NHS emergency care is in crisis. A new approach is needed.
A new, national, emergency care improvement programme is needed. Pouring in new money and using heavy performance management will not work. A different, more strategic approach is required.
It is difficult to escape the constant stories of how the NHS is struggling to cope with demand for emergency care. At present the NHS as a whole is failing to meet the main target that 95% of patients should be seen, treated or discharged within 4 hours of arrival at A&E. Stories of hospitals like Colchester having to close its doors to emergency admissions, or Addenbrookes having the worst weekly performance for three and half years (60.0%) are becoming a weekly occurrence.
In response the government has provided funding to ‘ease winter pressures’, to the tune of £700m so far this year. This has been announced in two tranches, £300m being announced in November following an earlier announcement of £400m. This money is not included in baseline allocations to Clinical Commissioning Groups (CCGs), meaning it is not possible to plan for this money to come and there is no certainty the money will come next year. This forces the NHS into putting short term solutions in place, using high cost bank and agency staff, or into implementing changes that create huge financial pressures in the system the following year. This cannot be the right approach.
When Alan Milburn published the NHS Plan in 2000 and announced the 4 hour target, it caused uproar because, worthy as the aspiration was, many did not believe it could be achieved. Performance as a whole was nowhere near the target, and the service was struggling with patients staying for longer than 12 hours in A&E, often in trolleys in corridors receiving inadequate nursing care.
But what did happen was that a structured improvement programme for all A&E departments was introduced through the NHS Modernisation Agency (now abolished). I was the Programme Director for that programme, known as the Emergency Services Collaborative, and for me the best part of that programme was the structured approach to improvement that it took. Historic attempts to improve emergency care had focussed on patient populations (e.g. patients with chest pain, patients with pulmonary disease, elderly patients with no specific diagnosis), but, because of the differences in need between the patients in each of these groups, efforts to improve their journey time as a whole were not successful.
Instead in the Emergency Services Collaborative we grouped patients with similar steps to their journey, regardless of their condition. So we looked at patients with a minor illness or injury, patients who required a longer assessment or very short stay, patients who required a medical admission, and patients who required a surgical admission. By encouraging all sites to focus on improvements for these four groups, and by enabling these groups to share their lessons with each other, we were able to support delivery of a target that many thought would never be achieved.
This programme cost £30M over 2 years, most of which went to the sites themselves, and when you compare this to the £700M the government is putting into winter pressures this year it represents real value for money. So the question that springs to my mind is do we need another national emergency care improvement programme?
Well the world has moved on. The problems we are facing at present are not primarily ones of flow through a hospital. The improvements made in the Emergency Services Collaborative are not the ones that are going to make the difference today. Instead we have general practice in crisis, community services that cannot cope with demand, and social services that have suffered at the hands of local authority savings programmes. We have the legacy of successive years of cuts made within individual organisations in isolation from each other, and the result is a rapidly growing number of attendances to A&E and admissions to hospital, and increased number of delays to discharge.
But the principle that underpinned the original Emergency Services Collaborative programme is still valid. If we group patients by the common steps of their journey (rather than their condition, or age) and use these groups as a basis for improvement, then we will give ourselves the greatest chance of success. Now, I don’t have the answers to what these groups should be, and we spent a year and half getting these groupings right before we started the Emergency Services Collaborative, but I know how I would start to look at it. First, I would split into two broad groupings: ‘arrivals’ and ‘discharges’, and then build specific groupings within each of these two.
For ‘arrivals’ a tentative split could be: those who walk in; those who come from their GP; and those who arrive by ambulance. Potentially you could also have: frequent attenders; those who come from residential care; and patients arriving with mental health needs.
For discharge a tentative split could be: those who can be discharged home without any ongoing care requirements; those who require domiciliary care; and those who require residential care. The key here is not to get side tracked by the destination immediately post-hospital, such as community beds or re-ablement services, but to focus on the end destination, as this is what will free up the flow through the system. Locally we identified domiciliary care as the key constraint and by focusing on that have started to see delays to discharges reduce.
Whilst the exact structure clearly needs some defining, an approach that enables local areas to identify which of these groups requires the most focus, that has an identified improvement methodology, and that enables sharing of ideas and successes where problems had been solved with others areas, would in my view add far more value than the approach we have in place at present. Not only would it be less expensive, it would support systems to be sustainable, and be a platform on which real integration across health and social care could develop.
So I think we do need another national emergency care improvement programme. Leaving sites to their own devices, pouring new money into those failing the most, and using heavy performance management is not going to provide sustainable solutions.
The Five Year Forward View (5YFV) talks about ‘urgent and emergency care networks’ as one of the new models of care (despite being advocated by Professor Sir George Alberti in his ‘Transforming Emergency Care’ document in 2004) and it could be we use some of this thinking to support implementation of this model.
The 5YFV also goes on to say that they will develop, ‘National and regional expertise and support to implement care model change rapidly and at scale. The NHS is currently spending several hundred million pounds on bodies that directly or indirectly could support this work, but the way in which improvement and clinical engagement happens can be fragmented and unfocused.’ Well maybe here is somewhere they could get started!
The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.
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