Summary
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The NHS England medical director, Sir Bruce Keogh, and others highlighted issues with social care provision as a significant factor in the pressures A&E departments are currently experiencing. Professor Keith Willett, director for acute episodes of care at NHS England, said delayed discharges accounted for about 20% of beds over the festive period.
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Cliff Mann, president of the College of Emergency Medicine expressed concerns that the £700m of winter resilience funding had not all been used to alleviate pressures in A&E departments. King’s Fund chief executive Chris Ham suggested some of the cash may have been used to “paper over financial cracks”.
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Mann said the NHS is struggling to retain emergency doctors because after three years on the job they realise that the work/life balance is inferior to other specialities. The job needs to be made less stressful, he said.
Before the session, committee chair Dr Sarah Wollaston (Chair), a GP, says that, for the purposes of clarity, she wishes to point out that fellow committee member and Tory MP, David Tredinnick, was speaking in a personal capacity when he asked the NHS to look at a homeopathic flu remedy. She says she would be “horrified” if it was adopted.
The session closes with Keogh thanking staff in the NHS for their “goodwill, professionalism and desire to do well for the people they treat”.
Asked about the impact of GP practices being closed over Christmas, Jim Mackey, chief executive of Northumbria NHS Foundation Trust, says it is a big factor but would not have had an impact on the extra demand the trust experienced over Christmas as most cases would have ultimately ended up in A&E anyway.
Willett says there has been an increase in delayed discharge, to about 20% over the festive period. A third are due to social care and two-thirds are down to the NHS, he says.
Asked whether NHS money will be used to prop up social care where cuts have been made, Willett says: “We have to look after patients.”
He suggests the winter resilience funding will be used to support more social care.
Sir Bruce Keogh says the Better Care Fund, which aims to give elderly and vulnerable an improved health and social system, offers hope for the future with respect to the issue of delayed discharge but that social care is not within the NHS remit.
Willett says the emergency and urgent care review includes a modern education framework for what kind of nurses are needed.
But asked by Labour’s Barabara Keeley about who will pay for 12,000 district nurses that she says are needed, Willett says commissioning responsibility for recruiting new district nurses rest with local clinical commissioning groups.
Professor Keith Willett, director for acute episodes of care at NHS England, says there has to be a transformation of the whole system, particularly the out-of-hospital care with respect to demand and freeing up beds. He names other things that need changing, including the tariff system.
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There is a question on why the NHS is not good at implementing the best practice seen at the likes of Luton and Dunstable.
Pauline Philip, chief executive of Luton and Dunstable trust, says there is appetite from others to learn from them.
She says the trust’s performance is down to the overall culture.
Sir Bruce Keogh says that the use of winter resilience funding is being tracked and evidence is that it is being used for extra beds. Earlier, Cliff Man, president of the College of Emergency Medicine, expressed fears that not all of the funding was being used to relieve the pressures on A&E and said he had sent FOI requests to trusts to try to spend out how it was being spent.
Jim Mackey, chief executive of Northumbria Healthcare NHS Foundation Trust says the winter resilience money was received a bit late.
Philip, chief executive of Luton and Dunstable University Hospital NHS Foundation Trust, said one of the downsides about winter funding is that it does not support long-term recruitment of staff, only temporary.
Pauline Philip, chief executive of Luton and Dunstable University Hospital NHS Foundation Trust, one of the first services to be rated as outstanding by the Care Quality Commission, says they have a range of services on site, including a GP clinic on site.
Philip says the hospital has seen 98% of patients within the four hour target in recent months.
Mackey is asked about the model in Northumbria, which is rated one of the top 40 hospital trusts, in terms of patients coming in and being discharged and how better flow is achieved.
Mackey says he doesn’t think there were lots of people attending inappropriately over the past six weeks. There were lots of frail, old people who could have seen a GP but probably would have been admitted anyway.
He says they probably have more services open on weekends and in evenings compared to others.
That said we did still struggle over Christmas.
Keogh is asked about the latest figures. They show that A&E is under considerable pressure, says Keogh.
There were 20,000 more patients in A&E than in the same week last year.
Three out of the last four weeks have seen less than 90% of patients seen within the four-hour target, he adds.
Keogh is asked about whether the failure to meet targets has a detrimental impact on patients or whether it is purely administrative. Keogh responds by saying it is not just a box-ticking exercise.
When people are waiting for services there is a detrimental impact but we don’t know the chain of causation, says Keogh, which is the chicken and which is the egg.
Now up are NHS England medical director Sir Bruce Keogh, Professor Keith Willett, national director for acute episodes of care at NHS England, Dale Bywater, director of delivery and development (Midlands and East) at the NHS Trust Development Authority, Pauline Philip, chief executive of Luton and Dunstable University Hospital NHS Foundation Trust and Jim Mackey, chief executive of Northumbria Healthcare NHS Foundation Trust.
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Asked about his key recommendations, Ham says there must be in every community a single joined up emergency system (i.e. including social care services) with a single budget.
In the short-term it’s about co-location and getting flow within hospitals, he says.
They move on to the impact of social care.
A quarter fewer people are receiving social care than in 2010, that is bound to create pressures, says Ham. He says in Torbay they have social care services fully integrated with the NHS and it has worked well.
He is asked whether integration of social care with healthcare is sufficient in the absence of more money. Ham says more money is needed and a single NHS and social care budget, a change the King’s Fund has previously highlighted.
Mann says that from his experience, the problems with social care are much greater with respect to timely discharge from hospital, rather than social care services pushing people towards A&E departments.
Mann says there is a lack of seven-day services in social care, on weekends, bank holiday problems etc and in their absence there will have to be a default option, which currently is A&E departments.
The next question is on patient demand and whether young people are simply not prepared to wait three days for an appointment (a factor raised by the NHS in explaining the recent problems).
Ham says this is true in part but the bulk of the demand is from old, frail patients who do need emergency care.
If people are turning up, don’t blame them but create other services for them, he says. It’s not surprising that they go to A&E because it is open 24 hours, says Ham
Mann says there is little evidence to point to a surge in demand from people aged 18-30 and we shouldn’t blame people when we’ve told them to go to A&E, e.g. via the 111 helpline.
Mann says there is no barrier to recruiting A&E doctors, they always hit their targets in terms of recruitment, but the problem is retention. After three years they feel the work/life balance is inferior to other specialities.
The tariff system is penalising acute care says Mann, so that hospitals lose £2.5m to £3m a year. That forces them to do more elective care etc to make a profit but that then means that when there is an upsurge in demand in A&E, the ability of the hospitals to respond is diminished.
Mann says he is not convinced that the £700m winter resilience money has been invested properly to help relieve the burden on A&E departments. The vast majority of that money should have gone into frontline services and getting patients discharged in a timely fashion.
He says the money was given to clinical commissioning groups to be invested in the local health economy but he is unconvinced it has gone into the necessary area. He says he has submitted Freedom of Information requests to find out what the money was actually invested in.
Ham says he wouldn’t be surprised if some of the winter resilience money is being used to “paper over financial cracks” rather than on relieving pressure on emergency departments.
Paramedics have a key role to play in relieving the pressure on A&E departments, says Mann
But he says they must be given option other than taking people to A&E, such as arranging a visit from a district nurse, otherwise they will always take them there.
They are asked about the “inefficiency” of ambulances lining up outside A&E departments with “stable” patients.
Mann says at peak activity times it is probably sensible to have a more rational system, which might involve more nurses or healthcare assistants looking after such patients until an emergency cubicle is available to them so that paramedics can then return to the field. But that should not become the norm, he says.
On the number of acute beds, Ham says that England has less than comparable countries but that if it the worst hospital was operating at the same level as the best hospital, that would not be an issue.
He once more highlights the importance of patient flow and the impact of the squeeze in social care but says two-thirds of delayed transfers from hospital beds are due to problems in NHS coordination.
If you cut the beds without first building up other services, it is pretty clear you will experience problems, as has happened this winter, says Ham.
Mann says if the number of delayed discharges were addressed, there would probably have been enough beds this winter.
Asked about major incidents - at least 16 hospitals have declared a major incident in recent weeks - Ham says that many hospitals are having to cancel planned operations, which may have an impact on other waiting times like the 18 week target for referral for treatment.
First up are Dr Clifford Mann, president of the College of Emergency Medicine, and Professor Chris Ham, chief executive of the King’s Fund
Ham starts by saying the recent problems are the result of increased demand and constrained supply over the past four years.
The biggest problems are outside hospitals, including problems in discharging patients due to inadequate social care resources, he says.
The solution lies not just in hospitals and certainly not just in A&E but in implementing a joined up system.
Mann says latest figures show attendances are up 460,000 over last year. It may be only 3% but it’s equivalent to eight or nine extra emergency departments he says.
Asked if there is a link between targets and quality of care, Ham says research from Australia shows a relationship between longer waiting times, higher bed occupancy and poorer patient outcomes.
You will be able to watch the committee meeting live at this link when it starts.
Good morning. Welcome to live coverage of the Commons Health Select Committee session on winter pressures in accident and emergency departments, which is due to start at 9.30am.
Sir Bruce Keogh, medical director of NHS England, will be among those questioned amid concerns that A&E departments are struggling to cope.
NHS statistics have shown performance in A&E departments regularly falling to new lows with respect to their targets. The latest figures show that emergency departments across England managed to treat just 79.8% of patients within the four-hour target, the worst performance ever.
At least 16 hospitals have recently declared a major or serious incident, meaning they are struggling so much with demand that they are being forced to cancel planned operations or asking people to come to A&E only in an extreme emergency.
The committee will begin with evidence from Dr Clifford Mann, president of the College of Emergency Medicine, and Professor Chris Ham, chief executive of the King’s Fund, before moving on to Keogh.
Keogh will be questioned alongside Professor Keith Willett, national director for acute episodes of care at NHS England, Dale Bywater, director of delivery and development (Midlands and East) at the NHS Trust Development Authority, Pauline Philip, chief executive of Luton and Dunstable University Hospital NHS Foundation Trust and Jim Mackey, chief executive of Northumbria Healthcare NHS Foundation Trust.
