Sir Bruce Keogh admits health system is ‘creaking’ and ‘under pressure’

Prof Sir Bruce Keogh, medical director of the NHS, has admitted the National Health Service is ‘creaking’ and ‘under pressure’, at a conference held at the King’s Fund on 19 December.

The Urgent and Emergency Care Conference, hosted by the King’s Fund, provided an update on progress with the Urgent and Emergency Care Review, as well as exploring the immediate challenges facing urgent and emergency care services.

Prof Chris Ham, chief executive of the King’s Fund, opened the event by asking delegates: what kind of urgent and emergency care system do we need in the future? Ham proposed that we need a much more joined up and integrated system than the one that is currently in place.

Prof Sir Bruce Keogh delivered the keynote speech on the future of urgent and emergency services in England, placing an emphasis on the long-term vision for transforming urgent and emergency care. Keogh explained that over the past year there has been a steady and relentless growth in the number of A&E attendances, and in light of reports of additional pressures placed on services during the Winter months, he admitted:

‘The system is creaking. A&Es are having to address increasing demand, the ambulance services are struggling in many parts and we have a number of issues to deal with, which we are tackling.’

Keogh acknowledged that responsive services need to be provided closer to home and that highly specialised centres must be made available. It is only through this way that we can ensure patients in life-critical conditions receive the right level of treatment at the right place.

Keogh outlined that the current urgent care system is complex and confusing, and so a simple and intuitive system is needed if patients are to access the right care, at the right place, at the right time. The introduction of urgent care networks, as a means to dissolve boundaries between hospitals and community services, and join up pathways of care, will be integral to ensuring this is possible.

Dr Robert Varnam, head of General Practice Development for NHS England, followed with a talk on the contribution of primary care in the provision of urgent and emergency care. Varnam stressed the need to develop more responsive and joined-up approaches from general practice, noting that only by seeing the whole system can the needs of patients be properly met. He also stressed the importance of primary care colleagues collaborating with the urgent care pathway, and the need to think about access in primary care. Varnam questioned what the point in quick access is if what you get access to doesn’t address need.

Dr Clifford Mann, president of the College of Emergency Medicine, gave the final talk before delegates broke for coffee on the next steps for emergency medicine. Following on from the publication of the College of Emergency Medicine’s CEM10, which outlined 10 priorities for resolving the crisis in emergency departments, Mann gave an overview of the College’s STEPs to rebuilding emergency medicine. These consist of staffing, tariffs and terms, exit block, and primary services.

After coffee, procedings were separated into two streams: one on urgent care, the other on emergency care. Within the urgent care stream, Richard Hunt, chair of the London Ambulance Service NHS Trust, delivered the first talk on supporting the development of ambulance services as out-of-hospital providers. This was given on behalf of the Association of Ambulance Chief Executives (AACE).

After giving a background to the AACE, Hunt outlined the potential role of ambulance services in transforming urgent and emergency care. Through the development of the paramedic workforce—to include more specialist and advance paramedic roles—it is hoped that ambulances could be used as mobile urgent treatment services capable of dealing with complete episodes of care without transport to hospital. Improving the range of clinical assessment and decision-making skills of paramedics so that they can manage patients closer to home, and the introduction of independent prescribing for paramedics could help achieve this.

This was followed by a panel discussion on providing a highly responsive urgent care service outside of hospital. Panellists included: Dr Chaand Nagpaul, chair of the General Practitioners Committee, British Medical Association; Adam Duncan, chief operating officer, London Central and West Unscheduled Care Collaborative; Dr Simon Abrams, GP and chair, Urgent Health UK, Federation of Social Enterprise Out of Hours Providers; and Ashok Soni OBE, clinical network lead, Lambeth Clinical Commissioning Group and president, Royal Pharmaceutical Society.

Key issues discussed in this session included: improving access for patients to ensure they can easily navigate the system; developing and implementing plans to meet predictable surges in demand; the role of GPs in urgent care now and under new plans for two types of urgent care networks: strategic and operational; and aligning 999 and NHS 111.

After lunch, Rob Webster, chief executive of NHS Confederation, spoke on new models for urgent and emergency care. Webster offered a system perspective on challenges and opportunities for urgent and emergency care networks, outlining that urgent and emergency care networks provide increased access to a simplified urgent and emergency care system, and better integration between urgent and emergency care services.

Examining existing evidence on networks, Webster looked at functions for network models, including strategic leadership for urgent and emergency care; to coordinate operational implementation at a local level; and to address fragmentation within the urgent and emergency care pathway.

This was followed by a panel discussion, where speakers gave an overview of existing networks and coordination at local level. Dr Nav Chana, chairman of the National Association of Primary Care, gave an interesting talk where he argued primary care should be defined by its function not its membership.

Stephen Dalton, chief executive of the Mental Health Network, delivered a talk on mental health and crisis care. Explaining that mental health service users have double the A&E attendance rate of the general population, Dalton gave an overview of the Mental Health Crisis Care Concordat, whose vision is for services to work together to deliver a high-quality response when people—of all ages—with mental health problems urgently need help.

Solveig Sansom, head of commissioning for integration, South Devon and Torbay Clinical Commissioning Group spoke on the Newton Abbott Frailty Hub, an initiative aiming to increase the number of patients who are proactively case-managed at home. Utilising a joined-up approach for frail elderly care, its predicted outcomes include a reduction in long-term care placements, as well as a reduction in emergency admissions from care homes.

The closing session of the day saw Adrian Masters, managing director, sector development for Monitor, speak on implementing a new payment approach to support improved delivery of urgent and emergency care. Masters highlighted that payment needs to change to support the service reforms and that Monitor are working with their partners on a wider programme of work on payment, which offers a coordinated and consistent payment approach across all parts of the urgent and emergency care network.

The final talk was given by Prof Keith Willett, director for acute episodes of care, NHS England, on progress made with phase two of the Urgent and Emergency Care Review. Outlining the next steps in delivering change following the review, Willett explained how emergency care networks will connect all services together into a cohesive network so that the system is more than just the sum of its parts. NHS England is now at the stage of moving from design to delivery; however, it faces a number of significant challenges, including payment system reform, information sharing, workforce and skills shift.

Taken from Journal of Paramedic Practice, published 9 January 2015.

The waiting game: resolving the crisis

Last month saw the highest number of patients who waited more than 4 hours in Type 1 A&E units (major A&E) before they were treated since figures began in 2010 (Campbell, 2014).

Figures from NHS England revealed that for the week ending 7 December, 35 373 patients waited more than 4 hours from arrival to admission, transfer or discharge at Type 1 A&E units (NHS England, 2014a). Of the total number of attendances, only 87.7% were treated in 4 hours or less. This is below the target set by the Government of 95%. This also marks a 66% increase on figures from the same week last year (NHS England, 2013). For the week ending 12 December, this rose to 44 153, which represented a drop in the number of patients treated within 4 hours to 84.7% (NHS England, 2014b).

The number of patients spending between 4 and 12 hours on a trolley from decision to admit to admission was similarly high: 7 760 patients for the week ending 7 December and 10 126 for the week ending 14 December, respectively (NHS England, 2014a; 2014b). This is more than double the numbers of 2013 (NHS England, 2013).

Following a decision made by health secretary Jeremy Hunt not to publish performance figures over the festive period, so as to give staff a break, data published on 6 January revealed that only 92.6% of patients were seen in 4 hours from October to December (Triggle, 2015b). This performance is the worst quarterly result in a decade.

It is undoubted that A&E departments are facing difficult times. At a King’s Fund conference in December, Prof Sir Bruce Keogh admitted that the health system is ‘creaking’ and ‘under pressure’ as a result of the strain brought on by increased attendances during winter months. The need for radical change within the urgent care system, therefore, has never been so apparent.

In England, an extra £700 million has been set aside to help the NHS, through the provision of additional staff. However, Dr Clifford Mann, president of the College of Emergency Medicine, has raised concerns that it has not gone through to all the places it should (Triggle, 2015a).

With major incidents being declared at a number of hospitals, new measures need to be implemented if targets are to be met. Keogh’s vision for a new urgent and emergency care system outlined in the Urgent and Emergency Care Review could present an answer, but it is expected to take 3–5 years to enact the major transformational changes. Although the Keogh Review wants to avoid risky ‘big bang’ change, that change is needed now. It is, therefore, a neverending waiting game.

References

Campbell D (2014) Record A&E waits show NHS is cracking under pressure—doctors’ chief. The Guardian. http://tinyurl.com/llm54sy (accessed 5 January 2015)

NHS England (2013) A&E weekly activity statistics, NHS and independent sector organisations in England. Week ending 8/12/2013. NHS England, London

NHS England (2014a) A&E weekly activity statistics, NHS and independent sector organisations in England. Week ending 7/12/2014. NHS England, London

NHS England (2014b) A&E weekly activity statistics, NHS and independent sector organisations in England. Week ending 14/12/2014. NHS England, London

Triggle N (2015a) A&E performance in England ‘likely to hit new low’. BBC. http://www.bbc.co.uk/news/health-30679949 (accessed 5 January 2015)

Triggle N (2015b) A&E waiting in England worst for a decade. BBC. http://www.bbc.co.uk/news/health-30679949 (accessed 6 January 2015)

Taken from Journal of Paramedic Practice, published 9 January 2015.

Greater role for practice nurses needed in London

A report published by the King’s Fund has outlined that care in London is not as consistently good as it could be. Analysis suggests that general practices need to do more to ensure that all Londoners experience high-quality care that is appropriate to their needs.

The report highlights the great variations that persist in both the availability and quality of care experienced by patients across London. While improvements and innovations can be seen in some general practices, they need to be spread more rapidly, with commissioners of primary care needing robust systems in place if they are to tackle unacceptable standards of care.

The report’s authors argue that GPs must be supported by a wider range of health professionals if they are to manage the growing range and complexity of health needs of patients. A greater role for practice nurses must be provided if future demands on primary care in London are to be met.

London GPs work with fewer practice staff than elsewhere in the UK. There are only a little over two practice staff per GP in London, compared with 2.47 nationally.

The quality of consultations with a GP and/or practice nurse was revealed in a 2011/12 patient survey to be lower in London than elsewhere in the UK. 87% of Londoners were satisfied with their consultations with a practice nurse compared to 91% in the rest of England. But’ as in the rest of England fewer patients were satisfied with their GP (84%) than with their practice nurse.

This new report affirms many of the findings of previous studies. The key issues and recommendations for changes to primary care raised in previous reports are still being issued today. Therefore, unless there is change in the way care is delivered in other settings, the transformation agenda for primary care and general practice cannot be achieved.

Taken from Practice Nursing, published 21 Jan 2013.