On 15th January 2015, the Bishop of St Albans, the Rt Revd Alan Smith, led a question for short debate in the House of Lords on the pressures facing accident and emergency services. In his opening speech, the Bishop called for the House to disregard the media frenzy and political partisanship of the past week, and instead take a level-headed look at the issue – moving the debate away from scapegoating ‘inappropriate attender’ and seeking rather to find new ways of linking those within the health system with the most appropriate services for their needs.
The Lord Bishop of St Albans: To ask Her Majesty’s Government what is their assessment of the pressures facing accident and emergency services.
The Lord Bishop of St Albans: My Lords, I come to this debate not as a doctor with specialist medical knowledge nor with any special insights into the complex processes which hospital managers have to manage. I approach it as someone from an institution, the church, which has been concerned for healing, in its broadest sense, from its very foundation and I live opposite what is left of the great medieval monastery of St Albans, which for centuries was a centre of healing, with its infirmary and herbarium. In my present role, I have regular contact with the hospitals across Hertfordshire, Bedfordshire, Luton and Barnet, which make up the diocese of St Albans.
I also come as someone who has received the benefits of A&E departments in my own family. Not many years ago, my eldest nephew was diagnosed with a brain tumour and had to have serious surgery on several occasions. Sadly, he has since died from the tumour. About five years ago, he and all the extended family were staying with me for Christmas and, in the early hours of Boxing Day, he had a fit. I remember vividly the intense panic as we were all roused out of sleep to find what was going on; as we waited anxiously for the ambulance, willing it to come because we all felt so helpless; as he was rushed into Watford General Hospital A&E department. What a relief it was, in that terrible time, to feel there were people around who knew what they were doing. I am well aware from talking to doctors and nurses and visiting hospitals that the widespread coverage in the media about A&E departments has not only been frustrating for many of those front-line people but profoundly demoralising. I pay tribute to all who work in such departments and thank them for their tireless service, not least those in Watford General Hospital.
The House will be aware that pressures on A&E services have been mounting over a number of years. While the NHS always faces pressures in the winter, these have been compounded by our ageing population. We now have 350,000 more over-75s than four years ago. This rise has occurred simultaneously with a significant increase in A&E attendances and a greater level of sickness among those who arrive, leading to an increase in emergency admissions of nearly 6% on last year. In my own diocese, the A&E departments are facing these challenges with varying degrees of success. For the week of 5 January, Watford General Hospital fell below the Government’s target of 95% of patients seen in four hours, while Luton and Dunstable University Hospital exceeded this target, in line with its track record as one of the top 10 trusts in the country.
What is causing this? Attendances are up, but the problems go much deeper. Reports have emerged of people in some places having difficulty getting appointments with their GPs. There have been discussions about changes in social care leaving some elderly and frail people without the necessary support. There are staff shortages and recruitment difficulties in A&E units. Many in your Lordships’ House will be aware of A&E’s three main areas of activity: triage, treatment and referral. Problems tend to arise in bottlenecks at the triage and referral stages. Effective triage is compromised by the presence of patients whose needs do not fit the current services offered in A&E departments. Until quite recently, these individuals were often referred to as “inappropriate attenders”, but current research suggests that it is not the patients who are inappropriate, but the services that emergency departments provide. Estimates vary that between 15% and 40% of patients require services other than those offered by an emergency department and it is the presence of these patients that creates part of the bottleneck at the triage stage.
At the other end, efficient referral after treatment is compromised by problems in bed allocation in acute medical and surgical wards as well as by accessing appropriate services. In many cases, A&E doctors admit patients for further diagnostic tests or when the additional expertise of medical or surgical staff is required. Around 20% of referrals from A&E to acute wards involve patients whose conditions could be treated appropriately by their GPs or in the community. Up to 40% of patients referred to acute wards are discharged within a few hours of admission. The Department of Health says that the effective management of the flow of patients through the health system is at the heart of reducing unnecessary emergency admissions and managing those patients who are admitted. The problem is how to identify how this can best be done.
Much of the debate in the other place has, not surprisingly, been highly politicised because we are approaching an election. I hope that, in this debate, this House can stand back and take a more dispassionate view, drawing especially on the huge knowledge and experience of some noble Lords who have intimate, personal working experience in the National Health Service. I hope that we can set this debate in a slightly wider and longer term context. Certainly, it needs to be set against the background that A&E services across Europe are facing similar challenges.
Until recently, some emphasis has been placed on attempts to demagnetise emergency departments, even though it has long been established that this tactic meets with little success. Both self-referrals and referrals from GPs willing to short cut protocols have resulted in increased numbers of patients presenting for treatment. Some 20% of A&E patients decide to attend a day in advance, the majority do not consider going first to their GPs, and 80% fail to make use of advice services such as NHS Direct. While there has been a change in people’s expectations and preparedness to wait for an appointment with their GP, we must not overstate the extent to which A&E services are being clogged up by misuse. The vast majority of A&E users are not inappropriate attenders; that is to say, they should be within the health service.
Recently, some pilot projects have begun to change the range of services available in A&E departments. For example, some GPs co-locate in emergency departments as primary care physicians while others locate out-of-hours GP services adjacent to A&E departments. Other GP practices have supplemented NHS Direct with their own telephone consultation services, enabling patients to speak with their own doctors. There is growing evidence over the past decade that these approaches relieve pressure on A&E staff and enable efficient triaging at the front door. Similarly, pilot projects that locate acute medical and surgical staff in or approximate to A&E departments at peak times have enabled improved patient flow as additional diagnostic expertise has resulted in inappropriate admissions to acute wards being minimised. Co-location of acute assessment units has also enabled patients to be monitored and assessed without them either remaining in A&E or by being admitted to acute wards. These approaches require strong leadership, close co-operation among health professionals, focus on patient care and strategic implementation. What more can be done to enable every hospital to have its own 24-hour GP practice?
Ultimately, resolving the current and on-going A&E crisis involves a systematic change to the ways in which health and social care are organised. Access to good social and community care can relieve pressure on GPs, enabling them to play a greater, proactive role in emergency medicine. Allied with a willingness to break down barriers within hospitals between emergency departments and acute wards, strain on A&E staff can be alleviated and patient experience improved. I hope that this debate will play a small part in exploring the complex reasons for the current problems and help us in addressing the challenges facing A&E departments today.
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I very much welcome the opportunity to debate this important issue and I pay tribute to the right reverend Prelate the Bishop of St Albans for introducing it so admirably. The NHS is facing unprecedented demand with record numbers of people attending A&E and the ambulance services providing record numbers of emergency journeys. Despite this, the NHS is still providing high-quality care, and alongside the right reverend Prelate the Bishop of St Albans and other noble Lords, I place on the record my thanks to all NHS staff for their hard work in responding to this challenging time.
Winter is always challenging and this year it comes on top of a general increase in A&E attendances. In 2013-14 these were up one-third on 2003-04. So far this year, A&E attendances have been higher than in any year since 2010 with, on average, almost 3,500 more people a day attending. This has led to an increase in emergency admissions of nearly 6% on last year. The noble Lord, Lord Hunt, said that this was nothing new. I have to tell him that it is. It is about the double the trend of increase that we have seen in recent years.
There is no single cause of the increase in A&E attendances. Healthcare is a system and problems that arise in one part of the system will impact elsewhere. Commissioners and providers need to look at what is happening not just in hospitals but more widely, and address the issues that are most salient in the particular area. That is what they have done in drawing up local plans to spend the £700 million of additional support mentioned by my noble friend Lord McColl that the Government have made available to the NHS so it can ensure urgent and emergency care services are sustainable year round and ready for the pressures of winter. In addition to providing more staff and beds, the money has funded local initiatives including: local information campaigns so people are better informed on where and how to access the services they need; seven-day pharmacy services; enhanced NHS 111 and GP out-of-hours services; and schemes to help people recover in the comfort of their own home after surgery. Some £50 million of the winter money was specifically to support ambulance trusts.
I have set out what the Government have done in response to the immediate winter pressures. However, we recognise fully that we require system-level change to ensure that services can be delivered on a long-term sustainable basis. I will now set out our longer-term plans to achieve this goal. The right reverend Prelate the Bishop of St Albans called for a systematic review and that is already under way. NHS England’s urgent and emergency care review should improve access to, and the availability of, services outside hospitals. This will involve providing consistent and same-day access to primary and community services.
The vision for the review is simple. For people with urgent but non-life-threatening needs, the NHS must provide highly responsive, effective and personalised services outside hospital and deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families. For people with more serious or life-threatening emergency needs, the NHS should ensure that they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery. If the NHS gets the first part right, it will relieve pressure on hospital-based emergency services, so that the focus can be on delivering excellent care.
NHS 111 plays an important role in ensuring that people get access to the right care when they need it. Only around 8% of calls handled by NHS 111 result in advice to attend A&E. In November the figure was in fact 6%. Moreover, 30% of callers say that they would have attended A&E if NHS 111 had not been available. That indicates that NHS 111 is instrumental in diverting people from A&E rather than adding to those attending. It is a myth that NHS 111 makes matters worse.
Implementation of the urgent and emergency care review will include enhancing NHS 111 so that it becomes the smart call to make, offering a 24-hour, personalised priority contact service. The service will have access to people’s medical history and allow them to speak directly to a nurse, doctor or other healthcare professional if that is the help and advice that they need. NHS 111 will also be able to directly book a telephone call-back service.
Another key aspect of improving services outside hospitals is providing seven-day access as a matter of course. Currently, not all services are delivered at weekends, and sometimes staff cannot get the advice and decisions that they need from more senior colleagues on Saturdays or Sundays. Delivering the vision of seven-day services could improve the clinical outcome for patients. NHS England is therefore working with NHS employers and staff to develop plans on how seven-day services can be delivered. This should improve outcomes and experiences for patients as well.
I should like to move on to the better care fund. For the first time, this Government will join up health and social care services through the £5.3 billion better care fund. I can say to the noble Baroness, Lady Gale, in particular, and to the right reverend Prelate the Bishop of Ely that the vast majority of this money is being spent on social care and out-of-hospital community health services. These aim to keep people—especially the frail elderly—out of hospital and, if they have to be admitted to hospital, support them to leave safely as soon as they are well enough to do so.
Underlying the new approach are improvements in seven-day working across health and social care to help quicker, more appropriate discharge from hospital. One of the metrics for the fund is the number of people supported to remain at home at least three months after discharge from hospital. Plans project that over two years, the number of older people supported to remain at home at least three months after discharge from hospital will increase by 33.7%. That will be good for those patients but it will also save a great deal of money. Schemes in plans typically focus on things such as increasing capacity in reablement or intermediate care services, or multidisciplinary emergency response teams, which focus on avoiding unnecessary admissions to hospital.
I now turn to our plans for access to primary care. We are offering 7.5 million more people extra evening and weekend appointments, as well as e-mail and Skype consultations, through the Prime Minister’s Challenge Fund, and by 2020 we will offer seven-day GP services to everyone in England. We have announced a £1 billion primary and community care infrastructure fund, which will improve access for millions more people through introducing new models of care and improving estates and infrastructure—including, I am sure, GPs’ surgeries. There are now more than 1,000 more GPs working and training in the NHS compared with the position in September 2010, and there are 40 million more appointments every year than there were in 2008-09.
I turn to some of the questions that were asked during the debate and, as usual, I shall write to noble Lords whose questions I cannot answer today. The noble Lord, Lord Hunt, made me prick up my ears when he said that the problem is that no one is actually in charge of the system. I contend that the system is now more co-ordinated than it has ever been with the system resilience groups that we see in every single area of the health service. These groups comprise commissioners, acute providers, social care and all the players in the system so that they can genuinely co-ordinate their actions and assess the risks and priorities that they need to address.
The right reverend Prelate the Bishop of St Albans said that people are turning up at A&E when they could go elsewhere, and he is absolutely right about that. The urgent and emergency care review that I referred to noted that it had been estimated that about one-quarter of A&E attendees could have been treated elsewhere. A number of local areas are taking action to make people aware of the range of different urgent and emergency care services that are available and the circumstances in which they should be used, as well as the alternatives, such as pharmacies, that are open to people.
The right reverend Prelate also asked about staffing, especially doctors—a point also raised by the noble Lord, Lord Hunt. Compared with last year, more than 260 more new doctors will be available in A&E. That is good news. It includes British trainees but also senior staff from other countries, including India, the UAE, Egypt and Malaysia.
A number of noble Lords, including the right reverend Prelate the Bishop of St Albans, called for more collocation of services. I fully agree with the wisdom of that suggestion. As part of the urgent and emergency care review, NHS England is supporting the collocation of community-based urgent care services in co-ordinated urgent care centres. He may like to know that 112 out of 143 NHS hospitals already have GPs working in, or collocated with, A&E departments.
My time is nearly up but I want to touch briefly on ambulances. The department is working closely with NHS England, Monitor and the NHS Trust Development Authority to improve performance, and the Government have provided an extra £50 million of funding to ambulance services. However, these services are facing unprecedented levels of demand, with an additional 2,000 emergency journeys a day. Despite that, they are still providing high-quality care. We have introduced the ability to fine providers where handover delays at hospitals are unacceptable. Since then, those delays have gone down markedly.
I will respond to my noble friend Lord Greaves about the North West Ambulance Service, and I will also respond on the incident of the dead body, which the noble Lord, Lord Hunt, mentioned in relation to the East of England Ambulance Service.
My time is up but I hope that noble Lords have been able to glean from what I have said that there is a great deal going on. We are gripping the issue. There is no one cause of the increasing pressure on A&E, but we have comprehensive plans, which I have just covered in some detail, to relieve the pressure that we are currently seeing on our A&E services.
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