilise its staff.

3.10 The College of Emergency Medicine believes a combination of tactics, including recruitment from overseas could bridge staffing shortages until adequate numbers of staff were trained in the UK. If anything it is a failure of NHS planning not to ensure sufficient staff; this is not a reason in itself for closing A& E departments. 3.11 Indeed very recently concern was expressed that there were not enough posts being created for junior doctors completing their training. In fact England has substantially less specialists per head of population than many other leading European countries: 0.91 per 1,000 in England compared with 2.39 in Denmark, 2.29 in Germany, 1.75 in Belgium, 1.71 in France and 0.98 in the Netherlands (Kok et al. 2012). The obvious answer to the passing of the EWTD—and it was first introduced as long ago as 1993—was to plan seriously to implement the EWTD by employing more junior doctors and increasing the numbers of available consultants to support 24/7 working. 3.12 Recommendation 2: the Committee examines why the EWTD has not been implemented effectively in the UK despite resources being available and the need being obvious.

4 Impact of Changes to Ambulance Services 4.1 It has been suggested that the best way to reconcile the interests of emergency and non-emergency patients is the rapid triage of the relatively few patients who require tertiary care (specialist care). The role of the ambulance service is crucial in this respect. Byrne and Ruane (2007) argued, This would be achieved through training ambulance paramedics to recognise them and take affected patients to the appropriate regional centre which will have a clinical network of cardiologists, neurologists, vascular surgeons and other specialists plus the appropriate support resources. This means that the District General Hospital can have the best of both worlds by treating the majority of patients near its catchment area and ensuring the minority who require the services of more specialised facilities access these in time.

4.2 The commissioning of ambulance services is now the responsibility of CCGs, ie GP commissioners. A recent NAO report “Transforming Ambulance Services” (NAO 2011) recognised the pivotal role of ambulance services in the performance of the whole emergency system. However, as the report pointed out, much work is required to achieve cost-effective integrated emergency care and there is a paucity of data to support benchmarking of ambulance services.

4.3 The NAO report was unable to comment on the value for money of ambulance services but did express concern that decisions by local commissioners may not represent best value for money or provide essential access to emergency services.

4.4 Recommendation 3: The impact of the introduction of CCG commissioning on the response times of ambulance services and other quality measures should be closely monitored by NHS England; centralised commissioning of ambulance services should be re-introduced if standards fall unduly. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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5 Concluding Remarks: What Really Drives Plans to Close Local A&E Services 5.1. If the evidence is as we claim then why is there this drive towards the closure of A&E departments, and with them eventually whole hospital sites. One obvious reason is to save money, not in terms of providing services more efficiently though that is what is often claimed, but in aggregate terms by providing less services and probably these less efficiently. More than one NHS guru and manager has been hard-nosed enough to say the way to stop people using hospitals “inappropriately” is to close them. The evidence for this being achieved successfully is however non-existent. 5.2. Reconfigurations are costly to establish in capital terms; costly in staff and patient travelling terms; and risky in terms of whether the service objectives can be achieved, eg can reductions in attendances be realised? Kings Fund researchers have noted in their studies on reconfiguring services that savings are often non-existent (Imison 2011). 5.3. Recommendation 4: the Committee examines the cases made for closures of A&E departments in the last ten years against evidence of what has actually happened to ascertain the extent to which they have successfully achieved their initial objectives. 5.4. Another important factor that may come into play is the self-interest of professionals providing services: in particular, consultants and GPs. 5.5. The UK has fewer hospital specialists than elsewhere in Europe and they are among the best paid, once private earnings are taken into account. Centralisation enables the continuation of a system based on junior medical staff doing the majority of the day-to-day work while leaving hospital consultants free to provide care to fee-paying patients. 5.6. One other major vested interest present is those providers of primary and community care who see a possibility of re-directing work to GP-managed services. We have already drawn attention to the paucity of evidence for the success of such transfers of care (Purdy et al. 2012). But there are genuine difficulties in drawing conclusions because of the lack of objective, reliable data within primary and community care. This is a good reason to be cautious rather than go full steam ahead. 5.7. Although it is good practice to involve clinicians in decisions on reconfigurations there is the risk that professional self-interest will capture health care delivery leading to heavy-handed rationing, the redirection of patients towards private suppliers, and loss of access. The cost of lack of access often falls on those least able to afford or negotiate such a system. 5.8. The people who have a real interest in the quality of provision of local health services, the public, are not involved through a genuine process of consultation. It is not clear how CCGs, if in the hands of pro- reconfiguration GPs, can play a true role as guardians of the health of local people. 5.9. Thus, as Richard Scorer (2007a, 2007b), a solicitor drawn into a reconfiguration proposal, found, In practice many if not most of these consultations are perceived by the public as a charade. In my view that perception is largely accurate. Options are typically circumscribed from the outset. Consultations are given euphemistic titles (“Making it Better”, “Healthy Futures”,” Investing in Excellence”). The public can see through these titles and find them patronising, particularly if they fear that the reconfiguration is not “making it better for them”. The language of consultation documents is often dense, technocratic and inaccessible, and perceived by the public as deliberately so, in order to obfuscate popular outcomes. Consultation documents are perceived as disingenuous—details of the financial pressures to close facilities are often buried in the small print. 5.10. Recommendation 5: there should be better safeguards for local people to prevent the run-down of local services. These would include more rigorous quality control of planning, business case presentation and public consultation processes designed to prevent abuse of due process.

References 1. Barrett P (2012). Safety, Sustainability, Accessibility—striking the right balance, Reflections of a retiring Chair. London: Independent Reconfiguration Panel. 2. Boyle S (2011). United Kingdom (England): Health system review, London: European Observatory on Health Systems and Policies. 3. Byrne D and Ruane S (2007). The Case for Hospital Reconfiguration—Not Proven A Response to the IPPR’s The Future Hospital, Keep Our NHS Public. 4. Carson D, Clay H and Stern R (2011). Breaking the Mould without Breaking the System. London: Primary Care Foundation 5. Harrison A (2011) Acute care: elective and emergency, secondary and tertiary, in Healthcare Management, eds. Walshe K and Smith J. London: Open University Press. 6. Harrison A (2012). Assessing the relationship between volume and outcome in hospital services: implications for service centralization. Health Services Management Research. 25.1 pp 1–6. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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7. Haynes R, Bentham G, Lovett A and Gale S (1999). Effects of distance to hospital and GP surgery on hospital in-patient episodes, controlling for needs and provision. Social Science and Medicine, 49: 3: pp 425–33. 8. Hurst J and Williams S (2012) Can NHS hospitals do more with less? London: Nuffield Trust. 9. Imison C (2011). Reconfiguring Hospital Services. London: King’s Fund. 10. Independent Reconfiguration Panel (2012). Press Release 6 November 2012: IRP undertaking independent health review. London: Independent Reconfiguration Panel. 11. Independent Reconfiguration Panel (2010). Learning from Reviews: an overview—Third Edition December 2010. London: Independent Review Panel. 12. Kok L, Lammers M and Tempelman C (2012). Remuneration of medical specialists: An international comparison. Amsterdam: SEO Economic Research. 13. Maynard A (2013). Community Care is no panacea for the NHS, Guardian Tuesday 9 April 2013. 14. National Audit Office (2011). Transforming Ambulance Services, London: TSO. 15. Purdy S et al. (2012). Interventions to reduce unplanned hospital admission: a series of systematic reviews: final report. Bristol: University of Bristol. 16. Scorer R (2007a). NHS on Trial. New Law Journal, 157: 7254, 5 January 2007. 17. Scorer R (2007b). NHS reconfigurations, New Labour and local democracy. Renewal, 1. May 2013

Written evidence from South Western Ambulance Service NHS Foundation Trust (ES 05) The Prospects for Better Integration of Ambulance Services with Primary Care under the New Commissioning Regime established in April 2013 As a Trust, SWASFT supports the statements set out within the National Ambulance Commissioners Group (NACG) brieﬁng “Integrated ambulance commissioning in the new NHS”. In particular: — Getting ambulance commissioning right is vital because of the impact ambulance services have on the wider healthcare system and their inﬂuence on overall costs; — Maintaining a safe and effective service for patients is essential while managing the risks of changing commissioning structures; — CCGs that commission ambulance services collaboratively will be in a stronger position; — With the new arrangements, there is potential for CCGs to help commission a better service from ambulance providers through greater clinical engagement in service design and evaluation. However, the Trust has a number of concerns in progressing this: — 2013–14 feels very much like a “transitional year” as CCGs establish themselves and decide what contractual arrangements will exist in the future for ambulance services; — The Trust acquired GWAS on 1 February 2013.The outcome of this is that two contracts are being negotiated for A&E services in 2013–14 led by South Devon and Torbay CCG for the former SWASFT area (Devon, Dorset, Cornwall and the Isles of Scilly and Somerset) and Gloucestershire CCG for the former GWAS area (former Avon area, Gloucestershire and Wiltshire). Contract negotiations for 2013–14 have yet to be concluded fully and the lead commissioning arrangements going forward remain uncertain. The expectation is that our commissioners will move towards a Commissioning Support Unit model for 2014–15 with an intention to negotiate a single contract from 1 April 2014; — As CCGs have a different footprint to ambulance services there needs to be a system wide approach to join up commissioning arrangements, service delivery and funding in order to support the delivery of integrated care across the whole health system. One response to this locally has been the establishment of Urgent Care Boards at a local urgent care system level however the CCGs and/or ambulance services need to ensure that they are engaged at key discussions to ensure a collaborative approach (see the case study in NACG paper); — Whilst the provision of emergency ambulance care is being commissioned by CCGs, primary care is being commissioned by the Local Area Teams. This adds another layer of complexity to better integrating the commissioning and delivery of emergency, urgent and primary care moving forward.

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— There are different people around the contract table. Recently, a number of clinicians including General Practitioners from local CCGs have joined the meetings bringing an enhanced clinical focus and essential clinical engagement. SWASFT is hoping that this will shift the focus of future commissioning debate and create opportunities to have new and different conversations about the role ambulance services can play within the wider health system; — The Trust, in resetting its strategic direction, has already identiﬁed a number of developments that could be taken forward in conjunction with primary care. This includes the ambulance service providing as an example an “in-hours” visiting service on behalf of GPs, packages of care, urgent care triage, etc all designed to better support the urgent care pathway; — SWASFT is planning to host a CCG stakeholder event as part of a range of activities to refresh its ﬁve year strategy. A key aim of this will be to ensure the Trust’s strategy is aligned to local commissioner priorities regarding primary care as well as engaging the CCGs in the wider role for the Trust; — Since the acquisition of GWAS on 1 February 2013, SWASFT has a regional footprint that covers the whole of the south west whilst in parallel; the NHS landscape has got smaller and increasingly localised. SWASFT is in a position to provide a partial system oversight and management role however the Trust is conscious that it cannot insist on a regional approach for all activities. SWASFT will therefore need to work harder to ensure it is engaging locally with CCGs and key stakeholders to ensure appropriate integration across the whole south west region.

The Ability of Ambulance Services to continue to meet Increased Emergency Demand whilst Contributing to the Nicholson Challenge The ambulance service is a key enabler in maximising opportunities to manage demand and increase efficiency, in particular in areas linked to optimising urgent care pathways, shifting settings of care and adopting best practice care pathways. This is reflected in the service development strategy of the Trust. There is no doubt that in order for the trust to continue to meet increasing emergency demand SWASFT will need to rethink aspects of its role, skill mix and ways of operating. The Trust’s recent experience of demand increases in quarter 4 of 2012–13 highlights that the trust cannot be purely reactive and that that it needs to play a more active role in managing demand across the whole health system. The trust believes that as a result, ambulance services will need to become increasingly assertive if the service is to continue to add value being positioned as both a gateway, and ultimately the backstop, for patients with emergency and urgent care conditions accessing the NHS. Ambulance trusts are exceptionally well placed to understand the causes of increasing demand and in developing solutions to coordinate a proportionate response. However, the Trust has a number of concerns about its ability to continue to meet increased demand whilst contributing to the Nicholson challenge: — Recent conversations with NHS Commissioners lead the trust to believe that it will be in a flat cash environment from 2014–15 with minimal growth. Unless demand is matched with growth in funding the Trust’s ability to continue to deliver efficiencies at the pace required will be severely limited, particularly given that this will increasingly require fundamental changes to service delivery; — In addition the ambulance sectors ability to drive out further sustainable efficiency savings within the A&E call cycle is restricted under the current emergency response time regime. Without a change to the current approach of measuring the clock start the focus of ambulance trusts will remain on dispatching the nearest available resource to incidents, rather than necessarily the most appropriate resource for all incidents. A change to the clock start position, and a shift from focusing on response times to the new outcome measures, would create substantial opportunities for better resource management within all ambulance trusts; — In order for ambulance trusts to continue to deliver more care in the community/home setting the local network of community services needs to keep pace and be aligned with developments in the ambulance service and vice versa. Otherwise opportunities, particularly in rural areas will continue to be limited.

The Implications of the shift away from determining the Success of Ambulance Services via Indicators based on Response Time to the New Measures Designed to assess Clinical Effectiveness The Trust agrees with the shift to provide a more balanced view of performance by applying indicators that more accurately reﬂect the nature of the service delivered and promote consistency across the ambulance sector. The increased clinical focus is supported although the Trust recognises that response times still add value as a determinant of outcome and improving the patient experience. This is reﬂected in the Trusts internal Performance Management Framework and Strategy. Currently, the fundamental principles of commissioning, contract negotiation and management and the regulation of ambulance NHS Foundation Trusts focus upon ambulance response times. Unless this changes ambulance services will be required to continue to prioritise investment and resources to meet the national cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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targets not necessarily supporting the delivery of outcome measures. Whilst the Trust has seen some changes in commissioning, with the introduction of shadow currencies in relation to hear and treat, see and treat, see and convey, investment for 2013–14 continues to be on the basis of achieving activity growth coupled with response times. In addition, the thresholds for ACQIs are still agreed and performance managed locally with commissioners. Any shift away from response times to more outcome based measures within the national contract would need to be accompanied by a programme of work to standardise the thresholds for each ACQI therefore ensuring consistency in measurement across all ambulance trusts. In respect of tariff the Trust supports a local, rather than a national tariff for a number of reasons: — The job cycle time, which is a key cost driver, varies significantly between urban and rural services linked to miles travelled and location of acute hospitals; — The level of resource required to provide coverage and deliver response times over a large geographic area with low population density compared to a small geographic area with high population density has a direct impact on the model of service; — The patient pathway for 999 services is not defined. Traditionally patients accessing the 999 service were taken to the nearest A & E department. The direction and pace of pathway redesign has been led locally; — The development and introduction of defined pathways such as for primary angioplasty and trauma although nationally driven is implemented on a local basis. For example, the impact of secondary transfers has a greater resource consequence where the determined trauma centre is at a longer distance from receiving units; — The starting point for 999 pathway redesign is the local availability of alternatives to acute hospital A & E departments. This varies from health community to health community and will have been influenced by historic investment levels in community and primary care services; — The skill mix of the ambulance workforce has developed through investment in care pathway redesign. For example, the Emergency Care Practitioner role which is an advanced paramedic grade is used differently across England based on local agreements; — The 999 service is described as a “waiting service”. In other words regardless of activity levels (unplanned) sufficient resource must be available to respond to an emergency call whenever and wherever it is received. The level of waiting resource will be influenced by a range of local rather than national factors such as available road networks, travel distance to the nearest acute hospital and population density within a given geographical area.

The Causes of Delays in Handover from Ambulances Services to A&E or Transfer between Different Levels of Urgent Care, and Actions Required to eliminate them The Trust has agreed a set of handover action plans across the Trust’s geography at an operational locality level. These have been signed off by the Trust, the relevant CCG and acute trusts. These are primarily focused on a set of actions around escalation, not necessarily prevention, in other words the steps to be taken when certain trigger points are reached. The plans focus on internal escalation procedures, agreeing trajectories for improvement and actions speciﬁc to an individual hospital. The Trust maintains that there is a clear differentiation between action plans agreed locally between an individual acute hospital and the ambulance trust and the need for a wider, strategic CCG level plan focusing on all key stakeholders contributions and the role of the CCG in setting priorities and managing demand. The causes of handover delays are multi faceted, varying from hospital to hospital and from health system to health system. Example causes include, but are not limited to: — Ownership by the leaders in the hospital/health system; — A&E capacity and manpower resources within a hospital (medical and nursing); — The extent to which the A&E department is “joined up” and integrated with the rest of the hospital— is the problem owned?; — Bed blocking with clinically assessed patients waiting for discharge to a step down bed; — Timeliness of escalation within the Trust when pressures are building; — Reductions in physical bed capacity within the acute hospitals and community; — Leadership and decision making within A&E departments; — Attitude and behavior towards handover delays as exhibited by the hospital; — The effectiveness of operations in “pulling patients” from A&E to ward; — The effectiveness of urgent care pathways keeping demand away from the front door; — Phasing demand from healthcare professionals. Ambulance trusts are in a position to provide a range of timely data however the difﬁculties arise in pinning down the “softer” issues such as senior leadership, ownership and operational grip. Where ambulance cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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handovers have been addressed in the past this has largely been the result of strong relationships between clinicians and managers in the acute hospital and the Trust. During April 2013, in discussion with NHS Commissioners, the Trust revised its local hospital handover delay arrangements to include an addendum to the handover escalation protocols. This change was in response to a number of factors locally including unprecedented increases in activity since the beginning of March 2013 and increasing concerns in regard to patient safety. There was also a feeling that ambulance handovers have become “normalised” in some hospitals with an expectation that the ambulance service will continue to look after patients for extended periods of time following arrival at the emergency department. The national ambulance contract and “Everyone Counts” 2013–14 establishes a penalty regime for handover and crew clear times. Within the SWASFT region both lead commissioners have adopted a different approach to their application in both the acute hospital and ambulance service contracts. The risk of inconsistent application is that this may promote and lead to different behaviours within the south west as organisations seek to mitigate the level of penalties applied in-year. It is also emerging that some acute hospitals may not sign contracts which invoke the handover penalty clause—if this is indeed the case, NHS Commissioners will need to agree other ways of incentivising the system to reduce delays. There is no doubt that NHS Commissioners within the south west want to improve handover performance. The Trusts view is that there needs to be more focus on shared leadership and in bringing local providers together to tackle obstacles to the effective operation of the system. May 2013

Written evidence from NHS Benchmarking Network (ES 08) The NHS Benchmarking Network is pleased to write with a copy of the summary findings from a report that benchmarked emergency care services across the NHS in 2012. The benchmarking study involved 60 NHS Trusts and provides a wide source of evidence on NHS urgent care facilities. The report covers some community based walk-in facilities but Accident and Emergency Departments are the main focus of the benchmarking project. Our overall summary is that much variation exists in the provision of urgent care services across the NHS. The work was led by the NHS Benchmarking Network in partnership with its members. The findings from this first stage of benchmarking are exciting and point towards clear benefits in rolling out the project across the NHS. The next stage will include amendments to the data specification which will be actioned in line with a next stage data collection that will analyse the position at year end 2012–13. All NHS Trusts and commissioners will be invited to take part in the next stage of the work. Emergency Care is a complex service with many facets across the NHS. Our report focuses on the provider perspective and reviews the provision of Accident and Emergency services as well as alternative community based services such as Walk In Centres and Urgent Care Centres. The 60 Emergency Care service providers covered by this project employ a total of 6,200 WTEs, and have a total ED revenue budget of around £250 million. Although the sums of money invested in Emergency Care are highly material there is limited national benchmarking information available on the service beyond profiling of access arrangements, waiting times, and demand levels. The project aims to supplement available national metrics with relevant data on service models, infrastructure, capacity, demand, workforce, finance and service quality. The project offers the NHS an opportunity to develop a benchmarking approach for emergency care, with scope for further work to be carried out in the increasingly important areas of patient and system level outcomes. A feature of the Network project is that a number of key activity and workforce metrics have been benchmarked using the denominator of number of attendances at AED/Urgent Care Centres to provide a basis for comparison that allows for the relative size and complexity of the providers taking part.

Key Findings for Contributing Trusts: Service models All participants provide a range of services. Large teaching Hospital Trusts typically provide most complex services, whilst Community services providers typically focus on walk in facilities. The main observations on service models used are as follows; — 90% of participant organisations use patient streaming — 42% use rapid assessment and treatment systems — 75% of Trusts have experienced Doctors in A&E on a 24/7 basis — 55% of Trusts report availability of senior clinical staff to perform early assessments — 70% of Assessment Units/Acute Medical Units are Consultant led with rolling ward rounds. Two thirds of these units have medical specialty in-reach. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— 50% of providers have a separate Children’s Emergency Department — Two thirds of Trusts report having an adequate place of safety for children who may be disturbed — The average hours of availability for Consultant presence in the Emergency Department is 80 hours per week covered directly by Consultant presence in the department. One Trust reports that 168 hour Consultant presence in A&E is achieved. — Only 9% of Consultants work on a 24/7 ED shift — 81% of Trusts achieve 24/7 Consultant cover through a 1st on-call system — Directors of Emergency Care have been appointed in one third of Trusts. — In terms of A&E relationships with senior decision makers in other high volume medical specialties, 45% of Trusts report that these senior decision makers can attend A&E within 30 minutes of request. — 45% of A&E departments can directly admit patients to other specialties.

Access — Patient access to emergency care services is tightly monitored by the Department of Health. Performance against national access targets can be viewed in the Emergency Care benchmarking toolkit developed by the NHS Benchmarking Network and available to download from the website www.nhsbenchmarking.nhs.uk — 9 of the participating Trusts in this phase of benchmarking report four hour waits in 5% or more of patients. — The mean length of stay in A&E reported by participants is 138 minutes. This reﬂects the position at the end of 2011–12 and compares with the 127 minutes NHS wide average reported by the NHS Information Centre for 2010–11.

Infrastructure — 85% of participants conﬁrm having trolley and resuscitation areas — 60% have Clinical Decision Units/Observation wards — 61% have developed ambulatory care areas — 45% have rapid assessment and treatment areas — The number of majors cubicles ranges from one–28 across participants, with a median position of between 11 and 15 cubicles (Four Trusts have more than 20 cubicles) — The number of minors/treatment rooms has a median position of six–10 rooms per Trust — Amalgamating majors, minors/treatment rooms shows a mean of 25 rooms per Trust. The highest number provided is 47. — The number of resuscitation trolleys ranges from one to 10, with a median position of four. Resuscitation area capacity also averages four trolleys. — 51% of Trusts report some non-compliant facilities within ED and compliance issues around Health Building Note 22. — The provision of patient transport services from A&E covers an average of 120 hours per week.

Diagnostics — Point of care testing for pathology is available in most providers — Participants state that pathology results reporting works well in two thirds of Trusts — A one hour pathology results target is the norm in most Trusts — 90% of ED providers report having 24/7 access to plain ﬁlm Radiography. The few exceptions are community based providers. — All participant Trusts conﬁrm that PACS is in place for viewing Radiology images. — The average (median) reporting time for Radiology reports is 48 hours — 80% of Emergency Departments have their own ultrasound capability — 80% of EDs also have 24/7 access to CT scanners (CT reports are also generally immediately available) — 28% of EDs have 24/7 access to MRI scanners

Information Management and Technology — Two thirds of Trusts have Emergency Department speciﬁc IM&T systems — 63% of participants reported that these are good and help workﬂow and management within ED — 18% reported that their IM&T systems are “unhelpful” cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Activity — Average ED attendance levels are 77,000 attendances per annum. The largest attendance numbers are from two Trusts providing over 200,000 attendances per annum, the smallest from a community based service delivering less than 10,000 attendances per annum — Conversion rates from A&E attendance to admission to a bed average 24%. This ranges across participants from 15% to 37%. — When viewed on a WTE per ED Consultant basis the average activity is 12,700 attendances per ED Consultant WTE. — When viewed on a total WTE per member of staff in ED basis the average is 844 attendances per WTE. — Related analysis of Radiological examinations by specialty conﬁrms that Accident and Emergency is the specialty with highest Radiology utilisation within NHS secondary care services.

Workforce — Analysis of ED professional mix across the 60 participants confirms Nurses as the largest professional group, followed by Medical staff, and administrative staff. — ED Consultants are employed at the rate of 8.7 WTE per 100,000 attendances. A large number of other medical staffing grades are also employed and detailed in the report. — Consultants average 67 direct clinical care sessions per 100,000 attendances. 76% of ED Consultant time is reported as direct clinical care sessions. — GP time is used in just one in six providers. Where this is used it averages 2.2 WTE per 100,000 attendances. — Analysis of Nurse staffing confirms that on average, the following Numbers of staff are employed per 100,000 attendances; ED Nurse Practitioners (12.1 WTE), Other Qualified Nurses (66 WTE), Non-Qualified Nurses (15 WTE). — A&C staff are employed at an average rate of 18 WTE per 100,000 attendances. — Band 5 is the most frequently occuring AfC banding which reflects the large incidence of Nurses at this grade. Highest staffing levels are at specialist and teaching hospitals. Lowest staffing levels are at district general hospitals, although this trend is not completely consistent across all providers.

Finance — Total revenue budgets for ED 2011–12 has a median position of almost £10 million per 100,000 attendances. — Payment by Results categories VB08Z (category 2 investigation with category 1 treatment) and VB07Z (category 2 investigation with category 2 treatment) are the most prevalent codes and both attract a tariff payment of £110 per patient. — Direct pay spend per 100,000 attendances has a median position of around £6.2 million. Average non-pay spend per 100,000 attendances is around £0.8 million. — There is variation in how Cost Improvement Programme (CIP) targets have been set across the participating Trusts. The average cost improvement programme is 3.6% of total ED budgets. This ranges from 0.5% to 8%. — CIP targets range from zero to £800,000 per 100,000 attendances. The average is £230,000 per 100,000 attendances. — Service line reporting (SLR) is used in 50% of Trusts for ED. Around two thirds of Trusts report an SLR deficit position with the total average SLR surplus/deficit position across participants being a deficit of -8% of total costs.

Clinical Outcomes — The Standardised Hospital Mortality Index is a ratio of the observed number of deaths to the expected number of deaths for a provider. This covers all Trust activities. Analysis of the number of Emergency Department Consultant staff confirms that Trusts with the highest number of ED Consultants have the lowest mortality rates. Although there is no suggestion of a causal relationship, Trusts with low ED staffing levels also have higher mortality levels in general. This may be more reflective of overall lower Consultant staffing levels across all specialties for these Trusts. — A number of Trusts monitor the frequency with which they operate escalation arrangements. The average number of days reported for escalation status was 170 days per year. Three Trusts reported being in an escalated status for 365 days a year. — Patient satisfaction levels are reported in the national ED patient survey. Compliment levels average 92 per 100,000 attendances. — Complaints average 57 per 100,000 ED attendances cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— Serious and untoward incidents average 10 per 100,000 attendances. — All ED contributors take part in annual audit programmes.

Good Practice — A large number of good practice examples have been provided by the participants in the project. These are detailed at the end of the report and include examples of innovative use of technology, clinical excellence, flexible use of workforce, productivity enhancements, rapid service access, outcomes improvement, and patient customer focus initiatives. — 60% of Trusts use predictive forecasting tools to help align capacity with demand. We hope you find these summary findings useful. Our benchmarking work will take place again in 2013 with updated reports available by October 2013. May 2013

Written evidence from Miss Beverley Griffiths (ES 10) These thoughts and ideas are written on behalf of myself. I have been a A/E Nurse manager for over 20 years and for the last 2.5 years worked in an Urgent Care Centre as a Nurse Practitioner. The topics I want to touch on are — Urgent care centres (UCC) Accident and emergency departments. — Community services including the work of GPs. — Ideas for the long term solution (10 to 15 years). — Local authority involvement. — Ambulance handover. However I truly believe that the only way to plan for the long term future is to educate people in schools starting in primary schools (especially socially deprived areas) how to self care. Many people seek immediate medical advice for conditions that we would not have dreamt of doing years ago, e.g sore throat (same day or two days) minor cut requiring a run under the tap and a plaster, abdominal pain, mouth ulcer, mechanical or muscular back pain. Many minor injuries seen have occurred in the past two or three hours of presentation with no attempt to take a couple of pain killers and see how things go. It is this immediate need to seek attention and lack of any knowledge of self care that will continue to put a drain on our NHS resources. (Some people attend just to get free prescriptions) The Government could put health advice notices out between all adverts on television telling people how to treat certain simple conditions. School nurse should have allocated slots for teaching self care in schools. I have only just become aware of the opportunity to submit ideas so am afraid this is a very shortened version of what I would like to say. As you are aware UCCs vary considerably throughout the country in the services they provide; this in itself causes confusion to the general public. The very fact that the word urgent is in the title suggests to the public that they can attend with conditions that require a greater input than a UCC can provide. Much of the public do not know the difference between urgent and emergency. The UCC I work in is not attached to a general in-patient hospital but would be more effective and efficient if it was. However as there is no other hospital in its town this is unavoidable but does result in us transferring a fair amount of patients out to other acute hospitals mostly by ambulance. This is not only inconvenient for the patient who gets to queue twice at two different places and has to repeat their story at least three times but is also a waste of ambulance resources. I believe there is an opinion to move some UCCs out of general hospitals which I believe would be a mistake. When a patient enters an A/E dept they should be signposted straight away to the most appropriate facility for them e.g UCC, their local GP, pharmacy mental health worker etc. I would say at least 50% of patients who go to A/E do not need to be there. Patients will always vote with their feet. If you have an A/E department and a UCC in one town in two different areas then it just gives patients a choice of where to go. Most make that choice on which is nearest to them and which on whatever day will see them the quickest. Staff who signpost should be experienced nurses who have the support of their Trust for relocating patients, i.e make a GP appointment for them there and then. One other thing which would release the pressure on A/E doctors would be if patients who had an on-going problem which they were already under a specialist for were seen by the speciality on-call doctor when they came to A/E instead of first having to see an A/E junior doctor who then refers to the speciality doctor. This would not work for every condition but would for many. For example, a patient attends A/E with a sudden cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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increase in pain to knee following a knee replacement three weeks previous. The on-call Orthopaedic doctor should see this patient, not A/E. The UCC I work in was established when the A/E department closed. It is a very successful department and sees minor injuries and illness from newborn to the elderly. As previously stated we do transfer patients out for speciality opinion on a daily basis and also have to dial 999 for patients on a daily basis, and further work is required to look at this. I want to emphasise that a UCC such as this is not a cheap option. We have two doctors on duty up until midnight and four practitioners although we really require ﬁve. We see up to 196 patients a day. Finding Practitioners who are conﬁdent and competent to see such a wide variety of patients is not easy but as more are trained hopefully will get easier. If UCCs like ours were to open around the country please make sure you can staff them adequately and safely (another reason to leave them attached to district hospitals where possible). Unfortunately I have run out of time but one last thing that really does need sorting out (in some areas probably not all) is GP services. The amount of patients who visit us because they are unable to get a GP appointment is huge. The GPs who have a system of only giving out appointments on the day you ring are particularly unpopular with the public in my area. Patients have to ring at 8am for an appointment and if unsuccessful are told to ring the next day (where the same thing happens again). Patients think their condition is urgent so attend the UCC which will soon be over capacitated and will experience the same as A/Es are now if things do not change. GP surgeries are not open enough hours (4.5 days for many) and this needs to increase as does the access to them. Auditing of all services in what is actually happening as well as what the public think is happening should also be increased. For example, a patient may think he/she has had a good experience if they come away with antibiotics; the fact that the condition they presented with did not require antibiotics does not seem to get picked up. This also perpetuates the patient’s belief that there was something wrong with them! May 2013

Written evidence from Pharmacy Voice (ES 11) We are pleased to submit this brief response to the Health Select Committee’s Inquiry into Emergency Services and Emergency Care.

The Role of Community and Primary Care Services in the delivery of Emergency Health Care 1. Community pharmacies are located where people live and work, on the high street, in supermarkets, and in the heart of local communities. They are typically open for longer hours than GP surgeries; there has been a trend in recent years for pharmacies to open for longer hours to meet public demand; some are open for 100 hours per week. According to our estimates, pharmacies in England now provide the public with immediate access to a registered health professional—a pharmacist—without an appointment for more than 100,000 extra hours a week than in 2005. 2. Pharmacists are highly trained health care professionals able to advise people on treatment for a wide range of common conditions. They know when to refer to GPs, out of hours (OOH) services or emergency care; they will call 999 appropriately in an emergency if necessary. 3. A 2003 study1 of A&E attendances found that 8% could have been adequately treated in community pharmacy. With A&E attendances running at 18.3 million a year,2 this means approximately 1.5 million people could have been treated at a community pharmacy (and the range of pharmacy services has increased since 2003 so this may now be an underestimate) 4. In Scotland and Northern Ireland, and in some areas of England, community pharmacists have been formally commissioned by the NHS to handle minor ailments differently. A pilot along the same lines—the Common Ailments Scheme—is underway in Wales. Regardless of the nomenclature, these schemes enable community pharmacists to supply, when appropriate, certain medicines (including, under protocols, prescription only medicines) to treat immediately a range of common conditions such as uncomplicated urinary tract infections in women, conjunctivitis, hay fever, contact dermatitis, diarrhoea, back pain and vaginal thrush. Where schemes are established in England, patients pay charges on the same basis as for prescriptions. In all cases, entitlement to free prescriptions is passported into these services. 5. Schemes such as these enable patients to get the advice and medicines they need without needing to visit a GP or OOH service; importantly, they bypass the need to access the GP or OOH service to obtain a medicine free of charge. If properly publicised, these schemes can reduce demand on GPs and OOH services. A national minor ailments scheme in England would deliver this beneﬁt at scale. 1 Family Practice (2003) 20 (1): 54–57 2 Hospital Episode Statistics, February 2012 to January 2013 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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6. Providing alternative points of access has also been shown to reduce demand for immediate or emergency services in other speciﬁc cases. For example, the provision of emergency hormonal contraception (EHC) through pharmacies—EHC must be used within a discrete time window, has been shown to reduce demand on other sexual health services and on GPs. In Scotland, where there is a national sexual health service commissioned from community pharmacy, over 89%3 of all EHC supplies are made by community pharmacists. Other providers are GPs, nurse prescribers, and primary care and hospital clinics. In one study in Kent,4 access to EHC was found to be faster in pharmacies (median time to access 16 hours against 41 hours for traditional family planning services), with pharmacy access skewed to weekends and Monday consultations. The researchers calculated that a community pharmacy service had increased by 10% the prevention of unwanted pregnancies due to speed of access (and consequent efﬁcacy of EHC) alone.

7. Whilst this scheme is available in many areas, a national scheme would not only increase access but could also provide the platform for speciﬁc activity designed to improve the public’s awareness of the availability of this service in their local pharmacy.

Experience to Date of the Transition from NHS Direct to NHS 111

8. Organisations representing pharmacy nationally have been working with teams developing NHS111 from its inception. However, the locality approach to NHS111 means that engagement with pharmacy on the ground, in each of the NHS111 areas, is hugely variable. In a survey conducted by Pharmacy Voice across England between February and April 2013, with locality responses representing 80% of the country, we found that in fewer than half of all the localities had there even been any initial contact between the NHS111 organisation and the local pharmacy committee.

9. It is no surprise, therefore, that we should be disappointed at the lack of “pharmacy endpoints” in the algorithms used by the NHS111 call handlers. This means that calls that would have been referred to community pharmacy by NHS Direct under the old system may now be being referred to GPs or OOH services or emergency care by NHS111.

10. This could have, and still could, be tackled with a twin-track approach. Locally, NHS111 organisations need to contact their local pharmacy representative organisation to discuss how pharmacy might be used as an endpoint to calls, which will be facilitated by an understanding of the availability of local services. Local pharmacy organisations will also be able to contribute to agreement on the most effective mechanism for the collection of up-to-date information about local pharmacy services. The commissioning of national minor ailments and EHC services would enable call handlers to be able to recommend community pharmacy for those services, without recourse to a local service directory.

11. In passing, it is worth reflecting that the continuing insistence of local commissioners and commissioned service providers to develop new, bespoke databases of, for example, local pharmacy services, is incredibly inefficient, and undermines the efficacy of systems designed to provide a one-stop solution for information for the public, and which is easier for providers to keep up to date, such as NHS Choices.

12. We are also disappointed at the absence of pharmacy advice within the call centres themselves. In a recent article, a community pharmacist reﬂected on how pharmacist skills could be used to support callers to NHS111.5 A signiﬁcant number of calls to NHS111 are the result of people running out of, losing, or if away from home, forgetting to take their medication with them. Currently, in most NHS111 sites, these patients will be referred to a GP or OOH service even though community pharmacists are already able to make an emergency supply of the medicine, following certain checks.

13. Most people are either unaware that pharmacists are able to make emergency supplies, or they may be reluctant to or unable to pay the full cost of the medicine (which is how this service is usually funded). We would suggest that there is scope here too for a national service enabling pharmacists to supply patients with the medicine they need in a deﬁned set of circumstances, for the same charge as a prescription, to facilitate direction of callers to their nearest community pharmacy. A national scheme of this type operates in Scotland. 17,2126 emergency supplies (or 0.2% of all prescriptions dispensed) were made from community pharmacies last October averaging at 14 supplies per pharmacy for the month. Anecdotal evidence indicates that this number increases in months which include a bank holiday.

About Pharmacy Voice

Pharmacy Voice (PV) represents community pharmacy owners with the principal aim of enabling community pharmacy to fulﬁl its potential in playing an expanded role as a healthcare provider of choice in medicines optimisation, long term conditions and public health. Its founder members are the Association of Independent 3 Data for 2011 supplied by NHS National Services Scotland in response to an FOI request 4 Br J Clin Pharmacol. 2006 May; 61(5): 605–608. 5 http://www.guardian.co.uk/society/2013/may/14/day-worked-nhs-111-helpline 6 Community Pharmacy Scotland cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Multiple pharmacies (AIMp), the Company Chemists’ Association (CCA) and the National Pharmacy Association (NPA). May 2013

Written evidence from North East Ambulance Service NHS Foundation Trust (ES 12) — Ambulance journeys and hospital attendances are just two “links in a chain” that includes GPs, out- of-hours providers, community services, mental health and social care. — The pressures evident in ambulance response times and in handover delays at hospitals cannot be addressed by the ambulance service alone. They are visible signs of a system that needs attention across the board to address three issues: — Managing demands made upon the system, to avoid the need to go to hospital — Managing the processes involved in dealing with the demand both within individual providers and at times when patients are passed on from one part of the system to the next eg on transfer from the ambulance to the hospital or from the hospital to community/social care etc. — Assessing whether there is a need to put more resources into the system where it can be demonstrated that good practice is already being adopted — We have faced regular handover delays across the North East, but with exacerbated difﬁculties at speciﬁc provider hospital emergency care departments. — Hospitals often report a lack of beds (A&E and on wards). — The impact on NEAS has been delayed response times to GP urgent calls, low priority 999 calls not assessed as life threatening and increasing demand for ambulance resources outstripping resource at certain at certain times of day. The latter has been due partly to batching of urgent work, eg following morning surgeries and at times when the public are “on the move” after hours.

1. The Role of Community and Primary Care Services in the Delivery of Emergency Healthcare 1.1. Community and Primary care staff, with appropriate technological links to the Ambulance service, could provide rapid response to life threatening cases in rural areas; but there so far seems little appetite from such staff to work across boundaries in this way. 1.2. The NEAS has worked closely with Community and Primary care staff to introduce a Community Paramedic role which has been proved to beneﬁt health services in rural areas. In particular in North Northumberland where Community Paramedics are integrated with GP services and nurses to avoid unnecessary admissions to hospital when appropriate. 1.3. The difference comes from their increased involvement in primary health care and not just emergency patient management. This includes assisting the primary care team to keep patients in their own home. 1.4. Since community paramedics started working in North Northumberland seven years ago, there has been a drop of nearly half of all patients being transferred to the local district general hospital because they are being seen and treated quicker in their communities.7 Previously most, if not all, would have travelled to hospital, leaving the rural areas without Paramedic ambulance cover. 1.5. Unfortunately not all GP’s recognise the beneﬁts of this model of working at this stage.

2. Progress towards moving some Minor Injury and Urgent Care Services out Of A&E and into more Accessible Community Settings 2.1. As providers of the NHS 111 Service across the North East, NEAS use a capacity management service and directory of service to ensure that patients are given the most appropriate pathway to the care they need. However, unless this is continually updated by commissioners, we have experienced issues with local proﬁling of services which are suitable to treat patients with minor injuries and conditions. 2.2. These proﬁling issues impact negatively on the quality of service provision and needs to be considered carefully if more services are moved from A&E to community settings.

3. The Range, Severity and Incidence Of Conditions that can be Treated Within an Accident and Emergency Unit but not managed at an Urgent Care Centre 3.1. A recent audit8 of admissions by ambulance into Sunderland Emergency Care Department over two days highlighted only one inappropriate referral. 3.2. However, it should be noted that ambulance crews are acting on the clinical decisions of others, eg General Practitioners, 7 Taking Healthcare to the Patient 2, Association of Ambulance Chief Executives, June 2011, p26 8 Internal audit, September 2012 commissioned jointly by Sunderland PCT and NEAS cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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3.3. Paramedics operating within their code of conduct do not challenge or question the decisions of more senior clinicians. As a result, we are aware of anecdotal stories of inappropriate referrals.

4. The Prospects for Better Integration of Ambulance Services with Primary Care Under the New Commissioning Regime established in April 2013 4.1. It must be recognised that there has been a dislocation across the NHS as a result of the reforms. 4.2. Contracts have not being signed with the new commissioners, as they seek to establish themselves and decide upon arrangements for the future. 4.3. Ambulance services are provided on a regional level. The rationale was to create economies of scale to invest in the technologies that help support quick response times to potentially life-threatening calls. But there are obvious difﬁculties in ﬁnding the resource to engage with each of the 12 CCGs now in our service area. 4.4. We feel CCGs must commission collaboratively when appropriate to maintain these economies of scale whilst providing a higher performing urgent and emergency care service, particularly in rural settings.

5. The Ability of Ambulance Services to continue to meet Increased Emergency Demand whilst contributing to the Nicholson Challenge 5.1. NEAS has been the most consistently successful and innovative ambulance service in the country over the past decade. We continue to deliver our national performance targets despite very significant challenges. 5.2. We have adopted “lean” thinking in our approaches to utilising all our resources as efficiently as possible. This has enabled us to deliver a cost improvement program amounting to at least £4 million in each of the last three years ie £12 million cumulative (from a total budget of just over £100 million). 5.3. Nevertheless, it is the Board’s view that the North East-wide emergency ambulance service has been consistently under-funded by comparison with other English ambulance services for a considerable number of years.9 5.4. The service is provided at a cost which is 15% below the average costs associated with other ambulance services in England. Were we to be funded at average costs we would be in a position to increase our budget by more than £12million per annum. With such resources at our disposal we would, in due course, make very significant improvements to the service provided to the North East as a whole. 5.5. The distribution of that funding would be a matter for discussion between us and our commissioners, but we are confident that it would have a positive impact upon our ability to respond to patients’ needs wherever they live, including those patients referred to us by the GP community.

6. Experience to Date of the Transition from NHS Direct to the NHS 111 Service 6.1. NEAS is the provider of NHS111 in our ambulance area. 6.2. For many years, we have looked to address the imbalance between emergency and urgent care pathways and the increasing pressure this was putting on colleagues in the acute and emergency care sector. 6.3. The result was a telephone triage service model based on the NHS Pathways clinical decision support system, which we had introduced into our 999 services in October 2006. 6.4. We believe that this model of integrating 999 and 111 services on the same platform, supported by a capacity management system and well-populated directory of services, best delivers a “whole-systems” approach around what patients understand. 6.5. It also drives patient flow to the most appropriate care by identifying the clinical need of patients and matching these to the services available in their area. 6.6. This approach is critical in ensuring patients are not unnecessarily transported to emergency departments (ED). An independent study carried out by Sheffield University highlighted that in our 111 pilot area there was a 3.9% reduction (raw figures) in attendances at ED; the best performing overall service.10 6.7. In the words of Sir John Oldham, we have ceased to “educate” patients as to what is urgent or not; and instead educated the system to respond rationally to whatever anyone calls urgent. 6.8. This has worked because our 999 and 111 services both use NHS Pathways to ensure there is consistency of clinical assessment without the variations that can occur when patients are assessed without such a system. 6.9. Our assurance of NHS Pathways is gained through a continuous review by an independent National Clinical Governance Group chaired by the Royal College of GPs, with representatives from all the royal colleges and professional bodies including the College of Emergency Medicine and the British Medical Association. 9 National Audit Office, June 2011 10 Evaluation of NHS111 pilot sites, Sheffield University, August 2012, available at http://www.shef.ac.uk/polopoly_fs/1.227404!/ file/NHS_111_final_report_August_2012.pdf cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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6.10. Our Trust has consistently met or exceeded performance standards and, as a result, we were the only service to have been granted permission to roll-out 111 across the North East region on 2nd April 2013. 6.11. Our experience is that where NHS 111 is correctly commissioned, with a functioning Capacity Management System, a fully populated Directory of Services and a provider capable of fully integrating with the emergency and urgent care framework of their region, NHS 111 can deliver a service that is right for patients. 6.12. We would go further and add that our success is because we are an ambulance service. Our core business is expert call handling and telephone triage of complex calls. 6.13. We are best placed to understand the inter-relationship and mutual dependence of urgent and emergency care. We have a vested interest in ensuring patients receive the right care, in the right place and in the right time. A signiﬁcant increase in ambulance activity would negatively impact on our operational performance and we are particularly focused on avoiding ambulance dispositions where clinically unnecessary.

7. The Implications of the Shift Away from Determining the Success of Ambulance Services via Indicators based on Response Time to the New Measures Designed to Assess Clinical Effectiveness 7.1. We welcome the move towards clinical effectiveness measures to drive up standards of patient care. However, this must be evidence-based with standards that have not been imposed or set as targets. 7.2. We also recognise that Rapid Response for some life-threatening conditions will always be needed and so it is unrealistic to move away entirely from response targets. We would favour a balance between speed and quality of care.

8. The causes of Delays in Handover from Ambulances Services to A&E or Transfer between Different Levels of Urgent Care, and Actions required to eliminate them 8.1. The pressures evident in ambulance response times and in handover delays at hospitals cannot be addressed by the ambulance service alone. They are visible signs of a system that needs attention across the board to address three issues: 8.1.1. Managing demands made upon the system, to avoid the need to go to hospital 8.1.2. Managing the processes involved in dealing with the demand both within individual providers such as mine and at times when patients are passed on from one part of the system to the next eg on transfer from the ambulance to the hospital or from the hospital to community/social care etc. 8.1.3. Assessing whether there is a need to put more resources into the system where it can be demonstrated that good practice is already being adopted 8.2. NEAS has engaged two senior managers from ECIST (Emergency Care Intensive Support Team) to study the issues underlying the delays at hospital handover and determine a system for measuring each stage of the handover process. 8.3. We agree with the assessment made by NHS England that a number of factors are assumed to have played a part in handover delays. Not all of them pertain to every situation. These can be read at http://www.england.nhs.uk/wp-content/uploads/2013/05/ae-imp-plan.pdf

9. Clinical Evidence about Outcomes Achieved by Specialist Regional Centres, taking account of Associated Travel Times, compared with more Generalist Hospital based Services 9.1. Our experience and understanding is that ambulance conveyance to specialist centres such as Major Trauma units; primary percutaneous coronary intervention (PPCI) units for certain types of heart attack; and stroke units give patients a higher likelihood of survival and better quality of life. 9.2. However, when commissioning specialist centres, consideration needs to be given to ambulance response times and the impact on ORCON performance that longer journeys can have on our responses to other 999 emergencies.

10. The Ability of Local Authorities to challenge Local Proposals for Reconﬁguration under the Revised Oversight and Scrutiny Powers included in the Health and Social Care Act 2012 10.1. In the view of a regional NHS organisation like the ambulance service, the issue is how we balance region-wide consultation with parochial interests that can potentially disrupt service–wide improvements. May 2013 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Written evidence from the Royal College of Surgeons (ES 13) 1. Introduction 1.1. This evidence sets out the Royal College of Surgeons’ (RCS) view on the delivery of emergency care in England. 1.2. Patients requiring emergency surgical care are among the sickest in the NHS. These patients are often older and with signiﬁcant medical problems; the risk of death or serious complication can be high. For this reason, managing emergency surgical patients in the safest and most efﬁcient manner is vital.

2. Executive Summary 2.1. Many of the most serious, life-threatening cases in A&E require surgical care so improving the provision of A&E, and emergency care more broadly, is crucial for the 1.2 million patients per year who require emergency surgical assessment or treatment. 2.2. There are a number of significant issues facing emergency surgery including: problems with care pathways for patients, waiting time targets and their impact on availability of hospital beds, provision of cover due to working time regulations, sufficient availability of generalist surgeons, and ensuring the payment system incentivises best practice. 2.3. Reconfiguration of emergency care is essential if patients are to be treated quickly and in the best setting. Consideration should be given to separating unplanned emergency and planned elective care in order to reduce cancellations and delays, achieve more predictable levels of work, and provide supervised training opportunities. 2.4. Where appropriate, major general surgical emergencies that require specialist treatment and facilities should be centralised, with patient assessment and less complex surgery delivered closer to patients’ homes. 2.5. Commissioners and the Government need to urgently address the alternatives to A&E based within the community, in full consultation with patients and the local community.

3. Emergency Surgical Services in Context 3.1. A&E attendances are rising. Comparing the ﬁrst three quarters of 2012–13 to the same period in 2009–10, attendances have increased by 353,457 (+3.4%) in major (“type 1”) A&E departments and by 829,995 (+5.3%) for all types of A&E departments.11 3.2. Surgical assessment and treatment is an essential part of emergency care. The College of Emergency Medicine estimate that around 20% of A&E attendances require surgical opinion. Hospital Episode Statistics (HES) data on medical specialties for 2011–12 also shows that approximately a quarter12 of surgical admissions are emergency cases. This equates to around 1.2 million admissions per year. 3.3. The most common reasons for an A&E attendance which leads to surgery or a surgical consultation are overwhelmingly for general surgery followed by orthopaedics. This is often for lower abdominal pain or injury to bones or joints. 3.4. General surgical emergency cases alone presently account for 14,000 admissions to intensive care—for conditions which are life-threatening and need constant monitoring and support—in England and Wales, this is estimated to cost approximately £88 million per year.13 Emergency major gastrointestinal (GI) surgery (a form of general surgery) has one of the highest mortality rates due to the complexity of the surgery, which can reach over 50% in the over 80s.14 Better organisation of care should create an improvement in outcome for these patients.

4. The Challenges facing Emergency Surgery 4.1. The ever growing pressure on A&E services has an impact on the whole hospital. The RCS is concerned that the current crisis in accident and emergency departments is directly hampering emergency surgical care, as patients who are inappropriately admitted to meet the A&E target are using hospital beds that are required by patients who require surgery in emergency theatres. Surgical patients who are admitted to any available bed can prevent consistent access to consultant-led care. It is only by tackling inappropriate emergency care admissions that the system will remain safe for patients and sustainable in the future. 11 http://www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing 12 This is based on combining HES data on general surgery; urology; trauma and orthopaedics; ear, nose and throat; oral surgery; oral and maxillo facial surgery; neurosurgery; plastic surgery; cardiothoracic surgery; and paediatric surgery. 13 Intensive Care National Audit & Research Centre (ICNARC), London 2010. Data derived from Case Mix Programme Database based on 170,105 admissions to 185 adult, general critical care units in NHS hospitals across England, Wales and Northern Ireland. 14 Cullinane M, Gray AJ, Hargraves CM et al. The 2003 Report of the national Conﬁdential Enquiry into Peri-Operative Deaths. London: NCEPOD; 2003. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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The care pathway of patients 4.2. Services must be conﬁgured to help patients be seen by the most appropriate healthcare professional as quickly as possible following their initial contact with the health system. Studies show that mortality increases if patients have to wait longer.15 The current pathway of care for many surgical patients is not joined up between primary and secondary care, nor within the secondary care setting, with the potential for patients to be delayed in receiving necessary surgical consultation. 4.3. Triaging patients correctly in emergency and acute care is essential to ensure patients receive the right type of care as quickly as possible. At present, this process is variable across the country and we support guidance in this area by the College of Emergency Medicine,16 which sets out how triage should work in practice.

Waiting time targets 4.4. The pressure on hospitals to meet waiting time targets for both A&E admissions and for elective surgery is in some hospitals delivering a chaotic system in which patients are unable to be treated in a timely manner or according to their clinical need. Time-limited targets that exist for treatment in A&E can result in inappropriate admissions to hospital. For example, some patients are being admitted to the nearest available bed to allow hospitals to say they have dealt with a patient within the target, even where this may not be clinically appropriate and may result in patients being sent to the wrong ward. This results in a lack of availability of beds for elective surgical patients and causes patients to be dispersed across the hospital leading to ineffective, inefﬁcient and often, unsafe care. This view was recently echoed by the Royal College of Nursing.17

Staff availability 4.5. The Academy of Medical Royal Colleges recently published standards for seven day consultant care which stated that “inpatients should be reviewed by an on-site consultant at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway”. We do not believe this is consistently happening at present. In emergency care, this consultant review should be more frequent. For example, in emergency general surgery the College believes there should be a consultant review at least every 12 hours. The presence of a senior decision maker who is able to treat or supervise the treatment of patients can lead to quick decision making and better patient care. 4.6. The cost and requirements of working time regulations have also had a detrimental impact on the delivery of emergency surgical services as a whole. Not only have the number (or tiers) of surgeons available to deal with emergencies been reduced as a direct result of the lack of flexibility in working hours, but also the ability to provide continuity of care to patients has been eroded. Where the impact of the regulations has not been properly managed, trainees are now less experienced in dealing with emergencies. 4.7. The NHS also needs to examine what more it can do to motivate and support medical staff to work in A&E as part of their career. Many junior doctors are initially keen to work in A&E but find the pressure and intensity of work understandably difficult. According to the College of Emergency Medicine there continues to be a considerable shortage in the number of senior training posts filled for emergency medicine.18 The profession and the NHS needs to look at developing an attractive career structure which encompasses a sizeable emergency workload with sufficient and supported elective practice.

Rewarding best practice 4.8. Monitor and NHS England should develop payment systems for the NHS to reward the delivery of care which incentivises doctors to treat patients in the most appropriate clinical setting and in the most effective way. Designing appropriate payment systems has signiﬁcantly changed emergency orthopaedic surgery, including hip fractures where hospitals were rewarded for treating patients within 48 hours of the hip fracture as part of best practice standards. 4.9. There also needs to be more active engagement between commissioners and surgeons about how cost effective and efﬁcient solutions can be delivered. The College and Surgical Specialty Associations have also created a suite of NICE-accredited commissioning guides to assist commissioners in this regard. Our recent submission to the Health Select Committee’s inquiry on the implementation of the Health Act sets out our views on how to improve joint clinician and commissioner working.

Availability of generalist surgeons 4.10. Advances in surgery have, in recent years, encouraged the development of a workforce that is increasingly focussed on delivering surgical care in specialist areas rather than dealing with a wider breadth of emergency surgery. A major challenge for the profession in training the next generation of surgeons is to ensure 15 http://www.acutemedicine.org.uk/index.php?option=com_content&view=article&id=110:as-waiting-times-increase-death-rates- rise&catid=76:press-releases&Itemid=83 16 College of Emergency Medicine. Triage position statement. April 2011. 17 http://www.bbc.co.uk/news/health-22269688 18 http://secure.collemergencymed.ac.uk/code/document.asp?ID=7030 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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that there are adequate numbers of surgeons able to deal with patients requiring emergency surgery, such as lower risk abdominal surgery in local hospitals. This is an issue that primarily affects general surgery. The profession is seeking to address this imbalance through the surgical curricula. The NHS also needs to support and recognise the importance of generalist surgical care.

5. Reconﬁguring Emergency Care

5.1. The RCS believes that emergency care needs to be reshaped (or reconﬁgured) to help provide care to patients in the most appropriate clinical setting and to improve the delivery of emergency care.

Separating elective and emergency care

5.2. The College believes that, when carefully planned and adequately resourced, the separation of unplanned emergency and planned elective services will improve the quality and safety of care delivered to patients. In our 2007 publication Separating emergency and elective surgical care: recommendations for practice we outline the beneﬁts of separation and ways to implement such change. In particular we highlight that the use of dedicated beds, theatres and staff for either elective or emergency surgery can reduce cancellations and delays, achieve more predictable levels of work, and provide supervised training opportunities.

Reconﬁguring emergency surgical care

5.3. The College believes that where possible, major general surgical emergencies that require specialist treatment and facilities should be centralised with patient assessment and less complex surgery delivered closer to patients’ homes. Specialist centres should work in operational networks of local providers to support collaboration, common standards of care and good patient transfer arrangements, according to clinical need. The network will enable the patient to be treated at the most appropriate hospital depending on the complexity of the case and the resources available to treat. The interdependencies with supporting services include emergency medicine, medical gastroenterology, acute medicine and care of the elderly services, need to be considered.

5.4. In remote and rural areas a different solution will be required given the difﬁculties in transferring patients who require emergency treatment to specialist centres. This will mean a wider range of skills will be required in the local workforce.

Alternatives to A&E

5.5. It is vital that reshaping secondary care services is aligned with improvements in access to primary care. There is now a growing consensus that access to primary out-of-hours care in particular is poor, with patients frustrated at being unable to attend GP services in the evenings and at the weekends. While improving access to primary care may not directly reduce A&E admissions for surgical care, this should result in quicker diagnoses and a reduction in A&E attendances for other non-emergency cases. The Department of Health and NHS England must urgently review how to improve access to primary care and this may include greater use of GP services present within hospitals to reduce pressures on acute services.

5.6. It is also important for the names and functions of primary care services to be clear to the public. Patients have traditionally not understood the myriad of alternatives to A&E, such as “urgent care centres”, “walk-in centres”, “minor injury units”, “out-of-hours doctors services”, “primary care assessment services” and “community hospitals” but A&E is a term the public do understand. Clarity over the functions of each of these services is vital, combined with clear and consistent communications from the Government, commissioners, and primary and secondary care clinicians to the public, to ensure these options are navigable.

Consulting on change

5.7. Too often reorganisations result in patients and their carers or families being pushed to one side of the debate, their questions ignored or their approach labelled as Luddite by the health service. The public needs to be at the centre of the decision-making process. Where there are problems, these need to be addressed with honesty and proper debate, informed by facts. It is imperative that patients must be fully involved in changes to their local services.

5.8. Furthermore, local and national politicians can have an important bearing on any reorganisation. It is often the case that a natural reaction of the local community is to protect their local services. As discussed in the College’s recent publication Reshaping Surgical Services, politicians should engage with the clinical case 19 Royal College of Surgeons. Reshaping Surgical Services: Principles for change. January 2013 cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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for reshaping as much as public concerns, and support solutions that improve patient treatment and care. Once a decision has been made, it should be implemented quickly as delays can affect future planning of services.20 May 2013

Written evidence from Priority Dispatch (ES 14) 1. Priority Dispatch manages the clinically tried and tested ambulance dispatch triage used by most ambulance trusts in the UK. We are the only emergency dispatch system provider to be clinically tested, approved and supported by the International Academies of Emergency Dispatch (IAED). The Advanced Medical Priority Dispatch System has been in use for the last 30 years with frequent and substantial updates. 2. Priority Dispatch welcomes the work of the Committee to examine emergency services and emergency care and the opportunity to comment on the issues impacting on the emergency services. Our submission sets out our views on three of the Committee’s core issues, with a focus on the ambulance service.

Summary — Ambulance services are already struggling to cope with emergency demand. The predicted increase in demand and the strain on their existing resources is likely to severely impact their ability to cope with demand in the future. — Over the past two years Priority Dispatch has expressed concerns about the rush to implement the NHS 111 service. We have made regular calls for the roll-out of the service to be delayed in order for more thorough testing and engagement to take place. The roll-out of this service is placing more pressure on ambulance services and impacting on patient safety. — Greater monitoring and evaluation of call handling and dispatch determinants is required to help ambulance services meet increased demand and improve the patient experience.

The Inquiry’s Key Issues The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge 3. Ambulance services are already struggling to meet emergency demand. Emergency calls are increasing by 3–6% every year (The number of emergency or urgent calls that the ambulance service receives has increased by about 4% each year since 2007–08)21 and the UK’s growing ageing population is likely to have significant consequences for ambulance services and demand for their services. 4. The Nicholson challenge is already having a detrimental impact on ambulance services and their ability to meet increased emergency demand. Ambulance services are seeing their budgets cut and consequently experiencing a real strain on their resources. 5. We believe that greater investment in the dispatch process could deliver significant benefits to the ambulance services. In our view a stronger clinical base in the secondary triage system would generate greater “hear and treat” response thereby avoiding admissions to A&E departments and reducing ambulance runs in the longer term. We believe that this initial investment has the potential to save thousands of pounds in the long term. — The experience of some ambulance Trusts is a key example of a where stronger clinical base in the secondary triage system pay dividends, utilising experienced clinicians in this very important watershed area of initial contact with the healthcare system have shown in the past to pay dividends on the investment in human capital. 6. We have grave concerns about the impact of NHS 111 on the ambulance service, such as the increased pressure to respond to more calls. We strongly believe that to continue with this service in its current form will severely impact the ability of the ambulance service to meet their natural increasing emergency demand. 7. Currently, ambulance services are not regularly evaluating emergency calls. In order to improve the ability of ambulance services to meet emergency demand a system of monthly evaluation needs to be put in place. Regular evaluation of the dispatch determinants will ensure call handlers are providing the best response for patients whilst increasing the effectiveness and efficiency of call processing, for example, assessing which calls can be allocated to secondary triage. — Great Western Ambulance Service is currently carrying out regular evaluation of emergency calls and as a result they are achieving a consistent figure of around 7.5% “hear and treat” response—one of the highest in the country22 20 Royal College of Surgeons. Reshaping Surgical Services: Principles for change. January 2013 21 Auditor General Report by the Comptroller and Auditor General HC 1086 Session 2010–2012 10 June 2011 22 Ambulance Quality Indicators: System Indicators, Ambulance trusts in England October to March 2012–2013 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Experience to date of the transition from NHS Direct to the NHS 111 service 8. As one of the leading providers of clinically tried and tested ambulance dispatch triage in the UK, we welcome the concept of NHS 111 and what it is aiming to achieve. 9. However, we remain extremely concerned about the implementation of the service, specifically around the insufficient testing prior to roll-out and the lack of engagement with key groups, such as the ambulance service. In order to gain vital, on the ground input, engagement with ambulance trusts should have taken place months, if not years, ago 10. We urge NHS England to look closely at the University of Sheffield’s review of the NHS 111 pilot schemes. The primary objectives of NHS 111 are to make cost savings and reduce the pressure on urgent care services and the emergency care system. The findings of the University of Sheffield report suggest that neither of these core aims were achieved during the pilot schemes. Indeed, the pressure on the ambulance service significantly increased. At one Trust an 11.2% increase in call volume on average over the last couple of months directly contributable to NHS 111 has been experienced on top of the annual increase, with other Trusts also experiencing higher volumes. The worryingly high volume of patients referred to Out of Hours (OOH) throughout the pilots indicates this pressure could be even larger when OOH is absorbed by 111. 11. We strongly believe that NHS 111 should not impede on the ambulance services’ core business of dispatching emergency ambulances to people who need them. Fundamentally, we want to ensure that the public receives the correct response for emergency treatment within the right timeframe. We believe the rush to implement NHS 111 is creating a threat to public safety and unjustified expenditure. 12. While NHS 111 is suited to out of hours treatment and non-emergency calls, it is not a satisfactory substitute for patients requiring immediate care because it relies on non-clinical call handlers who will not always have the medical expertise to correctly assign ambulances for genuine emergencies. 13. Reports in the media about the impact of NHS 111 on patient safety are becoming all too frequent. We have previously questioned the use of call handlers who do not have the medical expertise to correctly assigned ambulances for genuine emergencies. We maintain that public safety will be compromised due to the high chance of inappropriately referring patients to another service. 14. NHS 111 was designed with the fundamental aim of saving money, largely by employment of non- clinical call handlers at the primary triage system. However, the lack of medical expertise leaves too much scope for mistakes to be made, resulting in increased pressure on ambulance services and inappropriate referral of patients, which, in reality, leads to increased costs.

The Implications of the shift away from determining the Success of Ambulance Services via Indicators based on Response Time to the New Measures designed to assess Clinical Effectiveness. 15. We welcome the shift towards new measures designed to assess clinical effectiveness and believe that the implications for the ambulance service have the potential to be positive. 16. Indicators based on response time (category red and category green) do not have patient care at the centre. 17. However, in order for these new measures to work effectively they must be outcome based. A robust triage system must be in place in order to assess clinical effectiveness, providing a level of detail and granularity to ensure patients are not pigeon-holed into broad categories. 18. Any new measures must be regularly reviewed through an effective monitoring system to ensure patient safety. 19. We are keen to work with NHS England to offer our advice, experience and expertise on new measures. May 2013

Written evidence from the Royal College of Nursing (ES 15) 1.0 Introduction 1.1 With a membership of more than 410,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations. 1.2 The RCN welcomes the opportunity to respond to this timely inquiry into emergency service and emergency care. In this response the RCN will respond to selected questions in relation to the terms of reference as provided. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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2.0 Background

2.1 There is substantial pressure on Accident and Emergency (A&E) services at present. Patient attendances at A&E in England have increased by over one million in the last year.23 This has understandably resulted in delays in the provision of care. The RCN Frontline First campaign has highlighted that, in England, twice the number of NHS foundation trusts failed to meet their A&E waiting times targets in quarter three of 2012–13 compared to the previous year.24 Also, during the ﬁrst three weeks of 2013–14 (April 2013), the Government’s four hour A&E waiting time target was widely missed.25 The RCN has repeatedly raised concerns about the service’s capacity to cope; these concerns have been echoed by the Foundation Trust Network and the College of Emergency Medicine.26

2.2 Such pressures have raised concerns about patient safety and the quality of patient outcomes. For example, RCN members have noted that “queue nurses”, whose role is to manage the queues in corridors of patients ofﬂoaded from ambulances, have been introduced in at least at one trust. Other stakeholders have highlighted that medical admissions are being moved up to ﬁve times without a consultant taking overall responsibility for their care.27 Such situations could obviously compromise patient safety if patients are treated in inappropriate settings and if there are long waits for treatment.

2.3 Whilst recognising other contributing factors, the RCN believes that some of the pressures on A&Es must be attributed to insufficient nurse staffing levels. The RCN has developed, via its Emergency Care Association and the Faculty of Emergency Nursing, the Baseline Emergency Staffing Tool (BEST).28 BEST is a workforce planning tool for use at a local level. It allows the volume and pattern of the nursing workload in an A&E department to be tracked against a rostered staffing level. This then shows any disparity between the nursing workload and staffing levels. The tool does not produce recommended staffing levels but will allow A&Es to work locally to provide adequate staffing levels in response to need.

2.4 The RCN is represented on the reference group for NHS England’s review of urgent and emergency care. The group has representation from the Royal Colleges, the health education sector and patients. We welcome this opportunity to be a part of this work and look forward to contributing to the resulting consultation in spring 2013.

3.0 Executive summary

3.1 There is extreme and growing pressure on A&E services in England, which raises serious concerns for patient safety, quality of care and staff morale.

3.2 This situation has culminated as a result of many factors, such as: — the seeming reduction in out of hours services; — poor patient signposting to appropriate services; — increased number of patients presenting at A&E services; — declining NHS workforce; — reduction in the availability of acute specialist and general hospital beds; and — the lack of investment in community services to prevent presentations.

3.3 An issue signiﬁcantly affecting the current ﬂow of patients to A&E services is the problematic introduction and varied quality of NHS 111. The RCN supports the idea of having a single point of contact for patients who need unscheduled care, however, the RCN has serious concerns regarding the quality of this service.

3.4 To support A&E at this difﬁcult time, appropriate resourcing to ensure patient care is not compromised in A&E services must be released; patient education of the appropriate services must be improved; and a thorough national review and action plan for NHS 111 and other out of hours services must be implemented.

3.5 Currently, patients have been left unsure where to turn when they require unscheduled care in an “out of hours setting”. In such circumstances patients will turn to the constant and comprehensive service that is A&E. This situation is unsustainable in its current form and requires urgent and real attention. 23 Health and Social Care Information Centre https://catalogue.ic.nhs.uk/publications/hospital/monthly-hes/prov-mont-hes-admi- outp-ae-apr-jan-12–13/prov-mont-hes-admi-outp-ae-apr-jan-12–13-rep.pdf 24 RCN Frontline First: Nursing on red alert, April 2012 www.rcn.org.uk/__data/assets/pdf_file/0009/518499/FF_England_ briefing_Apr_2013_FINAL.pdf 25 HSJ, A&E performance plummets http://www.hsj.co.uk/5058128.article?referrer=e2 26 BBC News—A&E must change or face collapse http://www.bbc.co.uk/news/health-22529561 27 Royal College of Physicians 2012, Hospitals on the edge, http://www.rcplondon.ac.uk/projects/hospitals-edge-time-action 28 RCN Baseline Emergency Staffing Tool (BEST) http://www.rcn.org.uk/development/communities/rcn_forum_communities/ emergency_care/baseline_emergency_staffing_tool cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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4.0 The role of community & primary care services in the delivery of emergency healthcare & appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas 4.1 Regardless of the location, care should be commissioned for whole care pathways, from presentation, to discharge and potential follow up care. 4.2 High level principles on the necessary role and structure of services should be set centrally, and should be based on utilising appropriate clinical skill in the most appropriate and accessible locations for patients. Local commissioners should then use these principles to help them commission local services that provide safe and high quality care. 4.3 Rural health care services sometimes have to cover vast areas that can be difﬁcult to access. This can make service provision more expensive in comparison to urban locations. Therefore, the RCN believes local and national commissioners need to acknowledge this and tariffs must be set which are sufﬁcient for rural areas to accommodate this additional requirement on their emergency services and care. 4.4 Nurses working in the community can play a key role in reducing the amount of A&E presentations. As community champions and ambassadors engaging with people about their health they can help maintain patients’ conditions so they do not require unscheduled care. This is particularly true for patients with long term conditions or those who have recently been discharged from hospital. Unfortunately, despite widespread support for moving care away from acute settings and into the community, the RCN Frontline First campaign has highlighted that the community nursing workforce has actually contracted, rather than being supported to rise to this challenge.29

5.0 Progress towards moving some minor injury & urgent care services out of A&E and into more accessible community settings 5.1 No matter what setting or location, local service provision must utilise all the local service capacity within the health care system, to ensure access to appropriate services for each particular case. 5.2 It is important to note that terms such as minor injury unit and urgent care centre do not offer the same services universally. Urgent and emergency care as a whole should minimise the number of titles used and design appropriate and consistent services, which are well understood by patients and the local population. 5.3 It should also be recognised that a continued failure to educate patients and signpost them to the appropriate available services will continue to encourage inappropriate presentations at A&E. Contributory factors to this are: — the closing of NHS Direct; — problems with, and the delayed introduction of, NHS 111; — poor advice given by NHS 11130 and patients losing conﬁdence in NHS 111;31 and — the apparent reduction in NHS walk-in centres.32 5.4 To ensure patients present at the most suitable locations there must be a concerted effort to educate patients on the available services and their remits as well as “good signposting” to services locally and nationally.

6.0 The range, severity & incidence of conditions that can be treated within an accident & emergency unit but not managed at an urgent care centre 6.1 The remit of urgent care centres can loosely be defined as an NHS service for patients whose condition is urgent enough that they cannot wait for the next GP appointment but who do not need emergency treatment at A&E. 6.2 It is extremely difficult to provide a definitive answer to what services can and cannot be delivered by an A&E unit and by an urgent care centre. Regional specialist centres, variations in the severity of the patients’ condition and the skill of staff, for example, blur the picture somewhat. 6.3 Some specialist pathways have been taken out of A&E departments to provide specialist services designed around the highly complex needs of patients. Hyper-Acute Stroke Units (HASU) in London are seen as a positive example of this type of service redesign giving patients access to a more highly specialised service, but potentially not at the nearest hospital. 6.4 However, access to specialist pathways need to be made consistent nationally, for example, HASU and Percutaneous Coronary Intervention (PCI) pathways, where the entire population can expect equal outcomes 29 RCN Frontline First, Congress 2012 Update http://www.rcn.org.uk/__data/assets/pdf_file/0008/450539/10.12_Frontline_First,_ Congress_2012_Update.pdf 30 BBC News, NHS 111 helpline incidents http://www.bbc.co.uk/news/health-22401585 31 The Guardian, NHS 111 non-emergency helpline in chaos http://www.guardian.co.uk/society/2013/may/10/nhs-111-helpline- chaos-doctors 32 BBC News Are NHS walk-in centres on the way out http://www.bbc.co.uk/news/uk-politics-18503034 cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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regardless of location. The decision to move specialist pathways outside of A&E departments needs to strike a balance between proximity and the quality of the service provided.

7.0 The prospects for better integration of ambulance services with primary care under the new commissioning regime established in April 2013 7.1 Ambulance service colleagues are often placed in challenging situations where a decision to not take a patient to hospital is impossible on the scene of an incident. This may be because they do not have access to the necessary specialist acute advice required to allow on scene discharge or because access to, for example, out of hours GPs, community services and often social care providers is not available. 7.2 As Clinical Commissioning Groups (CCGs) are now commissioning ambulance services there is the potential for a more integrated service provision with primary care. However, as neither acute, nor ambulance service representatives are mandated on CCG boards, it is necessary for CCGs to draw on appropriate experience before designing their services or pathways.33 7.3 If commissioners miss this opportunity to better integrate and coordinate ambulance services with primary and other care services, it will have a knock on effect on the level of service provided and may continue the problem of inappropriate admissions and the resulting costs of this.

8.0 The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge 8.1 Ambulance services have no control over their patient load, this makes finding efficiencies and financial savings particularly difficult. This means in parts of the country there are recruitment freezes and an increasing ratio of technicians to fully qualified paramedics.34 8.2 The RCN is also aware of this situation being replicated in nursing care where we are seeing a reduction of staffing levels and the dilution of skill mixes based on cost rather than clinical rationale or need.

9.0 Experience to date of the transition from NHS Direct to the NHS 111 service 9.1 In theory, a single point of initial contact for those who need unscheduled care should help to reduce inappropriate presentations. To facilitate this, NHS 111, the new non-emergency point of contact replacing NHS Direct’s 0845 services, must be resourced and staffed effectively to provide suitable advice. NHS 111 operators must have a keen appreciation of the local health care system and what each part can offer—including primary care, out of hours, specialist services and emergency care so they can properly advise callers. 9.2 However, since the launch of NHS 111 a number of worrying problems have come to light which have not only compromised patient safety, but have piled pressure on already over-stretched emergency departments. NHS Direct, which was supposed to have ceased its national function, has had to step in to maintain the non- emergency 111 service. The RCN has had serious cause for concern over patient safety relating to NHS 111 service provision. This is due to the following contributory factors: — Over the first week of “full roll out” of NHS 111 (21–28 March), less than 50% of calls were picked up by the NHS 111 providers. In these circumstances NHS Direct has had to step in to provide contingency cover. — There is variation in the quality of service provided. The implementation of NHS 111 moved away from a national service to a locally commissioned service. There are now a number of service providers offering a varied service across the UK. Some have been widely discredited in the media for the quality of the advice given, how timely calls are answered and if calls are answered at all. — The highly skilled nursing staff of NHS Direct, band 6 nurses, had been threatened with significant job losses and the potential down banding of their posts. If this was to occur there would a significant loss of expertise, negatively affecting the quality of service provided by NHS Direct’s 111 service. Only recently have selected parts of the workforce had their job security confirmed and their banding restored. However, due to this uncertainty it is expected that a certain level of expertise will have already left the system. 9.3 The RCN, therefore, welcomes the NHS England review of the service in an attempt to counter some of the serious problems facing NHS 111. If NHS 111 is to continue without the support of NHS Direct it must be a nationally commissioned service which is led by properly trained nurses, rather than the current fragmented model which is damaging for patients, staff and the health service as a whole, particularly A&E services. 9.4 Given the problems that this transition has presented, focus now needs to be on making NHS 111 an effective single point of contact for the population. This requires NHS 111 to be consistent nationally and call handlers need to be adequately skilled to be able to reach a decision that is right for the patients. For this to 33 NHS Confederation, Integrated Ambulance Commissioning 34 The Telegraph, Ambulance services launches investigation into deaths of 13 patients http://www.telegraph.co.uk/health/ healthnews/9963588/East-Midlands-Ambulance-Service-launches-investigation-into-deaths-of-13-patients.html cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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work, NHS Pathways and 111 services need to link seamlessly not only with urgent and emergency care but also the ambulance services, out of hours service, specialist nursing, GPs, social and mental health services.

9.5 The RCN believes that this will help to ensure high quality patient care and reduce pressure on A&E departments. Effective and appropriate stafﬁng is key and the RCN hopes that the retention of band 6 NHS Direct nurses within the NHS 111 service will help to facilitate this development.

10.0 The causes of delays in handover from ambulances services to A&E or transfer between different levels of urgent care & actions required to eliminate them

10.1 There are many contributory factors to delays in handover from ambulance services to A&E, these include: — the signiﬁcant growing pressure on A&E services; — declining workforce numbers; and — reduction in the availability of acute specialist and general beds.

10.2 Levels of demand on A&E departments in England have been described as unsustainable by David Prior, Chairman of the Care Quality Commission.35 The College of Emergency Medicine has also made warnings of a “meltdown” in the A&E departments.36 These reports add further commentary to what our Frontline First campaign shows, and what our members are telling us.

10.3 Since the election in May 2010 the NHS workforce in England has shrunk by 23,628 (14,134 Full Time Equivalent).37 With such a reduction in NHS staff, blockages throughout the NHS system such as support services will occur, especially in an already stretched system. This can potentially delay vital treatment and negatively affect patient outcomes.

10.4 According to the Royal College of Physicians, there are a third fewer general and acute hospital beds now than there were 25 years ago, however, the last decade alone has seen a 37% increase in emergency admissions. Hospitals have coped with this increase by reducing the average length of stay for patients. However, in the past three years length of stay has started to rise for patients over 85.38

10.5 The RCN is not opposed to service reconﬁguration or redesign when based on clinical evidence. Our members tell us that they would willingly input into a discussion on service redesign to improve the current A&E system. The RCN would, therefore, support discussions between commissioners, A&E staff and ambulance services, about how services can be adapted and re-designed to cope with the growing pressures on the service. May 2013

Written evidence from The Royal College of Radiologists (ES 16)

1. The Royal College of Radiologists (RCR) has over 9,000 Fellows and members worldwide, representing the specialties of clinical oncology and clinical radiology. The role of the College is to set and maintain the standards for entry to and practise in these specialties, in addition to leading and supporting practitioners throughout their career.

2. The RCR has, in this submission, offered a response to those issues of relevance to our specialties regarding emergency services and emergency care.

3. Appropriate diagnostic support will be required to deliver this service and must be part of a co-ordinated plan. Although the RCR is unable to comment on issues of geographic location, we would refer the Health Committee to the joint guidance published by the RCR, the Royal College of General Practitioners and the Society and College of Radiographers—Quality imaging services for primary care: a good practice guide.39 The guidance was prepared with the aim of ensuring that primary care has access to high quality imaging services. 35 BBC News, A&E facing serious problems http://www.bbc.co.uk/news/health-22460741 36 The Times, A&E departments “facing meltdown” www.thetimes.co.uk/tto/health/article3754933.ece 37 Health and Social Care Information Centre , www.hscic.gov.uk/searchcatalogue?productid= 11436&topics=0%2fWorkforce& sort=Relevance&size=10&page=1#top 38 RCP, Hospitals on the Edge www.rcplondon.ac.uk/sites/default/ﬁles/documents/hospitals-on-the-edge-report.pdf 39 Quality imaging services for primary care: a good practice guide cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings 4. The RCR would wish to comment on the provision of locally situated radiology and the way in which this should link into secondary care radiology reporting. It is essential that there are networked links for reporting on images acquired in the community setting, and for the onward transfer of patients’ images, both x-rays and ultrasound. This is to ensure that where patients are found to have an injury or condition requiring further treatment, such as fractures, unnecessary repeat imaging is avoided.

Clinical evidence about outcomes achieved by specialist regional centres, taking account of associated travel times, compared with more generalist hospital based services 5. Evidence shows that prompt access to Interventional Radiology improves outcomes for trauma patients. In this regard the Health Committee may ﬁnd helpful the RCR standards document, Standards for providing a 24-hour interventional radiology service,40 and the paper cited below, The role of interventional radiology in trauma.41 May 2013

Written evidence from the College of Paramedics (ES 17) This evidence is submitted on behalf of the College of Paramedics for the Health Committee Inquiry regarding Emergency Services and Emergency Care. The College is supported by the Allied Health Professions Federation that represents the third largest clinical workforce in the United Kingdom.

Introduction — The College of Paramedics is the professional body for paramedics in the UK. Paramedics ﬁrst voted to become registered in 1999 with the Council of Professions Supplementary to Medicine (CPSM). The CPSM was superseded by the Health Professions Council (HPC) due to statutory legislation, Health Professions Order (2001). In response to this the professional body was set up as the British Paramedic Association (BPA) in 2001. In 2009, the BPA completed a two-year transition to trade solely as the College of Paramedics. — The College of Paramedics is not a trades union and is one of 1642 professions that are members of the Allied Health Professions Federation, regulated by the Health and Care Professions Council. There are almost 4,800 members of the College including 3,150 paramedic registrants. There were 990 new members in 2012 with this trend continuing in 2013. The College of Paramedics represents the UK’s paramedics and is their primary voice on matters relating to professional practice and the development of the profession. — Paramedics work in an unpredictable and high risk environment. All indications appear to be that pressures on unscheduled care will continue to grow whether through the 999 or the 111 systems. It has been demonstrated in some parts of the UK that with appropriate education and support structures and systems in place, both the critically ill patient and those with low-acuity (but often complex) conditions can be managed safely and effectively by specialist paramedics. And it has been demonstrated overseas that paramedics can be educated to safely delivery complex interventions for critically ill and injured patients which could reduce the pressure on healthcare resources by appropriately deploying an effective clinical skill-mix in the pre and out of hospital setting.

Summary The College welcomes the Health Select Committee’s Inquiry into Emergency Services and Emergency Care and is pleased to have the opportunity to comment on the questions which have been raised. — We believe that continued development of the paramedic profession will increase the capability of the health system to offer a safe and effective alternative for patients whose needs are best met by care pathways other than attendance at accident and emergency departments; — There is evidence in Australia that paramedics can undertake more complex procedures to play a more signiﬁcant role in managing the critically ill and injured patients, thereby minimising the need for doctors in the pre and out of hospital setting. — The College of Paramedics believes that clinical commissioners of services have an opportunity to increase alternatives for patients and drive down costs by increasing the numbers of specialist paramedics and through close integration of 999 and 111 responses with the full range of community health and social care services. 40 Standards for providing a 24-hour interventional radiology service 41 Zealley I and Chakraverty S. (2010) Clinical Review The role of interventional radiology in trauma BMJ: 340; c.497 42 As of 19.05.13 HCPC holds the register for 16 professions. With a total of 311,366 Registrants. Of which 19,428 are paramedics, the 6th largest of the professions. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Evidence 1. The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas 1.1 Our view is that the 999 telephone number is the trusted access point for urgent and emergency care used by the public. Previous attempts to discourage “inappropriate” use of 999 appear to have failed. We believe it would be more realistic to recognise that 999 will continue to be used and that more effort should be put into telephone triage and advice by specialist paramedics to enable the most appropriate response to be made. This means having available paramedics who can meet the range of needs and also access to alternative community providers (to be alerted and dispatched by the ambulance service), for example community falls services to respond to non-injured fallers. Paramedics must be seen to “support the patients’ own self-triage decision” and to mitigate the cascade of downstream spend by effectively and safely gatekeeping. 1.2 We recognise that the best interests of patients are acclaimed through a multi-disciplined team from other health professions. Paramedics working closely with Occupational Therapists, Nurses, and Physiotherapists within a Care Centre would beneﬁt patients more, at a point of delivery.

2. Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings 2.1 Accident and Emergency Departments offer a no-barriers access for a huge range of patient conditions. There have been many reports highlighting the high proportion of low-acuity attendances at A&E, and it would make good sense to have facilities available at-source for patients who believe their condition may be minor. Such location would allow for swift transfer to A&E without calling on paramedic resources for the transfer. 2.2 Where these services are located at a distance from A&E Departments, there should be an emphasis on the location being easily accessible for ambulance services. Care centres (for Minor injuries and Urgent care) are often commissioned on the assumption that the ambulance service does not deal with minor injuries (which is far from the case) so they do not provide ambulance bays and they often exclude referrals from paramedics in service speciﬁcations. Paramedic education includes recognition and treatment of minor injuries and criteria for transporting to minor injuries units, and specialist paramedics can be deployed to bring the minor injury unit to the patient. The need to reduce patient mileage must be considered in context to the environmental impact of accurate patient disposition—particularly as specialist services centralise (for example; Major Trauma Network).

3. The range, severity and incidence of conditions that can be treated within an accident and emergency unit but not managed at an urgent care centre 3.1 We believe a signiﬁcant number of conditions can be dealt with in the community by paramedics with the appropriate skills. We have examples of specialist paramedic practice from around the country where 77.2 percent43 and 84 percent44 of patients were discharged on scene as they had a specialist paramedic assessment. In these parts of the country, the specialist paramedic is known as an Emergency Care Practitioner, however it is recognised nationally that this terminology is misleading. Ambulance Trusts are currently refocusing their titles to the career framework published by the College. 3.2 Some ambulance services have invested in telephone advice, and specialist paramedics have reduced their conveyance rate to below 53.2 %45 although for others without similar services the rate remains much higher. 3.3 Care centres could be staffed by paramedics in a multi-disciplinary setting, providing emergency assessment if required and, like minor injuries units, they should also be able to accept referrals from paramedics; this is not currently the case.

4. The prospects for better integration of ambulance services with primary care under the new commissioning regime established in April 2013 4.1 There is a clear opportunity to enable paramedics to be able to refer patients in the same way that other allied health professional are able to access. To achieve this, the paramedic scope of practice needs clear definition and paramedic education should be designed to match the scope; which in turn will require access to appropriate higher education funding. There are current barriers to achieving an educational funding and a national delivery model for paramedics, partly because the main employers of paramedics, NHS ambulance service, still work on regional basis. 4.2 The role of the paramedic in context to exacerbation of disease and the intervention in the disease processes of known patient cohorts must be considered. Paramedic prescribing would provide significant benefit to these patient groups by ensuring minor deviations from their care plans does not mean a trip to A&E. There 43 http://www.sheffield.ac.uk/polopoly_fs/1.43742!/file/EffectivenessECPsPaper.pdf 44 http://www.eastamb.nhs.uk/Downloads/Board%20papers/2013/March%202013/ 27%2003%2013%20Trust%20Brd%20Pub%20Sess%20Agenda%20Item%204%20Unconfirmed%20Mins%20of%2027%2002%2013.pdf 45 http://www.england.nhs.uk/statistics/ambulance-quality-indicators/ambqi-2012–13/ cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

Ev w30 Health Committee: Evidence

is emerging data that the 999 activity of patients on clinical registers is predictable, and access to data and appropriate and expedient care can reduce conveyance by over 20%. Ambulance patients also have a relatively low conversion rate from A&E to hospital inpatient spell (around 30–40%, which is not much higher than for patients who self present). These points all suggest changes to reporting required in order for paramedic practice to ﬂourish without being limited by response targets alone.

5. The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge 5.1 Appropriately educated paramedics can make a significant contribution to savings within the NHS as the following practical examples illustrate: 5.1.1 Ambulatory care pathways, such as: 5.1.1.1 Assessing low-risk Transient Ischaemic Attack (TIA) and referring directly to seven-day outpatient clinic. 5.1.1.2 Deep Vein Thrombosis/Venous Thrombosis pathways. 5.1.1.3 Rapid Access Clinics for Older People/Falls clinics. 5.1.2 Independent prescribing for specialist paramedics (for example antibiotics for urinary tract infections), preventing the cost of duplication since one practitioner would be able to treat and discharge at the point of contact. 5.1.3 Further development of “hear and treat” which means specialist paramedics providing advice in the call centre to 999 callers and negating the need for ambulance dispatch. 5.1.4 A prevention and detection role in areas where disease or injury can be prevented or exacerbation avoided. 5.1.5 A role in primary prevention, for example running events to test for risk of stroke, reporting risk locations for stabbings, public education. 5.1.6 Staffing temporary and special units on weekend evenings in areas where many A&E attendances are for alcohol-related problems. 5.1.7 The introduction of a new medical sub-specialty in pre-hospital emergency medicine in the last two years will surely exacerbate the situation in recent reports on the potential shortage of A& E doctors.46 The potential for paramedics to take on part of the more specialised47 role in pre-hospital acute emergencies should be explored. It is expected this would represent value for money and alleviate some of the problems in staffing A&Es with medical professionals.

6. Experience to date of the transition from NHS Direct to the NHS 111 service 6.1 Anecdotal reports continually suggest that additional 999 demand has been generated attributable to the 111 system which appears to be overly risk-adverse, with examples of patients who said they did not want an ambulance nonetheless being sent one. We believe that integration of 999 and 111 is necessary and that both levels of telephone response should use specialist paramedics alongside other clinicians in the call centres.

7. The implications of the shift away from determining the success of ambulance services via indicators based on response time to the new measures designed to assess clinical effectiveness 7.1 We fully support the increasing balance of clinical performance indicators, which sit alongside response time targets. We recognise that response times affect the patient and relatives’ experience and that rapid responses are critical in some conditions -for example cardiac arrest, major haemorrhage and choking— although even in these cases alternatives such as bystander CPR can improve outcome even if the time target is not achieved. However, we do not believe in response times as either the sole or the primary targets as measures of performance. They have distracted from holistic patient care, are generally disliked by front-line clinicians who feel they detract from what should be the core aims of the service, and because they require blue-light responses. 7.2 We support measuring patient outcome rather than process measures even where the outcome may not be affected regardless of the intervention, which in itself provides valuable information. We also acknowledge that measuring patient outcomes is potentially complex and will require smart systems and increased inter- organisational data sharing. However, this should be within the scope and ambition of a modern health system and would enhance integrated working within the NHS. 7.3 The implication of the change includes a signiﬁcant cultural shift in performance management of ambulance service. Another implication and one that would require well-planned strategies to manage the general reaction, would be that some patients wait longer for an ambulance, but if overall outcomes can be improved we believe this is an education and awareness programme that would require commissioning to ambulance services through the guidance of central government. 46 http://www.hsj.co.uk/5058677.article?referrer=e19 [Registration is required] 47 National Institute for Health Research (2011) Critical Care Paramedics: Delivering enhanced pre-hospital trauma and resuscitation care: a cost-effective approach. London. The NHS Confederation cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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7.4 The Francis Report has raised questions within the paramedic community and there are four key areas which must be addressed, and for which the paramedic profession can mitigate: 7.4.1 Target driven culture—Paramedics recognise the need for better outcomes rather than simply a rapid response. 7.4.2 Chaotic/unpredictable demand—By optimising accurate disposition and patient ﬂow, paramedics can contribute to the whole system health economy and allow demand to be managed safely and effectively. 7.4.3 Financial pressures—Paramedics can through accurate patient ﬂow, contribute to the mitigation of downstream costs. 7.4.4 Investment in leadership—Paramedic career frameworks are often seen as expensive and limit ambulance trusts ability to deploy a cost effective workforce. The College of Paramedics has a clear career and leadership framework which would support paramedics and support staff, and would pave the way for even greater clinical input.

8. The causes of delays in handover from ambulances services to A&E or transfer between different levels of urgent care, and actions required to eliminate them 8.1 We believe there are several reasons for delays in A&E and between levels of care as follows: 8.1.1 Too many people attending A&E whose needs could be better directed and managed on alternative care pathways. 8.1.2 Paramedics frequently report they feel there continues to be either a lack of trust or an absence of respect between clinicians often leading to repeated and unnecessary observations which consume time and resources and almost certainly affects patient perceptions of a joined-up NHS. 8.1.3 There are opportunities to enhance patient flow through hospitals by introducing more effective handover processes. This must include placing more trust in the paramedics’ findings, and the development of more fast-track admission pathways for patients with unequivocal need. This could reduce bed days/length of stay by speeding up the pathway to definitive care. 8.1.4 The variation in entry-level qualifications to the profession, and variations in scope of practice and the availability of specialist paramedics in some areas, there is a lack of recognition for paramedics’ abilities to safely refer to non A&E facilities. As the professional body we have published a Curriculum Guidance and support the higher educational establishments through our career framework, we activity encourage collaboration across the health disciplines to reduce barriers and educate colleagues on the scope of the paramedic profession.

Conclusion The College of Paramedics, welcomes new direction for Allied Health Professionals and recognises the need for inter-professional collaboration to improve the services provided. We strongly believe that the paramedic profession has a signiﬁcant role to play in the direction of future services considering the diversity and possibility of specialist practice. May 2013

Written evidence from the Board of Directors of University Hospitals Coventry and Warwickshire NHS Trust (ES 20) 1. Introduction This submission is made on behalf of the Board of Directors of University Hospitals Coventry and Warwickshire NHS Trust. The principle author is the Chief Operating Ofﬁcer and the paper has been approved by the Chief Executive Ofﬁcer. The submission is made without prejudice and is based on our experience as an acute provider organisation working within a challenged emergency care system. The purpose of this submission is to contribute to the understanding of the Parliamentary Health Select Committee with regards to this important matter and to suggest systematic solutions to this problem.

2. Community and Primary Care Service Delivery — Our clinicians believe that community services across our health economy are inadequate to meet the needs of patients requiring urgent care. — Speciﬁcally, a proportion of patients attending Emergency Departments each day could be managed in primary care if services were available to meet their needs. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— Access to GP services for Urgent Care is variable dependant upon neighbourhood and service provider. This results in services which are inconsistent and therefore difﬁcult to navigate across the health economy. — The health economy has lost commissioner system leadership through the introduction of the Health and Social Care Bill and the new arrangements will require time to bed in. The development of a Health Economy Emergency Care Strategy should, in our view, be a priority for all health economies. Leadership for this needs to be offered at a system level. — Ambulance Services have a key role to play in primary/emergency/urgent care; this is not exploited to its full potential, particularly in inner city areas, and this needs to be a primary focus going forward.

3. Minor Injury and Urgent Care Centre’s — The number and distribution of Urgent Care Centres do not, in our view, reﬂect demand. These centres have a critical role to play in admission avoidance and attendance avoidance. — Co-locating Urgent Care and Minor Injury Centres with full scale Emergency Departments (ie placing on the same site but distance from the Main Emergency Department) is likely to provide infrastructure and impact with ﬂexibility.

4. Ambulance Service Integration, Demand Management and Turnaround Times — We believe that there are many opportunities to prevent ambulance conveyance to ED and a national strategy to ensure this happens is required. — This strategy should include, but not be limited to: — GP deployment to 999 calls where primary care or non-hospital attendance urgent care response would be appropriate. — Deployment of Emergency Care Practitioners in support of 999 crews. — Extension of Community First Responder Networks. — Access to telemedicine and strengthened expert primary care advice from remote clinicians. — Use of technology and telemedicine including enhanced point of care testing for speciﬁc conditions and imaging devices to send pictures to a consulting clinician. — Extension of non-conveyance guidelines for crews. — Deployment of community paramedics. — Ambulance services must be encouraged to operate as part of the “whole health” system and must not be allowed to establish a “fortress” mentality. Effective healthcare relies on the whole system working together and partnerships are the key to success in this regard. The Focus on Turnaround Times as a speciﬁc performance measure has not, in our view, been handled in this way across the West Midlands.

5. Specialist Centres and Improved Outcomes — There is clear evidence that, Specialist Centres with developed expertise in particular areas of care, deliver improved clinical outcomes. The creation of a regional trauma network is a good example of this with demonstratable improvement in outcomes in morbidity and mortality.

6. Case Mix and Complexity — The age of the in-patient medical population (the predominant non-elective inpatient cohort) has risen signiﬁcantly particularly in the >75 years age group. — The creation of competent Elderly Care Pathway’s across health economies needs to remain a key strategic focus. — National understanding of the implications needs to be developed.

7. Discharge — The creation of flow through acute hospital is significantly reliant on activity to discharge patients in a timely way. — A focus on reducing delays to discharge is critical and this should go beyond the current delayed transfer of care definitions. The measurement of DTOC during the current definitions is not sensitive enough. — Delays of hours can have a significant impact on hospital flows and current DTOC measures are therefore inadequate and require review.

8. Why is the Whole System Struggling? Failure of the four hour target represents a single crude measure of failure. The four hour target is an indicator rather than an absolute measure of performance. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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The range of measures used to measure system performance should be widened to include measures of flow across all parts of the system: — Primary care. — Ambulance. — Acute hospital. — Mental Health Services. — Community provision. — Local Authority provision. — Discharge performance. This should be built into a single health economy dashboard and used by System Boards to manage the whole pathway from beginning to end. This would give a whole pathway view, prevent a focus on Acute Trusts and allow other elements of the pathway to be held to account. It would also allow better analysis of the problem and therefore better solution generation. The current penalty regime for service provision (including the 30% marginal rate and the fines for A&E target performance) appears perversely to skew further the pressure onto acute providers yet “reward” commissioners. System Boards should have clear oversight of the emergency care financial arrangements; these should be transparent and equitable across the whole pathway. Providers need to be paid fairly, consistently and predictably so that operational decisions can be taken within clear financial parameters. Financial mechanisms should align to performance measures of flow across the system (set out above); criteria for calls on risk reserves should be agreed in advance and use of reserves should be reported on openly. A range of hypothesis has been generated as the situation has changed. These should be expanded and explored to either burst the myth or confirm their validity. This should include analysis of the following hypothesis: 1. Primary care has failed and hospitals are mopping up this work. 2. Hospitals have cut services so occupancy is high resulting in no headroom to deal with otherwise normal demand variation.

9. Integration with Social Care A clear strategy and guidance of integration with Social Care should be developed. Roles and responsibilities should be clearly deﬁned and a single lead agency should be accountable for delivery.

10. Summary This Trust believes that improvements to performance across the Emergency Care Pathway are important and will result in improved quality of care and safety. The feedback and suggestions set out in this paper are aimed at improving care across the whole system and are submitted in the spirit of constructive challenges and learning. May 2013

Written evidence from the Emergency Medicine Trainee Association (ES 21) Emergency Medicine (EM) a Specialty in Crisis The Emergency Medicine Trainees Association (EMTA) is the national body, which represents the welfare of junior doctors training in EM. We are a part of the College of Emergency Medicine and we welcome this review but would like the committee to carefully consider the evidence, which we have laid out in written report. We strongly feel that issues around workforce and working conditions are central to all of the themes the committee has requested comments on.

Summary — Acute specialties such as EM have a real crisis with recruitment and retention to the specialty. This is a national problem, which requires urgent and immediate action. — Factors such as work-life balance and intensity of workload have a major bearing on recruitment and retention. — Junior doctors (non-consultant grades) in EM are ﬁnding that current practices of work patterns are not sustainable in the short or long term. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— These working patterns together with increased demands on meeting national targets and service delivery is having an impact on training opportunities as well staff morale. — Any future contractual discussions regarding junior doctors working in ED needs to take the above considerations seriously in order ensure that the contract offers an appropriate remuneration as well as terms and conditions that promote sustainable working patterns, which facilitate the provision of high quality ﬁt for purpose training to be delivered. This would require a review of remuneration offered according to the current banding system, which does not consider volume, intensity or pressure, related to workloads in the ED. — Any discussion around these issues should involve appropriate stakeholders including representation from junior doctors from emergency medicine as well as other acute specialties. — Recruiting and retaining more ED doctors especially at the middle grade level (by making the specialty more attractive) will result in a reduced requirement for temporary locums. This will not only provide a net cost saving of millions to the NHS but has a major potential for improving patient care.

1.1 Background Although emergency medicine (EM) is a relatively new specialty it has come a long way since the early days when our surgical colleagues ran the specialty. The specialty has the responsibility for managing over 20 million patients annually and provides a 24/7 open door unrestricted service. Furthermore EM physicians are the only true generalists who provide “around the clock” emergency cover for the nation. We now boast our own college, a robust training programme and an examination structure that ensures EM clinicians of the future not only have the necessary clinical skills but have critical appraisal skills as well as the ability to engage in evidence based research through their clinical topic review (CTR). Despite being a very attractive specialty we have seen a dramatic decline in the fill rates at ST4 (middle grade) levels, which has resulted in significant rota gaps across the country. This problem is not just simply a recruitment issue it also due to a failure to retain quality EM doctors at the middle grade level. These groups of doctors are the backbone of the workforce who act as the key decision makers when consultant cover is not available. This has hit many emergency departments extremely hard and it is not uncommon to see a number of departments heavily staffed with locum doctors who do not necessarily have the clinical experience or the drive to work effectively in the emergency department (ED). Although the cause for this decline is multifactorial the overarching causes were highlighted by a national EM trainee survey in 2011 of over 650 trainees ranging from ACCS to ST7 (Appendix 1). The main findings were summarised below: — Poor work-life balance in terms of the highly anti-social hours worked. — A shift towards service delivery, which compromises training. — A need for greater consultant supervision. — Working in very intense and pressurised environments, which impair opportunities for learning as well as accessing minimum recommended rest, breaks at work. — Pressure on junior doctors to meet targets and other service related metrics. Recent figures from the Department of Health (DoH) show that ED attendances are beyond 20 million and still rising. This growing demand has shown a dramatic increase and has seen many departments stretched to the limit and generated significant media interest. Stories of patients waiting for 10 hours in A&E before being transferred to the ward or ambulances waiting 4 hours to unload a patient are not uncommon. Few within the profession will argue that the lack of trained EM decision makers at middle grade and consultant level has a significant impact on the flow of patients through the ED which has a subsequent impact on waiting times, patient experience and ultimately patient safety. This has been highlighted in the recent Francis report.

1.2 Time for Action The findings of the trainee survey were very clear in that there is need for urgent action to address junior doctors concerns about the current working conditions. It was interesting to note from the survey that although a significant proportion expressed concerns about the intensity of work (which is not addressed by European Working Time Directive) and the serious impact of workloads and working patterns on their personal lives, they still felt that EM was an exciting career choice. Unfortunately it is clear that for many the pendulum is swinging away from a career in EM. Many junior doctors who enter at ACCS find the ED part of the job very difficult with the brutal working patterns and limited opportunities for training when compared to other specialties such as anaesthetics, critical care and general practice.

1.3 Engagement with Stakeholders As the trainee body for the UK EM trainees we are very keen to engage with every stakeholder that will enhance the recruitment and retention of the EM workforce in particular improving the work-life balance, training and remuneration for junior doctors working in EM. We would urge all key decision makers such as cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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the DoH, BMA, College of Emergency Medicine (CEM), Health Education England (HEE) and the Academy of Medical Royal Colleges (AoMRC) to actively engage with bodies such as the emergency medicine trainees association (EMTA) to ensure that the concerns and needs junior doctors in acute specialties are represented.

1.4 Training Training is an integral component of the goals of all junior doctors irrespective of which specialty they work in and it is the responsibility of the deaneries and employers to ensure that this commitment is met. EM juniors are unique amongst their colleagues as they have the direct responsibility of delivering national targets such as the 4-hour waits. Although EM trainees are fully aware of the importance of these targets on the patient experience and safety it is important that this does not impair their ability to train. We are also concerned that with the high patient turn around combined with the low consultant to trainee ratio makes the ED environment “educationally challenging” for training and new strategies are required to ensure that EM junior doctors training is protected from external factors such as staff capacity, service pressures and fatigue from a poor work-life balance. We would support any measure for training to become a central part of the new junior doctors contract and that quality metrics are developed to ensure that ED trainee doctors receive a high standard of training.

1.5 Work Life Balance and Intensity of Workload Our EM trainee survey clearly highlighted overwhelming concerns about the impact of intense and anti- social work patterns were having on their personal lives. It is still not uncommon for some juniors to work seven straight nights in EM usually under intense pressure due to the high volume of patients in the department. It is clear that these rota’s are not sustainable over the long term and this is a major reason for many excellent EM trainees are choosing other specialties. It is essential that the new rota not only addresses the anti social hours worked but also the intensity and pressure per shift. Many EDs are routinely seeing over 360 patients a day with 100–120 in the department at any given time. As 24 consultant cover is not the norm in most units, this combined with major gaps in the rota means junior doctors in EM are increasingly feeling the effects of this increased workload which clearly is non sustainable over the long term. It is not uncommon for many ED junior doctors to work through an entire shift without a rest break due to the service pressures or having to cover due to gaps in the rota. It is imperative that contracts for junior doctors in specialties which deal with high volume and antisocial working pattern offer compensation for this which is not met through the current banding system. We would call for a working group to explore how the current banding could be replaced by a system that also considered the volume and intensity as well anti-social hours worked. Our concern is that if this is ignored than we will see a further attrition in the EM workforce. This will cost more in terms of ﬁlling the gaps with expensive locums (typical trust will spend £.5m/yr) who may not be adequately trained to function in the ED. No doubt any further attrition will have an impact on patient safety, which may affect the public perception of the NHS.

1.6 Morale and motivation It is clear that the intensity of the workload for junior doctors in EM is very different from those in any other specialty. There are few opportunities to control the workload and ED juniors have to be able to adapt to work at the limits of the junior doctors capabilities. As a result not enough doctors are keen to work under these conditions, but patient demands for ED shows little signs of diminishing as healthcare provision in the UK is increasingly being front loaded with patients choosing to attend their local ED or urgent care center (UCC). It is not just about better financial remuneration but also about how we can develop and sustain an environment that will lead to an enjoyable career in EM. This will be impossible unless there is a significant improvement in working conditions for these doctors. An effective ED workforce needs to be highly motivated as well being highly trained. With the current flux in EM recruitment it is evident that staff morale amongst the trainees is at an all-time low. This was clearly highlighted in our trainee survey and only 39% of those questioned felt they had good job satisfaction. Trainees feel that they are not appropriately rewarded for the work they do. We would call for key stakeholders to look carefully at remuneration which is both fair and specifically reflects the intensity and work patterns EM junior doctors are working under. It is often quoted that there are no financial resources to achieve these goals but this has to be considered in comparison to the stark and realistic alternative of resorting to a fragmented, poorly motivated ED workforce. We are very concerned that a lack of urgent action will seriously impair the ability of the specialty to recruit and retain ED doctors which are a prerequisite to providing a stable and sustainable workforce which can deliver an around the clock service. We feel that better working conditions will not only improve the attractiveness of the specialty but will also facilitate the delivery of a safe and world class emergency care to our nation. EMTA as the national representative body of EM trainees is committed to ensure that the needs and concerns of its workforce are represented at every level.

1.7 The Way Ahead and the New Junior Doctors Contract Work has begun where a DoH and College of Emergency Medicine (CEM) taskforce was convened to look at how this workforce crisis could be best addressed. Although work is still in progress it is clear that urgent cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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action is required to resolve the issues around the working conditions faced by the EM doctors. We feel the workforce issue needs to be at the centre of any review or debate around emergency care and that in order to provide a quality service we need a healthy, motivated and highly trained workforce. It is also important that the new junior doctor’s contract has to recognise that the needs of acute specialties are very different from the non-acute specialties and that “a one size ﬁts all” approach will be disastrous for the specialties such as EM. We believe that special attention should be paid in deﬁning these needs in terms of workable terms and conditions as well as appropriate remuneration. Junior doctors working in EM currently get the same banding as other specialties who do not work under the same intensity or pressure as those working in EM. We believe that a new contract, which recognises and addresses these issues, will go a long way in turning around some of the recruitment issues we have in emergency medicine and reduce the burden and costs of locum staff. May 2013

Appendix 1 FINDINGS OF THE NATIONAL 2011 EMTA TRAINEE SURVEY — Trainee survey of 652 trainees conducted in Nov 2011. — All regions covered across the UK including Northern Ireland and the armed forces. — CT1-CT3 (34%), ST4—ST7 (41%), old style registrars (7%). — 90% FT, 10% less than full time training. — 48% stated that their work life balance is poor, 39% stated it was reasonable and only 6% stated that it was good. — 39% stated they had good job satisfaction. — 21% stated their job provided opportunities for personal development. — 46% felt the quality of their supervision was poor. — 89% felt the poor rota’s, working unsociable hours and poor stafﬁng levels had a negative impact for a career in EM. — 86% felt achieving a work life balance was a challenge in EM. — 51% felt that hostility from other specialties was a challenge in EM. — 89% felt strongly about the need for a greater emphasis on training compared to service provision. — 91% feel a need for a better work life balance. — 17% of trainees had not time to undertake audit or clinical governance. — 56% had no time for research. — 40% expressed extreme concern about trying to maintain a work life balance once they became a consultant.

Written evidence from Janet Egan (ES 22) Summary I am a member of the public who has recently participated in a consultation on local A&E/maternity reconfiguration proposals, in my case the TSA consultation in South East London. I believe that the consultation process was flawed and potentially misleading to the public, for example by omitting important options from the consultation questionnaire (such as the absence of any option to retain a fully-operational A&E at Lewisham Hospital) and by including apparently fictional characters and invented case studies as part of the consultation document. The clinical case for change presented during the consultation process appeared to lack evidence of how any anticipated benefits would be attained in practice—for instance, how the plans for greater community care (to replace certain types of hospital care) would be resourced or funded. I am particularly concerned about the planned reconfiguration of maternity services that is associated with the A&E reconfiguration proposed for SE London, as this will leave the existing midwife-led unit at Lewisham Hospital unsupported by emergency services. I believe that the Committee should include as part of its investigations an examination of the impact of A& E reconfigurations on the safety of women and babies in maternity/birthing units where emergency support is withdrawn under such reconfigurations. 1. This submission is from myself, in a personal capacity. 2. I write primarily to address the following point under consideration by the Committee’s investigations: “The effectiveness of the existing consultation process for incorporating the cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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views of local communities into A&E service design” and also to briefly comment upon certain other of the terms of reference included in its remit. 3. I have recent experience of participating in a local consultation process into A&E service design. This was under the NHS Unsustainable Providers Regime as conducted by the Trust Special Administrator (TSA) for the South London Healthcare Trust (SLHT) during autumn 2012. Although my local hospital, Lewisham, is not part of the SLHT, the TSA decided to include this hospital as part of the reconfiguration proposals and I was one of the local residents who responded to the consultation over these proposals. As part of this process, I read the TSA consultation document48 and associated material, attended three of the public meetings held by the TSA and completed the consultation questionnaire. I additionally emailed a letter to the TSA as part of my response to the consultation.49 4. The consultation document and questionnaire that I completed as part of the consultation process were designed in manner that appeared to me to be an attempt to secure the type of answers required by those managing the consultation process. I believe that my letter to the TSA highlights some of the deficiencies of the consultation process, including the omission of relevant options as potential responses to questions set out on the questionnaire and the lack of explanation/definition of terms used within the consultation document/questionnaire. Examples include the following: — the absence of any option on the questionnaire to express the view that Lewisham A&E should remain fully-operational or that a supported (as opposed to a “standalone”) maternity service should be retained at Lewisham; — the lack of any definition of what is meant by a “standalone” maternity unit, which I believe to be a particularly serious flaw as it means that some respondents may not understand the risks associated with the maternity proposals; — the failure to even mention that the Children’s A&E at Lewisham would be closed as part of the proposals, although this was implicit in the report, let alone to express any opinion on whether or not this should happen; — the use of fictional characters and invented case studies to illustrate how change might work in theory, in my opinion in a way that could mislead the public (see pp.44–46 of the consultation document); and — the failure to include details of the estates plan for Lewisham Hospital, including the sale of much of its estate, in the main consultation document and rather to “bury” this information in an annex to the main TSA report (Annex K, p.41).50 5. Because of its flawed design, the consultation process adopted by the TSA over the proposed A&E reconfiguration seems to me to be both disregardful of people’s time in responding and a poor use of a considerable amount of public money at a time when funding is obviously tight. 6. I am also aware that consultations over A&E reconfigurations have taken place or are ongoing elsewhere in the UK, meaning that the type of issues raised in this submission are not limited to South London. I hope that that the committee will examine the issue of how such consultations are managed, particularly with respect to: — whether or not the Committee believes these consultation exercises represent a genuine attempt to seek the views of local people to A&E configurations; and — whether the Committee regards the cost to the taxpayer of the consultation exercises on A&E reconfigurations as good value for money. 7. It is primarily for those with medical/clinical qualifications to comment in detail on the potential benefits/drawbacks/risks to patients associated with A&E reconfiguration. However, I would offer below a few general observations, drawing in particular on my experience of the TSA consultation process and the potential clinical impact of changes presented to the public as part of that process (and other research/evidence relevant to the claims made). 8. The case for change presented during the TSA’s public meetings suggested that lives are at risk under current A&E arrangements because fewer consultants are on duty out-of-hours (for example, at weekends); and that the way to increase consultant cover at weekends is to close some A&E units, hence centralising consultant cover at fewer units. Among a number of assumptions under this model is that care for many patients can be provided more effectively in community settings thus reducing the need for hospital attendances/admissions. However, in my opinion, no convincing evidence was presented during the consultation process of the practical measures (particularly the availability of finance or resources) that would support the implementation of this model in practice. 9. I understand that a similar model of reconfiguration involving centralisation has reportedly worked effectively for certain other types of hospital provision—the example of stroke care 48 http:goonerjanet.blogspot.co.uk 49 http://www.tsa.nhs.uk/sites/default/files/documents/TSA-Consultation-web.pdf 50 Annex K, http://www.tsa.nhs.uk/sites/default/files/TSA-DRAFT-REPORT-APPENDIX-K.pdf cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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was cited at the public meetings. Having looked at a variety of reports and policy statements, there seems to be an assumption throughout many parts of the medical establishment that centralisation can yield similar benefit in other areas of hospital configurations (for example in the case of A&E and maternity). It seems to me essential that such assumptions be tested by thorough research relevant to each specialty to examine the evidence (if any) for such claims and beliefs. Given that many A&Es have already closed in recent years, it should presumably be possible to examine evidence of changes to patient outcomes in the remaining A&Es. 10. In respect of the proposed reconfiguration in SE London, the clinicians from Lewisham have detailed knowledge of local health needs and provisions. The evidence presented to the TSA by the Lewisham clinicians51 reaches different conclusions to A&E reconfiguration compared with that put forward by the TSA during the consultation process. I believe this local evidence is worthy of consideration by the Committee. 11. The issue of achieving higher levels of consultant care on an out-of-hours basis seems to be one of the central issues affecting proposals around reconfiguration of A&E (and maternity) units, both in SE London and more widely. In addition to looking at the how reconfigurations work in practice, the Committee might wish to examine alternative/complementary solutions to this issue. This might include examination of the efficacy of current incentives for NHS staff to work out-of-hours shifts—for example the adequacy of current levels of shift premium payments as well as the potential for options such as self-rostering to allow greater autonomy over shiftworking patterns. 12. In respect of maternity, the facilities at Lewisham Hospital currently include a midwife-led unit together with a co-located obstetric unit supported by emergency/intensive care. The TSA proposals originally included plans to retain an obstetric-led unit at Lewisham in addition to the midwife-led unit. The TSA’s final proposals downgraded the planned unit further to simply a midwife-let unit which, it is deemed, could be used by “low-risk” women. It seems to me that neither the original, nor the final, TSA proposals can be deemed to constitute an improvement in maternity/childbirth services for women and babies at Lewisham Hospital as there would no longer be any provision to support unforeseen/unforeseeable emergencies. I believe it may be possible that the reasoning behind this policy is that the benefits assumed to be associated with centralisation within the remaining “major” maternity units outweigh what are perceived as the relatively less common risks to those women and babies served by the inferior facilities that would be available under the proposals at Lewisham Hospital. I believe that the people of Lewisham are entitled to receive answers to the question of whether or not this is the case. May 2013

Written evidence from UNISON (ES 23) Summary — There is increasing concern about problems with patient handovers from ambulances to hospitals. — Ambulance response times are also under pressure. — There has been a marked rise in the use of private ambulance services in parts of the country. — The move from NHS Direct to 111 has been handled very poorly by the government, with many problems emanating from the fragmentation and privatisation of a previously successful service. — There is a lack of clarity about the remit of 111 and the quality of service has been badly affected. — Staff working at NHS Direct continue to experience huge anxiety and uncertainty in the transition.

Introduction 1. UNISON is the major trade union in the health service and the largest public service union in the UK. We represent more than 450,000 healthcare staff employed in the NHS, and by private contractors, the voluntary sector and general practitioners. In addition, UNISON represents over 300,000 members in social care. There is also a wider interest in the NHS among our total membership of more than 1.3 million people who use, or have family members who use, health services. 2. There is currently a great deal of media coverage around emergency services and emergency care, so UNISON’s submission focuses largely on the direct experience of UNISON members, working in the ambulance service or affected by changes to NHS Direct and the new 111 service. The union would welcome the opportunity to provide oral evidence to the Committee to add further detail.

Delays in Handover from Ambulances Services to A&E; increased Emergency Demand 3. There is increasing concern about the ongoing problem of patient handovers from ambulances to hospitals. Handover times cover the point at which ambulance crews arrive at hospitals to when the patient and their 51 http://www.savelewishamhospital.com/specialists-say-no/ cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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medical notes have been handed over to hospital staff. The target is set at 15 minutes of an ambulance’s arrival at A&E. This is not an official target but it is accepted as good practice across the health service. 4. In many cases, the handover time has become unacceptably long and UNISON members report that such delays have an adverse impact on patients’ experience of the service, may increase risks for patient safety, and affect the morale of staff. The delays also have an effect on 999 call response times. 5. Although performance is measured differently in all ambulance trusts, some managers specifically expect their hospital to meet this target. In some areas, such as London, hospitals are expected to meet the target in 85% of cases; however in the North of England compliance of 100% is expected and some hospitals can face a fine for failing. The expectation continues to be that handovers occur within 15 minutes of an ambulance’s arrival at A&E. 6. In the South West, the ambulance trust has issued a Standard Operating Procedure to all staff instructing them to leave patients at hospital if there is a significant handover delay, by finding the nurse in charge, giving them the paperwork and telling them they are leaving the department. It is likely that other trusts will go down the same road to try to achieve their targets. 7. There are a variety of reasons for these delays. Increase and surges in demand are a factor in many cases with more than 8 million emergency calls made in England each year—an increase from 2.6 million in the mid 1990s and 5.6 million just 6 years ago. While not all of these end up with patients being taken to A&E, a significant number do so. And while many trusts try to filter these calls so that patients are either treated at the scene or taken to other destinations, the service is increasingly struggling to meet its target to reach patients who need an ambulance. 8. Likely reasons for this increase in demand include cuts to social care leaving vulnerable people with nowhere else to turn, and a fear about the quality of out-of-hours GP services—particularly those delivered by private companies. Harmoni, now owned by Care UK, has faced allegations from senior doctors that its out- of-hours service in London is so short-staffed that it is regularly unsafe,52 and recently admitted running one of its centres without any doctors on duty.53 It came as little surprise, therefore, when the Care Quality Commission was reported as having severely criticised the company for failing to provide enough doctors to keep patients safe.54 Serco has also faced reports that its managers told workers to manipulate computer systems to “stop the clock” on emergency calls.55

Response Time Indicators; Cuts and the Nicholson Challenge 9. Consistently less than half of trusts are meeting their target to reach the most critically ill patients within the eight minute (A19) target. For this reason some trusts have introduced creative ways of meeting their target. In the East of England a collective grievance has been taken out by UNISON members about the way the trust has chosen to interpret and implement the A19—they claim the target on arrival of a car, despite the fact that the majority of the most serious Category A patients cannot be transported by car to hospital. Members believe that claiming a transportable target with a vehicle that in most cases is unable to transport that patient, is at best dishonest and at worst a deliberate attempt to put targets ahead of patient safety and to hide ambulance delays. 10. Cuts or reductions in the levels of staff within A&E are also an issue leading to a shortage of staff to take patients. Some rural ambulance stations have been closed and replaced by a lesser number of hubs. This means that ambulances needed in rural areas have to travel long distances from city bases and also that staff have to travel further to pick up their ambulances before starting work. This will have implications for service delivery. 11. National guidelines state that at least 75% of the most serious Category A 999 calls should be responded to within eight minutes. Figures for the ﬁrst four months of 2013 show that in Nottinghamshire this target was met for only 68% of those calls and across Derbyshire this was only 66%. 12. Within the East of England Ambulance Trust there has been a reduction in the number of staff and vehicles delivering emergency response services across the area at a time when demands on the service are increasing and population numbers are rising. During this time the employer had decided to reduce the number of staff and vehicles delivering emergency response services. 13. UNISON members have expressed concerns that increasing delays in ambulance response times in the East of England are putting lives at risk. The policy to despatch cars to some incidents is of particular concern as the necessity for back up (by fully crewed vehicles) can often be delayed. EEAST provides ambulance services in Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk. The ambulance service 52 The Guardian, “Harmoni out-of-hours GP service putting patients at risk, say doctors”, 18 December 2012, www.guardian.co.uk/ society/2012/dec/17/harmoni-gp-service-patients-risk 53 GP Online, “Harmoni admits running out-of-hours centre with no doctors”, 16 May 2013, www.gponline.com/news/1182598/ 54 The Independent, “Privatised service “puts patients at risk” with lack of out-of-hours GPs”, 20 May 2013, www.independent.co.uk/life-style/health-and-families/health-news/privatised-service-puts-patients-at-risk-with-lack-of- outofhours-gps-8622961.html 55 The Guardian, “Private health contractor’s staff told to cut 999 calls to meet targets”, 24 January 2013, www.guardian.co.uk/ society/2013/jan/23/private-health-contractor-999-calls cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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has recently revealed plans to recruit more than 350 employees to improve patient care and staff morale. This decision followed an order to improve by the Care Quality Commission after its response times deteriorated. 14. As a result of the drive for efficiency savings, the deployment of double crewed Emergency Care Assistants (ECAs) is becoming an increasing common policy in some ambulance trusts, despite advice from other trusts who have discarded this model due to the clinical risks involved. ECAs receive basic training, are not subject to registration by the Health and Care Professions Council and, unlike paramedics, are unable to administer medication if an emergency arises. The introduction of double ECAs as urgent crews is a major concern; at least one crew member should have sufficient training to be able to clinically assess any changes in a patient’s condition on transportation to hospital. It is also a dilution of skills within the ambulance service and the recent inquest into the death of Sarah Mulenga demonstrates the risks of this policy.56 Increased training for ECAs should be introduced to comply with the findings of the Francis report to ensure better patient care; until this occurs, ECAs should always be accompanied by a fully trained paramedic.

Private Ambulance Services 15. There has been a signiﬁcant rise in the use of private sector ambulances by some trusts. Recent Freedom of Information requests reveal increases on spending by three English ambulance services on private contractors in the last two years. South East Coast Ambulance service spent £7.3 million in 2012–13, up from £1.9 million in 2010–11. In Yorkshire the spend on private contractors went up from £500,000 to £1.8 million in the same period and in London it rose from less than £400,000 to £4.2 million.57 16. Concerns have been expressed that even the most serious 999 calls are being handled by private ambulances without properly trained staff and equipment, with a real risk that patient safety will be compromised. 17. In Greater Manchester the patient transport services has been outsourced to bus company Arriva. The decision was fought hard by local people who fear a loss of accountability and quality in crucial local services.

Experience to date of the Transition from NHS Direct to the NHS 111 Service 18. UNISON was strongly opposed to government proposals to scrap NHS Direct in 2010 as proposed by the previous health secretary. The outcry against these plans demonstrated the high esteem in which the service was held and led to some backtracking by the government, with Andrew Lansley claiming that all that would change was the number of the service—with 111 for non-emergency calls running alongside 999. However, the turmoil that has now been created within the system has demonstrated the folly of more wide-ranging plans that have dismantled a successful service. 19. UNISON has never opposed the idea of NHS 111 in itself, but the market-driven approach has had major implications for NHS Direct. In addition, government implementation has excluded giving nurses the ability to clinically assess, leading to a series of “work-ins” in May 2012 in Exeter, Truro, Bristol and Nottingham by staff seeking to highlight their concerns for patients. 20. A major problem with 111 has been the fact that it is not a national service, with delivery fragmented across 44 local services resulting in an uneven service and great inconsistencies. For example, each London borough has its own contract. 21. Such concerns have been exacerbated by the increasing proliferation of private providers in this new marketplace. Harmoni came in for particular criticism when it emerged in March 2013 that NHS Wiltshire was considering pulling out of its contract with the provider following dozens of ambulance crews being sent to deal with inappropriate cases such as earache and hiccups.58 NHS Direct staff have been called upon to help bail out the service. 22. UNISON believes that there was insufficient recognition of the issues raised by the 2012 Sheffield University report into the 111 pilots. This found for example that: “One year after launch, the pilots had not delivered the expected benefits in terms of improving satisfaction with urgent care or improving efficiency by directing patients to urgent rather than emergency care services. There was evidence of a reduction in calls to NHS Direct but an increase in emergency ambulance incidents... The primary economic analysis based on the pilot site activity identified a low probability of cost savings to the emergency and urgent care system.” 59 23. There are concerns too about particular gaps within the remit of 111. For example, it has still not been clarified as to whether 111 will offer emergency dental advice, emergency contraceptive advice, or mental health advice (as previously offered by NHS Direct). It would be a major blow to the public if such areas were 56 BBC News, “Sarah Mulenga died after trainee paramedics” “failings””, 14 May 2013, www.bbc.co.uk/news/uk-england-london-22519477 57 Evening Standard, “Labour warns on private ambulances”, 21 April 2013, www.standard.co.uk/panewsfeeds/labour-warns-on-private-ambulances-8581605.html 58 BBC News, “NHS Wiltshire considers leaving helpline contract”, 21 March 2013, www.bbc.co.uk/news/uk-england-wiltshire-21856525 59 University of Sheffield, Evaluation of NHS 111 pilot sites—Final Report, August 2012, p11, www.sheffield.ac.uk/polopoly_fs/ 1.227404!/file/NHS_111_final_report_August_2012.pdf cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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lost, and would likely contribute to further costs in hospitals with patients taking to A&E for the likes of emergency dentistry. Given that in at least half of the country NHS 111 failed to go live in April 2013 as planned,60 there could even be further concerns about how resilience will be maintained in the event of a pandemic or a serious terrorist incident.

24. UNISON’s members at NHS Direct have faced a torrid time in recent months and much uncertainty remains. By the end of 2012, the switch to 111 had already led to the loss of 300–400 nurses, who had been replaced by non-qualified call handlers. Then it was announced that 24 of NHS Direct’s 30 call centres would be closed placing around 750 nurses and call handlers at risk of redundancy, alongside attempts to reduce the wage bill by changing staff bandings for those that remained employed. But when NHS Direct found that it had insufficient staff to carry out its contractual commitments, many of these workers appeared to have won a reprieve—welcomed as a victory for common sense by UNISON. However, as reported in Nursing Times in mid-May, the situation has now changed again, with NHS Direct telling staff that the board has decided it would not be “appropriate” to ask staff to stay on given that its plans beyond the current financial year have not been set in stone.61

25. The union is clear that it is only due to the professionalism and commitment of staff operating in extremely trying circumstances during this period of upheaval that any sort of 111 service has been delivered at all.

26. UNISON notes the recent report of concerns from the NHS Alliance that the procurement process for 111 has been more focused on cost than quality.62 Certainly for patients, the outcome of the chaos around 111 seems to have led to quality of service taking a backseat. NHS England reported recently that the service was “still fragile” and providing an “unacceptable” level of service, particularly at weekends.63 Doctors have raised concerns that it is putting people’s lives at risk,64 and Pulse reported at least 22 possible serious untoward incidents relating to NHS 111 since the soft launch of the service, including three incidents where a patient died.65 Figures from NHS England revealed a huge rise (more than 300%) in abandoned calls, with the number of people hanging up after waiting for more than 30 seconds increasing from just under 7,000 in February to more than 29,000 in March.66 May 2013

Written evidence from Carers UK (ES 24)

1. About Carers UK

1.1 Carers UK represents the views and interests of the six million people in the UK who care for their frail, disabled or ill family member, friend or partner. Carers give so much to society yet as a consequence of caring; they experience ill health, poverty and discrimination. Carers UK seeks to end this injustice and will continue to campaign until the true value of carers’ contribution to society is recognised and carers receive the practical, ﬁnancial and emotional support they need.

1.2 Carers UK is an organisation of carers, run by carers, for carers, with a reach of around 1,500 organisations, including many run by carers, who are in touch with around 950,000 carers between them. Including Carers Week our reach extends to around 4,000 groups and 2.5 million carers.

1.3 Carers UK runs an information and advice service and we answer around 16,000 queries from carers and professionals every year. We also provide training to over 2,600 professionals each year. Our website is viewed by nearly 50,000 unique visitors every month and nearly 5,000 carers are registered members of our website forum.

1.4 Carers UK has offices in Wales, Scotland and Northern Ireland. This response reflects the views of the organisation, UK-wide. 60 The Guardian, “GPs call for rethink on delayed 111 health hotline”, 2 April 2013, www.guardian.co.uk/society/2013/apr/01/ delayed-111-health-hotline 61 Nursing Times, “Future of NHS Direct becomes more uncertain”, 17 May 2013, www.nursingtimes.net/5058777.article 62 Health Service Journal, “Exclusive: DH “pressure contributed to 111 failure”, Alliance report finds”, 13 May 2013, www.hsj.co.uk/news/commissioning/exclusive-dh-pressure-contributed-to-111-failure-alliance-report-finds/5058534.article 63 BBC News, “NHS 111 advice line “still fragile””, 1 May 2013, www.bbc.co.uk/news/health-22350814 64 The Independent, “New NHS helpline is putting people’s lives at risk, say doctors”, 5 May 2013, www.independent.co.uk/life-style/health-and-families/health-news/new-nhs-helpline-is-putting-peoples-lives-at-risk-say-doctors- 8604624.html 65 Pulse, “22 NHS 111 serious untoward incidents reported, including three deaths”, 3 May 2013, www.pulsetoday.co.uk/ commissioning/commissioning-topics/urgent-care/22-nhs-111-serious-untoward-incidents-reported-including-three-deaths/ 20002842.article 66 Health Service Journal, “Minister admits “very disappointing” 111 start”, 15 May 2013, www.hsj.co.uk/news/acute-care/emergency/minister-admits-very-disappointing-111-start/5058678.article cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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2. Summary — The role of families, and the need to support carers through community and primary care services, have a key part play in the prevention of critical healthcare needs and in easing the strain on emergency services. — Carers UK evidence from families shows that additional and better quality care services would prevent emergency hospital admissions of their loved ones; and that involving and consulting carers about hospital discharge can help to prevent readmissions due to health deterioration. — This link between investment in lower-level preventative care and support services and demand for emergency care must be a core part of NHS England’s review of emergency care—to understand the unnecessary, knock-on costs to the NHS and to families of underfunding of social care which result in unnecessary, costly and distressing emergency admissions to hospital.

3. The Role of Community and Primary Care Services in the Delivery of Emergency Healthcare 3.1 Community and primary care services can play an important role, not only in the delivery of emergency healthcare, but also in the prevention of emergency admissions. A key factor for whether someone needs emergency care is whether they are supported in the community. If care services are able to support ill, frail and disabled people effectively, and support families to care for them at home, then fewer emergency admissions will be necessary and the pressure on emergency services will be reduced. As experts on the care needs of the person they care for, it is essential that carers are consulted about the delivery of care services. 3.2 Adequate care services are also necessary to support carers to care. Carers are signiﬁcantly more likely to be in poor health than non-carers, particularly if they have heavy caring responsibilities. 13% of carers who provide 50 hours or more of unpaid care per week are in bad or very bad health, compared to only 5% of the non-carer population.67 3.3 Physical strain, anxiety, lack of sleep and social isolation can often lead to physical and mental ill health or stress related illness. Carers often put their own health needs last, putting off medical appointments and treatment68. Poor carer health that goes unaddressed can result in carer breakdown—resulting in unnecessary, distressing and expensive emergency admissions—sometimes double admissions of both carers and the people they care for—putting further strain on emergency services. 3.4 Effective community and primary care services can reduce pressure on carers and thereby prevent them from reaching breaking point. This has the potential to ease pressure on the NHS and social services as carers will be more able to continue caring for their loved one long term and will be less likely to need emergency medical attention themselves.

4. Emergency Admissions to Hospital 4.1 Carers UK’s State of Caring survey of over 3,500 carers,69 asked a wide range of questions about their experiences of caring. 55% of survey respondents said that the person they care for has been admitted to emergency hospital services in the last three years.70 4.2 Many survey respondents attributed emergency admissions to a lack of support.Whilst 64% of survey respondents did not believe that the emergency admission of their loved one could have been prevented, significant percentages identified areas where additional support could have prevented readmission: — 16% of respondents said more support from care services could have prevented readmission. — 6% said replacement care (for when they, the carer, needs medical treatment). — 21% said higher quality care and support for the person they care for. — 10% said adaptions in the home of the person they care for. — 7% said telecare or telehealth (eg monitoring equipment, alarms and sensors) could have prevented the need to return to hospital. This evidence shows that greater and higher quality support from care services could have a significant impact on the number of emergency admissions to hospital.

5. Hospital Discharge and Reablement 5.1 8 in 10 (81%) of carers responding to the survey said that the person they look after had been discharged from hospital in the last three years. 5.2 60% of respondents thought that the timing of this hospital discharge was “just right” or that the person they care for could have come home earlier. However, two in ﬁve carers said that the discharge was too early 67 2011 Census (England and Wales) 68 In sickness and in health (2011) Carers Week 69 At the time of writing, 3,505 carers had completed the State of Caring Survey 2013 70 76% of these admissions were due to deterioration of health and 35% were due to an accident or fall (respondents were able to choose multiple options if appropriate) cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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because their loved one was not ready to come home (25%) or the support was not available for them to come home (15%).

5.3 Only 24% of survey respondents were offered options such as care or reablement services when the person they care for was discharged71 while 76% were not offered any options for their loved one’s care after discharge. 60% of respondents said that they did not feel that they had a choice about starting to care for their loved one when they left hospital.

5.4 If a carer is unprepared or unable to care for their loved one when they are discharged and no care services are put in place then the family will be put under stress and re-admission and even further emergency admissions will be more likely.

5.5 One carer told us: “I work full time as well as taking care of my husband who has MS. When he recently left hospital, I was not asked about the impact this would have on us, what help we had in place or if he would be able to manage in our home. He had to sleep on the sofa for three weeks following his release and had many bathroom accidents as both the bedroom and bathroom is upstairs and he cannot reach them. It was very stressful for both of us.”

5.6 However, it is appreciated when hospital staff make an effort to involve and inform carers and family members: “I’m full of praise for the Learning Disability Liaison Nurse who attended my brother in hospital. I live 170 miles away and she liaised with my cousin, who lives nearer, and kept me informed of his progress and helped plan his care when he was discharged.”

5.7 71% of respondents said that the person they care for did not have to go back into hospital soon after being discharged. However, 26% said that their loved one had to go back into hospital within one–two months because their health had deteriorated again. This ﬁgure rises to 31% for respondents who were not consulted about the discharge of their loved one,72 strongly suggesting that involving and consulting carers can help to prevent readmissions due to health deterioration.

6 Underfunding of Social Care

6.1 There is an inextricable link between demand for emergency care, particularly for older and disabled people, and the funding and quality of care and support services in the community. This relationship must be taken into account as part of this review—particularly in assessing the impact on high-cost emergency care of investing in lower-cost interventions via social care services.

6.2 Funding for statutory services failed to keep pace with demand over the four years between 2005/06 and 2010/11; demand for care had outstripped expenditure by nine%.73 Families are unable to absorb this growing unmet need. Over the next 20 years, the supply of care by families is likely to grow by 13%, while demand will increase by 55%.74

6.3 As long as social care continues to be underfunded, the NHS will see the extra costs of unnecessary admissions to hospital, including emergency admissions, which could be prevented by adequate care and support services.

6.4 As fewer older and disabled people are able to access overstretched social care services, growing numbers of family members are being forced take on signiﬁcant caring responsibilities and give up work to care for ill or disabled loved ones, unable to get ﬂexible, reliable or affordable support. It is estimated that by 2017 we will reach a “tipping point” in care where demand will outstrip what families are able to provide.75 Unless social care is better funded, the strain on emergency services will only increase.

6.5 Carers UK welcomes new duties in the Care Bill on ensuring sufficiency of supply of care services and we anticipate that this could be a significant lever in stimulating the greater provision of services for local care—however generating a vibrant market of private purchase services must also be accompanied by sufficient funding for statutory services. May 2013

71 Temporary residential care (6%), permanent residential care (4%), sheltered housing (1%), reablement services (6%), care at home (provided by someone other than the carer) (11%), a “telecare” package in the home (2%) 72 37% of respondents were consulted about the hospital discharge “in plenty of time”, 34% were consulted only at the last minute and 29% were not consulted at all 73 Commission on Funding of Care and Support Fairer Care Funding. Analysis and evidence supporting the recommendations of the commission on funding of care and support. Vol II (2011) 74 Ibid. 75 Pickard, L. (2008) Informal care for older people provided by their adult children: projections of supply and demand to 2041 in England. Report to the Strategy Unit and Department of Health. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Written evidence from The Medical Care Research Unit, School of Health & Related Research, University of Shefﬁeld (ES 25)

Transition of NHS Direct to NHS 111 — A full evaluation of the ﬁrst 4 NHS 111 pilot sites was commissioned by the Department of Health to gather evidence on the impact and costs of introducing this new service. — Following a change of government a policy decision was made to roll NHS 111 out as a national service before the pilot sites had been evaluated. — As a consequence the full evaluation ﬁndings were unavailable to commissioners and providers to consider in developing these services across the country. — The evaluation found a high level of user satisfaction but also found NHS 111 resulted in a higher number of ambulance service incidents which was contrary to the expected objective of reducing demand for emergency ambulances.

In 2009 four pilot sites were chosen to test a new service for accessing urgent rather than emergency care— NHS 111. At the same time the Medical Care Research Unit at Sheffield University was commissioned to conduct an evaluation of these pilot sites to assess the impact of the service on users, the rest of the emergency care system and the associated costs. The aim was to provide evidence to inform future decisions on a national roll out of the service. The decision to roll out the service was taken by a new ministerial team in 2010— before the pilot sites had gone live with a national service expected by 1st April 2013. The evaluation proceeded as planned assessing early lessons on implementation published in the first interim report and assessing the operation and impact of the first year of the live service (2010—2011). The final report was published in the autumn of 2012. By this time additional NHS 111 services had gone live expanding from the original 4 to 18 by the end of 2012. The evaluation found a high level of user satisfaction, a call handling service that exceeded national quality standards, no change in population use of urgent care, higher overall emergency and urgent care system activity and an increase in emergency ambulance incidents in the pilot areas. The final report recommended that further work needed to be done to better understand this increase and to find solutions to reduce the likely impact with associated risks to the ambulance service. Another key point was that during the pilot sites NHS Direct was also still operational. The final evaluation report cautioned that the full implications of shifting all the NHS Direct workload to NHS 111 needed to be considered. A period of testing this would have been helpful. The problems with NHS 111 appear to have been worse during the most recent launches— no major problems were reported for the 18 services that went live up to the end of 2012. We offer a number of possible explanations although these would need to be further tested: — The full impact of moving NHS Direct calls to NHS 111 and the consequences for call handling services was unknown. — Some areas, because of the complex procurement processes, had little time to get the services developed and tested, staff trained and the Directory of Services completed before the deadlines. — NHS 111 is the front entrance but it is only as good as the system behind it—in particular o the referral pathways and services which underpin the Directory of Services need to be robust—a key factor identified by the pilot sites in our evaluation—if the service is to function as intended. — The use of non-clinical call handlers has meant the training of a whole new workforce. There may have been insufficient time in some areas to complete this to a satisfactorily high standard. — As with all new services work needs to be done to assess whether the introduction of NHS 111 has created new demand which may in some part be exacerbating the problem.

Change in measuring Ambulance Service Performance from Response Times to Clinical Indicators

This is just a note to support this transition. I was involved in the original work with the Department of Health Ambulance policy team to develop these indicators. Response times may indicate efficiency but they only say something about how quickly an ambulance arrives and nothing about the care patients receive or their outcomes. It is also only relevant to a small population of patients with out of hospital cardiac arrest which comprises less than 2% of ambulance service emergency responses. The Universities of Sheffield and Lincoln together with East Midlands and Yorkshire Ambulance Services were awarded a five year, £2 million grant by the National Institute of Health Research in 2011 to further develop outcome based performance and quality measures for pre-hospital care using linked NHS data. This will contribute to the further development of measures that are much more closely aligned to clinical care and the direct impact on patients health and wellbeing. May 2013 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Written evidence from the British Medical Association (ES 26) About the BMA The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 150,000.

Executive Summary — The NHS is going through major structural change at a time of significant financial pressure, putting the system under strain and compromising the ability of the NHS to cope with demand. What is needed to address the current demands on urgent and emergency care is not further centrally dictated, whole system solutions but patient centred, locally negotiated and managed arrangements between care providers, which meet the needs of the local population. — There is no evidence to support the contention that the increase in demand on emergency departments results solely from the changes which took place in 2004 to the way GPs out-of-hours (OOHs) services are arranged. — 76 —Theincreased pressure on emergency departments is caused by a range of complex issues including the current staffing and recruitment crisis in emergency departments, gridlock elsewhere in the system and increasing demand, particularly amongst frail and elderly patients. The flawed introduction of NHS 111 has further added to the pressure on out-of-hours and emergency care admissions. The Government needs to take urgent action, increasing the seniority, skills and expertise of those handling telephone triage services. No areas should go live with NHS 111 until it is clear beyond doubt that the service is safe. — In addition to traditional A&E (now emergency) departments and out-of-hours primary care services, there are walk in centres and minor injuries units delivering urgent and non urgent care, adding to patient confusion and increasing demand. Greater clarity and information is needed for patients about the appropriate options for unscheduled care. — Newly established clinical commissioning groups (CCGs) should be allowed to bed down and work with the full range of local care providers, including local authorities with their new responsibilities for public health, to find solutions which meet the needs of their local population, without further centrally dictated initiatives adding further pressure.

Introduction 1. Data from the Department of Health shows that emergency department77 (ED) attendances were subject to a step change in 2003–04 and have followed a steeper trajectory since that date.78 However, there are major issues around the collection of A&E data, and comparisons between new data sets and older methodologies show significant discrepancies. Until 2003–04, statistics on A&E attendances included “major” A&E units only. Thereafter, the introduction of walk-in centres and minor injury units led to attendances being recorded for these units as well. To this end, much of the increase relates to previously unrecorded attendances at these units. These units are treating less serious cases than those at A&E units.79 A literature review undertaken by the Primary Care Foundation certainly came to the conclusion that the overall impact of the introduction of newer types of facility appears to have been to increase demand rather than substitute location.80 Looking at Type 1 A& E facilities, attendances have increased at 1.7% per year over the nine year period to 2011–12 as against 1.5% per year over the preceding nine years. This does not support the suggestion that there has been a dramatic increase in attendance caused by changes to the GP contract introduced in 2004.81 The inclusion of other facilities in the data collection did contribute to an average increase between 2002–03 and 2011–12 of 4.5% per year. This in turn suggests a measure of supply induced demand. 76 See response by Anna Soubry MP, Parliamentary Under Secretary of State for Health, to debate on A&E waiting times, Westminster Hall, 23rd April 2013: “One million more people—perhaps this is not understood by some hon. Members—are using A and E departments every year, and it is important that we understand why that is. We know that there are nearly 4 million more A and E attendances compared with 2004, when the previous Government carried out what I and others believe was a disastrous renegotiation of the GP contract, which has had a clear knock-on effect on access to out-of-hours services”. http://www.publications.parliament.uk/pa/cm201213/cmhansrd/cm130423/halltext/130423h0001.htm#13042356000135 77 The College of Emergency Medicine notes that while Departments of Emergency Medicine may be known by several names (Casualty, Accident and Emergency, or Emergency Department) Emergency Department may best reflect the nature of the work, and is also the name used in other countries such as the USA and Australia. The BMA refers to Emergency Departments as well as A&E departments throughout this submission, where appropriate. http://www.collemergencymed.ac.uk/Public/ What%20is%20Emergency%20Medicine/? 78 http://www.nuffieldtrust.org.uk/data-and-charts/ae-attendances-england 79 Are accident and emergency attendances increasing? The King’s Fund, 29 April 2013 80 What works best? Review of Urgent Care Centres. A discussion paper from the Primary Care Foundation October 2012 81 Data from Accident and Emergency Attendances in England—2011–12, Experimental statistics, Health and Social Care Information Centre, January 2013 (as mentioned in paragraph two ) demonstrates that the attribution of changes in the volume of A&E attendances to changes in general practice behaviour is not supported by the information on patient demographics and timing of attendances. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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2. The attribution of changes in the volume of A&E attendances to changes in general practice behaviour is not supported by the information on patient demographics and timing of attendances. In 2011–12, 43.4% (7,651,005) of all A&E attendances were for patients aged 29 or under and 16.3% (2,875,643) were for patients aged 20–29.82 This latter cohort tends to be a light user of general practice.83 When looking at the day and hour of arrival of A&E attendances, the busiest day continues to be Monday, with 15.8% of all attendances (2,781,531). The busiest time of arrival on that day is 10 am (hour) with 211,569 attendances (1.2% of all A& E attendances). There is little evidence of an increase in OOHs attendances and the vast majority take place between 8am and 7pm.

The Role of Community and Primary Care Services in the Delivery of Emergency Healthcare, and the Appropriate Structure for Service Delivery to meet the Demands of Different Geographic Areas Particularly Sparsely Populated Rural Areas 3. At the end of December 2004, GP responsibility 24-hour for patient care ended and responsibility for providing OOHs urgent care cover in most areas was transferred to Primary Care Organisations.84 This was one of the key changes to the GP contract, intended to help address the serious recruitment and retention crisis in general practice at that time.85 Many GPs still choose to provide OOHs services to their patients, either directly or by working for an OOHs organisation. Many GPs worked in GP co-operatives until 2004 and continued to do so after the contract changes. A number of OOHs co-operatives continue to provide care now; almost all out of hours services continue to employ large numbers of GPs. 4. The BMA believes it is wrong to suggest that the huge pressures on accident and emergency departments, as raised most recently by the Secretary of State for Health,86 are caused solely by the changes in 2004 to OOH delivery of primary care. The Government’s analysis of where responsibility lies for the huge and increasing pressure on emergency care is overly simplistic. The causes of the very real increased pressures on EDs are due to a range of complex issues including insufficient staffing in emergency departments, gridlock elsewhere in the health system (see paragraph 8) and an increasing demand on health budgets. 5. OOHs care suffered from historic underfunding prior to 2004. The BMA has been pressing for improvements in OOHs care for many years and believes that the introduction of competition for OOHs contracts has exacerbated the pressure on resources and not reversed the Government’s neglect of this crucial service. The BMA has expressed concerns that the failure to invest in OOHs services and the perceived drive towards low cost OOHs providers by Primary Care Organisations was a key factor in forcing some successful OOHs to close. In the past three years, funding has remained static at a time when patient demand is increasing: GPs are undertaking increasing numbers of GP consultations87 and the profession remain key providers of urgent care during the weekend and evenings. 6. Improvements in access to and information about OOHs services could be beneficial for patients and could ease pressure on emergency departments by encouraging greater self management.

Progress towards moving some Minor Injury and Urgent Care Services out of A&E and into more Accessible Community Settings 7. Anecdotal evidence from BMA members working in primary and secondary care suggests that the number of unscheduled care services available (such as EDs, urgent care centres, walk in centres and GP OOHs services) may, in part, be adding to the confusion experienced by patients when seeking appropriate urgent or emergency care. Evidence also suggests that the increase in the supply of newer types of emergency care facilities appears to have led to increased patient demand.88 The BMA believes that patients would beneﬁt from greater clarity and information about the variety of unscheduled care settings available. This would help improve patient awareness of the options available to them and the circumstances in which emergency services ought to be used. It is essential that patients have a better understanding of when self-care is ideal and appropriate. Recent research by Dr Foster shows that hospitals are under increasing pressure from a rising 82 Accident and Emergency Attendances in England—2011–12, Experimental statistics, Health and Social Care Information Centre, January 2013 83 https://catalogue.ic.nhs.uk/publications/primary-care/general-practice/tren-cons-rate-gene-prac-95–09/tren-cons-rate-gene-prac- 95–09–95–09-rep.pdf, page 16 84 Since 2004, GPs have been able to choose whether to provide 24-hour care for their patients or to transfer responsibility for out-of-hours services to primary care trusts (PCTs). From April 1 2013 this will be dealt with by NHS Commissioning Board Area Teams. NHS Commissioning Board Area Teams are responsible for providing services for the local population. Some NHS Commissioning Board Area Teams provide care themselves. Others provide care through external organisations. This means different areas can have slightly different services: http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/out-of- hours-services.aspx 85 For a personal account of a GP’s experience of providing OOHs care, please go to http://abetternhs.wordpress.com/2013/05/10/ true-history/ 86 Speech by Jeremy Hunt, Secretary of State for Health, at the Age UK Conference, 25 April 2013, http://www.gponline.com/ channel/news/article/1180157/jeremy-hunt-speech-age-uk-conference-full/ 87 Data provided for the Department of Health by Qresearch for the period from 1995 to 2008 shows a sustained increase in consultations per person per year: the mean number increased from 4.71 in 2003 to 5.45 in 2008: https://catalogue.ic.nhs.uk/ publications/primary-care/general-practice/tren-cons-rate-gene-prac-95–09/tren-cons-rate-gene-prac-95–09–95–08-rep.pdf. The BMA is not aware of any more recent data. 88 What works best? Review of Urgent Care Centres. A discussion paper from the Primary Care Foundation October 2012 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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number of emergency admissions, particularly amongst frail elderly patients.89 The research demonstrates that 29% of hospital bed days are taken by patients whose admission might have been avoided if their care was better managed.90 The research also shows that within the hospital bed days taken by patients whose care should have been better managed outside a hospital, 11.9% of all hospital beds were occupied by people with a condition that should not require emergency hospitalisation, and a further 5.6% of all beds were occupied by people who have been readmitted as an emergency within a week of being discharged.91 8. The study suggests that improvements in community and primary care, as well as changes in hospital practices, could reduce these admissions. In our view such improvements would be very welcome but would require the recruitment of large numbers of trained district nurses and other community services at a time when budgets and establishments are being cut and community staff are retiring. Early assessment by senior medical staff can help tackle inappropriate or unnecessary hospital admissions. Deploying the expert opinions of senior doctors at an early stage ensures safe, fast and efficient care. Evidence has shown that it can reduce mortality (in stroke care92 for example) and complication rates in patients.93 However, work needs to be undertaken to address recruitment and retention of Emergency Medicine trainees as a priority.94 Anecdotal evidence from BMA members suggests that an unacceptable level of work intensity restricts opportunity for training and weakens morale amongst emergency medicine trainees. Increasing the number of consultants in ED settings, particularly those with expertise in treating frail elderly patients, as well as greater access to district and community nursing staff and social services facilities, may help ease the pressure on emergency care facilities. 9. Introducing the changes mentioned above would help move some minor injury and urgent care services out of EDs and into more accessible community settings. In addition, the Kings Fund is clear that incentives are needed to flex capacity and create better flow through the system.95 To that end, the Payment by Results system needs to be reformed as hospitals are currently incentivised to maintain income, at the same time as being penalised through being paid a marginal tariff rate of 30% for increases in emergency activity above 2008–9 admission levels. It is clear that any proposals to move care into primary and community services would need to be accompanied by adequate resources. 10. Greater sharing and adoption of best practice is also needed, along with a more collaborative leadership model, improved availability and quality of data to allow the system to be effectively managed and improved matching of demand with supply.96 For example, the Health Foundation established a programme97 to help two trusts examine patient flow through the emergency care pathway and develop ways in which capacity could be better matched with demand, preventing queues and poor outcomes for patients. Both trusts reported early indications of apparent reductions in mortality, maintained performance during difficult financial times and, in some instances, removal of considerable capacity while improving quality of care and reducing length of stay. 11. We note with concern, however, the mortality figures that have been linked to the closure of Newark A&E and await the results of the investigation that has recently been launched. 12. We do not see how ambulance services can be better integrated with primary care because the two parts of the service have no connection now: the only link since April 2013 has been the ability of CCGs to manage the commissioning of ambulance services.

The Ability of Ambulance Services to continue to meet Increased Emergency Demand whilst contributing to the Nicholson Challenge 13. Pressure on emergency services could be alleviated by increasing the seniority, skills and experience of those handling telephone triage services, paramedics and pre-hospital care and promoting a culture of decision making at an early stage in order to reduce unnecessary admissions.

Experience to Date of the Transition from NHS Direct to the NHS 111 Service 14. The BMA has consistently expressed serious concerns about the transition from NHS Direct to the NHS 111, the new telephone triage service for people with urgent but non-life threatening conditions. The BMA wrote to the then Health Secretary, Andrew Lansley, in February 2012 warning of the dangers of rushed implementation. The BMA also wrote to the Health Minister, Earl Howe, and NHS England Chief Executive Sir David Nicholson urging them to delay the launch of NHS 111 beyond 1 April 2013 due to concerns that 89 http://drfosterintelligence.co.uk/thought-leadership/hospital-guide/ 90 However, research from the King’s Fund suggests that that some interventions being used in the NHS, although designed to avoid admissions, do not work: http://www.kingsfund.org.uk/sites/files/kf/field/field_ publication_file/avoiding-hospital-admissions-lessons-from-evidence-experience-ham-imison-jennings-oct10.pdf 91 http://download.drfosterintelligence.co.uk/Hospital_Guide_2012.pdf, page 10 92 Reducing deaths from stroke: a focused review of the literature Nursing Older People, October 2004 93 Raising the benchmark for the 21st Century- the 1000 cataract operations audit and survey: outcomes, consultant-supervised training and sourcing NHS choice British Journal of Opthamology,2007 94 Shape of the Medical Workforce, August 2011, Centre for Workforce Intelligence 95 Urgent and Emergency Care, A Review for NHS South of England, Kings Fund, March 2013 96 Page 4, Urgent and Emergency Care, A Review for NHS South of England, Kings Fund, March 2013 97 Improving Patient Flow, Health Foundation, April 2013 cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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many areas were not ready for the transition.98 The BMA repeatedly asked for the implementation of NHS 111 services not to be rushed, as a smooth transition was essential for patient safety. Concerns were expressed about the decision to split call handling from service providers, which now appears to have been borne out. The Government has conceded that the launch of NHS 111 “did not go as smoothly as planned and that a number of providers have delivered an unacceptable service, especially at weekends.”99

15. Serious problems were encountered with NHS 111 when the system was launched in a number of areas including Greater Manchester, parts of London, the West Midlands and the North East of England. In Manchester, where NHS 111 was launched on 21 March 2013, patients reported waiting for several hours for calls back. Reports also indicate that the North West Ambulance Service was overwhelmed by 999 calls from patients because of an inability to get through to NHS 111 and long waiting times for responses to calls. The BMA is also aware of similar concerns about transition to NHS 111 in South London with reports of patients experiencing delays before receiving calls back. NHS 111 was put on hold in Southwark, Lambeth and Lewisham until 9 April 2013 after problems with the service emerged in Bexley, Bromley and Greenwich. In both Manchester and London, GPs and other doctors took back call handling of patient calls because of safety concerns.

16. Not all regions implemented the NHS 111 service from 1 April 2013. The service is currently running in 22 areas of England; the service will be introduced on a phased basis with areas that are not currently ready having until 30 June 2013 to roll out the service. The BMA believes that NHS England needs to be more transparent about how the system is functioning across the country and that no area should have to go live on any particular date until it is clear beyond doubt that the service is safe and resources are being used appropriately.

17. The chaos affecting NHS 111 is placing an additional strain on other already over-stretched parts of the NHS, such as the ambulance service, EDs and GPs, as well as potentially putting patients at risk. Media reports suggest that at least 22 possible serious untoward incidents relating to NHS 111 have been reported since the service was launched.100 The BMA believes that calls to NHS 111 must be responded to with immediate, sound advice and not be subject to any forms of delay. Despite being designed to alleviate pressure on the NHS, the ﬂawed introduction of NHS 111 appears to be adding further pressure on OOHs care and emergency care admissions.

The Implications Of The Shift Away From Determining The Success of Ambulance Services via Indicators based on Response Time to the New Measures Designed to Assess Clinical Effectiveness

18. There is evidence of gaming101,102 arising from the response time targets set for ambulance services in the NHS. The study found that as a result of intense focus on the response time target, some ambulance trusts were purposefully not classing urgent calls from GPs as “category A.”103 The research also found that a number of trusts put higher numbers of ambulances in densely-populated areas where it was easier to meet the target, at the expense of rural populations. The shift away from performance managing ambulance trusts on response times in favour of clinical effectiveness is welcomed.

19. The BMA has repeatedly warned that targets imposed by the Government on the NHS can distort clinical priorities, with some patients being prioritised over others with greater clinical need. The BMA broadly welcomes the emphasis on outcomes as an approach to help assess performance.

The Causes of Delay in Handover from Ambulance Services to A&E or Transfer between Different Levels of Urgent Care, and Actions Required to Eliminate between them

20. Any action to eliminate delays in the handover from ambulance services to EDs or transfer between different levels of urgent care needs to take into account how NHS targets are applied, monitored and managed. Although the 4 hour A&E target can have serious perverse consequences, and is unachievable in some areas as the service is presently constituted, for many patients it contributed to better and more timely care. Gridlocks within the hospital need to be addressed, as noted by the Health Foundation, to eliminate delays. 98 http://bma.org.uk/news-views-analysis/news/2013/march/gps-implore-government-to-delay-nhs-111 99 Earl Howe, Parliamentary Under Secretary of State for Health, Parliamentary Question on NHS 111 telephone service, 13 May 2013 http://www.publications.parliament.uk/pa/ld201314/ldhansrd/text/130513–0001.htm#1305137000230 100 http://www.pulsetoday.co.uk/commissioning/commissioning-topics/urgent-care/22-nhs-111-serious-untoward-incidents- reported-including-three-deaths/20002842.article 101 Bevan Gwyn and Hamblin, Richard (2009) Hitting and missing targets by ambulance services for emergency calls: effects of different systems of performance measurements within the UK. Journal of the Royal Statistical Society: series A (statistics in society), 172 (1). Pp. 161–190. ISSN 0964–1998 http://onlinelibrary.wiley.com/doi/10.1111/j.1467–985X.2008.00557.x/pdf 102 http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/our-publications/browse-category/guidance-foundation- trusts/monthl-8 103 Category A ambulance calls, which include the most serious life-threatening conditions, need to be responded to in eight minutes. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Clinical Evidence about Outcomes Achieved By Specialist Regional Centres, Taking Account of Associated Travel Times, Compared with More Generalist Hospital Based Services 21. The London Trauma System appears to have resulted in improvements in both processes of care and patient outcomes since the network was completed in January 2011.104 As part of the System, a consultant is now available 24/7 in each of the four major trauma centres, which has enabled immediate assessment and treatment of seriously injured patients. Assessments have shown that an additional 58 Londoners who were expected to die of their injuries have survived as a result of the introduction of the London Trauma System.105 22. A key criterion in the development of the centralisation of stroke care in London model was that all London residents should be within 30 minutes travelling time of a hyper-acute unit. Evidence suggests this has been achieved with an average travel time of about 15 minutes from home to hospital; patient outcomes have also improved.106 23. Outcomes data collected by the Vascular Society also supports the move towards performing major arterial surgery in larger volume units in order to further optimise outcomes.107

Aspects Of Care Which are Likely to Improve by Being Located in Regional Specialist Units and the Risks Associated with Removing Services from Existing A&E Provision 24. A recent review of stroke care in London highlighted that outcomes have been improved following a decision to concentrate specialist stroke care in eight hyper-acute units.108 Other aspects of care may also improve by being located in regional specialist units, although it is clear that centralisation does not always lead to improved outcomes. Further research should also be conducted to ascertain whether outcomes are also improved in rural areas. 25. The BMA acknowledges that not all hospitals may be needed in their current form in the future. In some cases, clinically appropriate reconfiguration may involve the merger or closure of units, departments, or even whole hospitals.109 The BMA believes reconfiguration is acceptable where it is evidence-based; clinically led in partnership with patients; safe; and maintains or enhances standards of care across a health economy.110 Further integration between health and social care and co-operation between services are likely to have a beneficial impact on both patient care and demand for ED services.

The effectiveness of the existing Consultation Process for Incorporating the View of Local Communities in to ED Service Design 26. The BMA believes that any service reconﬁguration ought to follow the principles outlined in our publication “Engaging in local healthcare developments”, which include having a thorough impact assessment, including an examination of safety issues. The Government’s four key tests for service change should also be applied.111

The Ability of Local Authorities To Challenge Local Proposals for Reconfiguration under the Revised Oversight and Scrutiny Powers Included in the Health and Social Care Act 2012 27. The BMA notes that new arrangements for local authority health scrutiny have been put in place as a result of the Health and Social Care Act 2012. If local authorities are to carry out their new responsibilities effectively, they will need to have a properly resourced and qualified public health team in place, led by a Director of Public Health, to provide an independent opinion of the impact on the population’s health. 28. The BMA agrees that there may be some advantage in agreeing a timetable for decision-making.112 It is also reasonable for local authorities to be able to consider the financial implications of plans when considering a referral as such factors are likely to be drivers for change in the current financial climate. While the cost of any proposed reconfiguration is a relevant factor, it is essential that local authorities are able to challenge the financial arguments for change and can refer plans for further scrutiny if deemed appropriate. Any such challenges should be recorded in the Director of Public Health’s Annual Report. 104 http://www.londontraumaoffice.nhs.uk/silo/files/lto-annual-report-2010-to-2011.pdf 105 http://www.londontraumaoffice.nhs.uk/silo/files/lto-annual-report-2010-to-2011.pdf 106 Tony Rudd: the legacy of NHS London- stroke programme 107 Outcomes after Elective Repair of Infra Renal Abdominal Aortic Aneurisym, Vascular Society, March 2012 108 http://www.kingsfund.org.uk/audio-video/tony-rudd-legacy-nhs-london-%E2%80%93-stroke-programme 109 The BMA’s Consultants Committee passed the following motion at its conference in 2010: That this conference recognises that things change with time, so not all current hospitals may be needed in their current form in future, so in some cases clinically- appropriate reconfiguration will involve merger or closure of units, departments, or even whole hospitals. However, all such change must follow the CCSC’s principles on reconfiguration, dated 28 August 2007, whose key principles are as follows: Reconfiguration is acceptable where it is: evidence-based; clinically-led in partnership with patients; safe; and maintains or enhances standards of care across a health economy 110 Engaging in local healthcare developments http://bma.org.uk/working-for-change/the-changing-nhs/reconfiguration-and- integration/reconfiguration 111 The Operating Framework for the NHS in England, Department of Health 112 The TSAs for Mid Staffordshire NHS Foundation Trust, for example, have clearly set out a 145 legal working day legal timeframe since it was announced that the Trust was clinically and financially unsustainable in its current form: http://tsa- msft.org.uk/about-the-tsa/ cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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29. The BMA has reservations about proposals to involve NHS England on some service reconfigurations, particularly as the Independent Reconfiguration Panel (IRP) has a proven track record and expertise in overseeing reconfiguration of NHS services. The BMA is concerned that referring service reconfigurations to NHS England could lengthen the reconfiguration process as well as increasing bureaucracy. May 2013

Written evidence from the London Ambulance Service NHS Trust (ES 27) The London Ambulance Service NHS Trust serves a population of 8 million people across London and last year took over 1.5 million 999 calls from people searching for help. Partnerships have been forged across London to ensure the highest possible care for our patients and this includes the creation of a number of pieces of evidence that may be of interest to the committee as to how services can work together to improve the outcomes for emergency service patients. These are outlined below. 1. The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas — Suggest we have no evidence 2. Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings — Evidence in Appendix 1: Agreed protocol of exclusions that the London Ambulance Service would not take to MIU or Urgent Care Services in London (Northwick Park Hospital—Urgent Care Centre Care Pathways) 3. The range, severity and incidence of conditions that can be treated within an accident and emergency unit but not managed at an urgent care centre — Evidence in Appendix 1: Agreed protocol of exclusions that the London Ambulance Service would not take to MIU or Urgent Care Services in London (Northwick Park Hospital—Urgent Care Centre Care Pathways) 4. The prospects for better integration of ambulance services with primary care under the new commissioning regime established in April 2013 — The London Ambulance Service would seek a balance of consistency/safety and triage across a broader geographical area than individual CCGs with the need for local responsiveness and differing models to ensure high quality clinical care can be provided simply across boundaries. 5. The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge — No evidence submitted 6. Experience to date of the transition from NHS Direct to the NHS 111 service — No evidence submitted 7. The implications of the shift away from determining the success of ambulance services via indicators based on response time to the new measures designed to assess clinical effectiveness — No evidence submitted 8. The causes of delays in handover from ambulances services to A&E or transfer between different levels of urgent care, and actions required to eliminate them — Evidence in Appendix 2: NHS London divert and closure policy (NHS Commissioning Board London) 9. Clinical evidence about outcomes achieved by specialist regional centres, taking account of associated travel times, compared with more generalist hospital based services — Appendix 3—outcomes of improved outcomes for patients attending STEMI centre (ST Elevation Myocardial Infarction Annual Report: 2011–12) 10. Aspects of care which are likely to improve by being located in regional specialist units and the risks associated with removing services from existing A&E provision — No evidence submitted 11. The effectiveness of the existing consultation process for incorporating the views of local communities in to A&E service design — The London Ambulance Service has been asked to contribute to all the reorganisation consultations within our region and have effectively been integrated in to all emergency care policies and plans where appropriate. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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12. The ability of local authorities to challenge local proposals for reconﬁguration under the revised oversight and scrutiny powers included in the Health and Social Care Act 2012 — No evidence submitted May 2013

APPENDIX 1 NORTHWICK PARK HOSPITAL Urgent Care Centre (UCC) Care Pathway EXCLUSION CRITERIA for Adult patients Notes: — Where the patient has an existing medical condition/diagnosis, consideration of their ‘normal/acceptable’ physical observations must be considered, eg a patient with COPD may present with an oxygen saturation which may appear abnormally low. — Some patients with existing conditions may have a ‘passport’ which provides specific details regarding their ‘normal’ illness presentation and management plans. PHYSIOLOGICAL — Altered level of consciousness (GCS of 14 and below) OBSERVATIONS — Respiratory rate <10 or >= 25 breaths per minute — Oxygen saturation < 92% — Tachycardia > 100 bpm — Bradycardia < 40 bpm — Hypotension < 100 mm Hg systolic (unless normal for the patient) AIRWAY — Airway compromise—including stridor or quinsy, oedema of tongue, unable to swallow saliva/drooling BREATHING — Inadequate breathing — Acutely short of breath — Severe asthma CIRCULATION — Shock — Dangerous bleeding — Uncontrollable major haemorrhage — Haematemesis/Melena OTHER — Sudden neurological deficit, eg stroke — Signs of meningism — Pain — Pain of cardiac sounding origin — Neck pain with neurological deficit — Abdominal pain radiating to the back — Sudden onset of headache — All severe pain — Injuries — Significant mechanism of injury — Open fracture — Stabbing/shooting/major trauma — Neurovascular compromise to limb — Burns — Greater than 3% in adults — Facial/eye involvement — Inhalation injury — Chemical/electrical involvement — — Psychiatric emergencies — Severe/acute psychosis with agitation/distress/threat to self or others — Possible lethal overdose/high risk of self-harm — Obstetric emergencies

Pathway Verification/Signatories For verification purposes, and to ensure all parties involved with the development and delivery of this pathway are clearly identified, please complete the boxes below identifying name, role and organisation in each box. Note this page will be filed and kept for admin use only. Expected signatories would include: cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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At development stage — Local LAS Area Operations Manager — Lead clinician/manager of the service provider — Lead commissioner of the service — Other party involved in pathway development

At ﬁnal LAS sign-off stage — Sector Assistant Medical Director — Sector Assistant Director of Operations Name, Role, Organisation Signature Date Peter Rhodes, By email 20/09/12 Area Operations Manager—Pinner Complex, London Ambulance Service Name, Role, Organisation Signature Date Sally Johnson, By email 20/09/12 Medical Director, Greenbrook Healthcare Name, Role, Organisation Signature Date Tina Benson/Sean Williams By email 20/09/12 North West London Hospitals Name, Role, Organisation Signature Date Peta Longstaff, By email 20/09/12 Assistant Medical Director—West, London Ambulance Service Name, Role, Organisation Signature Date Peter McKenna, pp. E. Williams 02/12/12 Assistant Director of Operations—West, London Ambulance Service

Written evidence from The King’s Fund (ES 28) 1. The King’s Fund is an independent charity working to improve health and health care in England. We help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate. Our vision is that the best possible care is available to all. 2. The King’s Fund has published work on urgent and emergency care including regular analysis of performance data (Appleby et al forthcoming), a study of emergency admissions (Imison et al 2012) and an analysis of the urgent and emergency care system in NHS South of England (Edwards 2012).

Summary 3. This submission does not address each item in the terms of reference for this inquiry individually but makes the following conclusions. — While demand for accident and emergency (A&E) services has risen considerably over the past 15 years or so, nearly all of this is attributable to increasing activity in walk-in centres and minor injuries units and for the past two and a half years growth has slowed considerably—to just over 1% per year (Appleby 2013). — However, there is evidence that the urgent and emergency care system is under pressure and performance on a number of important indicators, including the four-hour wait for A&E and ambulance handover targets, has been getting worse in recent months. — While the focus of attention has been on the pressures felt by A&E services, there is no single cause or solution to this problem. The pressures are caused by issues across the health and care system that prevent the flow of patients through the system and any solutions need to reflect this. These are complex issues that will not be solved just by short-term increases in funding. Financial disincentives that penalise hospitals for additional emergency activity over a baseline have not been effective. — To address the problems created by increasing demand on urgent and emergency care we need more strategic approaches that reduce the complexity of the system for patients; reshape primary care and chronic disease management; support patients in their own homes (including nursing and residential care homes); and provide flexible and timely community services that mean patients can be rapidly discharged from hospital. All of this requires leadership across a system rather than attempting to fix each individual component. We remain concerned that the fragmentation of commissioning and lack of strategic responsibility will make system-wide change more difficult to implement. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Urgent and Emergency Care Services 4. There has been a rise of around 7.5 million A&E attendances (a 50% increase) over the past decade. However, the facts about accident and emergency workload statistics are not straightforward and this increase is partly caused by changes in statistical collection (to include units not previously counted such as walk-in centres and minor injury units) and a degree of ‘supply-induced demand’ as these new routes into emergency care have opened. 5. However, providers are reporting pressures on A&E services in particular. We recently surveyed NHS finance directors and when asked to pick just one immediate concern, 21 directors identified the four-hour maximum A&E waiting times target as their main problem at the moment. This concern is reflected in recent official data not just on the four-hour target but also the proportion of patients waiting more than four hours to be admitted to a hospital bed from an A&E department. In the last quarter, the proportion of so-called ‘trolley waits’—patients waiting more than four hours to be admitted into hospital from A&E—reached nearly 7%, the highest proportion since 2003–04. Nationally, more than 313,000 patients waited more than four hours in A& E departments in the last quarter—nearly 40% more than the same quarter a year ago. (Appleby et al 2013). 6. Weekly data in the three weeks to the week beginning 5 May 2013 (and beyond the quarterly data period) show that performance has improved, with less than 5% of patients waiting longer than four hours in the first week of May. However, it remains to be seen if this recovery continues. There is a similar recovery for trolley waits. Both may in part reflect a renewed focus on these performance metrics by hospitals as media attention has grown (Appleby et al 2013). 7. A&E targets have been in place for nearly a decade. The Prime Minister included A&E waiting times as one of his key pledges for the NHS in 2011. There is some evidence of a correlation between performance against the four-hour wait target and a relaxation of performance management by the government. 8. There is a huge range of advice on good practices that should be adopted by hospitals in managing the flow of emergency work, but our research found that they are rarely consistently and universally adhered to. Good practice is hard to sustain for a number of reasons, including a lack of attention to continuous monitoring and adjustment of the system; staffing pressures; and difficulties in changing job plans for doctors to ensure 24/7 cover. Systems are fragile and vulnerable to fluctuations in demand, changes in staffing or any hold up in the discharge process. 9. Provided that demand and capacity are in balance, there are a number of well-evidenced interventions for ensuring a smooth flow of patients through A&E services including: — creating separate streams for minors and majors — rapid assessment and treatment (RAT) for ‘majors’ patients — see and treat for patients with minor injuries and illnesses — reducing or eliminating triage — using College of Emergency Medicine guidance on capacity — robust job planning to meet demands on an hour-by-hour basis. 10. The pressures felt by A&E services are caused by issues across the health and care system that prevent the flow of patients through the system. Key to preventing long waits in A&E is making sure that patients flow quickly through the hospital and are discharged rapidly. There are a number of factors that prevent this, including: — misalignment of workflow between emergency departments and the rest of the hospital—hospitals still operate a five-day week for most of their activities which creates problems with the flow of patients. Our research found reduced diagnostic services during weekends and over lunchtimes impacted flow in emergency departments — efficiency and bed utilisation initiatives which have left hospitals running at high levels of occupancy and with reduced ability to respond to fluctuations in demand or to discharge patients — delays in transfers to community or social services (see below).

Community Health and Social Care Services 11. The evidence suggests that for community health and social care services, focusing on facilitating discharge, rather than preventing admission, has a greater impact on creating flow of patients through services and reduces the likelihood of problems in emergency departments. 12. Our surveys have found that delayed transfers of care are a concern for many NHS organisations. However, more investigation is needed to discover why, despite these concerns, official statistics show a relatively stable picture on delays. Discussion with directors of acute hospitals strongly suggests that the official data for delayed transfers of care do not accurately reflect the number of patients who are delayed and waiting for discharge (Appleby et al 2013). 13. There is more that hospitals can do to achieve timely discharge of patients, either from hospital beds or from emergency departments. However, community services are also important and these need to work at the cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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pace required by hospitals. Community health services are often commissioned using poorly drafted and inflexible block contracts, with response times measured in days, rather than the hours required by hospitals. In addition, community services can be complex and hard to navigate for emergency care staff, meaning that it can be easier to admit a patient than to find suitable support in the community at short notice. Our research suggests that to be effective, larger and more flexible community teams should be created that can provide an easy to access, 24-hour response and can respond to changing demand (Edwards 2013). 14. Timely access to social care services is also critical. Local authorities have tried to protect social care budgets, but net expenditure on adult social care has fallen in real terms for the past two years. The number of people receiving publicly funded social care through local authorities has also continued to fall—by 7% in 2011–12 and by 17% since 2006–07. Over the same period, the number of people aged 85 years and over has risen by more than 20%. A recent survey of Directors of Adult Social Services by the Fund found that transferred NHS money is being used to promote the closer integration of care but in many cases it is being used to offset general service pressures and councils are finding it much harder to find savings that do not impact on the quality or quantity of care (Appleby et al 2013). 15. There is limited evidence that community-based interventions have been able to reduce admissions at a large enough scale to make an impact on the operation of hospitals. Schemes aimed at avoiding admissions and A&E attendance are generally very poorly evaluated, too small to make much impact, hard to manage and prone to creating additional demand (Purdy 2010). This adds to the very high level of complexity that is already present due to layers of previous projects, national initiatives and unco-ordinated service developments. 16. The evidence that does exist suggests that successful examples are likely to be large scale and integrated with other services. The integrated care service in Torbay remains the best example of community interventions that have reduced emergency admissions to hospital.

Primary Care 17. Much attention has been paid to problems in access to primary care services, particularly out-of-hours. The data does not suggest a link between changes in out-of-hours provision at the time of the renewed GP contract in 2003 and an increase in pressure in emergency departments. 18. There is a lack of understanding about the demand for primary care and no consistent data about how many emergency GP appointments are available in any given area and how many might be needed. Recent work with one strategic health authority revealed wide variation in the use of out-of-hours care and the rates at which people were sent to hospital. Crucially, this data did not appear to be readily at hand or used by commissioners (Edwards 2013). 19. There have been many attempts to divert people from A&E services over many years by providing alternative primary care type services. These schemes appear mainly to increase overall demand, particularly for minor injury and illness, and have also had the effect of creating a highly fragmented system which generates confusion among GPs and other referrers about how and where to access care. There is anecdotal evidence that patients are also confused and turn to A&E services as they have confidence in them and find them easy to access. 20. As with community health and social care services, the evidence base for interventions that can help to prevent hospital admissions is patchy. For example, evidence suggests that there are limitations on what can be achieved using case identification approaches (which use a range of algorithms to identify high-risk patients in the community), and some studies have found little or no effect. There is evidence that encouraging patient self-management can be effective (Purdy 2010). 21. Evidence suggests that a senior person able to make a definite decision about diagnosis and treatment as early as possible has been a key feature of successful urgent and emergency care services. The development of NHS111 services, which rely on less-experienced call handlers, does not reflect this evidence. 22. Nursing and residential homes are an integral part of the care system and are caring for increasingly frail patients. Improving the management of nursing and residential home patients is an important task for primary care in order to prevent unnecessary admission to hospital.

Commissioners 23. There are signiﬁcant issues around how commissioners have operated to date in managing emergency activity. Some have taken adversarial approaches, while others have tried to implement overly detailed plans. In our research we found examples of questionable approaches to commissioning—for example, exploiting the difference between the community tariff and the hospital tariff. Commissioners we spoke to did not have a clear map of the system’s capacity or of the ﬂows between the different parts of it. 24. There is no evidence that the policy for hospitals to be paid only 30% of the tariff rate on emergency admissions that exceeded 2008–09 volumes has provided an effective incentive. 25. In 2013 The King’s Fund published a paper outlining the ten priorities for clinical commissioning groups (Imison et al 2013), one of which was managing urgent and emergency activity. In this report we emphasised cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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developing an integrated approach to urgent and emergency care, particularly emergency medical admissions to hospital. This requires involvement, involving hospitals, and community, primary and ambulance services through joint service planning and sharing of clinical information across different agencies. 26. There are now multiple commissioners of urgent and emergency care: NHS England has responsibility for commissioning primary care; clinical commissioning groups commission acute and community services; and local authorities commission social care and housing. Urgent care boards, now being established across the country, may be a useful mechanism for developing system-wide responses, although it will be important to be clear about their role, leadership and accountability if they are not to become just another component in a complex system. We remain concerned that the fragmentation of commissioning and lack of strategic responsibility will make system wide change more difﬁcult to implement.

References Appleby J (2013). “Are accident and emergency attendances increasing?” Blog. The King’s Fund website. Available at: www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing (accessed on 20 May 2013). Appleby J, Humphries R, Thompson J, Galea A (forthcoming). How is the health and social care system performing? Quarterly monitoring report. Edwards N (2013). Urgent and emergency care: Improving Urgent and Emergency Care Performance across NHS South of England. London: The King’s Fund. Available at www.southofengland.nhs.uk/wp-content/ uploads/2012/05/Kings-Fund-report-urgent-and-emergency-care.pdf (accessed on 20 May 2013). Imison C, Thompson J, Poteliakhoff E (2012). Older people and emergency bed use: exploring variation. London: The King’s Fund. Available at www.kingsfund.org.uk/publications/older-people-and-emergency-bed- use (accessed on 20 May 2013). Naylor C, Imison C, Addicott R, Buck D, Goodwin, Harrison T, Ross S, Sonola L, Tian Y, Curry N (2013). Transforming our Health Care System: Ten priorities for commissioners. London: The King’s Fund. Available at: www.kingsfund.org.uk/publications/articles/transforming-our-health-care-system-ten-priorities- commissioners (accessed on 20 May 2013). Purdy S (2010). Avoiding Hospital Admissions. What does the research evidence say? London: The King’s Fund. Available at: www.kingsfund.org.uk/publications/avoiding-hospital-admissions (accessed on 20 May 2013). May 2013

Written evidence from Nuffield Trust (ES 29) Key Points The Nuffield Trust welcomes the Health Select Committee’s decision to hold an inquiry into emergency services and emergency care. This brief submission offers some insights on the pattern of emergency admissions and what appears to work in preventing these admissions based on our research work at the Nuffield Trust. — The number of emergency admissions has been rising for a long time. Though there have been many initiatives aimed at reducing emergency admissions over the past decade, rates still rose by 33% from 3.9 million in 2001–02 to 5.2 million in 2011–12 (HSCIC, 2012).113 — This change has been characterised by a large increase in the number of short stay admissions leading to stays of one day or less. No comparable increase was seen for admissions leading to longer stays, suggesting a rise in admissions for less severe cases. — Unpublished work by the Nuffield Trust has continued to track these trends. It shows that since 2010, there has been a divergence between single-day stay admissions, which continue to rise, and zero-day stay admissions, which may have reached a plateau at just over 120,000 admissions per month. — The reasons for this increase are complex and include changes in the needs within the population (demand) and in the way services are delivered (supply). On the demand side, less than half of the rise in admissions 2004–05 to 2008–09 was accounted for by an ageing population. — On supply there have been many changes to the way urgent care is managed. In becoming more efficient (through shorter stays in hospital) hospitals have more capacity to treat more patients. They are therefore “running hotter”. It is questionable whether there are concomitant efficiencies in primary care and social care to reduce the risk of admission for patients. 113 Health & Social Care Information Centre (2012) Hospital Episode Statistics: Admitted Patient Care Summary Report. https://catalogue.ic.nhs.uk/publications/hospital/inpatients/hosp-epis-stat-admi-pati-care-eng-2011–2012/hosp-epis-stat-admi- head-figs-11–12-rep.pdf cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— The results of evaluations of initiatives to reduce emergency admissions through preventive care in the community suggest that reductions are theoretically possible but very difﬁcult to achieve. Policymakers must maintain realistic expectations of what can be delivered at scale in the short run. — Careful evaluation of such initiatives is essential and there is a case for real-time monitoring which would allow initiatives to evolve appropriately.

Long Term and Continuing Trends in Emergency Care There is a consensus that emergency care is currently under considerable pressure as a result of the rise in emergency admissions over the past decade. However, the causes of this rise are the subject of much debate, and are likely to be the interaction between a number of factors rather than a simple single cause. It is important that policymakers bear in mind the particular characteristics of this rise in admissions before they consider how the situation might be improved. An analysis by the Nuffield Trust in 2010 explored the reasons for the rising trends and showed that from 2004–05 to 2008–09, emergency admissions in England rose by 11.8%. The increase was fairly constant over time (echoing rises in earlier years) and much of it was linked with a rise in admissions resulting in stays of one day or less. The changes in emergency admission varied between trusts: some saw emergency admissions double while elsewhere they were reduced by as much as a third. The increasing numbers of older people in the population could have accounted for some of the rise— however, we estimate that this contributed no more than 40%. Increased admissions were observed across all age groups. The pattern of admissions showed no consistent response to central policy initiatives such as the 2005–6 introduction of the Payment by Results tariff or other initiatives such as the four-hour A&E waiting target. However, we did find specific examples where the introduction of these and other national policies appeared to influence behaviour in individual trusts. We found no evidence that the rise was linked with any particular type of illness or with self-reported levels of ill health. The report concluded that there was no obvious single cause of the rise in emergency admissions— it is likely to be a combination of factors. We hypothesised that improvements in the efficiency of bed use (eg, reductions in the average length of stay) had increased bed availability, which could impact on the propensity to admit.114 Where beds are available, it in effect reduces the threshold for acute admission. There is literature confirming the link between bed availability, inpatient admissions, and activity in A&E.115 It must also be recognised that the decision to admit will also be influenced by the availability of care outside the hospital—in GP practices, community settings or social care. For older people with complex health problems, who make up a large proportion of emergency admissions, these out of hospital services can be especially important. Ongoing unpublished work at the Nuffield Trust has continued to track these trends. It shows a levelling off in the increase of emergency admissions since 2010 when adjusted by age. Underlying this, analysis shows that while admissions resulting in stays of one day continue to rise, admissions resulting in stays of less than one day have been relatively stable for the past two years.

Evaluation of Programmes Aimed at Reducing Emergency Admissions There have been many attempts to enhance the provision of community care in order to improve preventive management of people with long term conditions. Such programmes aim for improvements in efficiency and patient quality of life and are intended to reduce the level of avoidable emergency admissions. However the evidence of success for these is not promising.116 Recent research by the Nuffield Trust looked at trends in emergency admissions for patients with conditions classed as “ambulatory care sensitive” (ACS). These are a group of conditions where it is felt that hospital admission can be reduced by good quality primary and preventive care. For some conditions such as angina, we saw reductions in hospital admissions—an indication of better health in the population and better services. However these gains were offset by increases in ACS admission for a range of other conditions—typically linked with older people Overall, we found ACS admissions were rising, with no sign that initiatives aimed at improving preventive care had led to a reduction in emergency admissions relating to ACS conditions.117 114 Blunt I, Bardsley M and Dixon J (2010) Trends in emergency admissions in England 2004–2009. London: Nuffield Trust 115 Vermeulen MJ, Ray JG, Bell C, Cayen B, Stukel TA, Schull MJ (2009) Disequilibrium between admitted and discharged hospitalized patients affects emergency department length of stay. Annals of Emergency Medicine 2009 Dec: 54(6) pp. 794–804 116 Purdy S, Paranjothy S, Huntley A, Thomas R, Mann M, Huws D, Brindle P, Elwyn G (2012) Interventions to reduce unplanned hospital admission: a series of systematic reviews. Bristol University 117 Bardsley M, Blunt I, Davies S and Dixon J (2013) Is secondary preventive care improving? Observational study of 10-year trends in emergency admissions for conditions amenable to ambulatory care. BMJ Open http://bmjopen.bmj.com/content/3/1/e002007.full cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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We have undertaken a series of more specific studies tracking patient pathways and looking for reductions in emergency admissions. One study evaluated eight interventions which were part of the DH’s Partnership for Older People Projects initiative, aimed at providing more care outside hospitals. Our detailed analysis of eight projects did not find that any of them leading to a fall in emergency admissions beyond what we would have expected.118 We have also examined the North West London Integrated Care Pilot—a large scale initiative involving integrated management, multidisciplinary teams and shared data, which aims to improve care co-ordination for adults over 75 or living with diabetes. Ambitious targets were set for a 20% reduction in emergency admissions during its first year. However, our study showed no significant changes in emergency admission rates. Our report emphasised the importance of allowing sufficient time for complex projects to mature before they can be expected to deliver reductions in admission, and the importance of long term planning to allow them the time to do so.119 This is of special relevance, as the DH with other national bodies recently launched an initiative to encourage more integrated care through the integrated care pioneers, announced on 14th May.120 The Nuffield Trust’s 2012 evaluation of telehealth systems, part of the Department of Health’s Whole System Demonstrator trial, found that patients using telehealth experienced significantly fewer emergency admissions than a control group. However, there were compelling grounds for caution: the evaluation found no statistically significant evidence for cost efficiency, and a sharp rise in emergency admissions among the control group at the start of the trial may have reflected the discovery of unmet need through the trial process.121 We have observed how a programme to improve care quality for those at the end of life was associated with reductions in emergency admissions. Our research found that palliative care provided by the Marie Curie Home Nursing Service was associated with a reduction in all forms of hospital use, including emergency admissions, and resulted in a higher proportion of people dying at home. In this case an established and well-coordinated short term programme was seen to deliver reduced hospital use.122 Analysis by The King’s Fund in 2012 examining variation in emergency admissions showed that areas with well-developed integrated services targeted at the elderly tended to have lower rates of bed use by patients over 65 admitted as emergencies.123 It is possible that access to emergency care and services may contribute to changes in demand. Research has shown that people living further away are less likely to attend an A&E department.124 Upcoming work by the Nuffield Trust will look to provide further insight on this issue. May 2013

Written evidence from Dr Timothy Whelan (ES 30) I have been a full-time GP on the Isle of Wight for 20 years. Emergency care is an integral part of my daily work, but I also work shifts for our out-of-hours (OOH) co-operative staffed by local GPs. I am currently participating in a pilot project to determine whether the presence of a GP in our local Hospital Accident & Emergency Department (A&E) and Medical Admissions Assessment Unit can reduce the number of emergency admissions (the answer seems to be: not much). My hospital service is historical, but I worked as a junior doctor in the Oxford Accident Service and in neurosurgery and cardiothoracic surgery (including trauma) in the 1980s before joining the Army as a medical officer. There, I served with the airborne forces where we trained to manage potentially large numbers of casualties under adverse conditions. Subsequently, I have utilised this experience in rehearsing Major Incident Medical Management and Support (MIMMS) since this was promoted by the Department of Health in 2000. I am a Member of the Royal College of General Practitioners and was appointed a Clinical Commissioning Champion by them in 2009–10. I am also one of our “sandwich generation”, responsible for my 90 year old widowed mother living alone at a distance, as well as a daughter in Wales and a son in Scotland. 118 Steventon A, Bardsley M, Billings J, Georghiou T and Lewis G (2011) An evaluation of the impact of community-based interventions on hospital use. London: Nuffield Trust 119 Nuffield Trust and Imperial College London (2013) Evaluation of the first year of the Inner North West London Integrated Care Pilot. London: Nuffield Trust 120 Department of Health (2013) Integrated Care and Support: Our Shared Commitment https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/198748/DEFINITIVE_FINAL_VERSION_Integrated_Care_and_Support_-_Our_Shared_ Commitment_2013–05–13.pdf 121 Steventon A and Bardsley M (2012) The impact of telehealth on use of hospital care and mortality. London: Nuffield Trust 122 Chitnis X, Georghiou T, Steventon A and Bardsley M (2012) The impact of the Marie Curie Nursing Service on place of death and hospital use at the end of life. London: Nuffield Trust 123 Imison C, Thompson J, Poteliakhoff E (2012) Older people and emergency bed use: Exploring variation London: The King’s Fund 124 Hull SA, Rees Jones I, Moser K (1997) Factors influencing the attendance rate at accident and emergency departments in East London: the contributions of practice organisation, population characteristics and distance. Journal of Health Services Research & Policy 1997 Jan: 2(1) pp. 6–13 cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Summary — The NHS has become an international Health Service, treating people in Britain from all parts of the world, and is increasingly predominantly reliant on staff trained abroad (not just nurses and doctors, but also staff of residential care homes); nowhere is this more apparent than in emergency care. — A&E departments have always been frantically busy places to work; the rise in attendances has been going on for many, many years and the 2004 GP Contract was but a milestone along the way. The important difference now is that there is so much more effective treatment to offer. — The recent sharp rise is an inevitable (if unexpected) consequence of the loss of continuity of care in primary and secondary care, arising from modern work patterns, part-time and shift working. — Patient factors are becoming well known to the public: expanding population, net immigration (but not bringing 50 fully trained GPs, familiar with NHS practice, with every 100,000 people), fragmented families, more elderly people with yet more complex combinations of illness, greater exposure to health information (every tingling finger is a stroke until proven otherwise), society’s expectation of immediate answers to every query, etc. — Doctor factors are generally less well known, but if more work is to be done in primary care, where will all these doctors come from, especially in remote or rural areas where it is already difficult to recruit them? A huge swathe of older, experienced and mostly full-time GPs is due to retire even before the next general election. Their replacements will be fewer in number (training posts have had to be closed for want of good quality applicants), mostly part-time, used to working limited shifts, and less comfortable with bearing the responsibility of risk. — Many primary care premises are privately owned by these retiring doctors, so may be lost; young GPs are also averse to taking on the large personal loans needed to but in to these partnerships. NHS England has just announced, in its Premises Cost Directions 2013, its unwillingness to provide much support for the development of new premises—so where is all this emergency work going to be practised in primary care? — If we want more UK trained full-time equivalent doctors, consider positive selection of male applicants for medical school. — Send a small delegation to Stornoway in the Outer Hebrides and Wick in northern Scotland to see how emergency care is organised in such remote rural places. There is notable reliance on helicopters for evacuation of the more seriously ill. — Send another delegation to Camp Bastion in Afghanistan to see supremely capable emergency care of the very severely wounded, with the essential apposition of resuscitation facilities, diagnostic scanning and the operating theatres beside each other. (A soldier badly wounded in Afghanistan has more chance of survival than a civilian similarly injured in a British city). — Read the excellent and concise report published by the Royal College of Physicians last year “Hospitals on the Edge”. — Learning from mass casualty and military experience, triage (sorting—from the French verb) should be conducted by the most senior and experienced medic available. The opposite is currently the system used in most civilian emergency care, which relies on non-clinical telephonists (or nurses, at best) working through lengthy and necessarily cautious protocols. One solution would be to have doctors and nurses working together to respond to the initial calls for assistance. (The Stour Practice in Christchurch, Dorset published the benefits of such a high-level telephone triage system over 10 years ago). Appropriate calls could be referred to GP care rather than A&E so long as the staff (including receptionists, pharmacists and nurses) and premises were all made available and funded at anti-social hours. — Alternatively, perhaps we should accept the preference of the population to attend A&E for all types of perceived emergencies and plan to treat them there, with the required number of staff made available. — Only a King Canute would be fooled into thinking that we can make the tide of emergencies decline; a moment’s reflection on the underlying factors discussed above should make us all plan for a continuing increase. — Finally, if I may borrow from the French novelist Antoine de Saint Exupery: if you want to build a boat, do not simply send out men to find wood and then give them a list of construction tasks; teach them instead to long for the endless immensity of the sea, for that will spur them on to create a ship. Clinical Commissioning offers an overview of primary, secondary and social care, which should all be adapted to play their roles in concert. May 2013 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Written evidence from NHS Direct NHS Trust (ES 31) EXPERIENCE TO DATE OF THE TRANSITION FROM NHS DIRECT TO THE NHS 111 SERVICE Summary — The national rollout of NHS 111 as the new front door to the NHS had the potential to significantly affect the urgent and emergency care system. Despite this, and the piloting of NHS 111 services, the potential impact of the new service was not evaluated ahead of the national specification and local procurement of the service. — Key differences between NHS 111 and the NHS Direct service it replaced are important to the wider urgent and emergency care service. NHS 111 does not aim to promote self care as its first premise, uses less clinical input in assessments, uses clinical content that is new to the urgent care setting, meets a narrower range of patient needs, and is a telephone-only service. — The procurement process for NHS 111 has led to the imposition of contracts which are contributing to the poor performance of NHS 111 services around the country. — NHS Direct supported the central concept of a free-to-call memorable three digit number, integrated into NHS urgent and emergency care services. As the programme developed, NHS Direct raised serious concerns about the potential impact of the service and its governance and leadership. — As the NHS 111 service was rolled out on a large scale in the days preceding Easter 2013 acute problems emerged across the system. It was clear soon after the launch that NHS Direct had insufficient capacity necessary to handle the volume of calls to its NHS 111 services, the most significant problem being the unexpected length of calls. Patient safety was paramount and prompt action was taken with commissioners to stabilise the service in the immediate days after launch. NHS Direct’s 111 services have been running on a stable basis since Easter albeit at reduced volumes.

Background 1. The Secretary of State announced in August 2010 that a new free to call three digit number would be introduced in every part of England to enable patients to access non-urgent NHS care, and that when rollout was complete the NHS Direct 0845 service would close. The new NHS 111 service, designed to provide one- stop signposting to face to face care, was quite different from NHS Direct’s national multi-channel health assessment, advice and information service. NHS 111 was nationally speciﬁed but locally commissioned; procured on a competitive basis; telephone only; and relied on a different set of clinical content which was newly applied to urgent care. The Department of Health (DH) set a national timetable for procurement and rollout of NHS 111 by April 2013.

The Potential Impact of NHS 111 2. The new NHS 111 service is a significant new entry point to NHS urgent and emergency care services. As such, the potential impact of the service on the wider NHS system was a crucial issue in considering how the service should be developed and implemented. Despite the enormous significance of NHS 111 for the operation of the emergency and urgent care system and resources, the objectives and benefits of the NHS 111 programme were never accurately identified, articulated or quantified for commissioners or potential providers of NHS 111 and other affected NHS services. 3. NHS 111 was piloted in four areas of England in 2011 and 2012. NHS Direct provided three of the four pilots. National specification and local procurement proceeded ahead of the publication of the independent evaluation of the NHS 111 pilot services by Sheffield University commissioned by the DH. Publication was delayed until October 2012—after the vast majority of NHS 111 contracts had been let. The final Sheffield evaluation was unable to reach a conclusion as to the likely impact of NHS 111 on the wider NHS urgent and emergency care system. The pilots continued to operate alongside the NHS Direct 0845 service in each of the pilot areas—so the switch of calls from 0845 to 111 was not tested or evaluated as part of the Sheffield study. It is also worth noting the difference in cost of the pilot projects evaluated by Sheffield (around £13 per call without overheads) and the price paid by local commissioners for the actual service they procured (around £7.50 including overheads). This dramatic difference in cost is largely accounted for by a reduction in qualified clinical staff. A service with fewer clinical staff is less able to handle health enquiries and more likely to direct callers to face-to-face services. 4. It is too early for a definitive analysis of the actual impact of the NHS 111 service since the major launches in March. However, early data does suggest that urgent and emergency care services are being adversely affected by increased demand relating to NHS 111.

Key Differences between NHS 111 and the NHS Direct Service 5. There are a number of key differences which are driving the impact of NHS 111 on the wider NHS and increasing pressure on urgent and emergency care services. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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NHS 111 does not have an objective of supporting self care or reducing demand on other services 6. NHS Direct’s 0845 service was created in 1998 to improve access to health information and advice and to enable patients to care for themselves. Between 2007 and 2011, NHS Direct increased the proportion of calls completed within NHS Direct from 44% to 54%. This success did not become a guiding principle of the new NHS 111 service. As Professor Matthew Cooke, then National Clinical Director responsible for NHS 111, made clear “NHS 111 was not introduced to reduce use of NHS services. It was introduced to simplify and improve access to urgent care services for the public and patients”. It is therefore not surprising that in the NHS 111 pilots run by NHS Direct only about 8% of patients using the service were given advice to look after themselves without the need for onward referral (see appendix 1).

NHS 111 uses significantly less qualified clinical input than NHS Direct 7. In the NHS Direct 0845 service, callers are initially assessed by a trained “Health Advisor”, with approximately one in two passed on to speak to a nurse to receive a more detailed clinical assessment. In NHS 111, all patients are assessed by a call handler using the NHS Pathways system, with about one in five passed on to a nurse who “validates” the outcome reached by the call handler or assesses patients with more complex needs. The clinical content of Pathways deals with the emergency cases such as chest pain and breathing difficulties, but appears less able to support call handlers to signpost callers to an appropriate level of care. As a result of less clinical input a far higher proportion of callers being directed to other NHS services rather than supported to care for themselves.

The NHS 111 clinical content is being newly applied to an urgent care setting 8. The NHS Pathways content is immature, was not, on the whole, designed for use in an urgent care setting and appears to be more risk averse than its predecessor system used by NHS Direct. There are also concerns that the position of NHS Pathways as an effective monopoly supplier within DH reduces its responsiveness to issues raised by providers of NHS 111. Within the past two weeks, a new release of the Pathways content has been made with minimal assessment of its impact on providers or commissioners in respect of additional referrals to face-to-face services.

The nationally speciﬁed NHS 111 service does not provide for some important patient needs 9. Many callers to NHS 111 do not have emergency or urgent needs but have low level or routine health needs that, with further assessment by a clinician, can be supported to self care. Other callers to the NHS 111 service have general health enquiries. However, there is little provision for health information, complex medicines enquiries or dental advice within NHS 111. The result is that many callers are referred unnecessarily to face to face services when they could have their health enquiry dealt with over the telephone therefore not requiring expensive and in some cases unnecessary face to face healthcare.

NHS 111 was speciﬁed and procured as a telephone-only service 10. In marked contrast to the direction of travel of other consumer and public services, NHS 111 replaced NHS Direct’s multi-channel suite of highly successful, cost effective and popular digital offerings, with a telephone-only service. 11. NHS Direct launched its “Health and Symptom Checkers” in 2009, to provide a more cost-effective means of accessing health information and advice, as well as responding to the way in which the public now use web and mobile technology. The NHS Direct website and apps offer online advice with the ability to speak to a nurse where required. By 2012 this on-line service was being used around 11 million times per year. 12. In October 2012, when NHS England took over responsibility for NHS 111, they recognised the valuable capabilities within the 0845 service that were not being replicated locally in NHS 111. Rather than see these services disappear in March 2013, they agreed contracts of 12–24 months for the continued provision of complex health information and medicines enquiries, dental nurse assessment as well as the online service.

The procurement process, timing and pricing 13. The procurement process for NHS 111 has led to the imposition of contracts which are contributing to the poor performance of NHS 111 services around the country. Procurement coincided with momentous organisational change within the NHS. In many cases, those responsible for procurement had no stake in the sustainability of the service they were commissioning. Tendering took place in advance of the publication of the evaluation of the pilots and with limited meaningful clinical input from the embryonic CCGs. 14. The first procurement of NHS 111 commenced in August 2011, in the North East of England. The commissioners imposed a maximum cost of £7.80 per call, a block contract that transferred the risk of higher call volumes to providers, and financial penalties of up to 25% for failing to meet key performance indicators, significantly above the standard NHS contract. (See appendix 2). 15. The North East procurement set the approach for others in terms of specification, price and approach and this pattern persisted through virtually all subsequent NHS 111 procurements. The maximum price set by cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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commissioners ranged from £7 to £8 per call. In retrospect, this price was too low and the resulting lack of resources in the new service contributed signiﬁcantly to the service problems that arose at launch. The drive to commission the cheapest service was raised as a concern in an OCG Gateway review of the NHS 111 programme issued to the SRO in December 2011: “The [OGC] review team had some concerns that the procurement exercise may focus too readily on achieving implementation for the lowest possible cost. It is important to ensure that prospective cost envelopes are set at a level that is not only affordable but also supports appropriate quality of service to support service redesign.”

NHS Direct’s Response to the Introduction of NHS 111 16. NHS Direct welcomed the benefits of a free-to-call memorable telephone number for urgent care and embraced the potential for greater integration with local services offered by the NHS 111 concept. 17. Throughout the process, NHS Direct has aimed to contribute its experience of multi-channel remote and virtual health assessment, advice and information to the development of NHS 111 as well as the knowledge it accumulated during the NHS 111 pilots. Working constructively with DH colleagues, the leadership of NHS Direct has expressed serious reservations about the way in which NHS 111 has been specified, governed and implemented. 18. In February 2012, NHS Direct publicly supported calls from the BMA and other organisations for improved CCG engagement and to allow greater time for the development of NHS 111 services in the light of the independent evaluation of the four initial NHS 111 pilots. All parties felt that this would give CCGs the necessary time to understand the service they were taking on and its potential impact on their local health communities. 19. Concerns were raised in an OGC Gateway review of the NHS 111 programme in the Autumn of 2011 about the potential impact of the new system. 20. NHS Direct also raised its concerns at the potential impact of the switch from the 0845 service to 111, and the lack of appropriate action arising from the OGC review. These concerns were raised at the NHS 111 National Programme Board, with the three senior responsible officials at DH. (See appendices 3 and 4). 21. Once the nature of the NHS 111 contracts had become clear, with a very low price point and very high levels of risk transferred to providers, NHS Direct seriously considered whether it should bid for NHS 111 services. The models and operational assumptions underlying NHS 111 delivery were revisited and after very careful consideration, the decision was taken to bid to provide the NHS 111 service to commissioners’ requirements, even though the Board had significant reservations about the nature of the service that was specified and the procurement approach. 22. NHS Direct competed in many of the local procurements to provide NHS 111. It was appointed in eleven areas, covering 34% of England’s population.

NHS Direct’s Experiences since Launch 23. As the NHS 111 service was rolled out on a large scale in the days preceding Easter 2013, acute problems emerged across the system. In respect of NHS Direct’s services, it was clear soon after the launch that there was insufficient capacity necessary to handle the volume of NHS 111 calls. 24. The most significant issue was that calls took more than twice as long as expected. As a result NHS Direct’s 111 services did not have sufficient front line capacity to handle all of the calls that it received, and calls had to be diverted back to GP out-of-hours organisations and to the 0845 service (which had been retained for three months as a contingency in the event of slippage in NHS 111 rollouts). 25. Patient safety remained paramount throughout this period, and decisive action was taken with local commissioners, and other NHS providers to overcome these problems and to provide a stable and satisfactory service. A summary report of the performance of NHS Direct’s 111 services and the 0845 contingency service is attached as appendix 5. 26. NHS Direct’s Board reviewed the safety of its NHS 111 services at its public meeting in April 2013. The conclusion reached at that stage was that whilst there had been a number of incidents there was no evidence that the calls handled by NHS Direct had directly led to patient harm nor that there was a higher incidence of adverse events than in NHS Direct’s other services. The paper presented to the Board is attached as appendix 6. 27. The Board of NHS Direct, NHS England and the NHS Trust Development Authority jointly commissioned an independent review of the root causes of the service failures at NHS Direct when it launched its NHS 111 services. 28. NHS Direct is currently in discussion with local commissioners, NHS England and the NHS Trust Development Authority on continuing to provide safe and stable service for 2013/14 whilst a national review cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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of the NHS 111 programme is undertaken, as well as an assessment of our overall ﬁnancial position, and discussion at a national and strategic level of future viability and options. May 2013

APPENDIX 1 EVIDENCE PRESENTED TO THE DEPARTMENT OF HEALTH TO SHOW POTENTIAL IMPACT (BASED ON A POPULATION OF 500,000) cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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0845 46 47 SERVICE & NHS DIRECT-LED NHS 111 PILOTS—COMPARING REFERRAL RATES

APPENDIX 2 LETTER FROM NICK CHAPMAN, NHS DIRECT CHIEF EXECUTIVE TO DAVID HAMBLETON, DIRECTOR OF COMMISSIONING DEVELOPMENT, NHS SOUTH OF TYNE AND WEAR RE: NORTH EAST 111 PROVIDER CONTRACT NHS North East 111 Provider Contract Following confirmation that we have not been successful in your procurement for a 111 service, I wanted to write to you personally to explain why we were unable to submit a compliant bid. Over the last 12 months we have worked very closely with you and the other commissioners to understand what you need and how we can provide it and I remain convinced that NHS Direct has a significant contribution to make in the North East to help you better manage patient demand, improve patient experience and manage your risk in being England’s first fully operational 111 service at a regional level. We believe that NHS 111 has the potential to improve patient experience and to enable the NHS to manage unscheduled care more efficiently. NHS Direct is well placed to provide a high quality service for the North East and deliver the aspirations we believe commissioners are looking for, many of which resonate with your own specification: — NHS 111 will be a high quality service, focussed on the needs of the caller, simplifying access to urgent health care safely—NHS Direct has the most experienced health and nurse advisors supported by robust clinical governance structures and software, all delivered locally to your patient population. — NHS 111 is a major potential QIPP contributor and will offer the best value for public money— NHS Direct’s service has been proven to reduce patient demand on primary and secondary care services by promoting self care. — NHS 111 will be multi-channel—NHS Direct’s service is tried and tested with extensive experience of connectivity to other providers (999, OOH), other remotely offered health care services (the appointments line, language services, etc) and using the web. This will maximise the impact and reduce the cost of NHS 111. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— NHS 111 will be delivered consistently 24/7—NHS Direct is not commercially conflicted or biased. We have the ability to move demand to other call centres nationally, drive patient demand to the best point for them and the NHS, and have proven disaster recovery and business continuity processes in place. Unfortunately, there were significant procurement pre-conditions which prevented NHS Direct from submitting a compliant bid and which, in our view, will prevent any organisation from providing the service without cross-subsidy from another service line. This raises serious questions about competition and opens up the potential for challenge. Should the procurement process not continue we would welcome the opportunity to talk to you further about your aspirations. We see four main risks in your specification and procurement requirements:

1. Contract Value NE commissioners have indicated that £49 million is available for the life of the contract (5.5 years). Set against the forecast level of activity (circa 1.2 million calls per annum, 6.3 million over the life of the contract) this amount equates to a cost per call of £7.80 with no additional funding for set up. Based on our experience of delivering the end to end NHS 111 service in three areas of the country we believe this contract value is insufﬁcient to deliver a high quality, safe and effective service which provides access to those who need health information and advice whilst minimising demand on local face-to-face services. In particular, the value of the nurse in 111 cannot be under-estimated in terms of reducing demand on face-to-face services. The Department’s minimum dataset shows lower referrals to 999 and A&E with higher self-care rates in the E Midlands and East of England pilots than in the North East pilot—we believe the main reason for this is a greater and more cost-effective use of nurses as part of 111 delivery.

2. Block Contract The contract is currently organised as a block contract for the first three years with no facility for additional income should the activity be above the level defined in the ITT. Additionally, commissioners have control over the marketing of the service. From our perspective this presents a serious risk to the delivery of the service. The Department remains in control of the national branding of NHS 111 and it is not yet clear how widely it will market the scope of the 111 service. For example, should the Department decide that 111 becomes a main access route over and above the patient’s GP then this could have a significant impact on volumes to the service. The national brand will drive all local communication so much of this will be outside commissioners’ control. Added to this the completely reasonable desire to use NHS 111 for unexpected incidents eg local or national health scares, will further increase call volumes. With no additional funding to meet the increased activity there will be a significant impact on providers’ ability to deliver a safe service to patients whilst meeting the service KPls, thereby leading to possible damage to the credibility of the NHS 111 brand nationally and locally.

3. KPI Failure Penalties Over the last twelve months we have worked with East of England SHA and the Department of Health to negotiate a set of KPls for the NHS 111 service. The KPls agreed reflect the need to deliver a high-quality, safe and cost-effective service which, whilst at times of high demand on the service are challenging, are, in our view, at the right level to ensure the key aims of the service are delivered. For the last 12 months these KPls have been operating in “shadow” form until there is consistent information and use of the 111 service but we have discussed financial penalties in the order of 5%. The KPI penalties in the NE contract are set at 25% with a number of KPls being 100% achievement. Assuming the scenario that demand remains within the call volumes specified we believe that the penalties for KPI failure are unrealistic. For the reasons stated above—contract value, block contract, 100% target—regular KPI failure could be a reality. The worst case scenario would be that, should KPls not be met, a maximum penalty liability to the provider would be in the region of £12 million. This, in turn, reduces the funding available to providers to deliver a safe service to patients.

4. Penalties for Delayed Go-live Date We fully appreciate commissioners’ desire to ensure there are no delays to the commencement of the service. However, in our experience of setting up the existing pilots, given the complexities of delivering this service and the co-dependencies across multiple service providers there is a high level of probability that the go-live date could be delayed for reasons outside the main provider’s control. The implications of delaying go-live for one month in the North East would result in a penalty of up to £775,000. On top of set-up and running costs risk to the provider’s ability to deliver the service is high. I trust you will read the views above with the intention that they were written ie to set out some of our concerns based not only on delivering the 0845 service but as the current largest handler of 111 call volumes. I can assure you that this is not about NHS Direct protecting or positioning itself—we absolutely believe NHS cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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111 is the right service for the public. But, we want to work with commissioners to ensure it is delivered, irrespective of provider, to achieve a high-quality, cost-effective service in these ﬁnancially constrained times. I would be happy to discuss any of these points with you either on the phone, or face-to-face. In view of the wide signiﬁcance of procurement, I have taken the step of sending a copy of this letter to Ian Dalton, David Flory and Jim Easton. We sincerely hope that we can work together with you so that patient experience is enhanced, demand managed and risk minimised. That is NHS Direct’s promise to you. 29 September 2011 cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

Ev w66 Health Committee: Evidence (SV—Jan 2012—in progress) the transformation of localDoS, urgent Clinical care Governance services and (eg MI) move toward integrated 24hr urgent care service not (SV—for Feb board meeting) Monitor cumulative risk and(SV—Feb assumptions 2012—in at progress) a national level risks into national levelCommissioning impact Analysis assessment and(DH Intelligence—May 2012) Actions measured: APPENDIX 3 information regarding the usage of services including self care NHS 111 OGC REVIEW DEC 2011 — Provide commissioners with managementAssumptions about whole systemdeveloped impact based have on been pilotsdevelopment to of support local the 111 —Local business benefit cases profiles andare benefit in realisation Whole various plans system stagesbeing impact of established benefits just development, in should implementation with local be of targets business linked 111 cases to level for approval byDH PCTs participate and in CCGs. this SHAs111 process boards and as membersA of full local impact assessmentupdated cases at following in a final all national process evaluation remaining2012 level report areas will in in be April line with CCG approval Incorporate local analysis of business case sensitivities and Current status Expected benefits have been— defined in the Improve areas the of: public’s access— to Develop urgent healthcare overarching view Help of the people what programme use success and the looks proposals right like for service for how first this time can be — Focus on patient benefits and 111 being a catalyst for Timing rigorously and produce an review final business cases overarching national business plan for the programme. benefit targets for the programme and establish monitor their achievement. performance measures to This paper provides a summary of the recommendations from the OGC review of the programme carried out in December 2011 and the proposed actions to be taken. It is provided 2 The programme team should Do By end March 2012 111 business cases are being produced at a local Formalise plan for DH to scrutinise local 111 business Ref1 Recommendation Define and agree specific Do Now Recommendations and action plan—January 2012 v0.4—Incorporating comments from Jan 111 programme board and updates on progress 1. Purpose to the 111 programme board for approval. 2. Recommendations and Draft Action Plan cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

Health Committee: Evidence Ev w67 level services Actions RCGP to ensure thatto they the can programme challenge ascomplete) and a provide key input stakeholder Invite(CB—Jan BMA 2012— to attend(DH—Feb the 2012) national 111 programmeUse board the CCG signEngland up in tracking other tool SHAMonitor developed clusters the in(SV—Jan appointment South 2012—complete) of of an clinical indicator leads of in clinicalprogress) local engagement areas(SV—Feb as 2012—in Incorporate Clinical Governance reviewtracker point as into measure CCG of2012—complete) clinical engagement (SV—Jan captured (CB—Feb 2012—in progress) Create an additional document targeted at CCGs that how 111 works in their area and howlocal it determination is(SV—Jan implemented. 2012—complete) In can accelerate the learninganalysts—Jan from 2012—in the progress) liveReview pilots risk(DH of delayedboard lessons and learned agree at any the necessary Feb action 2012 (Board—Feb 2012) monitoring progress in the areas of: — Population of— the directory of services at Procurement a and local Establish mobilisation regular of monthly call reportingoffice handling upwards and to ministers top(SV—Jan of 2012—complete) the Current status CCGs are required toand approve service local specification business forLMCs cases 111 are engaged atRegular a meetings local Increase are level engagement heldbodies with with at BMA, GP a NHS representative national Alliance,RCGP level RCN and and NHS Allianceprogramme are board represented on the regularly at the SHAspecialist leads working group groups and thatcommissioners the support rolling other out theThe service final evaluation ofavailable the in national Feb pilots 2012 Assumptions will practical regarding be lessons whole learned systembeen that impact developed may have at not a otherwisecommunicated national be to highlights level commissioners. the and These choicesupdated will particular that following be highlighting commissioners the areas have finalRegular of regarding evaluation publication specification of that the are MDS for Explore whether the useCurrent of plans un-validated, and up controlsprocurement to are and date focussed mobilisation data on dates Service tracking readiness process assuresgovernance that Develop arrangements clinical overarching and plan directoryare and of in process services place for prior actively to launch — Local arrangements CCG signup and clinical governance Timing sought on the effectiveness of development of business cases programme management assure progress against agreed milestones. engagement with CCGs and ensure that all GP representative bodies have meaningful and appropriate engagement with the programme. pilot areas are applied in the and service specifications for procurement of local contracts. framework to monitor and Ref3 Recommendation Clear evidence should be Do Now 4 Ensure lessons learned from Do By Feb 2012 Lessons learned from the pilots are being shared5 Convene workshop including all live sites Apply to a pick more up rigorous Do Now cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

Ev w68 Health Committee: Evidence (NH—Mar 2012—in (SV—Feb 2012— (DH—Jan 2012—in progress) (TBC—Mar 2012) Actions Monitor delivery capacity riskdifferent as areas providers(SV—ongoing) are appointed in progress) Review plans with QIPPcomplete) PMO Incorporate escalation to Executivecontrol Group process into(SV—Feb change 2012—inArrange progress) review meetings betweenand Jim SHA Easton, Cluster Miles SROs Ayling (DH—May 2012—in progress) Current status The 111 SRO haspart been of invited the to process representGuidelines 111 have as been producedteam by in the DH Primary regardingservices Care the commissioning of Work OOH with Primary Care teamteam to to develop support to guidance the 111 specific DoS commissioners roll out and project office and bottlenecks part of the development of the NHS Pathways/CMS commercialisation strategy develops Timing capacity where necessary. guidelines to address the by an impact assessmentthe to 111 service. commercialisationpotential conflict of interest. commercialisation strategy exercise and strengthen NHS Pathways are informed NHS Pathways Ref Recommendation 7 The Programme8 Team issue Do Now Undertake a resource mapping Do By end March 2012 Additional resources are being added to the central Undertake independent assessment of resource requirements 6 That any future decisions on Do prior to decisions on DH Informatics are completing a risk assessment as Update programme board as NHS Pathways cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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APPENDIX 4

EMAIL FROM NICK CHAPMAN, NHS DIRECT CHIEF EXECUTIVE TO NICK HALL, HEAD OF URGENT & EMERGENCY CARE, DEPARTMENT OF HEALTH RE: OCG GATEWAY REVIEW ACTION PLAN:

Thank you for giving the 111 Programme Board the opportunity to discuss the OGC Gateway Review report and your proposed response. Having listened carefully to the discussion, I remain convinced that the proposed plan will not adequately mitigate the risks highlighted in the review and I felt it was appropriate to put this in writing to you and senior colleagues.

As you know, the review team highlighted a potential major risk of unplanned consequences from the current rollout plans for providers of urgent care services, particularly GP OOH care and the ambulance service. The Review team recognised this as “a potential major risk requiring major attention”. They went on to say “It is imperative that every opportunity is taken to evaluate and learn lessons from areas implementing pilot schemes prior to completion of service speciﬁcation and procurement of longer term contracts.” Without this learning, procurement exercises will be based on limited understanding of the potential impact on the urgent care system, with patchy “buy-in” from Clinical Commissioners.

Unless decisive action is taken now, OJEU-style procurements covering 75% of England’s population will commence by the end of February, locking future clinical commissioners into inﬂexible long term contracts with potentially adverse consequences for the achievement of QIPP targets and the stability of the urgent care system.

It is entirely possible to achieve rapid roll-out of 111 without locking the NHS into inﬂexible long term contracts for a service about which our collective understanding is still evolving. This could be done through wider adoption of the collaborative pilot approach being applied in some parts of the country, enabling the service to develop in response to emerging experience and commissioner requirements. Taking this approach would not hold up plans for nationwide coverage by April 2013.

We remain fully committed to the success of 111, and would be happy to continue to support you in exploring how this might be taken forward. Thu Jan 12 17:51:42 2012

APPENDIX 5

NHS DIRECT’S 0845 CONTINGENCY AND NHS 111 PERFORMANCE REPORTS AS OF 16 MAY 2013

111 DAY BY DAY SUMMARY TO 16 MAY cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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0845 CONTINGENCY DAY BY DAY SUMMARY TO 16 MAY

APPENDIX 6 BOARD PAPER: INCIDENTS & FEEDBACK FOR 111 SERVICES Agenda Item: 11.2 Reference: 13B.043 Trust Board Meeting: 29 April 2013

Summary This paper is intended to provide the Trust Board with insight into the challenges we have experienced since 18 March 2013 regarding the incidents and feedback relating to our NHS 111 and contingency services. Over the period 18 March to 11 April 2013 we have identiﬁed: — Eight serious incidents to date, but none, which at this stage of our investigations, indicate any serious harm caused by any act or omission by our services. — 12 compliments, 13 comments and 76 complaints from patients. 52 of the complaints were resolved in one working day and 24 formal complaints are still being investigated pending written response. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— Positive feedback from patients has been about professionalism of staff and speed of service. — Main areas of concern regarding feedback from patients were long waits for no access, complexity of process compared to previous system and outcome of assessments. — We have received a significant amount of feedback from health and social care professionals (HPF), mainly from ambulance services and GP OOH services. Of the HPF that we have received relating to calls within this reporting period there are 528 cases that we have had sufficient information to undertake an investigation. The main areas of concern expressed through HPF were regarding: — access to the service for patients; — outcome of assessment (mainly relating to unnecessary referrals, ie outcomes too high); and — technical issues experienced by call handlers regarding transfer of referrals to other services (mainly GP OOH services). Specifically over the four-day Easter weekend, to date, we are aware of one serious incident, 16 complaints (all dealt with in one working day) and 42 HPFs. At the time of writing this report we are still receiving feedback about the Easter weekend and we may become aware of incidents in the future that relate back to this period too. Incident and feedback activity will continue to be reported through the routine Clinical Governance reporting routes externally to commissioners and internally to the Board Clinical Governance Committee and Trust Board.

The Board is Requested to Consider the following Issues — None of the incidents identiﬁed to date suggest harm caused by NHS Direct’s act or omission; — The experience of patients and health professionals outside of NHS Direct; and — Signiﬁcant resources being used to investigate and respond to incidents and feedback.

1. Introduction 1.1 The recent launch of our bigger and more recent NHS 111 services has been challenging. This has resulted in an increase in the rate of feedback we have received from patients, the public and health professionals in the wider NHS and has been the subject of signiﬁcant local and national media interest. The purpose of this paper is to provide a brieﬁng to the Trust Board on the range of incidents that have occurred and the feedback we have received during this period; 18 March to 11 April 2013. This includes any serious incidents and feedback relating to our NHS 111 services and the contingency core service launched on the closure of our core 0845 46 47 service on the 21 March 2013. The results of our investigations into each of these incidents and items of feedback will be provided externally to commissioners through the routine “SitRep” process and the NHS 111 Service Clinical governance Fora and internally through the usual reporting route to the Board Clinical Governance Committee.

2. Incidents 2.1 To date we have identified eight serious incidents, which occurred during the period 18 March to 11 April 2013. The criteria for what constitutes a serious incident is agreed with commissioners and the Department of Health in readiness testing prior to go-live of the service. This is common with the definition applied across the wider NHS and our identification of a serious incident does not necessarily suggest that harm was caused as a result of the use of the NHS 111 service. As some of these incidents are relatively newly identified, we may have limited information at this stage. All these incidents will be subject to an investigation, the findings of which will contribute to wider learning and be routinely reported externally to commissioners and internally to the Board Clinical Governance Committee and then to Trust Board. 2.2 From what we do know about these eight incidents, none indicate any serious harm caused by any act or omission by our services. To date only one serious incident relates to the Easter weekend, but we may become aware of incidents relating back to this period in the future. Any incidents discovered in the future will be investigated and findings reported to the Board Clinical Governance Committee and then to the Trust Board. 2.3 The headline issues for the eight incidents are as follows: two relate to delay in accessing the 111 service; two relate to the outcome of the 111 assessment not being urgent enough; two relate to delays in verification of expected deaths; one relates to a delay in follow-up by a GP OOH service; and one relates the appropriateness of a referral back to a GP OOH service.

3. Complaints 3.1 We have received 76 complaints about our NHS 111 services for calls between the 18 March and 11 April with 52 being resolved in one working day and 12 being escalated as formal complaints requiring a written response. The main themes from complaints by patients/callers were: — 18 about assessments, call-backs or visits subsequently made by GPs following 111 calls; — 12 about access to the service; cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— 12 about the assessment process itself; — nine about the call handling process, such as collection of demographic information; — seven about the attitude of staff; — seven about length of time for call-back from the 111 service; and — the remaining 11 were other issues, such as incorrect information, both in DOS and/or given incorrectly by staff. 3.2 All complaints received are subject to review and feedback to the complainant. The outcome of our investigations will also be shared externally to commissioners through the agreed reporting route and internally to the Board Clinical Governance Committee and subsequently Trust Board.

4. Health Professional Feedback 4.1 As part of the Clinical Governance processes agreed by commissioners and the Department of Health, professionals in the wider health and social care services are strongly encouraged to provide feedback to providers on any individual patient or general service issues about NHS 111 services. However, during the period 18 March to 11 April we have received a signiﬁcant amount of feedback from health and social care professionals through the agreed process. The quality of information provided in this feedback has varied and in many instances we have had to request further details in order to commence a review of the calls. This has ranged from an ambulance service sending one form with 65 patient reference numbers for all non-conveyances (where paramedics attend, but do not transport the patient to hospital) to a GP OOH provider sending a single form, again with multiple patient reference numbers and a request to “look at these calls”. 4.2 Of the signiﬁcantly higher number of total forms received, 528 cases have been logged where we have been able to identify the patient and the nature of the feedback. Each of these cases will be looked at and a senior clinician will review the feedback and our records of the call. At this stage, it is not possible to say what proportion of these we’ve “upheld”, as many are relatively recent and still under investigation; however, the nature of this feedback includes: — 191 cases regarding the outcome of the call and the level of referral, mainly that the outcomes were too high, ie patient required less urgent level of care; — 117 issues with the quality of the Pathways assessment; — 67 issues with the call handler not following procedure, or providing incorrect information; — 56 cases regarding access to the service; — 50 relating to incorrect information given to patient or health professional, some being DOS issues and some being call handler error; — 13 cases regarding the advice given to the patient; and — The remainder relate to other issues, such as length of call-back time, no reply on call-back and incorrect advice given. 4.3 All cases raised through health professional feedback will be subject to review and feedback given to the health professional raising the issue. The outcome of our investigations will also be shared externally to commissioners through the agreed reporting route and internally to the Board Clinical Governance Committee and subsequently Trust Board.

5. Compliments and Comments 5.1 We have received some compliments during this period; however, due to the pressures on the services and our need for staff to be available to our patients, they are potentially not being particularly proactive in documenting/reporting positive feedback when it is received, which is perfectly understandable. The 12 compliments that have been reported include: potentially saving the life of a patient who had an ambulance sent; Chief Operating Ofﬁcer of a CCG receiving face-to-face positive feedback from a patient at an engagement event unrelated to NHS 111; and general positive comments about the friendliness and efﬁciency of the service and advice given. We have also received 13 comments about the service; these are feedback from patients, the public or health professionals that are neutral in nature, not requiring investigation and often are just suggestions about service improvement.

6. Core Service and NHS 111 Contingency 6.1 In some instances we have used internal contingency arrangements to provide continuity of service for our NHS 111 services. This has included handling NHS 111 calls through the core service contingency service. In addition to this we continue to provide a contingency service to some of England who don’t yet have the NHS 111 service fully in place following the ofﬁcial closure of our core 0845 46 47 service on 21 March 2013. 6.2 To date we are not aware of any serious incidents associated with either core service contingency or NHS 111 contingency. We have however received some feedback regarding calls associated with this. There have been three complaints from patients, all of which were resolved within one working day; these related to: cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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delay in access; delay in call-back from a GP OOH service; and access to emergency dental services following an assessment. 6.3 We have also received 15 items of feedback from health and social care professionals, which included: eight cases regarding incorrect information given about a referral to another service, which includes information not being correct in Directory of Services and staff not giving information correctly; two cases regarding delay in accessing the service; and other issues, such as demographic information not documented correctly and incorrect advice being given. All of these items of feedback will be investigated through the agreed process with feedback to the health professional raising the issue and the outcome of these investigations will be reported externally to commissioners and internally through the usual route to the Board Clinical Governance Committee. Accountable ofﬁcer: Author of paper Clinical Director/Chief Nurse Head of Clinical Governance 17 April 2013

Written evidence from Myasthenia Gravis Association (ES 32) Myasthenia Gravis Association (MGA) is a registered charity established in 1976 with three objectives: care; research and education. MGA represents a high proportion of estimated 8,000 myasthenia patients in the UK and Ireland. Myasthenias are rare diseases associated with varied disability, ranging from mild to severe muscle weakness. If untreated or when breathing and eating are affected the result can be life threatening—medical emergency and hospital admission are regular experiences for our members.

The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas For those with rare and life threatening conditions such as myasthenia it is unlikely that a community setting would be appropriate for emergency healthcare. Our members report that availability of ambulances, particularly in rural areas, can be limited. In addition to the effect on response to emergencies, this can limit the time available for staff to participate in vital training to increase their awareness and understanding of less common conditions.

Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings Whether services are provided in A&E or community settings our members face the same issues of lack of understanding about the nature of their myasthenia. This can result in treatment falling short of expectations. For example, patients are often told by First Response or Triage staff that they must not self-medicate for their myasthenia while waiting for examination or treatment, even for an unrelated condition, leading to a serious deterioration in their myasthenia while in the waiting area. Another example is that ambulance crews often make a patient lie flat for a blue light ride to hospital exacerbating the respiratory problems that the myasthenic patient is suffering. MGA is currently piloting a “Patient Passport” in two NHS Trust areas—the aim of this is to provide members with a booklet that includes personal information about them and their condition to assist the health care professionals treating them who often have very limited knowledge of myasthenia. We would like to see NHS financial support for initiatives of this kind which can have very beneficial effect on the outcome of the patient’s engagement with emergency services.

The prospects for better integration of ambulance services with primary care under the new commissioning regime established in April 2013 The experience of our members is that there is not sufﬁcient link-up between paramedics, ambulance service and A&E. Under the proposed arrangements if is essential that these issues are dealt with and each part of the service should be under a single management structure.

The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge MGA would like to see more emphasis being placed on quality of service rather than speed or cost savings and would welcome measurement of how the service delivered met up to patient needs and expectations.

The implications of the shift away from determining the success of ambulance services via indicators based on response time to the new measures designed to assess clinical effectiveness Our members would like to see the quality of service assessed rather than just time based indicators. We would like to see further training for emergency service staff to give them at least a basic understanding of rare diseases such as the myasthenias. Additional training delivered as continued professional development cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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does not have to be especially time consuming or expensive—MGA has experience of delivering an hour long session to paramedics and ambulance staff in the South West area as part of a training day. We would be very happy to repeat this in other regions and would suspect that other patient bodies representing a variety of conditions would also be keen to assist in any such training programmes.

The causes of delays in handover from ambulances services to A&E or transfer between different levels of urgent care, and actions required to eliminate them The introduction of a single management structure and additional awareness training, as above, would assist with this objective. For patients with unusual conditions such as myasthenia improved handover between different medical teams, including transfer of specific information about the underlying condition and the needs of the patient would be of great benefit. Due to the nature of the condition patients are sometimes unable to clearly communicate information about their condition to those treating them—the additional difficulty of having to do this more than once is particularly challenging. MGA would like to see improved transfer of information between levels of urgent care as well as reduction in delays.

Aspects of care which are likely to improve by being located in regional specialist units and the risks associated with removing services from existing A&E provision Given the lack of knowledge of myasthenia amongst health care professionals in an emergency care setting our view is that a specialist centre is probably the best place to deliver services to people with serious and rare conditions. This assumes that the ﬁrst responders are able to identify that the person has particular care needs and ensure that these are provided in an appropriate setting. May 2013

Written evidence from the Centre for Public Scrutiny (ES 33) This response draws on our thinking about transparent, inclusive and accountable health services and health improvement; our work on health and social care; our experience of developing policy and supporting successful practical programmes; and our work with local councils and partners to help implement the reforms locally.

Key Messages — Traditional approaches to public consultation are effective or efficient ways to influence decisions and the NHS should work towards a system where patients, carers, communities and their representatives are able to influence change to the extent that “formal” consultation is not required. — Greater co-ordination by councils of healthcare, social care and health improvement can help strengthen democratic legitimacy of decisions—health and well-being boards should use their duty to involve and relationship with council scrutiny to better integrate public involvement into the development of health and well-being strategies and commissioning plans. — Flexibility and freedom for commissioners and providers to better respond to local needs is important—but forthcoming guidance for the NHS and councils about duties to involve and consult and council scrutiny should give strong weight to local accountability and public involvement, providing checks and balances to greater autonomy and “reduced burdens”. — The retention of a separate council scrutiny function and its extension to cover all commissioners and providers of publicly funded healthcare and social care is important—the Department of Health should continue to invest in the development of council scrutiny.

About CfPS CfPS (an independent charity) is the leading national organisation for ideas, thinking and the development and application of policy and practice to promote transparent, inclusive and accountable public services. We support individuals, organisations and communities to put our principles into practice in the design, delivery and monitoring of public services in ways that build knowledge, skills and trust so that effective solutions are identified together by decision-makers, practitioners and people who use services. We work across government (for example with the Department of Health, Department of Communities and Local Government, Home Office, Department of Work and Pensions), with the Local Government Association and with stakeholders across primary and acute care (for example with the NHS Confederation, NHS Alliance, Foundation Trust Network, Care Quality Commission, Independent Reconfiguration Panel). We support councils and NHS bodies individually and collectively through published guidance, events and network of expert advisers. CfPS believes public services should be transparent, inclusive and accountable. In the context of emergency services and emergency care these principles should be applied to ensure that commissioners and providers understand and respond to the needs and aspirations of local people for their health and care. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Why Transparency, Involvement and Accountability are Important Leaders and organisations building a culture based on these principles are more likely to demonstrate themselves as credible to people who use services and communities. Acting in transparent, inclusive and accountable ways means working with different people in different ways—for example citizens, people who use services and elected representatives. Our four mutually reinforcing principles of good scrutiny can be adapted to support accountability in the new arrangements: — Responding to constructive “critical friend” challenge. — Understanding the voices and concerns of the public. — Supporting independent people to take responsibility for their role. — Driving improvements in health and health services.

The terms of reference for this inquiry are extensive—our submission covers only two aspects: — the effectiveness of the existing consultation process for incorporating the views of local communities in to A&E service design; and — the ability of local authorities to challenge local proposals for reconﬁguration under the revised oversight and scrutiny powers included in the Health and Social Care Act 2012.

Public Consultation People carrying out public consultations should be clear about the value, process and expected outcome of consultation, hear the right voices and provide credible responses to consultation. Four mutually reinforcing principles leading to improved decision-making need to be embedded: — clarity about how new proposals are developed; — optimise participation through the right information; to the right people; in the right ways; to achieve a credible outcome; — provide a credible response to what is heard; and — evaluate implementation of new services to demonstrate improvement. Our policy paper “Accountability Works” (2010) and our practical framework for action “Accountability Works for You” (2011) set out the case for stronger local accountability, arguing for joined up approaches that encourage the development of co-production ie professionals, the public and their representatives ﬁnding solutions to problems together. The need to improve outcomes at a time of economic and demographic challenge makes this an imperative and our “Accountability Works for You” framework is helping public organisations take forward these ideas in their areas in tangible ways. The Committee may wish to endorse our principles—the idea that the “culture and values” underpinning consultation are more important than the “structures and processes” through which consultation is carried out. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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We think that public consultation can be a catalyst for re-defining relationships and behaviours between: — professionals and people who use services (by understanding and acting on insight); — professionals and communities (by understanding and acting on aspirations); and — professionals and representatives of people who use services and the public (by understanding and acting on individual and collective voices). We are aware that government has reviewed its approach to public consultation—we welcome the review because we think the new principles could radically improve the culture and values of public consultation. But we also think the new principles present some risks. We think that government, in seeking to streamline consultation structures and processes they consider to be “red tape” that delay economic growth, risks removing an important check and balance—that good decisions depend on good insight. But we recognise that a “one size fits all” approach has not always worked in the past and that decision-makers have not always felt the freedom to adapt their approach to different circumstances. In this context we think the new principles could drive a positive approach to consultation (one that focuses on culture and values) so that there is clarity about how new proposals are developed; what is consulted on and why; how people can have their voices heard; how final decisions are made; and how credible responses are given. However, we think there is a risk that the new principles may re-enforce a negative approach to consultation (one that focuses on structures and processes) so that consultation becomes about “minimum compliance”— doing only what is necessary to avoid sanctions but missing the value of co-production. Given the challenges facing the NHS we think it would be a mistake to assume that solutions to problems can be identified only by professionals. So a relaxation of consultation after proposals are developed must be accompanied by better involvement before proposals are developed. We think the “proportionality” principle has potential to make public consultations more valuable but only if the NHS involves the right people to help develop new ideas before new proposals are published. The Committee might wish to consider practice in relation to the four “tests” to be satisfied before proposals for change are published for consultation. These “tests” are about providing assurance that proposals for new policies and changes to services have not been developed without people who use services and the public being involved. The four “tests” require proposals for service changes to demonstrate: — support of clinical commissioners; — the clinical evidence base; — promotion of choice for patients; and — engagement of the public, patients and councils.

The Committee might wish to consider how legal duties “to involve and consult” (inserted in to the NHS Act 2006 by the Health and Social Care Act 2012) are impacted by the new principles, for example the NHS Mandate and guidance from NHS England about public participation. Evidential indicators used to judge outcomes from the tests are important.

We think ﬂexibility is important so that consultation is proportionate—a “compliance” approach ie adherence to a “one size ﬁts all” regime has not always had valuable outcomes in the past. But we think decisions need to be in the public domain, otherwise there is a risk of the perception of secrecy.

We don’t have a ﬁxed view on the length of consultation because we think the timing and length of consultations depends on the extent to which new proposals have been developed with the right people. We are aware that it is important to respect the views of vulnerable people and groups about changes in services that might have been developed by others.

If there are “tests” to provide assurance about how new proposals are developed, it will help everyone judge when and for how long consultation should be carried out. We think that local elected representatives should continue to be consulted (for example through council cabinets, health and well-being boards and council scrutiny)—and this needs to take account of purdah.

Many people use digital technology to access information and express opinions and we think many people will be happy to be informed about, and participate in, consultations through digital channels. But there are signiﬁcant groups that do not use digital technology frequently and there are some that do not use it at all—so we think it would be a mistake to consider traditional methods of consultation redundant. We think the culture and values underpinning consultation will drive the methods used.

We think a “digital by default” approach to consultation risks missing some of the rich insight that can be gathered through human interaction—feelings and emotions that underpin people’s views and opinions are not easily captured through digital channels. There may be costs associated with gathering and analysing this kind of insight but we think this is something that the NHS needs to plan for and build in to their risk assessment of change processes. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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We think there is a risk that “digital by default” may encourage consultation questions to which answers are expressed quantitatively (because they are easy to capture and analyse) rather than often more insightful qualitative responses (that need investment to capture and analyse). We think there is no guarantee that the new consultation principles will result in better consultations or outcomes. The answer will depend on the extent to which the NHS embraces a culture of transparency, inclusiveness and accountability towards policy development as a whole. We are not arguing for “red tape” but for a partnership between citizens, patients and professionals.

Council Scrutiny Services providing local emergency care are under pressure—more people are using them than ever before and waiting times are going up. Council scrutiny can play a valuable role in ensuring that co-ordinated action is planned and delivered health and social care to understand and resolve pressures on emergency services through better design and funding of integrated services. Forthcoming guidance for the NHS and councils about duties to involve and consult and council scrutiny should give strong weight to local accountability and public involvement, providing checks and balances to greater autonomy and “reduced burdens”. CfPS has extensive experience of providing practical advice and support for councils and the NHS about scrutiny of health and health services that can inform the guidance. We believe that someone has to balance professional judgement (the views of clinicians and managers about the best forms of service delivery) and accountability (people’s opinions and experiences). There should be a strong role for frontline councillors as community leaders to determine whether well-being, health and care have been and are being shaped around the needs and aspirations of patients and citizens. We think that independent support for councils, the NHS and the public is important and that there should be continued investment, alongside support for other aspect of the health reforms. Review and scrutiny powers are now vested in local authorities (upper tier) themselves rather than in overview and scrutiny committees and regulations were published earlier in the year about how the function should operate, including the circumstances in which proposals for service changes could be referred to the Secretary of State. Council scrutiny of proposals for service changes are not new—since 2003 council scrutiny has been able to decide whether proposals for “substantial” changes should require formal consultation with scrutiny with opportunities for contested proposals to be referred to the Secretary of State. Council health scrutiny is a robust power—one that does not exist in relation to any other public services. As such, it is a key mechanism for elected councillors to hold commissioners and providers to account over proposals for changes to health services. The Independent Reconﬁguration Panel (that advises the Secretary of State about referrals of contested changes) has generally praised the way overview and scrutiny committees have exercised the referral option over the last 10 years. We think there is a risk that the regulations could restrict the operation of the referral power by requiring decisions to make referrals to be made at meetings of the whole Council. Guidance about council scrutiny has not yet been issued and we think there is a need for clarity about how decisions to refer contested proposals for service changes can be made—especially in councils that choose to operate health scrutiny in ways other than through overview and scrutiny committees. Guidance should cover the need for local agreements about local triggers for consultation with council scrutiny functions. We welcome the emphasis in the regulations on local resolution of disagreements about proposals for changes to services and we think this local process needs independent advice and support. Council scrutiny of proposals for service changes is important at a local level and this is clearly the case concerning accident and emergency services. But arrangements can become complex if proposals to change services cover more than one council area. Over the years large joint health scrutiny arrangements have been established in almost all parts of England to review various aspects of service change. A current example relates to child heart surgery services (the High Court has commented in judgements about scrutiny of plans to stop services in Leeds by the Yorkshire and Humber Joint Health Scrutiny Committee). Whatever the eventual outcome of the court proceedings we believe there are practical lessons to be learnt about how proposals for service changes are developed and consulted upon. We think that joint health scrutiny arrangement will beneﬁt from independent advice and support. The Committee may wish to consider the practical application of the NHS failure regime—the role of Monitor and the NHS Trust Special Administrator—and how this impacts on councils’ abilities to challenge proposals for change. A recent example in London affecting services at Lewisham Hospital illustrates some challenges about how different arrangements for service change can impact on local involvement and scrutiny.

Conclusion We have tried to make a positive response to the inquiry. We think that the aspects relating to public involvement, consultation and council scrutiny can support learning for the future. We have set out in this cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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submission some of the fundamental principles that we believe should be built in to the arrangements and we are happy to provide oral evidence if the Committee would ﬁnd this helpful. May 2013

Written evidence from Unite (ES 34)

This evidence is submitted by Unite the Union—the UK’s largest trade union with over 1.5 million members. The union’s members work in a range of industries including manufacturing, transport, ﬁnancial services, print, media, construction and not-for-proﬁt sectors, local government, education and health services.

Introduction

1. Unite welcomes the opportunity to submit evidence to this timely inquiry and would be willing to submit further written or oral evidence on any issues covered in this submission.

2. Unite represents approximately 100,000 members working in the health sector. These include members in seven professional associations—the Community Practitioners and Health Visitors’ Association (CPHVA), Guild of Healthcare Pharmacists (GHP), Medical Practitioners Union (MPU), Society of Sexual Health Advisors (SSHA), Hospital Physicists Association (HPA), College of Health Care Chaplains (CHCC) and the Mental Health Nurses Association (MNHA). It also includes members working in occupations such as allied health professions, healthcare science, applied psychology, counselling and psychotherapy, dental professions, audiology, optometry, building trades, estates, craft and maintenance, administration, ICT, support services and ambulance services.

3. Unite’s diverse membership includes a range of members who are involved in emergency service functions including members working in ambulances services, paramedics and doctors in the Unite/MPU section.

Emergency Services and Emergency Care

4. The NHS is under enormous strain due to the disastrous policy decisions of the government. Since taking office the NHS has experienced an enormous drain in resources through a real term freeze in NHS budgets and now an actual cut in spend on the NHS, the biggest top down reorganisation of NHS structures for England in its history causing major upheaval and costs and the extreme pressure on trusts to make £20 billion in efficiency savings over five years—the Nicholson challenge. These changes can not be separated from the problems A&E is facing.

5. Unite believes that at the heart of this issue is a clear structural problem in how people are accessing the NHS. As a result of failings in primary care, the new 111 service and GP services, particularly out of hours, for many people the only way to adequately access the NHS is via A&E. The solution to this is to recreate an effective primary care service including out of hours services for patients, based on GPs integrated into the multidisciplinary team alongside other health professionals with local knowledge not only of the patients in their area but also of how the wider NHS functions.

6. The alternative of trying to separate A&E departments from non-emergency care is dangerous as it relies on patients being able to self-diagnose and self-prioritise their own health needs and would make the system more complicated and inaccessible.

7. Unite is also concerned with the way the NHS pays hospitals for admitted A&E patients. Under current rules, if a hospital admits more A&E patients than it did ﬁve years ago, it only gets paid 30% of the cost of treating those patients. Two thirds of hospitals are admitting more patients than they did ﬁve years ago, some as many as 40% more. This means re-opening wards and employing more staff to cope with this extra demand. Yet hospitals only get paid 30% of these costs. Some are losing more than £5 million a year as a result, on top of the 5% savings they’re already being required to make.

8. Other drivers of these problems include the ideological and chaotic way that services are being designed and contracted out, fragmenting services and creating waste. The failures of GP out of hours services and more recently the shambles of the new 111 phone line show the severe impact that this disruption can have.

9. There is also clearly a breakdown of preventative systems in many other areas of public policy—from cuts to social care to poor housing and increasing poverty and social exclusion—all driven by the government’s ill thought out austerity agenda. A recent example of this is the abhorrent policy of excluding migrants from the health service, not only a breach of human rights and a public health disaster, but will also mean that many will have no choice but to go to A&E for health treatment.

10. Unite is therefore not surprised that emergency services are now reaching breaking point. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Staffing and Morale 11. These pressures on A&E services are reflected in staff morale. The NHS unions commission pay specialists IDS to run a biannual survey of union members in the NHS. The latest of these reports in 2012 has shown that staff are under severe strain. 12. Looking at ambulance staff, for example, the IDS survey showed that they were one of the groups most likely to be always (33%) or frequently (46%) working in excess of their contractual hours. Similarly 64% of ambulance staff reporting a substantial increase in their workload, with 68% reporting that they were under pressure to meet government targets. 81% of ambulance staff said that workplace morale/motivation has got worse in the previous 12 months, which is up from 71% for this group in 2010. 78% cited increasing workplace stress as a major cause of poor motivation and morale. These issues are also reflected in the 2012 NHS Staff Survey.

Specific Issues Raised by the Inquiry The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas 13. The challenge posed here is cost of resources against utilisation especially in rural areas where demand is low in terms of numbers and therefore the relative cost for keeping ambulance cover in the area (per patient carried) is high. Most areas now have community first responders (CFRs) who are trained volunteers responding on behalf of the ambulance service because these are cheaper. Whilst recognising CFR schemes for the value they bring, there is no point having them if it means that the ambulance is going to be even further away than it would have been if there was no CFR in the area. They are in the same situation as rapid response paramedics who arrive on the scene quickly but are unable to bring the patient back to a hospital if needed and end up watching patients deteriorating while they wait for a properly staffed and equipped ambulance. 14. There needs to be a good core ambulance cover that can be supplemented by rapid response vehicles (RRVs) and CFRs in the system rather than replaced by them. Ambulances must be crewed by a paramedic and emergency medical technicians (EMTs) to get to locations within eight minutes, but these need to be supported by a RRV to get there sooner within four minutes, to be of any use in a cardiac arrest. The biggest flaw to CFR schemes is that they are voluntary and when the volunteers dry up so does the scheme leaving a huge gap in the ambulance coverage. 15. Primary care has a role in providing pathways for crews who have a patient who does not need to go to hospital and can receive what treatment they need in the community from primary care. This underlines the need for primary care, either through the GP or a new multidisciplinary team to be open and available 24/7 not just nine–five Monday to Friday and readily accessible to support emergency service needs.

Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings 16. Unite would not oppose this if it was additional services. It is apparent that there are reductions in this cover or that it is being placed where other forms of urgent care should be sought, eg in general practice.

The range, severity and incidence of conditions that can be treated within an accident and emergency unit but not managed at an urgent care centre 17. As discussed above these decisions should be made by the GP as the ﬁrst port of call. CCGs now have the money and responsibility to commission services and should therefore take on the responsibility. 18. Unite members report that in many cases GPs have simply been referring patients to A&E to reduce their own case loads.

The prospects for better integration of ambulance services with primary care under the new commissioning regime established in April 2013 19. As above, commissioners and ambulance services need to work together, to look at what can be offered including paramedics working at or out of minor injury units (MIUs) and accepting referrals from emergency crews. 20. Unite is cynical about the possibility of this joined up and integrated working under the artiﬁcial market structures created by the Health and Social Care Act 2012. Integration has been seriously damaged by the chaos caused by the reorganisations that took place and that is even before the commissioning process has begun.

The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge 21. The ability of ambulance services to continue to meet increased emergency demand is all down to resourcing. As the Health Committee has correctly recognised in the past the Nicholson challenge has mostly cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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been met through cuts to staff pay and terms, cuts to the tariff and salami slicing cuts to services. These cuts are having a severe impact on ambulance and emergency services across the UK due to the systemic problems caused by cuts in other parts of the NHS and elsewhere. Either resources are increased and sufficiently trained in emergency services or they should be increased in other parts of the system to alleviate the pressures on ambulance and emergency services. 22. Unite members have also been in bitter disputes with their employers in various parts of the country as cuts are leading Trusts to send out ambulances and single response cars that are under-staffed or have replaced paramedics with unqualified employees. Crews are facing much greater pressure to respond to calls due to cuts to staff numbers and vacancies going unfilled. By cutting publicly-funded ambulance services so severely they have opened the service up to rapidly growing numbers of private firms which is leading to a postcode lottery of service quality. For example recent figures have shown an increase in spending of £5.4 million on private contractors by the South East Coast Ambulance Service, from £1.9 million, in 2010–11, to £7.3 million, in 2012–13; In London, that figure rose by more then £3.8 million, from less than £400,000, in 2010–11, to £4.2 million, in 2012–13 and in Yorkshire the figure rose £1.3 million, from £500,000 to £1.8 million.125 Privatisation of Patient Transport Services will also means that staff who are no longer able to work on the paramedic crew will not be able to be re-deployed to PTS services, which will bring additional pressures on the NHS. 23. The Yorkshire Ambulance Service Trust is probably the worst case. With budgets planned to be cut by £46 million over five years the Trust introduced a new operational model that threatens to downgrade all ambulance staff, removing professionally trained technicians from ambulances altogether and replacing them with untrained driver roles with minimum levels of training. Posts are not being filled and crews are driving from one 999 call to the next without the time to check or clean the back of their ambulances or have adequate rest breaks. Unite’s members in Yorkshire raised public safety concerns and have been derecognised as a result. This took place at the same time that the Francis report was calling for NHS staff to whistleblow on unsafe practices in their workplaces.

Experience to date of the transition from NHS Direct to the NHS 111 service 24. The Unite experience of the 111 service is that it has been a disaster. It is an example of exactly how the NHS is being fragmented and damaged by the government’s ideological obsession with markets and commissioning. NHS direct was a functioning services and it has been replaced with one that has been widely reported to be failing in different areas of the country.126 The service further fails service users with the call centre staff not having sufﬁcient training and medical knowledge. Unite ambulance members are reporting that on weekends the majority of 999 calls are now referrals from 111. When the crews then try and refer patients to urgent care facilities or GPs they are then referred back to the 111 service or may wait 3–4 hours on scene for a callback from a GP. The only option is simply to take patients into already overstretched A& E departments. 25. Unite ambulance crews have reported regularly receiving calls that are totally inappropriate while at other times they have been left idle due to failures to pass calls on. The demise of NHS Walk In Centres or the prevention of ambulance clinicians being able to directly refer petients to these facilities, has also added to the pressures. Unite members in the ambulance service have said that they think it should be stopped with the funding being put back into ambulance services to develop better community based care and response teams.

The implications of the shift away from determining the success of ambulance services via indicators based on response time to the new measures designed to assess clinical effectiveness 26. Unite agrees that response time is a crude target for judging the success of ambulance services as it says nothing about the level of care received once the ambulance has arrived. That stated, there needs to be a balance and caution with its design since if an ambulance does not respond in time then the quality of care becomes an academic concern. 27. Unite believes that all targets must be clinically led, agreed with health professionals and focused to avoid distorted outcomes.

The causes of delays in handover from ambulances services to A&E or transfer between different levels of urgent care, and actions required to eliminate them 28. Unite members report that this is usually caused by several issues; not enough staff in A&E to accept patients from crews, no beds available in the hospital and ultimately underfunding, closures, fragmentation and poor planning. Trusts are not prepared to breach their A&E waiting times targets, so will not admit patients until they know that they will be able to move them on from A&E within 4 hours. The shocking examples of tents being used to receive 999 patients illustrates this point.127 It has also been reported that some Trusts have had up to 20 ambulances queuing. This also causes disharmony between the two when considering who is responsible for patient’s welfare during extended waits. The government needs to address these issues ﬁrst and 125 http://www.bbc.co.uk/news/uk-22237075 126 http://www.bbc.co.uk/news/health-22401585 127 http://www.mirror.co.uk/news/uk-news/ae-tent-999-ﬁeld-hospital-1801854 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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closing centres which can provide transitional care, such as “cottage” hospitals is not going to help. These were the staging post for discharged patients who needed that little bit of extra care or rehabilitation before they went home but have now been curtailed or taken away which has ended up in patients staying at main hospitals for longer and causing a bed block. Finally, with the closure of some A&E departments, surrounding hospitals are ﬁnding the pressure of additional admissions difﬁcult to manage. 29. If there was more advance skilled paramedics and facilities in the community and primary care then paramedics could keep more patients out of main DGH type hospitals but ambulance services need the funding to achieve this. Unite believes that the funding would be easily recouped through admission avoidance.

Clinical evidence about outcomes achieved by specialist regional centres, taking account of associated travel times, compared with more generalist hospital based services 30. While there may be some evidence that specialist units can improve the standards of care, such evidence has to be weighed against the need for accessible care and access. Particularly the most vulnerable and socially excluded patients will find it extremely difficult to get to specialist units unless there are sufficient transport systems in place. Some emergencies should be dealt with at more local hospitals, as time critical admissions may not make it to the specialist emergency centres. The issues of health inequalities and of patients’ ability to self-diagnose are also of concern.

Aspects of care which are likely to improve by being located in regional specialist units and the risks associated with removing services from existing A&E provision 31. Unite has mixed views on this issues. There are clear risks about separating general hospitals and regional specialism. The patient will be unlikely to understand or know that they have a specialist problem, that a specialist hospital exists or they may have more than one problem that is unrecognised by the specialist units. Again having proper access to GPs that know their patients would improve this and help guide patients through the system. 32. There could be a case for separating geriatric A&E issues from general A&E in much the same way as is done for children. This could mean that specially trained geriatricians , with wider A&E knowledge could handle these cases that may also involve serious chronic health issues that A&E might not pick up. 33. When A&Es close, there is an impact on the other clinical services provided by a Trust. The hospital can then be destabilised, and other services have to also be lost, thus downgrading the centre. This then has an impact on access to local services. More clinically evidenced work has to take place to model the right structure for hospitals to ensure that they are providing the safest levels of care. The current models are too simplistic.

The effectiveness of the existing consultation process for incorporating the views of local communities in to A&E service design 34. Current consultation processes are clearly failing as closures are taking place against the backdrop of large scale public opposition. As with so much of what is currently happening in the NHS the system of planning and coordination has completely broken down, with service fragmentation, cost cutting and lack of accountability. 35. Unite is supporting a growing number of local campaigns about changes to local health services;128 the campaigns in Trafford,129 Redditch130 and Lewisham131 are all focusing on A&E closures and have begun mobilising large numbers of people, including 25,000 that marched for Lewisham. The Health Committee should actively seek evidence from these campaigns on the consultation process in their areas. 36. If there are real clinical reasons to reorganise emergency services then these should be done in a planned, coordinated and evidence led way involving all the trusts and communities affected so that there is no loss of access, quality or coverage for that service.

The ability of local authorities to challenge local proposals for reconfiguration under the revised oversight and scrutiny powers included in the Health and Social Care Act 2012 37. The ability of the local authority to challenge decisions taking place in the health service is crucial and a vital avenue for members of the public to be able to take in order to save the services provided in their area. This obviously depends a lot on the quality of the councillors running the local authority and how overview and scrutiny is organised in specific local authorities. The flexibilities in the Act have fuelled further concerns about a postcode lottery due to this. 128 http://www.unitetheunion.org/how-we-help/list-of-sectors/healthsector/healthsectorcampaigns/unite4ournhs/ savingournhsinthenickoftime/ 129 http://savetraffordgeneral.com/ 130 http://savethealex.co.uk/ 131 http://www.savelewishamhospital.com/ cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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38. There is still a serious lack of clarity about how overview and scrutiny powers will be applied after the Health and Social Care Act 2012. Health and Wellbeing Boards do not appear to have the power to police changes and this seems to be a toothless concession to partnership working. 39. Unite is also concerned that if local authorities start having a commissioning role this may compromise their ability to challenge health services in the future. May 2013

Written evidence from NHS Clinical Commissioners (ES 35) 1. NHS Clinical Commissioners is the independent membership organisation exclusively for Clinical Commissioning Groups.132 We exist to help CCGs get the best healthcare and health outcomes for their communities and patients. 2. NHSCC also hosts the National Ambulance Commissioners Group (NACG) which provides access to, and support from, the leaders of ambulance commissioning across the country. NACG have submitted evidence separately on behalf of the network members to the inquiry. 3. Our response is in the form of a short statement, which outlines a number of key points highlighted by our members. 4. NHS Clinical Commissioners role is to speak for local commissioners, but as membership organisations we recognise that the morale of GPs is fundamental to how CCGs can operate. We are hearing growing concerns from our members that at practices across the country workloads are at breaking points and GPs are ready to buckle under the strain. Morale is being affected by comments implying that GPs are responsible for perceived problems in Accident & Emergency Departments, with primary care provision, the GP contract and Out of Hours Care being dragged into the mix. 5. It is clear that the roots of the problem are complex with many different factors coming into play. More than that there is no one over-arching issue causing the problems and local dynamics clearly play a major part—meaning that a one-sized fits all top-down imposed solution is bound to fail. It is evident that pressure in the GP surgery and pressure in A&E Departments are manifestations of pressures throughout the whole system. 6. As CCG leaders our members absolutely recognise that there are issues which need to be addressed in A&E. They also recognise that the pressure which is falling there is a symptom of far wider problems rather than being the cause themselves. While some of these will take longer to rectify, for example transforming primary and community care to support the frail elderly appropriately so that A&E isn’t the only option, it is essential that commissioners and providers across the system work together to find a sustainable solution that works for the patients across the NHS, whatever the setting. 7. In the new system established by the Health and Social Care Act it is the CCGs who have the statutory duty to commission emergency care. Given that statutory responsibility, it is for CCGs to determine how things need to be done (with NHS England assisting with disseminating good evidence about what works). We are concerned that they are being given the opportunity to do so as the current NHS England Plan133 seems to be getting into that detail and circumventing the CCGs role. 8. Our members are of the view that key factors driving individuals to attend A&E inappropriately include deprivation and distance from department. They also point out that A&E attends have shown steady increase since the introduction of four hour targets and removal of needs based triage such as the Manchester triage system.134 A&E now provides a stratified response to all primary presentations which, our members argue, over stresses the system and systematically disadvantages those with the greatest need as they are no longer a system priority. Senior decision makers within A&E with responsibility for resources are continuously diverted to facilitate assessment and discharge to maintain four hour targets. 9. There has been no evidence of change to the trend in growth of A&E attendance since change to the GP contract. It is a legitimate hypothesis but when members tested this in a part of North West England the bulk of attendance occurred in-hours and patients had not even tried to get a GP appointment. 10. Moreover while some places opened Walk-in Centres and Darzi centres, this had no impact on acute care services, and when some of these facilities were then decommissioned there was no impact on acute services, especially A&E. 11. In Warrington the CCG has set up a pilot primary care urgent care unit to divert away from AED locally which is running at about 16% divert and offers primary care management of non-AED problems also seeks to modify future choices. Evaluation is currently in progress. 132 NHS Clinical Commissioners has been established through a partnership between the NHS Alliance, National Association of Primary Care and NHS Confederation as the independent collective voice of Clinical Commissioning Groups 133 Letter and A&E Improvement Plan from NHS England—Gateway reference: 00062—Improving A&E Performance (http://www.england.nhs.uk/2013/05/09/sup-plan/) 134 Mackway-Jones K. Emergency triage: Manchester Triage Group. London: BMJ Publishing Group; 1996. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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12. It is also worth noting that every medium attend at AED cost the same as an entire year of care in primary care. 13. We are also hearing that improvements are occurring in many areas due to clinician to clinician discussions between commissioners and consultants in Local in A&E departments. 14. It is the view of our members that CCGs are best placed to lead on developing local solutions for local circumstances. However we do believe the solutions for the current problems have to be ones for the system as a whole. Clinical engagement, across the system, is vital to understand and reduce the pressures on services in primary, community and hospital services. We are therefore seeking to work with partners representing commissioners and providers including NHS England, the Foundation Trust Network and the NHS Trust Development Agency to identify solutions at scale which can then be adapted and implemented by Clinical Commissioning Groups and Area Teams in their role as direct and specialist commissioners. May 2013

Written evidence from the Royal College of Paediatrics and Child Health (ES 36) The Royal College of Paediatrics and Child Health (RCPCH) has four substantive points to underline to the Health Committee: — urgent and emergency care admissions amongst children, particularly those under ﬁve years, has been growing substantively over the last decade, and continues to grow; — further research is needed into the causes of this growth, and innovative models explored to deal with this increased demand, including improved assessment of children with acute illness in primary and secondary care; — urgent and emergency care needs to be reconﬁgured, in line with the principles laid out by the CEM, to ensure that care continues to be safe, high quality, and in the most appropriate setting for the needs of the child; and — all emergency settings should provide care that complies with the intercollegiate Standards for Children and Young People in Emergency Care Settings.

Context/Background 1. The Royal College of Paediatrics and Child Health (RCPCH) is pleased to respond to the Health Committee’s call for evidence on Emergency services and emergency care. Our response focuses on three priority areas for the RCPCH, including: — the role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas; — progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings; and — the range, severity and incidence of conditions that can be treated within an accident and emergency unit but not managed at an urgent care centre. 2. In common with many other areas of healthcare, paediatric emergency admissions have been steadily rising. Gill et al document that these admissions have increased by 28% in the last decade, with a particularly sharp increase for those under ﬁve years old. Admissions of children less than one year increased by 52% in this period, and aged one–four by 25%. In 2010, two-thirds of admissions (68%) were for children aged under ﬁve. Many of these admissions are short-term, and for common infections.135 3. Gill and colleagues argue that although the reasons behind this substantial rise are multifactorial, they suggest that it indicates “a systematic failure of the NHS in assessing children with acute illness that could be managed in the community.”136 Whilst they decline to attribute causation to any particular part of the service, they suggest that improvements could be made in both primary care (by general practice, out-of-hours care and NHS Direct) and in hospital (by emergency departments and paediatricians) in the assessment of children with acute illness that could be better managed in the community.

Short Stay Paediatric Assessment Units (SSPAUs) 4. Anecdotally, the pressures on emergency departments may in part result from a lack of clarity amongst local populations about the most appropriate place to take a child to be treated. In the course of visits to paediatric departments whilst researching the RCPCH publication Back to Facing the Future: An audit of acute paediatric service standards in the UK, we found that many units used Short Stay Paediatric Assessment Units as a buffer to prevent admissions to the ward, and that this was partially as a result of “parents treating A&E 135 Gill P J, et al, “Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis” Arch Dis Child 2013;98:328–334 136 Ibid. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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as primary care”. To deal with these problems, some units had developed extensive public education literature, but also invested in Community Children’s Nursing teams to help proactively manage long term conditions in the community, reducing acute admissions.137

Standards for Children and Young People in Emergency Care Settings

5. In 2012 the RCPCH developed intercollegiate Standards for Children and Young People in Emergency Care Settings. These both acknowledge the complexity of pathways that lead a child or young person into emergency care, but also set standards for how this care should be delivered, regardless of setting. It also laid out a future direction for the provision of urgent and emergency care. It acknowledges that:

“The aim of providing expert help as early as possible in a child’s illness, in order to improve clinical outcomes, has to be balanced by the importance of accessible services as close as possible to home. This requires service planners, commissioners and providers to work together to assess need, clarify the roles of different access points, deﬁne patients who should be referred to larger, more specialist centres, and identify staff able to take these decisions.”138

6. The standards outline a service model where non-paediatric emergency staff’s skills are enhanced “particularly [in] distinguishing minor from more serious illness, life support skills, stabilisation and transfer skills, and child protection awareness.”139 It also suggests that areas which do not have 24-hour paediatric emergency care should nonetheless look to employ a senior paediatric-trained doctor, for example a specialty registrar (ST4, or equivalent experience in a non-training grade), and appropriate radiological, surgical and anaesthetic support provided. The standards further advocate a networked approach to care, ensuring that expertise is shared between units and “[s]hared protocols, shared training, staff rotations, and quality improvement programmes … operate across the whole geographical area covered by the network.”140

College of Emergency Medicine Principles for Reconﬁguration

7. The standards therefore both provide a framework for current provision of urgent and emergency care, but also point towards future models of provision. The College of Emergency Medicine (CEM) also published in 2012 10 principles for reconﬁguration of emergency services, which the RCPCH fully supports. They are predicated upon clinical leadership of, and engagement with, any service reconﬁguration, appropriate training of staff in emergency care settings, and detailed modelling of any proposed changes. The RCPCH would like to underline the important role that paediatric emergency care plays in this, and the aspects in which paediatric emergency care differs from that provided to adults.141

8. NHS London has recently undertaken a review of paediatric emergency services, and developed standards, heavily informed by both the RCPCH standards for emergency care settings and the College’s Facing the Future standards for acute care. This follows on from a detailed “case for change”142 which identifies where improvements in provision need to be made. These differ from the existing standards in that they take the broad principles of those developed elsewhere and use the available data to apply them to the particular circumstances in which emergency departments in London operate. For example, the standards suggest how quickly a child should be seen by an appropriately qualified doctor, the number of paediatric nurses that should be on duty at all times, and the number of ward rounds that should be carried out each day. This is a model that both the CEM standards and Facing the Future standards support. They comply with the CEM standards in that they provide a detailed case for change, and have applied the Facing the Future standards to an emergency context, expanding upon them by increasing the number of ward rounds and decreasing the time in which a child should be seen by a consultant. This model of close study of local circumstances and development of robust standards should be replicated elsewhere when reconfiguration of emergency services is taking place. May 2013

137 RCPCH, Back to Facing the Future: An audit of acute paediatric service standards in the UK, 2013 www.rcpch.ac.uk/ facingthefuture 138 RCPCH, Standards for Children and Young People in Emergency Care Settings, 2012, p.10 http://www.rcpch.ac.uk/ emergencycare 139 Ibid., p. 11 140 Ibid., p. 12 141 RCGP, RCN, RCPCH, CEM, Right care, right place, ﬁrst time?: Joint Statement on the Urgent and Emergency Care of Children and Young People, 2012 142 NHS London Health Programmes, Quality and Safety Programme Paediatric emergency services: Case for change, 2013 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Written evidence from the Foundation Trust Network (ES 37) Introduction 1. The Foundation Trust Network (FTN) is the membership organisation and trade association for NHS acute hospital and ambulance, community and mental health service trusts. The FTN supports these foundation trusts and trusts in delivering high quality, patient focussed, care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate. The FTN has 220 members—more than 90% of all NHS foundation trusts and NHS trusts—who collectively account for £70 billion of annual expenditure and employ more than 630,000 staff. 2. The emergency care system has been under huge pressure over the last few months and although recent weeks have seen performance stabilise, there is a danger the system will fail unless each local health economy plans effectively for the coming winter. It is important that any actions taken to stabilise the system in the short term should be consistent with the longer term changes that are needed, as this a complex, whole health and social care system, issue. We therefore welcome the Committee’s decision to conduct an inquiry into this area and hope that it will enable mature discussion of both the short and long term solutions needed. 3. The FTN has surveyed its members to assist the Committee in understanding the perspective of NHS foundation trusts and trusts operating at the frontline on the urgent and emergency care pathway. Our survey shows that acute, ambulance, community and mental health have different perspectives but there are also some clear common messages. We share some of our initial ﬁndings here but would like to provide more detailed results in a supplementary submission once we have gathered and then analysed all our survey data. We believe the Committee would beneﬁt from taking oral evidence from a panel of NHS acute (District General Hospital), ambulance, and community trust Chief Executives who can share their front line experience of why the system is under such pressure and what solutions are needed. If the Committee agrees, the FTN would be happy to arrange such a panel.

Key Messages Causes of pressure 4. The current pressures on the urgent and emergency care pathway are the product of systemic failure. Poor hospital performance against four hour A&E wait targets and ambulance call answering targets are only a proxy for system wide performance failures. Although the precise balance will vary in each local health economy, the principal reasons for the pressure on A&E Departments—“the biggest operational problem facing the NHS”143—are: — increasing demand; — increasing acuity of patients given an ageing population and greater prevalence of long term conditions and multiple co-morbidities; — failures in other parts of the system to manage demand, particularly GP surgeries and doctors out of hours services (recognising that these services are also under extreme pressure themselves); — slow progress in investing in community facilities for out of hospital care closer to home; — a broken hospital emergency care funding system; — the inability of many trusts to recruit and retain the right staff for this specialty; — the uneven introduction of the new 111 system; — issues discharging patients in a timely and effective way due to problems in social care; — poor patient signposting; and — failures by some acute hospitals to manage their patient ﬂow as effectively and efﬁciently as they could.

Immediate solution for this coming Winter 5. NHS England, Monitor and the NHS Trust Development Authority have recently announced a good ﬁrst step for planning for next winter.144 However, to be successful, the plans created by Urgent Care Boards need to be built from bottom up. To make the required long lead time decisions, the right level of funding to support these plans must be consistently made available by end June 2013. The plans must also be part of the long term solution rather than a temporary “stop gap”.

Short term funding and workforce solutions 6. The 30% marginal rate policy is fundamentally ﬂawed and should be replaced as quickly as possible. There is little evidence that the 30% marginal rate is facilitating more effective demand management. The NHS 143 Secretary of State Jeremy Hunt speech to Age UK conference, 25 April 2013 https://www.gov.uk/government/speeches/will-we- rise-to-the-challenge-of-an-ageing-society 144 http://www.england.nhs.uk/2013/05/09/sup-plan/ cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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also needs to quickly solve the shortage of middle grade doctors—an area where the current Government’s immigration policy is having a signiﬁcant effect.

Whole system long term solution to redesign the urgent and emergency care pathway

7. The wider NHS system is not working effectively. Our research indicates that at least 25% of patients currently attending A&E Departments could and should be treated by other parts of the NHS. Therefore a whole system approach is needed to tackle these issues longer term. This requires fundamental re-design of the whole pathway, including appropriate investment in primary, community and social care services and much better patient signposting to these services. The FTN believes that an effective, universally available, high quality, 111 service is a key part of this mix. Sir Bruce Keogh’s review of the urgent and emergency care pathway is the obvious place for this future design work to be undertaken.

The strategic funding and change conundrum

8. The NHS therefore faces a strategic funding and change conundrum. The NHS needs upfront investment to develop the long term, community, out of hospital services that are required. But we must also ensure A& E Departments have the funding they need to treat their growing volume of patients safely in the meantime. This financial “double-running” is very difficult to deliver at a time of major financial challenge. The FTN believes that any long term work on the urgent and emergency care pathway must find an effective solution to this key question.

FTN Evidence

9. Part 1 focuses on the headline results from the FTN’s survey of its members. Part 2 provides the FTN’s response to the cross cutting theme of how to meet increased emergency demand, picking up the individual themes in the Committee’s inquiry terms of reference.

Part 1—Headline Results from FTN Survey

10. Pressure on the emergency care system is growing and the reasons are numerous and complex as outlined in paragraph 4. In May 2013, FTN surveyed its members to gain a full understanding of the issues faced by those providing services on the frontline. We received 105 responses, largely from acute, ambulance and community trusts. These are summarised below as they relate to the committee’s inquiry.

Figure 1

PRESSURES FACED BY A&E DEPARTMENT145

145 In October 2012, FTN carried out a benchmarking study which brought together 11 acute trusts operating A&E services ranging from major specialist trauma centres to primary-care-led urgent care centres. This diagram represents the ﬁndings from this study. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Summary of survey results 11. The accident and emergency system is at a tipping point. On a scale of 1 to 5 (with 1= tipping point, 3= neither tipping point nor sustainable, 5 = good sustainable model), 72% of FTN members assessed the system to be currently at or near tipping point (1 or 2). 12. A&E performance is likely to worsen next winter. There was widespread agreement among respondents that the position for the coming winter (2013–14) is very likely to be worse than the 2012–13 winter.

Figure 2 EXPECTATIONS FOR NEXT WINTER

13. When asked to list the reasons for current system pressures 62% of survey respondents highlighted increased demand as a current difﬁculty in their local system. 42% cited increased acuity of patients as a factor. These combined with failure of primary and social care services (32%) were the most commonly identiﬁed reasons for the current pressure on the system. 14. While the majority of respondents said they are engaging with commissioners to address the pressures, the overall feeling is that these discussions are taking a long time to translate into real change or are being frustrated by a lack of incentives for commissioners to fund a new and different model. 15. Respondents saw the role of community and primary care as fundamental to reducing demand on the A&E system. However the majority lamented the lack of commissioner investment in out of hours, community and primary care services. The overall view was that until primary care was able to operate a 24/7 structure to match that of A&E, little would or could change. 16. Respondents reported that on average, 25% of patients presenting at Emergency Departments could be treated elsewhere in the health system.

17. Ambulances could, and are willing to, play a bigger role in managing demand by ensuring that patient referrals are more evenly spread across trusts and throughout the day; by redirecting more patients to cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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community services (which relies on the existence of such services); and by increasing the provision of “See & Treat”. While the Ambulance sector does a great job already, to be even more effective it needs more support. 18. On the move towards clinical effectiveness measures and away from response times, 68% of respondents were broadly supportive. However reservations were expressed over the complexity of such targets and the justiﬁcation for removing response time targets altogether. Approximately 17% were against the move. There is, anecdotally, strong support for the 95% A&E wait time target as a good and effective barometer of the overall health of the whole emergency and urgent care pathway (ie not just hospital A&E performance). 19. Where respondents had experience of 111 services, many pointed to an initial spike in A&E referrals in April. Others said it was too early to assess their experience of 111 services so far due to delay in roll out or lack of time to embed. Only three respondents had a good experience to report. 20. Five strong themes emerged as the reasons for delays in transfer between care environments. They were: — Lack of integration. — Excessive bureaucracy. — Issues with capacity. — Lack of Available Funding/Financial Incentives. — Lack of Social Services capacity. 21. Approximately 64% of respondents expressed a view that current consultative requirements on service change were not wholly effective. 31% held mixed views on its effectiveness whilst 5% felt that they were currently effective.

Part 2—Cross Cutting Theme—Meeting Increased Emergency Demand 22. The theme that runs through the committee’s terms of reference is how the NHS can meet increased and increasing emergency demand, as well as the increased acuity that comes from an ageing population with higher prevalence of long term conditions. The FTN believes that any solution to these problems depends on four key elements: — An immediate solution for the coming winter; — Creating the right funding mechanism and solution to current A&E workforce shortages; — Re-designing the urgent and emergency care pathway longer term, using a whole system approach; — Solving the strategic funding and change conundrum of how to keep the system afloat in the short term whilst investing in the long term shift to out of hospital community care Each of these elements is explored below. Key Message: In the short term, urgent action is needed to ensure that the A&E system is able to function effectively this coming Winter. While we welcome the recent focus on developing local plans, these need to be fully supported financially, drawing on funding from NHS England’s commissioning risk pool, with funding levels agreed by the end of June 2013. 23. The recent announcement on creating local Urgent Care Board plans is a good first step in planning for the coming winter.146 However, more clarity and certainty is urgently needed. The FTN believes: — Each Urgent Care Board plan must be created bottom up, not top down. The job for NHS England Local Area Teams is to support and enable the creation of these plans, not lead this process. — NHS England’s key responsibility, as the overall risk manager and funder of the commissioning system, should be to ensure that each CCG has the financial wherewithal to support each local plan. NHS England has announced that the withheld 70% funding from the operation of the 30% marginal tariff should be used to fund these plans. However, some CCGs were effectively being forced by financial circumstance to use this money to support their mainstream budget, despite the national planning guidance. — The FTN believes that the money withheld by CCGs from emergency readmission penalties should also used to fund Urgent Care Board plans. — Urgent confirmation of the total aggregate amount across the NHS and the amount to be committed to each local plan is needed by the end of June. With only 17 weeks to go till next Winter, providers and other parts of the NHS need this certainty now, so they can start making the long lead time decisions that are needed. — Confirmation is needed that this money will come from the NHS England overseen commissioning risk pool and will not be at the expense of ambulance, community, mental health and elective activity. At a system level, we cannot reach the end of 2013–14 and find that yet another £1 or £2 billion has been returned to the Treasury and the urgent and emergency care pathway has not received the funding it patently needs. 146 http://www.england.nhs.uk/2013/05/09/sup-plan/ cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— Each Urgent Care Board local plan should not be seen as a temporary “stop gap” solution only. Rather it should, wherever possible, progress the long term move to out of hospital care. — The operation of local Urgent Care Boards sets an important step for the future. So it is vital that they embody the culture of local ownership, collaboration and integration within the NHS and across health and social care that are required for the long term. Key Message: We must create the right funding mechanism to support rather than penalise NHS providers. The 30% marginal tariff is fundamentally ﬂawed and needs to replaced as quickly as possible. The NHS also needs to quickly solve the current shortage of middle grade doctors—an area where the current Government’s approach to immigration policy is having an adverse effect.

24. As the FTN has continually stated, the NHS must urgently abandon the policy of paying emergency admissions above 2008–09 levels at a marginal rate of 30% of the tariff. The aim of this policy was to incentivise admission avoidance and the delivery of care closer to home. However, admissions have risen in more than two thirds of hospitals since 2008–09, by as much as 35% in some trusts. This is losing some hospitals between £5 and 6 million a year and the sector as a whole an estimated £300 to £400 million a year,147 on top of the already stretching 5% Nicholson challenge savings these hospitals are being required to make.

25. The marginal tariff provides no incentive for primary care to take shared responsibility for emergency admissions since urgent and emergency care patients can be treated in hospitals for 30% of the cost of treatment. Hospitals are simply earning less for the work they undertake, despite the long term improvements they are making to their A&E services and the costs of temporarily re-opening wards and employing extra staff to cope with short term extra demand.

26. Furthermore, the ﬁnancial impact of the marginal rate is reducing the ability of providers to implement admission avoidance initiatives to support care closer to home. For example, initiatives in the South West to provide geriatric specialist support in emergency departments and comprehensive geriatric assessment of frail older patients have not been fully rolled-out due to lost income from the marginal rate. Similarly, pilot initiatives in East of England to offer acute geriatric support to nursing homes have reduced emergency readmissions to hospital signiﬁcantly, but with only a small pool of consultants that limits the roll-out of the initiative to more local nursing homes due to lack of funding.

27. We welcome the recently launched NHS England and Monitor review of the 30% marginal tariff. We need the review to quickly conclude that major change is required, agree a new approach and have it in place for 2014–15. We recognise that changes to the tariff do need to strike the balance between stability and change, but this is an area where change has been overdue for several years. We know the committee shares our concerns about the tariff as reﬂected in its recent report on public expenditure on health and would urge it, once again, to call for urgent reform in this area.148 View from the frontline: “If we had access to the 70% monies we could increase ambulatory day unit capacity and we could invest in a revised older people assessment and liaison service to prevent admissions in the ﬁrst place.” “…..one of the biggest problems with the current system is that the incentives are wrong. Emergency tariff is too low to create an incentive amongst commissioners to do something about it.” Acute NHS FT

28. Another area requiring short term solution is recruitment and retention of career-grade mid-level A&E doctors that are the centre of the A&E department shop floor, and ensuring there is sufficient senior consultant cover seven days a week.149 Members reported that staff shortages were having a range of impacts from potentially increased risk to patient safety to higher admission levels than necessary as junior doctors, due to lack of experience, ended up admitting more patients than experienced consultants. “Acute shortage of middle grade doctors and non-trainee doctors is having a huge impact. Consultants and junior contract has to change and we need more doctors on the floor to do the work.” Acute NHS FT Key Message: The wider NHS urgent and emergency care pathway is not working effectively. Our research indicates that at least 25% of patients currently attending A&E Departments could and should be treated by other parts of the NHS. Therefore a whole system approach is needed to tackle these issues longer term. This requires fundamental re-design of the whole pathway, including appropriate investment in primary, community and social care services and much better patient signposting to these services. 147 FTN internal analysis, based on CHKS data 148 Health Select Committee Eleventh Report, Public expenditure on health and care services, March 2013. 149 The FTN is working with its members to make sure that these recruitment difficulties are reflected in workforce planning models and government’s Shortage Occupation list. We are also influencing both the future shape of medical training and the current talks on possible changes to the consultant contract, particularly around defined career pathways for junior and middle doctors (SAS) and that these grades are clearly not attractive compared to other specialities and the GP route. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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The need for a whole system approach 29. Effective operation of the urgent and emergency care pathway requires all the different parts of the NHS and the wider social care system to perform their allotted task. Failure to do so just displaces problems to other parts of the pathway with A&E Departments currently acting as a default back stop.

The failures caused by the lack of a whole system approach 30. For example, while A&E and ambulance services operate 24/7, many other services on the pathway do not. If a patient with mental health needs attends A&E, the provision of expert psychiatric services is generally excellent between 9am and 5pm, but these services are often not commissioned by CCGs outside normal working hours. This places the strain squarely on A&E departments to deliver clinical care and manage referrals for these patients. 31. A similar situation exists in relation to the increasing number of older patients presenting at A&E because of inadequate out of hours GP services. One NHS Foundation Trust has recently completed a three year project to examine patient flow and develop ways in which capacity can be better matched to demand. Their project found significant improvements could be made through changes to their hospital’s own working and staffing practices.150 However their project also identified that: “the presentation of older frail patients out of hours means that they often get admitted for safety/ compassionate reasons rather than for a clear clinical concern. If these cases presented earlier in the day many could be managed outside of hospital by our community teams (who we also manage here) or by their own GPs”.151 32. While there are many examples of excellent partnership working between ambulance and acute services, including clear and well-used early warning and escalation policies, and sharing of staff between services, delayed ambulance handovers continue to be a key issue on the pathway. One member provides a good illustration of the system-wide nature of the problem. When GP home visits were done in batches late in the day, ambulance urgent referrals were arriving at peak times of A&E demand. Alternative services to A&E were switched off for the evening, community services were not funded adequately to arrange a night-sit for elderly patients, and there was insufficient bed capacity to process incoming admissions (in part due to lack of community beds to discharge to). The ultimate result was patients queuing in A&E and patients queuing in ambulances to get through the front door of A&E. It is only system-wide changes at a local level that can smooth out peaks in demand—for example acute trusts, clinical commissioners, and GPs working together to arrange staggered home visits to smooth out peaks in A&E referrals. View from the frontline: “We have the ability to refer patients to local services or transport them to services other than A& E if they exist. The issue is that the only place to take them is A&E which clogs up the A&E departments creating waiting time issues and the really urgent patients then have a delayed response because we are stuck at the hospital.” Ambulance NHS FT “Improved population of the Directory of Services, better weekend and evening service cover, more integrated commissioning of primary, secondary and ambulance sector services.” Ambulance NHS FT “Ambulance Service should provide 111 services. Huge benefits from ability to pass calls from 111 to 999 and vice versa seamlessly. Development of Directory of Services—huge task to maintain— afford opportunity to direct patients to most appropriate service and keep patients out of Hospital. But needs commitment from all whole system working together—eg GP’s, Hospitals, Out of Hours Providers and Social Services.” Ambulance NHS FT “111—if resourced properly and integrated with the Ambulance Service has enormous potential benefits for the Health Care System as a whole.” Ambulance NHS FT 33. Many hospitals are also facing an urgent and growing problem of not being able to discharge patients in a timely and effective way because of problems in social care stemming from funding cuts due to reduced local authority budgets. FTN members report problems with “hospital back door” discharge, leading to longer stays and higher bed occupancy rates. This rapidly leads to problems coping with “hospital front door” A&E admissions as beds are not available. Small increases in patient acuity—such as a 1% or 2% annual rise—can lead to increased admission levels that hospitals find it very difficult to absorb when they are running at or close to capacity. View from the frontline: “Discharge—this in my view is one of the biggest causes of the current A&E problem. Reductions in social care budgets leave older frail patients in hospital. The longer they stay the more their care packages or support mechanisms fall apart. So they stay even longer, sometimes then contract infections, or have falls due to their unfamiliar circumstances.” Acute NHS FT 150 The Kings Fund’s recent report for NHS South lists all the key improvements that acute trusts should be making to improve patient flow within their A&E Departments: http://www.southofengland.nhs.uk/wp-content/uploads/2012/05/Kings-Fund-report- urgent-and-emergency-care.pdf 151 South Warwickshire NHS Foundation Trust, 15 May 2013 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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“…cuts to Social Care budgets having massive impact on delayed transfers once patients are medically fit.” Acute NHS FT “The fragmented system of care is causing delays in supporting the discharge of the most vulnerable patients. Much of the delay in discharge is linked to the challenge of social care funding and delays in setting up packages of care and placements.” Acute NHS FT “[We need] Integrated service models with social care. “Combined Community & Mental Health NHS FT 34. Our survey showed that on average 25% of presentations at emergency department could be treated elsewhere in the healthcare system.152 Greater investment in out of hours primary and community services is therefore a key part of the long term solution to these problems. “I think 15–20% of admissions could be avoided with greater access to alternatives eg access to acute clinics, diagnostics, rapid access to social or community nursing care.” Acute NHS FT “At least 10% of patients in hospital are awaiting care in a different setting.” Acute NHS FT “Everyone is working very hard but in silos with conflicting agendas and cultures resulting in patient delays.”153 Acute NHS FT “Our different regulators and financial systems get in the way of true joint working.”154 Combined Acute & Community NHS FT 35. Those local health economies that have already invested in these approaches are seeing considerable benefit. For example, the benefits of rapid response community teams and “See & Treat” ambulance services are both clear and impressive. Investment in out of hospital facilities covering mental health and addiction has significantly reduced frequent A&E attendances by the same patient.155 Ambulance services also have an important role to play here. One ambulance trust has developed a falls referral form which is transmitted to community falls teams, GP triage systems, and then turned into a patient-specific ambulance anticipatory care plan which is held on the despatch system. This has helped identify and stratify patients such as elderly fallers, so that community and falls teams can see the most at risk patients as urgently as possible. As a result, more patients are being treated safely at home rather than being conveyed to emergency departments and admission units.

The need for a planned re-design of the entire urgent and emergency care pathway 36. All of this evidence points to the need for a re-design of the entire urgent and emergency care pathway. Sir Bruce Keogh’s review is the obvious place for this future design work to be undertaken and we are encouraged by early conversations with Sir Bruce and his team on the development work that has already been done. We also welcome the Secretary of State’s recent announcement in the Queens Speech debate to place this review in the broader context of creating the right NHS delivery model to manage increasing numbers of frail elderly and those with long term conditions. We wouldn’t wish to prejudge the outcome of Sir Bruce’s Review but assume that it would need to contain the following elements: — A long term approach to investing in community facilities closer to home, including more investment in higher capability ambulance services, so that A&E Departments are only used to treat those patients requiring acute care. — Ensuring that GP surgeries and out of hours services are able to meet their share of demand— this may, for example, require revisiting of the GP contract. — Ensuring that 111 services fulfil their potential. The FTN believes that NHS ambulance trusts are best placed to run these services. — Identifying an appropriate model for A&E Departments which is likely to involve reconfiguration so that appropriate elements of specialist care are increasingly rationalised and centralised where possible, as the NHS has done to great effect with stroke care in London. — Much greater attention to and investment in effective patient signposting so patients know where to go. 37. This work needs to be completed as quickly as possible. It is likely to involve difficult decisions in the run up to a General Election but we cannot afford to wait for the redesign that is so patently needed. “Wholesale reform of the system …. requires rebalancing particularly for the frail elderly and those with long term conditions. [This] requires patients and families to have more faith in community packages and out of hours schemes so they do not see A&E as the default position” Acute NHS Trust Key Message: Political and system commitment is needed to address the strategic funding conundrum that the NHS faces. While upfront investment is needed to develop long term, community out of hospital solutions, we also need to ensure A&E departments have the funding they need now 152 Foundation Trust Network Survey of 105 Foundation and NHS Trusts, May 2013 153 FTN Survey of members on emergency care, May 2013 154 FTN Survey of members on emergency care, May 2013 155 Foundation Trust Network Briefing: Driving Improvements in A&E Services, October 2012. cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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to treat their growing volumes of patients safely. How this conundrum can be addressed against a backdrop of major ﬁnancial challenge is both an immediate and long term challenge. The FTN believes that any long term work on the urgent and emergency care pathway must therefore also ﬁnd an effective solution to this key question. May 2013

Written evidence from Dr Daniel Albert (ES 38) 1. Introduction Thank you for inviting written submission for the inquiry on emergency services and emergency care. My particular interest is in exploring and extending the range of urgent medical problems that can be sensibly managed outside of hospitals. I believe I can make a useful contribution to the ﬁrst three issues on which you invited comment: — The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas. — Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings. — The range, severity and incidence of conditions that can be treated within an accident and emergency unit but not managed at an urgent care centre. A generation ago, many emergency conditions, such as heart-attack and pneumonia were routinely managed by general practitioners. A range of different tablets and good family nursing provided as good a chance of recovery as was possible anywhere. New hospital technologies have made care at home for many life- threatening conditions inappropriate. Unfortunately this has resulted in all patients with a slight suspicion of such a condition attending hospital and a diminution of GP acute skills. Busier appointment-based General Practice has also made it impractical for the GP to jump in his car and go out instantly to deal with the acutely unwell. The culture and expectations of patients and doctors have changed. The annual increase in hospital- based acute care has been met with increased investment and stafﬁng. There are now signs that this compensation has reached saturation point; even if more investment were possible, the skilled staff are simply not available. Various attempts have been made in recent years to restore good quality community urgent care, but most have had little impact as they have not appreciated the level of skill and technology needed. “Urgent Care Centres”, so-called, in England are such a watered-down version of their international namesake as to be virtually useless. My submission is that this does not need to be so. I am a GP with experience of working in a variety of clinical settings from urban GP surgery to rural community hospital emergency department. I have also been involved with health service planning as a PCG Chair and PCT PEC Chair. I am currently a Non-executive director of Leeds South and East CCG, a member of the Royal College of GPs, an Associate Fellow of the College of Emergency Medicine and a member of the British Association of Immediate Care.

2. Executive Summary — There is an evolving crisis with annual increases in A&E attendances no longer being manageable by increases in investment alone. — Current provision of telephone entry to the system, via 999 and 111, does not cater for the large number of patients who know what help they need, and wish just to go there. This group are ending up in A&E by default. — GP urgent care, although very expert for the most part, has not kept pace with advances in technology. — The fastest growing group of patients requiring urgent care services are those with chronic conditions. They rarely need hospital care, but their needs are not met by existing primary care either. — Examples of excellent, high-level, urgent care exist both in the UK and abroad. They generally bring together primary care and hospital doctors and are usually situated away from hospitals. — NHS England should take steps to arrange the provision of a network of local high-level urgent care centres across England, using existing estate and expertise, as far as possible.

3. Current Emergency and Urgent Provision At the moment, the majority of urgent encounters take place in primary care, with a smaller, but increasing proportion in hospital emergency departments. Only an insigniﬁcant number of cases are managed in services that combine, or cross, the two disciplines. Hospitals are struggling to cope, with the current Registrar shortage likely to translate into a Consultant shortage in a few years. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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The new approach, of asking patients to call 111 if they have a problem that needs something “less than 999”, is intellectually attractive as it can direct them to the most appropriate service. It has limitations however: — Not everyone wants to, or can, use a telephone. — Patients with new symptoms, on top of chronic disease, are very difficult to triage and mostly end up in the ED. — Many patients are determined about where they want to go; or where they do not want to go. — If the only place open 24/7 is the ED, that is where people walk into 24/7. — The volume of calls to 111 is so large as to be difficult to manage. Patients who turn up at GP out-of-hours centres, “urgent care centres”, “Darzi” centres etc expect to have X-ray, blood tests and specialist advice available to address their problems. Patients from oversees, including those from Eastern Europe, are horrified by the lack of medical facilities (although the furniture is often of a very high standard). It is my submission that, if patients expect that we are already doing something, it is probably something that we should already be doing. NHS urgent planning has instead tried to build new systems by rearranging inadequate components into new configurations.

4. The Rise in Chronic Conditions Improvements in healthcare have resulted in more people living with conditions that would previously have been life-shortening. These range from asthma to HIV. Although stable for most of the time, these patients do sometimes deteriorate quickly and require urgent care. Exacerbations of chronic conditions now far outnumber de novo acute presentations in Emergency Departments. They are difﬁcult to manage in existing primary care because clinical signs can be misleading and simple diagnostic technology is needed. Most of the investigations needed in urgent care are now available in cheap, compact and user-friendly packages designed for use in the community.

5. The Missing Component What is missing from the system is a network of local true urgent care centres with expertise from both General Practice and Emergency Medicine; and with suitable modern technology. These would have very little in common with current offerings with similar descriptions, although many of the current healthcare premises in the community would be ideally suitable. They should be able to take virtually all patients who currently walk into hospital emergency departments, including those who attend Minor Injury Units, Clinical Decision Units etc. They should also be a replacement for GP out-of-hours primary care centres. With suitable transport, they would replace most GP OOH home visits, apart from palliative care. Their success will depend on speciﬁc urgent care training of clinicians as well as the development of state-of-the-art dedicated diagnostic and information technology. Whether these centres are provided by NHS, private or third-sector organisations is largely immaterial, as is whether they are co-located with hospitals (although it should be noted that most successful urgent care centres are not on hospital sites).

6. Personal Examples I would like to describe three examples of attempts to provide good comprehensive community urgent care. 6.1 Shefﬁeld City GP Health Centre156 was an NHS “Darzi” centre that I was responsible for in 2011. The aims were i) To Reduce inequalities of care by providing easy access for those who worked and also for those who were alienated by mainstream services. ii) To take pressure off hospital Emergency Departments. It was intended to have the highest level of diagnostic expertise and extended acute care capability. Unfortunately neither the commissioner PCT, nor the provider company were far-sighted enough to invest properly. It was a huge success in improving access with many patients getting treatment at an early stage in their disease, who might otherwise have deteriorated. But hospital attendances did not fall due to the lack of extended capability. It was degraded to a nurse-led walk-in centre in a money-saving agreement between the commissioner and provider. 6.2 Terem Urgent Care Centres157 This network of urgent care centres in Jerusalem has reduced A&E attendances in the city to about 75% of the national per capita average. The centres are popular with the public for easy access and a reputation for completing episodes of care in one visit, in spite of charging a small co-payment. (A&E and primary care are both free of charge in Israel). All patients at Terem are seen by a doctor who has undergone speciﬁc training in urgent care, whether they come from a community or hospital background (about 50% come from each). X-ray and bench-top blood tests are available 24 hours each day, while specialists in orthopaedics, paediatrics and gynaecology visit in the evenings, as does an ultrasonographer. There are various extended services: eg children with pneumonia are treated with intravenous antibiotics as outpatients. 156 www.walkinwhenyouneedsus.co.uk 157 www.terem.com cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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6.3 Galloway Community Hospital158 This is where I work currently. The hospital, in Stranraer, is 75 miles away from the nearest general hospital. It serves a population of 20,000 people. The Emergency Department is run by a team of GPs with extended training. The GP out-of-hours service runs from the same site, with many of the doctors having dual roles. Overall, we have about 12,000 visits per annum. We provide acute medical care including thrombolysis for heart attacks and strokes. The service goes beyond what will be required of modern urgent care centre, but encompasses all of it. We have an acute medical ward, staffed by the same doctors. This could be a model for an urgent care centre being attached to a community intermediate care bed base. Diagnostic facilities include x-ray, CT scanning, ultrasound and laboratory services. Only a small proportion of patients are transferred for further care elsewhere, although the consultants in the base hospital provide useful telephone advice at all times. Doctors need a broad experience base, something we have each gained in different ways, often abroad. The nurses are more local and many have worked in the department for decades; they too are highly skilled and able to look after very sick patients unsupervised. It is an example of what can be achieved in the UK with practical joined-up planning. If a general hospital were closer, the more expensive infrastructure, such as CT scanning would not be necessary and the designation might be different, but the clinical process could be similar.

7. Recommendations It is recommended that NHS England gives consideration to the following: 7.1 Three portal entry—Explore the possibility of there being three standard ways of getting access to emergency and urgent services. — Telephone 999 for serious emergencies. — Telephone 111 for advice on getting urgent care. — Attend local Urgent Care Centre for treatment of all ambulatory care conditions. 7.2 Commissioning Framework—Produce a commissioning framework for CCGs to arrange provision of serious urgent care facilities in their communities, that build on local expertise and make use of local resources. 7.3 Education and training—Promote dedicated training in community urgent care for doctors and nurses from a variety of backgrounds. Also support a proportion of doctors who wish to work in General practice to get Acute Care Common Stem (ACCS) training ﬁrst. 7.4 24/7 Urgent Care—Consult on proposal to allow GPs to pay for daytime urgent care to be undertaken on their behalf at urgent care centres. Consideration would need to be taken of the amount of work that is currently being done in A&E so as not to defund general practice. 7.5 Information Technology—Commission the development of dedicated urgent care IT systems that allow for fast efﬁcient working. 7.6 Leadership—Appoint a lead clinician, with credibility across primary and secondary sectors, to develop this project nationally. May 2013

Written evidence from the Parliamentary and Health Service Ombudsman (ES 39) Executive Summary 1. The Parliamentary and Health Service Ombudsman welcomes the opportunity to contribute to this inquiry into emergency services and emergency care. One of our strategic aims is to enable public services, including those involved with the delivery of emergency services, to learn from complaints and use them to improve the service they provide to everyone. 2. With recent concern regarding the unprecedented increases in Accident and Emergency (A&E) attendances and admittances, as highlighted by the College of Emergency Medicine159 and NHS England,160 it is critical that this increased pressure on emergency services does not impair the quality of patient care. It is therefore vital that the complaints that are received regarding these services are taken into account in the identiﬁcation of areas of concern and ways to safeguard the quality of services. 3. One of the important issues regarding emergency services we have identiﬁed from the complaints we have received, are delays in handover from ambulance services to A&E, and transfer between different levels 158 http://www.nhsdg.scot.nhs.uk/Hospitals/Galloway_Community_Hospital_-_Stranraer 159 The College of Emergency Medicine (2013). The drive for quality—How to achieve safe, sustainable care in our Emergency Departments (http://secure.collemergencymed.ac.uk/code/document.asp?ID=7030 Accessed 22/05/13 160 http://www.england.nhs.uk/2013/05/09/sup-plan Accessed 22/0513 cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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of urgent care. The quality of those handovers is of critical importance to ensure that healthcare is delivered efﬁciently, patients receive the highest quality of care and that avoidable deaths are prevented. 4. We provide an illustrative example of failures in these services and make recommendations that: — Complaints regarding A&E services should be used to improve services. — Good practice guidelines and professional codes of conduct should be followed. — Healthcare providers should work together to establish clear and efﬁcient procedures to speed up the handover from ambulance services to A&E and transfer between different levels of urgent care.

Introduction 5. An effective complaints system is a core part of a well-designed and managed public service. When handled well, complaints make a difference. A good response to a complaint can ensure justice for the individual. Importantly, it can also ensure that learning takes place so that mistakes are not repeated and the quality of service improves for all. However, as detailed by the Francis Report,161 the reality is that too often complaints do not make the difference that they should. 6. To support the use of complaints in the improvement of public services, we investigate complaints that individuals have been treated unfairly or have received poor service from the NHS in England, Government departments and other public organisations, and from which the complainant has yet to receive a satisfactory response. If our investigations find significant or repeated mistakes, we share this information with service providers, professional regulators, Government departments and others involved in the delivery of public services to help them do their job. Most members of the public who bring their complaint to us, tell us that they are looking for three simple things: — an explanation of what went wrong; — an apology; and — an adequate remedy, with action to be taken so that other people do not have to experience the same poor service. 7. But sadly, the public perception of complaining is so poor that research we commissioned in 2012 showed: — the overwhelming majority (64%) of people who complain do not believe that their complaint will lead to any change; and — 39% of those who want to complain about a public service do not make a complaint. Almost 60% of this group told us that their reason for not complaining was that they believed the complaints process would be complex, involve them having to chase a response and that they feared nothing would change as a result of their complaint. 8. As a member of the public said to us, the complaints system “has not been designed with the public in mind”. This is a damning indictment of much of today’s public service complaint handling. We owe it to those who have a complaint to change this and to ensure that complaints make a difference in the future. 9. With this in mind, the following case study from the complaints we have received provides an illustrative example of how the poor management of a patient’s transfer to hospital and inadequate handover to A&E can result in an avoidable death. 10. The unprecedented increases in A&E attendances and admittances, as highlighted by the College of Emergency Medicine162 and NHS England,163 have the potential to significantly impair the quality of patient care. It is therefore vital that the complaints that are received regarding these services are taken into account in the identification of areas of concern and ways to safeguard quality of service. 11. The Joint Royal Colleges Ambulance Liaison Committee’s,164 the Health and Care Professions Council’s,165 the General Medical Council (GMC)166 and the Nursing and Midwifery Council’s (NMC)167 guidance clearly outlines good practice in the handover from ambulances services to A&E and transfer between different levels of urgent care. However, this case study demonstrates that these guidelines are not always enacted, which can have an adverse effect on the use of resources and the quality of care patients receive. 161 Francis R (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (http://www.midstaffspublicinquiry.com/ report Accessed 22/05/13) 162 The College of Emergency Medicine (2013). The drive for quality—How to achieve safe, sustainable care in our Emergency Departments (http://secure.collemergencymed.ac.uk/code/document.asp?ID=7030 Accessed 22/05/13) 163 http://www.england.nhs.uk/2013/05/09/sup-plan Accessed 22/0513 164 Joint Royal Colleges Ambulance Liaison Committee (2006). UK Ambulance Service Clinical Practice Guidelines (http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines Accessed 22/05/13) 165 Health and Care Professions Council (2007). Standards of proficiency—Paramedics 166 General Medical Council (2013). Good Medical Practice (http://www.gmc-uk.org/guidance/good_medical_practice.asp Accessed 22/05/13) 167 Nursing and Midwifery Council (2008). The code: Standards of conduct, performance and ethics for nurses and midwives (http://www.nmc-uk.org/Publications/Standards/The-code Accessed 22/05/13) cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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An Illustrative Example 12. Mrs L complained about the care and treatment provided for her grandson, Mr L. He had been assaulted and had fallen backwards, hitting his head on the surface of a road. With Mr L experiencing a decreased level of consciousness, emergency services were called and Mr L was admitted into hospital. However, Mr L subsequently died of his injuries. 13. In relation to the Ambulance Trust, Mrs C complained that the management of Mr L’s transfer to hospital and the handover with the A&E department were inadequate. Mrs L complaint that the medical treatment and nursing care provided by the Hospital Trust while Mr L was in A&E were inadequate and that staff delayed transferring Mr L. The Ombudsman investigated this case and upheld Mrs L’s complaint, making recommendations to the Ambulance Trust and the Hospital Trust involved to appropriately address the services failures that led to the death of Mr L. 14. In order to ensure Mr L received the highest quality of care, the paramedics should have taken steps to assess Mr L’s condition using appropriate diagnostic and monitoring procedures and then provided appropriate treatment. They should have acted in line with ambulance guidelines168 to assess possible causes for the period of unconsciousness experienced. 15. The ambulance trauma guidelines state that a decreased level of consciousness should never be assumed to be caused by alcohol. The paramedic took account of the injury suffered, the cut to Mr L’s head and his clinical condition. However, the paramedic did not recognise that this information, when taken together, can indicate a serious head injury. The paramedic failed to take a reasonable decision based on all relevant considerations. 16. The failure to properly identify the potential signiﬁcance of Mr L’s injury meant that the paramedic crew did not take important steps to ensure Mr L had a quicker handover at A&E. They did not transfer Mr L under emergency conditions with sirens and blue lights, in line with established good practice. They also failed to alert A&E that Mr L had a potentially serious head injury, which would have enabled a senior clinician to be available to assess Mr L upon arrival.

Nursing Care in A&E 17. Mr L suffered a serious deterioration in his condition when, following an agitated state, he vomited and stopped moving. In line with National Institute for Health and Clinical Excellence (NICE) guidance,169 Mr L should have been referred for an urgent medical review by a supervising doctor and there is no evidence that any nurse asked for a review, although a junior doctor did attended Mr L. 18. Nursing staff did not fully assess the situation and recognise the potential severity of Mr L’s injury. They did not demonstrate that they had the appropriate knowledge and skills to provide an adequate level of care for Mr L, which was not in line with the NMC Code.170 The NMC Code also requires nurses to treat patients with dignity at all times. In removing Mr L’s clothing and underwear in Mrs L’s presence and in view of other patients, the nursing staff failed to act sensitively and to protect Mr L’s dignity.

Medical Treatment in A&E 19. To ensure Mr L received the highest quality of care, the medical team caring for Mr L needed to act in accordance with GMC Good Medical Practice171 and undertake an adequate assessment of his condition and refer him for appropriate treatment. The ﬁrst medical review was by a junior doctor, who took appropriate action in line with established good practice and called the trauma team following his assessment of Mr L. The trauma team also responded appropriately to Mr L’s deterioration and took steps to stabilise him before referring him for a CT scan, in line with established good practice. 20. The trauma team decided on the basis of this scan that Mr L had a subdural haematoma (although this was incorrect as the injury was actually an extradural haematoma) and required a transfer to a neurosurgical unit. 21. Following the decision to transfer Mr L to a specialist neurosurgical unit, there was a delay in the arrangements for the transfer, which took an hour to complete, and it was almost two hours before Mr L arrived at the unit. There was no documentation in the notes to adequately explain the reason for this delay, and there has been no explanation why the arrangements for the transfer took an hour to complete. Timing was critical to achieve the best outcome for Mr L and the team did not act with sufﬁcient urgency and in line with established good practice to arrange the transfer. 168 Joint Royal Colleges Ambulance Liaison Committee (2006). UK Ambulance Service Clinical Practice Guidelines (http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines Accessed 22/05/13) 169 National Institute for Health and Clinical Excellence (2007). Head injury: Triage, assessment, investigation and early management of head injury in infants, children and adults (http://www.nice.org.uk/CG56 Accessed 22/05/13) 170 Nursing and Midwifery Council (2008). The code: Standards of conduct, performance and ethics for nurses and midwives (http://www.nmc-uk.org/Publications/Standards/The-code Accessed 22/05/13) 171 General Medical Council (2013). Good Medical Practice (http://www.gmc-uk.org/guidance/good_medical_practice.asp Accessed 22/05/13) cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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Injustice 22. There were missed opportunities to recognise the life threatening severity of Mr L’s injury sooner (by the paramedic crew and by the nursing staff) and take appropriate action to treat him (by the staff in A&E). If these failings had not occurred, Mr L would have been transferred more swiftly, could have undergone surgery earlier and may have survived his injury. This is an injustice to him that cannot be remedied. It is also an injustice to his family, who are left with the distressing knowledge that more could have been done for him, which could have meant that Mr L survived his injury. 23. Mr L was not given privacy when nurses removed his clothing, and the care Mr L received from the nursing staff in A&E clearly distressed Mrs L. It was upsetting for Mrs L to see this and this distress is a further injustice for her.

Recommendations 24. The failure to properly identify the potential significance of Mr L’s injury meant that the paramedic crew did not take important steps to ensure Mr L had a quicker handover at A&E. They did not transfer Mr L under emergency conditions with sirens and blue lights, in line with established good practice. They also failed to alert A&E that Mr L had a potentially serious head injury. 25. There were also delays in his treatment by both nursing and medical staff, with a lack of sufficient urgency which could have been vital in providing the appropriate healthcare which could have meant that Mr L survived his injury. 26. This example demonstrates that good practice and professional codes of conduct are not always being followed, with clear and efficient procedures regarding the handover from ambulances services to A&E and transfer between different levels of urgent care not fully implemented. While the increased pressure on A&E services172,173 could lead to an erosion of good practice, this will have further adverse effects on the efficiency of service delivery, further increasing delays in delays in handover from ambulances services to A&E, and transfer between different levels of urgent care. We would therefore recommend that: — Complaints regarding A&E services should be used to improve services. — Good practice guidelines and professional codes of conduct should be followed. — Healthcare providers should work together to establish clear and efficient procedures to speed up the handover from ambulance services to A&E and transfer between different levels of urgent care. May 2013

Written evidence from the Shelford Group (ES 40) Introduction 1. The Shelford Group comprises 10 of the leading NHS multi-specialty academic healthcare organisations. The following submission is written on behalf of all the Shelford Group members, listed below: — Cambridge University Hospitals NHS Foundation Trust. — Central Manchester University Hospitals NHS Foundation Trust. — Guy’s and St Thomas’ NHS Foundation Trust. — Imperial College Healthcare NHS Trust. — King’s College London Hospital NHS Foundation Trust. — Newcastle upon Tyne Hospitals NHS Foundation Trust. — Oxford University Hospitals NHS Trust. — Shefﬁeld Teaching Hospitals NHS Foundation Trust. — University College Hospital NHS Foundation Trust. — University Hospitals Birmingham NHS Foundation Trust. 2. Representatives of the Shelford Group would be willing to provide oral evidence to the Committee, should they be invited to. 3. This submission is intended to give the Committee a clear picture of the current pressures being felt in Accident and Emergency (A&E) departments, their consequent effects, causes and possible solutions. The submission addresses the following areas on which the Committee is seeking comment: — The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas. 172 The College of Emergency Medicine (2013). The drive for quality—How to achieve safe, sustainable care in our Emergency Departments (http://secure.collemergencymed.ac.uk/code/document.asp?ID=7030 Accessed 22/05/13) 173 http://www.england.nhs.uk/2013/05/09/sup-plan Accessed 22/0513 cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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— Progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings. — The range, severity and incidence of conditions that can be treated within an A&E unit but not managed at an urgent care centre. — Experience to date of the transition from NHS Direct to the NHS 111 service. — Clinical evidence about outcomes achieved by specialist regional centres, taking account of associated travel times, compared with more generalist hospital based services. — Aspects of care which are likely to improve by being located in regional specialist units and the risks associated with removing services from existing A&E provision.

Summary 4. All Shelford Group members are experiencing unprecedented levels of A&E attendances and admissions. The Group has undertaken a data collection exercise in order to illustrate the increased levels of attendances and admissions in the A&E departments of member Trusts over the last three financial years. 5. Shelford Group members are concerned about the impact that this increase is having on their own Trusts and on the entire NHS system. For example, increased admissions via A&E often lead to the cancellation of elective and specialist care operations for patients in need. 6. The Shelford Group has analysed some of the root causes of the increased pressures in A&E and these are listed in this submission under the following headings: — A Reduction in Bed Numbers and the Marginal Tariff for A&E. — Ageing Population and Acuity Issues. — Universal Increase in Demand. — Large Acute Trusts Absorbing Needs Arising from Closures or Reduced Capacity of Local A&Es. — Adverse Weather Conditions and Related Infection Outbreaks. — Inadequate A&E Staffing. — Inadequate Community and/or Social Care Provision. — Loss of Confidence in the NHS 111 Service and Reduced Out-of-Hours GP Services. 7. Shelford Group members want to continue to deliver high quality and safe patient care and believe that there are two short-term measures that could be taken to help alleviate these pressures: (a) A short-term relaxation of regulatory action following failure to comply with A&E regulatory targets, to ensure that patients are treated safely; (b) Hospitals should receive full payment for services provided to emergency attendances and admissions to enable them to provide the additional capacity needed in the short term. 8. The Shelford Group believes that the long-term solution to the increased pressure in A&E departments is the integration of primary care, social care and community care services with acute services. From the data included in this submission, it is evident that those Trusts with a degree of integrated services have more flexibility to manage the increase in demand than those that do not. That is not to say that having integrated services has in all cases prevented rises in A&E admissions and attendances. However, Shelford Group members believe that the situation may have been worse this winter had these additional services not be available. 9. The Shelford Group agrees that there is a need for a model of integration, and a definition of the term, which should encompass alignment between primary and secondary care, and care in the community.

Written Evidence Section 1: Gathered Data to Illustrate Rises in A&E Attendances and Admissions in Shelford Group Member Trusts 10. All Shelford Group member Trusts are experiencing unprecedented levels of A&E attendances and admissions. The impact is being felt even more acutely due to delayed discharges as a result of a lack of adequate community and/or social care provision. 11. The Group has, therefore, undertaken an exercise of gathering data from its Trusts to compare the extent to which A&E attendances and admissions have increased. The following graphs provide an illustration of the increased pressures in Shelford Group A&E departments.174 174 Please note that the data presented in these graphs may include some discrepancies due to the fact that each Shelford Group member Trust deﬁnes and collects their A&E data slightly differently. Nevertheless, the data presented gives an accurate indication of the trends felt across all Shelford Group organisations. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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12. The ﬁrst two graphs illustrate the growth of A&E attendances at Shelford Group Trusts over the last three ﬁnancial years:

13. The two following graphs illustrate the growth of admissions to hospital beds from A&E at Shelford Group Trusts: cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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University University Central Guy’s & Imperial Newcastle Oxford Sheffield Cambridge King’s College Hospital University Manchester St. Thomas’ College College Upon University Teaching Tyne London B’ham

14. The individual hospital breakdown of A&E attendances and admissions at Shelford Group member Trusts is available on request, should you wish to analyse the individual data. For brevity, these have been omitted from this submission.

Section 2: The Impact of Rises in A&E Attendances and Admissions in Shelford Group Member Trusts 15. Shelford Group members are concerned that the rising A&E attendance and admissions compromise patients’ hospital experience, given that staffing levels and resources are stretched beyond the hospital’s capacity. This also has a detrimental impact on staff morale. 16. The resulting levels of cancelled and/or delayed elective operations are a significant concern for many of the Group’s Trusts. In many cases, the cancellations of elective procedures take place either on the day of admission or the day before, causing distress and inconvenience to the patient. These are often patients with life-threatening conditions such as cancer, cardiac or neurosurgical problems. 17. Shelford Group members are also concerned that as leading regional specialist and major trauma centres, targets will not be met, compromising elective and specialist care operations and incurring penalties that could be financially and reputationally damaging.

Section 3: The Reasons Behind the Rise in A&E Attendances and Admissions in Shelford Group Member Trusts 18. The Shelford Group suggests that the increase in A&E pressure is attributed to a combination of the following factors, which are illustrated with examples from member Trusts: cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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19. A Reduction in Bed Numbers and Marginal Tariff for A&E: As hospitals do not receive full payment for services provided to emergency attendances and admissions outside contracted levels, there are frequently resource implications that can limit Trusts’ ability to enable them to provide short-term additional capacity when needed to meet demand. This is an issue felt keenly by Shelford Group Trusts because of their relative position in a local or regional health economy. Patients attending A&E departments can often by-pass other more local providers to receive care. This has a compound effect on the issue of the marginal 30% tariff for A&E. The issue of absorbing capacity is explored further below. 20. Ageing Population and Acuity Issues: Shelford Group Trusts have reported a large increase in the demands of the over-85 year age group. The needs of the ageing population are often acute and span multidisciplinary requirements. In many cases, Shelford Group members have noted that patients from this age group do not need to be hospitalised, however, there is inadequate care in the community to enable them to be safely discharged. 21. Universal Increase in Demand: Some Shelford Group members have noted that until very recently, A&E pressures tended to fluctuate across geographic sites, which offered the opportunity to agree ambulance diverts and balance demand overall. The current situation is such that often pressure is being felt across all hospitals in one geographic area. 22. Large Acute Trusts Absorbing Needs Arising from Closures or Reduced Capacity of Local A&Es: As large acute and regional specialist teaching Trusts, Shelford Group members do not restrict admissions or delay handovers from ambulances. This is not always true of their smaller neighbouring hospitals. Therefore, Shelford Group Trusts’ performance can also be affected by flows of attendances from beyond their normal catchment. They are the backstop A&E departments for the wider sub-regional population. It is possible that in the months ahead, as staffing problems in particular become more serious in smaller A&E departments, this will lead to smaller A&Es becoming unsafe and closing unexpectedly, immediately increasing reliance on the large acute teaching Trusts. Shelford Group members predict this will happen nationwide and feel the need to make contingency plans for this now. For example, Imperial College Healthcare NHS Trust reported the impact of closures by neighbouring Central Middlesex Hospital: “A&E is now closed out-of-hours and is threatened with closure so we have seen a big increase of attendances and ambulance arrivals at Hammersmith Hospital”. Similarly, King’s College Hospital NHS Foundation Trust reported that their Trust is of the view that its own performance has been impacted by the pressures that are being experienced across the wider South East London sector, where, “neighbouring Trusts have reduced bed capacity due to Norovirus outbreaks and going on A&E divert”. This point links back to paragraph 10 regarding bed capacity and marginal tariff. It is also impacted by the following paragraph, regarding external issues relating to severe winter conditions. 23. Adverse Weather Conditions and Related Infection Outbreaks: Long periods of adverse weather and unusual viral patterns, such as the Norovirus, have contributed to the recent rise in A&E pressure. As Newcastle-Upon-Tyne Hospitals NHS Foundation Trust reported: “Capacity has been affected throughout the winter through infection, particularly Norovirus. The Norovirus period appears to be prolonged this year, with cases starting as early as September and wards still being closed now within the Trust. This has added an additional set of pressures in terms of emergency and planned activity”. University College London Hospital NHS Foundation Trust has commented that: “capacity constraints now make ‘absorbing’ the impact of Norovirus, flu or other reasons for closing beds much harder. This in turn is then more likely to reflect pressure back onto our emergency department”. In University Hospitals Birmingham NHS Foundation Trust this year, it was found that media reports warning people to keep away from one hospital in the area that had repeatedly had Norovirus outbreaks, resulted in a sharp increase in admissions to UHB’s A&E department. 24. Inadequate A&E Staffing: Some Shelford Group member Trusts have found staffing requirements in A&E departments to be a challenge. Sheffield Teaching Hospitals NHS Foundation Trust, for example, noted that A&E is one of the specialities for which it is hardest to recruit. The problem is compounded by the “increased activity on top of the existing difficulties […] as well as changes to junior doctor training posts”. This also relates to paragraph 15, regarding the detrimental impact of increased A&E pressures on staff morale and patient experience due to stretched resources. 25. Inadequate Community and/or Social Care Provision: Some Shelford Group members have observed that a significant proportion of patients come to A&E because there is nowhere else for them to turn in the community. Equally there is inadequate provision of care for them cobber Pack: U PL: CWE1 [E] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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to be safely discharged following A&E treatment or admission. This can cause discharge delays, which in turn increases pressure on the system. 26. Loss of Conﬁdence in the NHS 111 Service and Reduced Out-of-Hours GP Services: As with the introduction of any new system for out-of-hours or urgent care, any resultant loss of conﬁdence results in a rise in patients seeking alternative points to access the care they want. When combined with changes to general practice, this can compound the impact on A&E departments.

Section 4: Shelford Group Recommendations for Solutions in the Short and Long-Term 27. Shelford Group members want to continue to deliver high quality and safe patient care and believe that there are two short-term measures that could be taken to help alleviate these pressures: (a) A short-term relaxation of regulatory action following failure to comply with A&E regulatory targets: Shelford Group members all support the 95% target and work incredibly hard to ensure that it is met. However, given the realities in which Shelford Group Trusts are operating, and the resulting increased pressure on workforce resources and local health economies, the Group is concerned that focusing on such targets could be detrimental to patient care. The Shelford Group is conscious to learn the lessons from the Francis Inquiry Report about preoccupations with financial and performance targets distracting organisations from focusing on the effect of the service on the patient. The Shelford Group recommends that regulators take into account the various pressures outlined above and allow a degree of relaxation around the regulatory action following failure to comply with the A&E targets, until the current pressures are shown to be alleviating. This would allow Trusts to concentrate on safely managing the increased A&E attendances and admissions, without having to worry about incurring vast financial penalties that may also damage the Trusts’ reputation. (b) Hospitals should receive full payment for services provided to emergency attendances and admissions: The 30% marginal tariff for A&E makes operating under the current pressures all the more difficult. The 70% funding is diverted into schemes that, up to now, have had no impact in avoiding hospital attendance and admission. Shelford Group members believe that by Trusts being allocated the retained 70% of funding, hospitals would be better placed to provide the additional capacity needed in the short term. Doing so would not add any cost to the system as commissioners have to pay the full price regardless. 28. The Shelford Group believes that the long-term solution to the increased pressure in A&E is the integration of primary care, social care and community care services with acute services. From the data referenced above, it is evident that those Trusts with a degree of integrated services have more flexibility to manage the increase in demand than those that do not. That is not to say that having integrated services has in all cases prevented rises in A&E attendances and admissions, although it has in some instances. However, Shelford Group members believe that the situation for their Trusts’ A&E departments may have been worse had these additional services not been available. 29. The Shelford Group recommends that a model of integration, and a definition of the term, be devised, encompassing alignment between primary and secondary care, and care in the community. May 2013

Written evidence from Circle Healthcare (ES 41) Circle Healthcare took over Hinchingbrooke Hospital, a small DGH with an Emergency Department in February 2012.

Before At that time performance of HHCT 4 hour A&E standard was at the bottom of regional performance and in the bottom 10 nationally. At the year ended April 2013, HHCT was top of the 4 hour standard in regional performance and in the top 10 nationally.

Now Our Emergency Department has been ranked as the 8th best in England for 2012–13 according to Health Service Journal having treated 98% of our A&E patients within four hours. cobber Pack: U PL: CWE1 [O] Processed: [26-07-2013 14:20] Job: 031945 Unit: PG01

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During this time there has been no change in net staff numbers, we have just profoundly altered the way in which we work. Our analysis is based on our experience in HHCT, but also from collective experience of 40 years of Emergency Care in medical, nursing ambulance and hospital management in different countries. 1. Over the past 10 years, Emergency Departments have picked up the role, previously undertaken exclusively by General Practitioners, of being the main sieve that filters which patients need to be in hospital and which do not. 2. This sieving process is more expensive, takes longer and is less accurate if one lacks a patient’s background information, which was always available to the patient’s own General Practitioner. 3. The narrative about Emergency Departments is often one of failure; that many patients should not be there. Emergency Departments are in fact a success story in the NHS in that large numbers of the public prefer the service that they receive in an Emergency Department to the alternatives on offer. 4. There have been large changes in societal expectations of healthcare and in patient demographics as well as the well-documented changes in Out of Hours cover. While there has been an increase in the number of patients attending, there has also been a marked increase in the complexity of the patients attending, and this has not been accurately measured, and is therefore easy to overlook. There have also been many more patients referred in to hospital Emergency Departments by GPs who find it too difficult to access inpatient clinicians. 5. The questions that frame this debate imply that small hospitals are necessarily inferior, and there is no logical reason for this to be so. Small hospitals exist for a reason—they meet a population need and both small and large hospitals are complementary components in the healthcare ecosystem. 6. Big hospitals are best at performing complex work like trauma and cardiac services that require economies of scale. Small hospitals can offer a safe and cost effective level of care and co-ordinate local services to local patients. There is local accountability that is eroded if all services are delivered from a long way away, particularly if the supplier is effectively a monopoly provider, eroding any market—testing. 7. Centralising all acute care to large hospitals physically remote from local populations looks attractive to those who would be monopoly providers in such a re-organisation, but would severely limit choice and would further concentrate power in the hands of a limited number of providers. 8. A good analogy is that we shop in both local convenience stores and in large out of town supermarkets, that may be run by the same organisation. We expect that the quality in the smaller shop will be just as good, but the range of goods will not be as wide. 9. We have demonstrated that good quality healthcare can be provided economically in a smaller hospital. The old model of the District General Hospital is not viable clinically or financially. District General Hospitals need re-invent themselves if they are to survive. We have achieved this by systematically engaging our staff— our partners—and using their skills and energy to build a better model of care. 10. We believe that there needs to be a profound change in the way the District General Hospitals manage their acute healthcare—they need to run “smaller and hotter”. This can only be achieved if there is clinical leadership, and the part of the organisation that owns the problem—the Emergency Department—must also own and manage the solution as we have demonstrated at Hinchingbrooke.

Data—Understanding our Business 11. One of the root causes of the current unhappy situation in Emergency/Acute Care is that very poor data are collected, and this has resulted in sub-optimal decisions at all levels. 12. We cannot hope to move to a system of Value Based Healthcare unless we understand our business. This is easy in elective healthcare but difﬁcult in acute healthcare eg: (a) Negotiations regarding provision of Out of Hours care in 2004. (b) No one knows who is attending Emergency Care with what conditions, what the ﬁnal diagnosis is, and therefore most importantly what value has been added—whether the “sieve” has worked correctly. 13. A core Circle belief is that high quality data is the foundation to delivering excellent healthcare, and this is backed up by a paper examining key factors that differentiate high quality from low quality organisations.175 May 2013

The Stationery Ofﬁce Limited 07/2013 031945 19585 175 Curry, L A, et al, What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Annals of internal medicine, 2011. 154(6): p. 384–90.