Category Archives: Urgent Care

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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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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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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The spate of stories about how badly NHS 111 is performing are just another example of how dysfunctional our urgent/emergency care system has become.

Child carried into ambulance about 1950

Child carried into ambulance about 1950

We know that over the last decade there has been a remorseless rise in emergency admissions, calls to 999, attendances at A&E and use of the other various parts of the system like the Out of Hours service.  We only vaguely understand the causes which will be many and varied.  But what we do know is the system does not work.  We have yet another “Review” under way to report next year and local area teams (LATs) are creating Boards to solve the problems (joy!).

Changes in the system took place over some years as we saw the rise of NHS Direct (phone and web accessible), the introduction of GP Out of Hours services, opening of walk in centres and minor injuries units, and the merger of ambulance services into regional bodies, alongside investment in A&E premises, waiting time targets and endless flavours of “lead” commissioning.  More recently we have the rise of acute specialisation with the idea of sub regional tier one hospitals for stroke, trauma and more, and the challenge to all small A&Es as being unable to meet Royal College guidance for safe care.

Various incarnations of “commissioners” have tried to reduce the rise in demand, with talk of alternatives to A&E, use of financial levers, and demand management all really functions of the internal market and almost without exception these have failed.  The market ideas have led to multiple semi-autonomous providers and fragmentation when what is needed is system management.

We know what is pretty obvious.  If you open new alternatives for people to access when they believe they have an urgent need then “demand” goes up.  If you improve a service then demand goes up.  If A&E waits were in days and ambulances were dirty and often broke down, then demand through 999 goes down.  If people might wait hours on the phone they are less likely to call.  If you close an A&E then not everyone will go further to another A&E, they go somewhere else, or self treat.  If you publicise alternatives to 999 for “non emergencies”, you probably do more harm than good.  We know but we do not learn.

In the early noughties integrated systems were proposed by various ambulance services which wanted a whole system approach; in part as they saw their role being threatened by alternatives to 999.

Anyway proposals were made for a system covering (say) a whole county or city and it would have covered all calls to 999, to the GP Out of Hours service and to NHS direct.  The response would be the same regardless of what number was called ranging from a blue light double crewed ambulance to information, advice or reassurance and encompassing simply booking an appointment to see a GP.  Few would get the blue lights as an increasingly capable force of paramedics, Emergency Care Practitioners and Nurses in fast cars would deal with patients where they were – less transporting to A&E, more being told to go to or being taken by car to other more appropriate settings.

The “Hub” would be collocated with the communications point for social care and mental health response teams.  Working in the hub would be clinical call handlers, dispatchers and GPs, with rapid dedicated communication to an emergency care consultant – all 24/7.  The hub would also hold a directory of services and so would know what primary care facilities were open, when and what capability they had. There would be settings where GPs could see patients and there would be a primary care front end in front of every A&E.  It was hoped then (!!!) that patient records would also have been accessible so that for example a patient with an acute episode of a long term condition could be identified and their existing care plan taken into account in any response!

Insofar as it matters the real A&E would become referral only as with elective acute care; with ambulance service, GPs referring, sometimes even into a ward and with a “front-end” run by GPs, nurses and ECPs as a physical gateway in front of A&E.

The emerging walk in centres, minor injuries units, urgent care centres and polyclinics would all be places were people could be taken rather than A&E.  Over time it was realised this would need to be rationalised as patterns of flow ere better understood – but closing them down would have been difficult.

Funding would be an annual sum for the lot including funding for the A&E, Walk In Centre, Minor Injury Unit and other facilities based on population,with  no trade offs no unintended conflicts between the parts of the system.

Anyway it was a whole system approach with the ambulance service in the role of what would probably now have to be called the lead contractor.  But it had one management system, one governance system one set of protocols and one assessment system.

Sadly these kind of whole system ideas were not accepted by policy makers who instead opted to regionalise the ambulance services (the wrong type of integration!) and by commissioners who thought they could control demand, and also sadly by many clinicians who saw ambulance services as drivers and transporters – scoop and drop.

Whole system ideas are still around but the market is now everything – ambulance services are already losing transport contracts of all kinds and NHS 111 brought in a whole swathe of new providers further fragmenting what was already a mess. Yet another species of commissioners, the  Clinical Commissioning Groups, have new ideas of how to manage demand (good luck).

It’s the system that is flawed. Commissioners cannot solve the problem (good ones will mitigate it).

Integration and cooperation not markets and fragmentation is the only way to solve the crisis in emergency care.

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This is NHS Check report no 6 originally published by Labour’s Shadow Health Team in January 2013

Not safe in his hands: A&E under David Cameron

Revealed: Worst winter in the NHS for almost a decade as cuts, under-staffing and reorganisation leave A&E services on the brink

Before the election, David Cameron said the NHS was safe in his hands. However, Accident and Emergency units have seen performance deteriorate significantly this winter. Labour has uncovered new evidence to show to patients are suffering delays at every stage of emergency:

  • More ambulances missing 8 minute arrival target
  • Patients waiting for hours in the back of ambulances
  • More patients waiting more than four hours in A&E
  • Patients waiting hours on trolleys for hospital beds Continue reading »
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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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