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    but they don’t relieve pressure from A&Es

    The rise and fall of the NHS walk-in centre

    Walk in health services of one form or another feature in many healthcare systems, including Canada and the United States. In England, the first NHS walk-in centre opened in the late 1990s but only became prominent in the late 2000’s following a policy initiative that led to the opening of around 150 new facilities.

    Offering extended hours and with no requirement for patients to pre-book or register, many new centres had proved highly popular with local residents with minor illnesses and injuries such as colds, eye infections, sprains and cuts. But despite this popularity, during the last parliament around a fifth of the facilities shut their doors, with a number of others, for example in Redruth, Hereford, and on Teeside, also currently at risk.

    Taking sides

    Why the services should have closed in such numbers is not immediately clear: the scale of local opposition to some closures – for example in Jarrow, Worcester and Southampton – was intense. Their supporters argue they reach new groups of patients, provide easy and convenient access to care, and take pressure off other stretched NHS services.

    At the same time, commissioners closing centres argue they represent a poor use of funds as many attendees have minor conditions that have little need for medical attention, and those that do could readily be treated elsewhere.  Some have cited the need to fund seven-day-a-week access to GP services as a more pressing priority.

    While not the whole story, one important question in these debates is whether walk-in centres divert patients from attending busy hospital A&E departments. This may be desirable since crowding at A&E is associated with high mortality and can have knock-on effects by reducing the capacity for hospitals to carry out planned medical treatments. In addition, many attendees at A&E have low severity needs which could be safely treated outside a hospital setting. Treating these patients as emergency cases in hospitals is considerably more expensive than treating them in walk-in clinics.

    Building the evidence: do walk-in centres divert patients from A&E?

    Until recently there was no conclusive hard evidence – from either side of the Atlantic – either way. When surveyed, around a quarter of patients attending walk-in centres say they would otherwise have attended a hospital A&E. However, academic research using statistical methods has been unable to detect any such effect.

    My research provides new evidence that goes some way to filling this gap. Combining detailed information contained in hospital records with difference-in-difference statistical techniques, I provide credible estimates of how patients’ use of A&E departments changes in response to the opening or closure of a new walk-in centre close-by.

    Two main findings emerge. The first is that walk-in centres do significantly divert patients away from attending A&E. The second, however, is that relative to the number of patients attending walk in clinics the effect is small, with calculations suggesting only around five to 20 per cent of patients attending a walk-in clinic would otherwise have gone to casualty. The implication is that they only make a small dent on the overall A&E figures.

    The research points to something of a dilemma for decision-makers. Easy access services such as Walk-in Centres are popular, which suggests they are valued by patients. The evidence suggests they do make a small contribution to relieving pressure at over-stretched emergency services, but with low diversion rates from A&E they may be an expensive way to do so. The cold reality of a chilly funding climate points to hard choices in allocating scarce NHS resources to best meet local demand. With this in mind, fights over the remaining centres look set to continue.

    this article first appeared on LSE Business Review.

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    (or You do your job and I’ll do mine).

     The notion of referred pain, where the symptoms of a health problem manifest themselves in a part of the body that is not itself the cause of the suffering, is well known. The care system increasingly suffers the organisational equivalent but those managing it- unlike most doctors attending on patients – seem incapable of adequate diagnosis and effective treatment.

    The author once worked with a “radical” surgeon of whom it was said that he  never made a three inch incision if a two foot one was possible. One only sought his skills when all else had failed.

    The care system has too much referred pain within it. Worse, politicians and managers continue to be distracted by where the pain appears, rather than attending to the root causes. A radical approach to treatment is called for.

    A few examples will suffice.

    The ambulance service regularly fails to meet its performance targets. (Unmanaged) demands have risen. Front line vehicles, languishing outside A&E because that department is overflowing are pressed into service as overflow treatment bays. Welsh Ambulance Services NHS Trust performance targets do not reflect that assumed role. Neither are resources made good to ensure it still reaches the ill and injured in time.

    A & E departments are overflowing partly because they never close and are the easy recipients of people who do not require its high powered skills and  partly because they struggle to admit diagnosed patients to appropriate wards,  or divert them elsewhere.

    Wards are full, partly because of rising demand, but also because we have been slow to re-engineer the total care system. We do not provide a complementary 24 hour emergency social care system and primary care is not appropriately keyed into the total care system when care deemed urgent   by the public is sought.

    What to do? We could follow the buccaneering approach of my surgeon friend and deliberately expose where the pain in the system is in order to fix it.

    For example:

    • ambulances arriving at A & E, would hand over and leave.
    •  A & E departments would only treat those needing its skills and would move diagnosed patient onto wards if a stay was needed, or would divert them to a 24 hour community based  care centre that would take over their care.
    • Wards would immediately move patients no longer needing their skills to settings and agencies better placed, or legally required, to meet their needs

    The last change probably requires home adaptations and home care packages to be managed differently, and for residential / nursing home placements to be more available. In short, a round-the-clock social care service designed to “take the pain” could be one result of meeting care needs in a more timely and appropriate way..

    Re-designing the care system as a whole to ensure that people rarely languish in the wrong bit of it would flow from knowing where the pain really is.

    The sooner we reach a stage where the pain in the system is traced to its proper source – and then addressed – the better.

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    Dear Andy
    I have read your new Health Manifesto which contains some significant steps forward in our health care but I am deeply concerned that I cannot find how our Manifesto redresses the attack on our District hospital A&E and Maternity Units. As a result there is no equity in provision of acute care, especially in the rural areas.
    As Chair of SOS Grantham Hospital and Labour County Councillor for Grantham South (and current District councillor for Grantham St Anne’s Ward) I can advise that we are about to lose what remaining A&E we have.
    The Hospital Trust (ULHT) are strapped for funds and are reviewing all acute care in the County. They propose a new Ambulatory Care Unit goes in, that is little more than a minor injuries unit and will not meet the acute medical needs of the population of people living in the East Midlands A1 corridor.
    Newark Hospital lost its A&E and now has a Minor Injuries Unit. At the time the cut was justified on the grounds Grantham could provide A&E services. This area has become a vacuum as far as A&E provision is concerned with acute services being ‘sucked’ away into the cities, despite the presence (and therefore associated high risks) of main rail routes, poor internal mainly single carriage A roads, the A1 and a mix of industry including agricultural, oil and mineral extraction. We also have a significantly increasing elderly population as people leave the South East and move up to Lincolnshire and extensive coastal area.
    I recall drawing this issue to your attention at your Workshop in Nottingham and understood you were going to address the loss of A&E Units which progressed under our former Government but I cannot see how the current Manifesto achieves this important step.
    The whole of Lincolnshire is to see a centralisation of its acute medical care. This is simply unacceptable when we consider it is the second largest county in the country and one of the poorest. It is very simple. If we allow this to happen then the free access to the NHS services we are committed to for all will not be delivered. Only those with a car will seek emergency medical attention unless in a critical condition. Our ambulance crews are already overstretched regularly taking up to an hour to respond (with the added travel time of an hour and more to an A&E Unit).
    The Golden Hour, once lauded as vital, especially in stroke situations, will be a thing of a the past for the majority of residents of this county.
    We have campaigned against cuts to our services ( a 25k petition went to Downing St) over historic threats (under your watch). The Labour Government did listen and whilst under Labour there were some reductions in service the A&E and Maternity Unit remained.
    Under the Tories despite a 7.7k signature petition objecting to the threats to our maternity unit being closed (so now 1000 mums to be a year are forced to travel from the Grantham area in labour) we lost a super Maternity Unit.
    Now our A&E unit is facing a death knell in the guise of an Ambulatory Care Unit. Despite thousands of petition signatures the United Lincolnshire Hospital Trust and SW Lincs Clinical Commissioning Group have paid lip service to the views of the  public.
    Again, on this front our proposals to sit round a table with the hospital managers seem promising but I doubt will make any difference unless there are real teeth to the proposals that ‘require’ the administrators to take the views of the public into account AND to demonstrate how their views have been reflected in the outcome of any consultation through changes to the proposals. (I am a Business Improvement Consultant). As a councillor I have to send a questionnaire to all households affected by a resident parking scheme and have a majority in favour for changes to go ahead yet the hospital trusts can withdraw vital healthcare provision with no such level of public engagement. This should be addressed.
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    Florence Cunningham trolley.jpg

    We know that Sir Bruce Keogh is very keen on ‘wearable apps’ – little apps you can download onto your smartphone to improve your health. NHS England seem enthusiastic about getting senior staff in the NHS to dream up apps to improve patient care. Part of this, presumably, is wishing to make the NHS profitable like Apple; but part of it is genuinely driven by a wish for technology at low or no cost to improve vastly someone’s quality of life.

    Apple in their recent launch proudly showed off a new app which could act as a mini research lab, taking samples of your speed of finger tapping for example. It boasted that you could contribute to a giant ‘research lab’, and the multinational corporation showcased people from prestigious American hospitals with impressive titles.

    The philosophy behind ‘targets’ in the NHS, latterly being rebranded as ‘ambitions’ in the innocent hope of diffusing their toxicity, was to ensure a minimum level of performance. It is a quick fix way for a politician or hospital manager to say that something is being done. Of course, to total embarrassment of everyone is when targets are regularly missed.

    In terms of ‘performance management’, it is hard to see how repeated missing of a target can be good for staff morale. One would think it at first is bad for morale, but, then as repeated missing of the target becomes the new baseline, it can theoretically implant a culture of ‘it cannot get any worse’. This is of course is bad for the organisational culture of any institute, let alone which is supposed to be driven by patient safety. It is this culture, together with a sense of ‘too something to fail’, which presumably kept Mid Staffs and Morecambe Bay in their bad times.

    You would not typically dream of rating your experience of a meal in a restaurant by how fast it took you to get your food, unless it was a very protracted way, rather than the quality of the actual meal. You should not wish your food to be rushed to your plate if half of it was blatantly undercooked, and not fit for consumption. You should not be particularly inspired if the restaurant were clearly understaffed, relative to the demand of customers, such that it took you a long time to get a waiter’s attention.

    Managers refer to this as the ‘visibility’ of ‘operational management’. A restaurant is a good example, compared to a NHS A&E department, not because of the similarity of the service it provides; but because it is a high visibility service. In other words, it is pretty clear to the ‘end user’ when the organisation of the operation is more chaotic than competent.

    In judging how long it takes for an Ambulance crew to arrive at a medical scene, there are clearly unsafe time windows, particularly for acute medical emergencies such as chest pain or anaphylactic shock. But there is a danger if something is then misdiagnosed, sending a patient on completely the wrong care pathway.

    What happens at 3 hrs 45 mins of the ‘four hour wait’ target is similarly interesting. A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, admitted or discharged in under four hours. The target was revised by the Department of Health to 95% in June 2010.

    If an A&E team have a few missing results from investigations they’ve ordered in assessing a patient, say a blood test has not even been ordered or the result has not come back from the lab, a clinician (or even potentially a non-clinical flow manager) might take a decision to admit the patient to hospital, or to discharge, to avoid breaking the four hour wait. This decision can therefore be primarily managerial.

    A disparity of information between patient and doctor, “information asymmetry”, can mean that it will be clear to the doctor when this 3 hr 45 mins time has been reached (but not clear to the patient). Anyone who has ever been a a patient in A&E, or even worked there, will testify what a stressful working environment it is, taking on a timeless feeling to it.

    But a smartapp on your smartphone would be able to tell you this information as you ‘count down’ your experience in A&E. You see, more helpful to you as a patient, and ultimately the NHS, is whether your experience in A&E has been a good one from the perspectives of patient safety and patient experience.

    A simple checklist on a questionnaire would be triggered at four hours so that you could ‘rate’ which staff you had seen, whether you had been seen by a senior clinician, whether your investigations had been ordered, whether your test results had arrived, at the four hour mark. If so many people are repeatedly missing the four hour target, there would be plenty of respondents to the survey. You could of course be asked to suggest what you think your working diagnosis might be.

    This information could then be downloaded by your GP, the hospital and NHS England, so that they get a feel for your experience in A&E in a way that would be beneficial for rating patient safety and patient experience. Such raw data would be likely to be much more helpful than filling a questionnaire for the ‘Friends and Family Test’ weeks after an event. Such information could be available in real time such that hospitals could be aware if their services in reality were understaffed compared to demand.

    The smartphone app might cost the NHS a minimum amount, if it could be downloaded by the NHS patient for 99p. You would not need the NHS to pay vast amounts of money to the types of IT companies you see at Olympia every year at these NHS ‘Expos’.

    Such an innovation is clearly disruptive. Disruptive innovation, a term introduced by Prof Clayton Christensen at Harvard, describes “a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”

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    It’s been a very difficult week for the NHS with hospitals across the country struggling to deal with significant pressures on their services.  While the political spotlight which comes with the start of an Election year hasn’t helped, talking to colleagues in the acute sector I am clear those pressures are very genuine and I am full of admiration with the work which they (both  front line staff and managers) have been doing to address them.  Furthermore as Nigel Edwards, Chief Executive of the Nuffield Trust, stressed in his blog on the issue while the problems are serious they are not catastrophic and performance is still good compared to historical and internal comparison.

    As most informed commentators have flagged up what is happening is not straightforward.  It is the winter with the usual seasonal upturn in illness and a corresponding upturn in demand at the front door.  Yet by all accounts that increase in demand is not unprecedented and it appears that A&E activity was higher in the summer.

    Delayed discharged is also an issue.  Some of this, unsurprisingly, has been due to pressure on social care budgets but a greater proportion of delays have been caused by issues around the co-ordination of NHS care.

    Linked to this the impact of a greater number of frail elderly and often isolated people in the community means there are more people with more complex needs who are at greater risk of needing hospital care and for whom the process of returning them safely to the community can be more complex and take longer.

    Finally there is the impression of what is a complex and stressed system operating close to capacity which becomes increasingly less able to absorb the pressure of significant if in some ways predictable demand.

    I do not claim to the have the answers to the woes of A&E but the recent events have reminded me of issues which arose when I worked in this area in my time at NHS Direct about how the urgent care system  operates and how we want to support the public in using it.  It also highlights key fault lines in the way in which we organise care and support, which while undoubtedly well recognised, need to be addressed with urgency.

    So on that basis I have a list of 5 things which we should use the present challenges to prompt us to make sure are different about access to urgent care in the future.

    First, in my view, there are strong arguments for a primary care led front door to the NHS round the clock and round the year.  As they are in hours, primary care clinicians are best placed to make a rapid initial assessment of the seriousness  of someone’s condition and whether to use the phrase of a clinician I worked with at NHS Direct, they are “big sick” or “little sick”.  In the small number of cases where there are good reasons for doubt there should be the scope for rapid referral for further assessment by hospital specialists.  We have been talking about this kind of changes in urgent care for years.  Now is the time to make it happen.

    Second we need to ensure that when patients are at risk of going into hospital their medical records and pre-existing care plans are able to follow them.  History and the knowledge of what support may already be in place for individuals makes a crucial difference in many of the cases where admission could be avoided.  As well as struggling with the technological solutions to enable this we still appear to be tying ourselves in knots in terms of information governance.  We should rapidly get to a position, which I am sure the vast majority of patients would support, that with appropriate but simple safeguards, information about a patient is able to follow them around the health and social care system.

    Thirdly we can longer afford a system where there is an institutional division between the delivery and, very crucially, funding of health and social care.  With the scale of pressure on local authority budgets it in the last couple of years there can be no surprise that there are difficulties in discharging frail elderly patients from hospital who need social care support.  Many commentators, most recently the excellent Barker Commission, have made the logical, moral and economic case for bringing these systems together.  Our next Government must grasp the nettle and make a reality of this in the next Parliament.

    My fourth point is to recognise that A&E has in too many cases become a default point of access for a range of groups, for instance people with mental health problems in crisis, who should have access to a more appropriate response to their specific needs.  Just before Christmas research by Paul Burstow MP suggested that in 2014 the number of people visiting A&E   with mental health emergency could have topped a million, a threefold increase from 2002.  This vividly highlights the impact of growing demand on mental health services during the period of austerity and the crucial need for investment to deliver parity of esteem.

    My fifth point is the need to think about the psychological as well as physical aspects of urgent care.  Many of the factors which drive the need to seek urgent help, which exacerbate symptoms or which erode the capability of family carers to cope are ground in psychological factors and in particular the difficulty of containing anxiety.  Such factors can also impact on staff working in highly stressed and unforgiving systems.  The development of and training in psychologically informed practice has a significant role to play in helping us design a holistic urgent care system which is fit for purpose.

    That leads me onto the issue of the conversation we want to have with the public about how they use A&E.  We need to recognise that there are variety of reasons why people come to A&E but in the vast majority of cases they are legitimate.  For many, unexpected ill health is a source of significant anxiety.  In some cases the difference between “big sick” and “little sick” is obvious but in many cases it isn’t.  The consequences of getting it wrong, especially if you are making that judgement on behalf of your child or an elderly relative.  It was one of the strengths of NHS Direct that it accepted that anxiety on a non-judgemental basis and provided support and reassurance which might help patients manage symptoms without needing urgent care.  If we want to support patients to take self-care seriously we must invest in those sources of information and reassurance which empower them to do so not spend money on advertising campaigns which tell them they might be stupid enough to think that A&E might be there “to kiss it better”.

    So for this week the right response to the difficulties in A&E is to praise the efforts of staff across health and social care that have gone the extra mile to ensure care is available for those who need it.  However it is doesn’t have to be like this and, together, we need to accept the challenge to change the system to make sure it isn’t.

    Paul Jenkins is the Chief Executive of the Tavistock and Portman NHS Foundation Trust. This article is reproduced by his kind permission from his personal blog.

     

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    Your chance of dying from a heart attack has about halved over the last ten years.

    Mortality from acute myocardial infarction in England, 2002-10

    Mortality from acute myocardial infarction in England, 2002-10

    But is this down to prevention or treatment?

    Number of heart attacks

    Number of heart attacks

    Your chance of having a heart attack is down about 30% Chance of dying after heart attack

    Your chance of dying if you have a heart attack is down by about a quarter

    Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study. ” both primary prevention and secondary prevention would have contributed to the decline in the rate of sudden deaths from acute myocardial infarction. In addition to reducing rates of sudden death, coronary prevention can reduce disease severity and therefore may contribute to the decline in case fatality for those who survive long enough to receive hospital care for acute myocardial infarction. Furthermore, changes in fatal outcomes among people admitted to hospital for acute myocardial infarction also reflect, at least in part, the contribution of improvements in acute medical treatment during the study time period.”

    What is already known on this topic

    Population based mortality rates from coronary heart disease and acute myocardial infarction have been declining in England and other developed countries since the 1970s.

    The relative contributions of changes in event rate and case fatality to the decline in total acute myocardial infarction mortality vary by country and are not known for England and many other countries.

    What this study adds

    In England during 2002-10 the age standardised total mortality rate fell by about half and the age standardised event and case fatality rates both declined by about one third.

    The determinants of the declining mortality rates differed by sex, age, and geographical region.

    Overall, just over half of the decline in acute myocardial infarction mortality rate can be attributed to a decline in event rate and just less than half to a decline in case fatality.

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    Most of us would accept that at least in some parts of England the urgent/emergency care system is under considerable stress.  The news is full of it.

    Most of the sensible and responsible people who understand these things say there is no single simple cause; it is a problem with the whole system.  Our NHS is actually (believe it or not) very efficient but some of that has been gained at the expense of resilience and sustainability – the system works well but at such high capacity that it does not take much for it to become unstable.

    So we have a system going wrong and we are not confident we understand why, or how to fix it.  Andy Burnham came up with a plan to address this:-

    • Call in all 111 contracts for review.

    These rely on using algorithms for triage with little clinical oversight

    • Ensure all hospitals have safe staffing levels and prevent further job losses.

    A recent HSJ survey revealed that over a quarter of Trusts are planning to cut the number of nurses over the next year and one in five plan to lay off doctors.

    • Provide immediate support for social care.

    Use £1.2 billion of the 2012/13 Department of Health under-spend (£2.2 billion)to shore          up social care over the next two years (2013/14 and 2014/15).

    • Halt the closures of NHS Walk-In Centres.

    Await the review being conducted by Monitor of NHS Walk-In Centre closures and the impact of closures on the local community and the NHS.

    • Review all planned A&E closures and downgrades.

    Review using the very latest evidence of local pressures and ensure there is robust clinical evidence supporting the plans.

    The alternative plan from Jeremy Hunt was:-

    • Claim there is no crisis
    • Hope we have a warm summer and something happens before winter
    • Blame Labour
    • Blame GPs, especially women
    • Leave it to commissioners
    • Errr that’s it.
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    At the heart of concerns about reconfiguration and the future of our District General Hospitals is the issue around A&E Closures.

     

    A real Accident & Emergency Department must have a genuine 24/7 consultant delivered surgical and medical service.  For a start it must meet the  Royal College of Physicians guidelines so that a consultant physician should always be available ‘on call’ and should be on site at least 12 hours per day, seven days per week with no concurrent duties.  And the admissions unit should have a consultant presence for more than four hours per day, seven days per week doing two rounds per day.  That alone rules out around half the current “A&E”s.  Then add the surgical capability to deal with the vast majority of cases and then the need for 24/7 diagnostics. In reality we have lots of places claiming to be A&E which are unsafe and unsuitable; many so called A&Es are actually already Urgent Care Centres.

    And the answer is not spending more money to upgrade those which don’t meet the standards.  Aside from how you pay for it there simply are not enough clinicians, nurses and diagnostic staff to go round.  To be able to justify the high fixed cost of a true A&E and to provide a sufficient volume of patients to justify having 24/7 cover across almost all specialities requires a certain population level. Whilst this is a subject for some debate most think that population is at least 1m, probably more.

    Given the needs of rural areas some kind of hub and spoke model has to be obvious, where some patients go to, or are taken to, a local spoke; part of an emergency care system.  The spokes can deal with the immediate needs in any type of emergency in any age group with cover from emergency care doctors 24/7 but may not have full on-site back-up services. A minority of patients may have initial treatment at a spoke and then be transferred using agreed protocols and procedures. Many “A&E”s do not even meet this lower standard.

    Despite widespread opposition we already have systems where some patients (such as those with severe trauma or stroke) go direct to a regional or sub-regional unit where possible, or else go to a more local unit for stabilisation before onward transfer.  The evidence shows that going to the right place is better than going to the nearest place.

    You then move to the next problem of what to do with some District General Hospitals if they no longer have A&E.  And that is the real issue – what is the best configuration for acute care and how do we get there from where we are today.  But politically we can’t have that debate and the Royal Colleges are not giving us the leadership, at least not yet.

    So “downgrade” an “A&E” and protests follow.  It is claimed, always, that lives are put at risk if a local “A&E” is closed and the ambulance has to travel further.  If anyone tries to point out there is less risk overall then they are shouted down.  This just reflects the sad truth that for many years the NHS leadership has totally failed to explain reality and everyone thinks closure = cuts; and it often does!  Maybe the time to rationalise our emergency care was when funding was less of an issue.

    The Department of Health fall back on the nonsense that “Changes to local health services are decided and led locally. Local healthcare organisations, doctors, nurses and other health professionals, with their knowledge of the patients they serve, are best placed to decide what services they need for patients in their area.”  This is so ludicrous they should have noticed.  Just about every contentious proposal actually gets referred up to the Independent Reconfiguration Panel and so to the Secretary of State – so hardly local.  Most proposals actually cover various “localities” not just one and there is unlikely to be a “local” voice with any clarity.  The classic is where everyone agrees one of two units must shut and services concentrated in one place – for perfectly sound reasons.  But which “locality” loses its service?  Where is the leadership then?

    The whole problem is compounded by the wider mess we have made of what should be a coherent urgent/emergency care system. Most urgent care is primary care, but we don’t invest in primary care. We failed to give the ambulance services the key role they merit and instead fragmented the system using competition for lots of urgent care providers and out of hours GP services and it’s an uncoordinated and confusing mess with ridiculous duplication of systems and processes.

    So it’s easiest to get out the placards, join the protests and defend local services.  See you at the barricades.

    Irwin Brown

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    SOME IMPLICATIONS FOR WELSH NHS

    In April 2013 the  First Minister, Carwyn Jones, established a commission chaired by Sir Paul Williams to independently review all aspects of Wales’ public services to see how they are currently working and how they can be improved in the future. On Monday, January 20th Sir Paul, who was formerly the Chief Executive of NHS Cymru, published his Commission’s report.

    It is a very important document which plans to fashion public services in Wales for the next generation. Due to its recent 2009 structural reform which ended the “internal market in Wales  the Commission was asked to exempt the NHS from direct recommendations. Nonetheless there are implications for the NHS in a number of its key  recommendations.

    Public Services in Wales

    The Commission’s overall view is that public services in Wales have islands of good performance. There is therefore an urgent need for these to be extended to become the norm.

    Welsh public services need greater ambition and greatly improved performance across the whole sector. We need to raise the bar to higher than being “best in Wales”. These problems run much deeper than what arises from the complexities and difficulties created by the myriad of existing structures and organisational boundaries. Transformative improvement is needed, not least because   projections anticipate that Welsh public services’ resource will decline by up to £4-5bn for the next decade or so.

    This reduction will have a major effect on the role of the state and public services in delivering “the common good”  both in terms of practical service delivery and in being an important dividing line in policy terms.

    The Report accepts that public services in Wales will not be subject to the invisible hand of  commercial and competition challenge. Consequently the  visible hand of public accountability and scrutiny must fill this gap as a means of driving performance. However this is done  very inadequately in Wales at the moment.

    Public engagement is often seen as a bureaucratic necessity which, as the Report agrees, almost invariably changes nothing. This perception is particularly true of the NHS. Scrutiny is seen as threatening and usually evokes a negative and defensive response.

    The Report recommends a move to a total integration of health and local government services in Powys on the basis that this large rural area has only community based health care with hospital services being delivered from outside its border. While earlier moves in this direction did not reach fruition, this integration should be welcomed as an important innovation which could provide wider lessons for NHS areas that do have a hospital network.

    Community Health Councils (CHCs) are recommended to continue with an enhanced advocacy role but probably with a diminished inspection role. CHCs spend a lot of time and effort on their inspection programme but it is not clear that it adds anything to the inspection programmes carried out by other regulators.  However the Commission does not acknowledge that while CHCs have been an important part of the NHS landscape in Wales for decades, they  have seriously underperformed in terms of being an effective patients’ voice.

    They do come to the fore when major service re-configuration is taking place but their day to day work is very low key and is almost unnoticed by the public. The purpose and role of CHCs is valuable but we need a better way of giving effect to it. One option is that this might be achieved by CHC functions being linked to more organically to mainstream democratic structures and processes.

    This might be a role for an enhanced CHC but also it could also be a role of a democratic body such as the local authority perhaps enhanced with third sector and other public interest groups. We could also consider an enhanced role for CHCs in social services scrutiny though there could be an overlap with local government scrutiny which would be an unwelcome duplication. Again this is an argument for an integrated public scrutiny system incorporating local government.

    A fundamental weakness in proposing democratic scrutiny of the NHS by local government is that its current scrutiny of its own services is not an exemplar of good practice. The Williams Commission makes clear that local government scrutiny must see massive improvement and the proposal to extend local government’s scrutiny role in the NHS should be seen in this context.

    The Report correctly is critical of the adequacy of the current performance of Local Health Board non-exec board members. They are appointed for their technocratic expertise but this creates a major gap in local democratic accountability. A balance  has to be drawn between local accountability and professional expertise in carrying out board duties but the Report suggests that the current balance is not right.  This seems to be correct.

    The present LHB structure ,which is the outcome of the abolition of the internal market in Wales, is correct but it needs to improve its governance performance. Too often LHB boards have the mind-set and behave like a former acute hospital trust board ( with all their weaknesses). They have not been able to incorporate the good community links that the earlier LHB boards had created, accepting that the former LHB boards were too big and unwieldy. As well they are still struggling to give effective priority to primary and community health care.

    Interestingly the Report highlighted the apparent paradox that Board members are corporately responsible for their own decision making and still have, potentially, a self-scrutiny role. It seems to suggest that the scrutiny role is not compatible with the corporate decision role. The unstated but obvious implication of that is that there is a need for external scrutiny and challenge. If this external scrutiny was to have some democratic basis it might help to fill the accountability deficit that the Commission identified.

    The Report did flirt with the idea of democratically elected LHB non-executives but it did not explore the idea in any depth. Is this something that the SHA might wish to consider though it is likely that LHB elections would resemble the Police Commissioner elections which have provided a somewhat limited popular mandate?

    The Report was very clear in  rejecting the transfer of adult social services to the NHS. On balance  their conclusions are correct even if the decision is fairly finely balanced. The Report says, as an alternative, that there are sufficient mechanisms in place to allow joint, integrated social services commissioning  and delivery. This is the case as there has been an insufficient use of these mechanisms — a symptom of the overall sluggish public service performance in Wales.

    The Report recommends closer links between the Ambulance and Fire Service. Again this is something that should be welcomed. The Fire and Ambulance service is a joint service in many countries like France and in parts of the USA. There are obvious synergies between the services though there are massive operational and cultural differences at the moment.

    Interestingly the Report is very positive about many aspects of the performance of the Fire & Rescue Service. This stands in contrast the on-going challenges facing the ambulance service. An immediate priority must be to improve the performance of the ambulance service. Nonetheless a clear signal as to the direction of travel should be given to both emergency response organisations with a medium objective of much closer integration of the two services. A key early issue in this context is the station network of both services. The Welsh Government should require that no decision on station network of either service is taken in isolation and should consider the implications for its partner blue light organisation.

    The Welsh ambulance service has been to the fore in enhancing the skills of its paramedic staff to cover conditions that are not immediate life threatening conditions. These enhanced skills do overlap with some GP out of hours work. At the moment the ambulance service is seen as part of hospital out-reach services. Consequently they are obliged to transfer their patients to Accident & Emergency Departments if they are not being brought to the hospital for admission. Some flexibility in these arrangements could allow the ambulance service to also interface with  primary care  and bring patients to that service if clinically appropriate rather than mechanically bringing them to A & E Departments.

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    This is NHS Check report no 11 originally published by Labour’s Shadow Health Team in June 2013

    REVEALED:

    • 66% increase in over 90 year olds arriving at A&E – 110,000 extra patients
    • Cuts to council Adult Social Care budgets now total £1.8 billion since the election

    Huge cuts to council social care budgets are leaving older people and their families without the care they need. Without this daily support, increasing numbers face no alternative but to turn to A&E departments.

    Labour would invest £1.2 billion of the NHS underspend – which Jeremy Hunt handed back to the Treasury – over the next two years to ease the crisis in social care and tackle this root cause of the pressure on A&E.

    Rise in elderly patients arriving at A&E

    Official NHS Hospital Episode Statistics reveal a hugely disproportionate increase in the numbers of elderly people arriving at A&E in ambulances in the first two years of this Government.

    The most recent data, for the year 2011-12, shows a 66% increase in over 90 year olds arriving at A&E compared to Labour’s last year – an extra 110,000 patients. A&Es saw a 19% rise in attendances from over 80 years olds too – 121,000 patients.

     Age group 2009/10 2011/12 % change 2009/10 to 2011/12
    0-9 273,207 263,687 -3.50%
    10-11 346,527 278,557 -19.60%
    20-29 413,346 449,675 8.80%
    30-39 361,469 367,277 1.60%
    40-49 404,799 435,371 7.60%
    50-59 347,329 390,456 12.40%
    60-69 395,486 435,698 10.20%
    70-79 562,854 601,637 6.90%
    80-89 635,834 757,555 19.10%
    90+ 165,910 275,883 66.30%
    Unknown 18,158 1,088
    Total 3,924,919 4,256,884 8.50%

    Cuts to council care budgets

    Figures from the House of Commons Library reveal year on year real terms cuts to local authority Adult Social Care budgets across England, now totalling £1.8 billion since the election.

    £000s 2009/10 2010/11 2011/12 2012/13
    Total Expenditure (including DH funds directed via PCTs) 14,902,492 14,439,270 15,353,842 15,173,007
    Projected Real Terms Expenditure if 2009/10 figures increased in line with GDP 14,902,492 15,306,968 15,622,862 15,825,959
    Real Terms Cut 867,698 269,020 652,952
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    There is much good sense in Sir Bruce Keogh’s  blueprint for urgent and emergency care across England, the latest in a long line.  It takes us back about ten years to when the Ambulance Services started to strongly develop into genuine healthcare providers rather than transporters.

    The move was to imbed ambulance services into the NHS rather than have them semi attached as a kind of paramilitary adjunct scooping up casualties and dropping them off at the nearest A&E.  It was about treating patients where they were as much as moving them about. It was about getting an expert to the scene to triage what was the best response for the patient rather than sending a double crewed ambulance in response to every 999 call.  We saw the developing roles of Emergency Care Practitioners – super paramedics.  We saw that sometimes the nearest A&E might not be best and a longer journey might lead to a better outcome.  We saw ambulance service bidding to take on GP Out of Hours work and integrating the communications infrastructure.

    We saw early attempts at building local databases of services available outside A&E (now the Directory of Services).  There were moves to allow even 999 patients to be taken to Walk in Centres or Urgent Care Centres which were beginning to be set up, rather than going to A&E.  Relationships were developed with Mental Health and Social Care out of hours teams and also with the then emerging NHS Direct; with collocation of teams.  We saw ideas around having extended triage of incoming calls using GPs and Consultants in control rooms and the idea that a 999 call might result in advice over the phone or an appointment with a GP.  It was about integration – now far more fashionable.

    It was known then that up to 80% of 999 calls could result in satisfactory outcomes which did not involve blue lights and A&E.  It was also obvious (as least to some) that routing all other demands for urgent care through an integrated system that could align the needs of the patient to the services that were available was a good thing.  It all depended on the idea that there was a strategic view across a system with some overall governance, not a set of competing market players without any glue to make it work.

    At least one ambulance service set out a strategy and consulted extensively with the public for a plan to have one single emergency care (included urgent care) system for a whole County (pop 1.5m) either through one organisation – an Emergency Care FT or through a tight network coordinated by the Ambulance Service through a single communications architecture.

    Sadly what happened was that instead of vertical integration into core healthcare we got horizontal integration to make regional sized ambulance services.  This coincided with a policy shift to favour more competition generally.  The integration plan was to save money but it also ironically opened the door for the later fragmentation of emergency/urgent care.  It was a mistake, no doubt well intentioned, of historic significance.

    We saw NHS leaders blaming the patients for not knowing what service they needed to contact, instead of realising that the system was incoherent.  We saw increasingly desperate attempts to promote the use of non A&E facilities like Walk in Centres to treat “minors” based on commissioner claims of cost saving and demand management which were entirely wrong.  Attendances at A&E and admissions from A&E continued to defy the optimistic claims by commissioners.

    Fragmentation has continued as ambulance services lose contracts for patient transport; NHS 111 set up as a market pretty much collapses and GP Out of Hours also gets put out to competitive tender with predictable results.  The “system” is a total mess and the outcome is huge stresses on A&E Departments.

    The latest Review goes some way towards recognising the role ambulance services could play but it might be a good starting point to dust off the plans made 10 years ago and implement them.

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    A&EJeremy Hunt has sunk to the lowest common denominator playing party politics by blaming General Practitioners and the last Labour government for the current NHS crisis in emergency care.  This clearly confirms that the Conservative party are prepared to blame anyone rather than take responsibility for their failings on their watch occurring during a massive top down reorganisation of the NHS.

    Using the 2004 GP contract to explain the current crisis is not only unhelpful in addressing the problem, it is factually wrong.  Jeremy Hunt knows this, notice his solution is not to renegotiate the contract.

    Working on the frontline in the NHS it is clear to see that Accident and Emergency departments are at breaking point.  This isn’t a new problem and has not arisen due to unexpected demands, it was wholly predictable.  Emergency attendances have risen over the last decade at a steady rate and there are many reasons behind this, none of which are directly related to the GP contract.

    Firstly the population is aging, baby boomers have reached retirement and are requiring more from the health service.  The NHS has also become a victim of its own success, people are living longer and surviving illnesses better than they ever have before.  Older patients have more complex medical and social needs and the system is not designed for this.  Accident and Emergency departments are very good at dealing with acute conditions such as fixing broken ankles and treating chest infections.  Where the system falls down is when patients with multiple coexisting medical conditions are admitted because their care needs can no longer be met in the community.  These patients require care, compassion and a helping hand but are instead stuck in a system set designed to deal with problems that can be easily treated with medicines or plaster casts.

    Whist resources are being inefficiently used to manage complex older patients there is increasing demand from the rest of the population.  Patients have high expectations and they want to be see a doctor quickly.  A&E is open twenty four hours a day, nearly everyone is seen within four hours and it is free.  This understandably makes it a service in high demand.  Expectations are rising, patients don’t want to wait and see if their earache gets better and instead turn up for a quick once over placing increasing demand on an overstretched service.  The solution to was the creation of minor injuries units and urgent care centres which rather than take the pressure off busy A&E departments have instead further created demand.  Out of hours GPs and the new 111 service have rightly received bad publicity all of which has made the problem in A&E worse not better.

    Not surprisingly many doctors don’t want to work in A&E.  Busy shifts working antisocial hours until the age of 68 is not an attractive proposition.  This needs to be addressed more than blaming GPs.

    All this has been brewing whilst NHS management has taken its eye off the ball by being reorganised due to the Health and Social Care Act.  Moving the chess pieces around has shifted focus away from the challenges the NHS faces.  GPs are now in charge as commissioners, the same GPs which Jeremy Hunt is trying to make liable for the A&E crisis.  This is the signal that the new system was set up with the intention of failure from the start.  The Conservatives can then hold the GPs responsible creating an argument for privatisation by the back door.

    Our vision of the future of the NHS is to get back to basics.  Put patients first and design systems around them.  Rather than try and put patients off using A&E departments, we should be catering better to the needs of those turning up.  GPs, hospital and care providers need to work closer together to deliver integrated solutions.  One practical example is to have GPs working in A&E.  It isn’t rocket science, but it is about challenging the current way of thinking.

    The Health Secretary should be leading this agenda from the top, empowering doctors, promoting innovation and defending the principles of the NHS.  Instead he is stirring up division within the medical profession and playing party politics with our NHS.

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