Health and Social Care Committee
Oral evidence: The situation in accident and emergency departments, HC 1056
Tuesday 24 January 2023
Ordered by the House of Commons to be published on 24 January 2023.
Members present: Steve Brine (Chair); Lucy Allan; Chris Green; Mrs Paulette Hamilton; Dr Caroline Johnson; Rachael Maskell; James Morris; Taiwo Owatemi.
Questions 1 - 77
I: Dr Adrian Boyle, President, Royal College of Emergency Medicine.
II: Chris Hopson, Chief Strategy Officer, NHS England; Professor Julian Redhead, National Clinical Director for Urgent and Emergency Care, NHS England; and Dr Vin Diwakar, Medical Director, National Transformation and Medical Directorates, NHS England.
Witness: Dr Adrian Boyle.
Q1 Chair: Good morning. This is the Health and Social Care Select Committee. This is the latest of our topical sessions, when we pick a very live issue in the NHS and talk to some of the key players. This morning, we have Dr Adrian Boyle, who is the president of the Royal College of Emergency Medicine. We will talk about all issues related to A&E, or the emergency department, whichever is your preferred choice. There is of course a difference. At about 10.45, we will talk to NHS England, led by Chris Hopson, who is the chief strategy officer for NHS England.
For those watching, I should say that we will follow up on some of the issues that we raise today when we hear from the Secretary of State, Steve Barclay, next Tuesday afternoon, 31 January. In fact, I suspect that they will form a big part of our conversation. We will ask the Secretary of State about winter pressures, emergency care and the current industrial action, assuming that it is not solved by then; we live in hope. That is the context for today.
Dr Boyle, thanks so much for coming in. Between December 2021 and December 2022, there was a 15.1% increase in attendances at tier 1 EDs. It is the highest-ever figure. Even compared with pre-pandemic levels in December 2019, it is an increase of 4.7%—nearly 5%. Those are NHS England’s own figures. Can we establish from the outset whether you accept that demand has risen significantly, and that is part of the context for what we are seeing?
Dr Boyle: It is a more nuanced question than that. Demand has gone up a little with those figures. However, the reason that we run into trouble is not necessarily around demand; it is the ability to deal with that demand. Things like actual hospital admissions from an emergency department have remained relatively static.
We have had problems with increased crowding and with care in our emergency departments for several years. Largely, that has not been because of increased demand and attendances in type 1s, but because of flow through the emergency departments. While I accept that over this year there has been an increase in demand in terms of numbers, it is not the main part of the problem.
Q2 Chair: But there has been a significant increase in demand across all EDs in the past year. That is true. Correct?
Dr Boyle: Yes. If you look back over the last 10 years, there has been extraordinary growth in the type 2s and the type 3s—the minor injury units, the eye units and the urgent treatment centres.
Q3 Chair: Okay. There are six Members sitting around this table. If there were 12 Members of Parliament sitting around this table, it would be a squash and a squeeze. There are the sheer mechanics of the numbers coming in and presenting—for instance, parents presenting before Christmas worried about strep A. That level of demand has impacted significantly on A&E and emergency departments. Is that correct?
Dr Boyle: A bit—yes. I am hesitating slightly because I think that it is still about the flow and the ability to manage the existing demand.
Q4 Chair: Okay. We will come on to that and delve into it in more detail.
The BBC reported that 650,000 excess deaths were reported in the UK in 2022. That is 9% higher than in 2019. There has obviously been a lot of coverage of that. You gave an interview to a radio station on new year’s day in which you said, “What we’re seeing now in terms of these long waits is being associated with increased mortality, and we think”—I presume that when you say “we” you are referring to the royal college—“somewhere between 300-500 people are dying as a consequence of delays and problems with urgent and emergency care each week. We need to actually get a grip of this.”
I was looking at the press and media section of your website. There is no statement in that gap—just before 1 January—where you have put out something based on a piece of work or a piece of peer-reviewed research. There is nothing on there that informed that. I do not believe that you went on Times Radio and just said that. You must have planned to say it. Presumably, you based it on something, because you said, “We think somewhere between 300-500.”
That is a big range, isn’t it? Of course, the BBC reported, “Excess deaths… among worst in 50 years.” “A&E delays causing up to 500 deaths a week, says senior medic”—that is you—is how The Guardian reported it, so they obviously take the higher figure. The reason why we asked you here today is that NHS England says that it does not recognise your figures. We will ask them about that next. As your teachers used to say, can you show us your workings-out?
Dr Boyle: I will be delighted. We have also shown the link between crowding and delays in emergency care. We have reported that previously. Back in 2021, we published a report called “Crowding in Emergency Departments”. We did an acute insight series. It was not a new thing for us to say that.
Let me talk you through the evidence, because it is an important question and I need to make sure that everyone is on the same page with it. A lot of it is based on a peer-reviewed study that was published in the Emergency Medicine Journal in 2022. They took the entire NHS England emergency department admissions dataset. They started off with 7 million people between 2016 and 2018 and excluded 2 million, because they were people who had reattended. These were emergency department admissions, not people who get sent home from emergency departments, but people who are admitted through a type 1 emergency department. They followed those up to see how many of them died within 30 days, which is a very standard measure and is data routinely collected by NHS England.
The variable that they were assessing was the length of time in an emergency department. They showed that, once you get up to five hours, you start to see an increase in your risk of subsequent 30-day mortality. It goes up in a linear fashion from about five hours to 12 hours. They stopped at 12 hours because, at the time, there were very few people waiting for more than 12 hours.
You might think that that is because people who stay in emergency departments are sicker, older, likely to have more long-term conditions and at greater risk of death, so they adjusted for that statistically. They did some statistical adjustment, looking at people’s comorbidity, age and the number of times they had been to an emergency department before. There was statistical adjustment to deal with that potential confounder.
Their results show that, for every 72 people who stay for more than eight to 12 hours, there is one excess death. For every 82 people who stay for between six and eight hours, there is one excess death. There is a gradual linear increase going up. You can apply that one in 72 number to the number of people who have stayed in our emergency departments for longer than 12 hours. We deliberately went for a conservative, cautious estimate. We did not have data for the people who stayed for more than 12 hours so we do not know the harm for them, but we applied the one in 72 excess harm figure to people who stayed for more than 12 hours.
Q5 Chair: I am looking at the paper here. For the record and for those watching, where was the paper published?
Dr Boyle: In the Emergency Medicine Journal.
Q6 Chair: That contains that detail. That is very helpful. I have here a paper from you titled “Tackling Emergency Department Crowding”. There is a section on what you call full capacity protocols—putting it into English, sending patients to where they will be admitted before a bed is available. Correct? Do I have that right?
Dr Boyle: Yes.
Q7 Chair: That is supported by the college. Correct?
Dr Boyle: Yes. These are also known as processes of one-upping, full capacity protocols or continuous flow models.
Q8 Chair: Can you explain exactly what that is? It is controversial, isn’t it? Not everybody in the acute setting and the secondary sector agrees with it, do they? I can understand why the Royal College of Emergency Medicine may push it, but people on the wards may have a different view. Can you explain what it is?
Dr Boyle: Yes. It is a way of sharing risk across the entire system and it requires a degree of system focus. We know that the most serious manifestation of a full emergency department is a delayed ambulance offload, so we need to create space in the emergency department to allow the ambulance offload. A continuous flow model is where, rather than wait for a bed to be available, you send the patient to the ward where that bed is going to be available. That stimulates the ward staff to prioritise moving a patient either to a discharge lounge or to a day room so that the bed can be used more efficiently. It is a way of decompressing and sharing risk across the whole system.
Q9 Chair: Where I am struggling with that is that you can admit somebody up to the ward, but if there is no bed, where do they physically go? Aren’t you just replacing patient in corridor in ED with patient in corridor on ward?
Dr Boyle: Yes, but if you take your standard hospital, which probably has 40 wards, which would you rather have? Would you rather have one person on each of those 40 wards or 40 people waiting for admission in an emergency department filling the corridors, and ambulances being unable to unload? It is not a popular thing, but it is a pragmatic approach to share risk. It is the least worst option when your emergency department is so full that you cannot offload ambulances.
Q10 Chair: I can see how it impacts on the ability to offload from the ambulance service, but going back to the methodology you talked about, the fact that you are in a different room in the hospital does not mean that your clinical risk changes, does it?
Dr Boyle: Except that the amount of work that the emergency department nurses are supposed to provide is very diluted. What we are seeing now is that in most emergency departments the staff, who are probably the same number of staff as last year, are running a medical ward in addition to being responsible for all the new arrivals. That means that they are being run ragged looking after patients who are sick and require in-patient care as well as trying to deal with all the new arrivals. The dilution and delay of care in the emergency department is such a risk that we feel that this is justified.
It is supported by some evidence. The evidence is not great, but Peter Viccellio was writing about it in the Annals of Emergency Medicine back in the early 2000s. On balance, patients tend to prefer it, but it depends a lot on the setting. It would be unwise to think that it is a solution for all of this, but it is certainly a key part of the picture.
Q11 Chair: Obviously, it would require the ward to take legal responsibility for the patient at the point of admission to the ward. We will ask them later, but is there anything in practice that NHS England would say that would block that?
Dr Boyle: I am not quite sure what you understand by legal responsibility.
Q12 Chair: It would require the ward to say, “Yes. We’ve got them. We take full responsibility for them and their care at the point of their entering through the door of the ward.” Therefore, it requires the whole system to agree with that.
Dr Boyle: Yes. Where it gets implemented is where the chief nurse and the chief operating officer of a hospital have said, “We must take a whole-system view of where the risk is and try to share it.” When you look at legal responsibilities, I think that everyone accepts that either the NHS trust is liable or that it is about individual practitioners’ registration.
Q13 Chair: Is anywhere doing this?
Dr Boyle: Oh yes. It was established very well in North Bristol, which established it in response to the heatwave.
Q14 Chair: Let me rephrase that. Is anyone doing it well?
Dr Boyle: North Bristol put up results. We looked at those and thought, “Actually, this works well.” Certainly, North Bristol’s ambulance handover times have improved dramatically. They run into operational difficulties, like everywhere else, but they seem to recover from them a bit more quickly because there is a system-wide focus on maintaining flow, both through ambulances and emergency departments and through admission units.
Q15 Chair: Finally from me, you attended the Downing Street summit on the first Saturday of the year. Afterwards you gave a pooled media clip in which you sounded quite positive about that session. Now, after a couple of weeks, how do you reflect on that session?
Dr Boyle: We welcome the fact that the problem is being taken seriously, because we think that our situation is so dangerous and serious at the moment that we are very glad that people are taking it seriously. It is great that there have been the one-off payments, and it is absolutely right that we focus on getting out of hospital people who do not need to be there and that the investment in social care is going into the right place, because that seems to be a key constraint. There are 13,000 people in our hospitals who can be got out, so the money is going to the right place.
The one bit we feel a bit uneasy about is that building areas outside emergency departments to help ambulance offloads is not necessarily the right thing. We think that it is much better for patients if those areas are after they have been through the emergency department.
Q16 Chair: Right. The surge capacity part—the £50 million of the £250 million—is the bit you have a worry about.
Dr Boyle: The intent to increase capacity and flow is absolutely welcome. We absolutely support that. It is just that the devil will be in the detail. We would be uneasy, and think it would be the wrong thing to do, if we were just to build a bigger ambulance-receiving area outside a department.
Q17 Chair: I presume that your view is that the stuff we talked about—full capacity protocols and people being up on wards—should come into play before that does.
When I was a Health Minister, I remember that we would have a conversation about the winter pressures in September or early October. Then a case would be made to the Treasury for extra resources, if they were needed. This meeting happened, and the money was announced, on 4 January. Is it too late to affect the system for this year?
Dr Boyle: We certainly had the worst December that we have ever had. If you look at performance figures, on every metric, what went on in December was terrible. This is a complex, multifaceted problem. We need to be realistic; just a little bit of money may not be a magic fix. It is not a magic wand. We have serious structural problems that impair our ability to deliver urgent and emergency care. We have the second lowest number of beds in the OECD comparators. We run our hospitals far too full, with very high occupancy levels. It is a step in the right direction, but it is going to take a long time to recover. Things have been going wrong for quite a long time, and they came to a head in December.
Q18 Chair: That leads to the question, are you confident that in the longer term that is being addressed? This surge capacity money—call it that—is till the end of March, so it is for this winter, albeit that it was announced late. We have taken some tens of thousands of beds out of the system in recent decades. To turn that around, even if 40 new hospitals were 40 new hospitals, we would struggle to staff them. That is not going to happen overnight. It is not going to happen over many nights. Does the royal college take a view on the longer-term trajectory of this?
Dr Boyle: Yes. This is what we want to see for the longer-term trajectory. The aspiration from NHS England is that we return to a four-hour target performance of 76%. We think that is too unambitious and will create all sorts of perverse incentives, because it will encourage managers and senior clinicians just to focus on the people who can be discharged from hospital, without dealing with our problem, which is exit block. We think the 76% is an extremely unambitious target. It was 95%. I know that it will be a long way to go back to that and that we have not achieved it since 2015, but we would say that we need to have a trajectory to a higher target.
Q19 Chair: What will be your message for No. 10 when it produces its UEC—its urgent and emergency care plan—which we understand is imminent?
Dr Boyle: The key thing is to reduce occupancy in our hospitals. That would be the single biggest thing. When everything is so pressured, there is a terrific tendency to come up with lots of initiatives and good ideas, but actually it is the simple stuff—reducing the hideously high occupancy that we have in our hospitals at the moment.
Q20 Chair: Domiciliary care is very important in this. The lion’s share of social care is not old people in care homes, which I understand may be the layman’s view, but domiciliary care. Is its role in patient flow taken seriously enough?
Dr Boyle: Absolutely. Most of the people who are in hospital awaiting discharge are not waiting to go to a nursing home but waiting to go home with a care package. We agree with that completely.
Chair: Thank you very much for that. Paulette Hamilton is next.
Q21 Mrs Hamilton: Good morning, Dr Boyle. For many years, the NHS has known that this was coming and has been talking about winter crisis. Do you feel that NHSE and DHSC have done enough to prepare for what has happened? We thought that this crisis would happen last year. We thought that it would happen the year before. We thought that it would happen the year before that. We have had plenty of time. I need your opinions as to why this has happened.
Dr Boyle: The answer is demonstrated by the outcome. We had such an awful December, with such terrible outcomes. You can make a plan, but the measure of whether a plan succeeds is in the outcome. The outcomes that we had over this December would say that the plans have not worked in the way we need them to.
Q22 Mrs Hamilton: I am going to go on a little bit about staff. I was a nurse myself and have worked in A&E departments. In the normal run of things, they are stressful areas to be in. How do you feel that staff are coping in emergency situations at the moment, over a sustained period of time?
Dr Boyle: Even before we went into this winter, we were concerned about staff retention and staff morale. Last year, the GMC did a survey of trainees, which reported that trainees in emergency medicine had the highest level of self-reported burnout and that it had got worse since the previous year. I am worried that burnout will lead to burn away.
I see that a lot of nurses, particularly the experienced nurses, who are almost like the NCOs of the health service—the sergeants, who know how to get things done—are leaving in droves. Every time I go into work, there are nurses asking, “Could you sign this leaving card?” We are haemorrhaging experienced emergency nurses because they find it very frustrating. The problem is not that there is too much work but that they are unable to do the work that they are trained to do. They find it immensely frustrating to be providing this level of in-patient care. They feel overwhelmed and that their registration is at risk because it feels so dangerous. They are finding it extremely difficult. Staff morale is a huge concern for us at the moment.
Q23 Mrs Hamilton: You talked to Steve about getting occupancy down. I am going to go back to staff. To get occupancy down, something fundamental needs to change in emergency departments in hospitals at the moment. Do you feel that the Government and NHSE are doing enough to address the workforce shortages in the NHS?
Dr Boyle: Again, look at the outcomes. We are losing nurses. I know that there has been a welcome increase in the nursing numbers that are coming into the NHS and that is right, but it would be much easier to try to make it so that we did not lose staff. I sometimes feel that the retention part is being neglected for the recruitment part of the piece.
Q24 Mrs Hamilton: This is my last question. It is not just nurses. We are losing physios, radiographers and ambulance drivers. There are pressures on the health service across the piece. I know a lot of nurses. I was speaking to a nurse just last week. She qualified—and lasted three weeks. Then she gave up the job, after training for three years-plus. How do you feel that people who are newly qualified and going into these areas need to be supported so that we can retain them? For me, we are not struggling to recruit them; we are struggling to retain them.
Dr Boyle: I agree with that. One of the big concerns about losing our senior nurses is that they are the people who mentor, support and supervise, and they role-model for those people. If they are looking burnt-out and cross, people will ask, “Is this really what I have signed up to as a career?” We are absolutely worried about the retention of senior nurses, because that feeds into providing a growth environment and a supportive environment for junior nurses to thrive in.
Q25 Mrs Hamilton: I have a last point—sorry. What are we doing at the moment to address this? Is anything happening at the moment to address it? I hear that we are worried, but worried is not going to save our NHS. Are we doing anything actively? Is anything being proposed? Staff are our most important asset.
Dr Boyle: In what we do for doctors, we are clear that we must always make sure that we are trying to develop our staff. We recognise that people will put up with a lot, and pretty terrible conditions, if they feel that they are being developed. I cannot talk about the nurses because neither I nor the college have any professional responsibility for them. We train some nurses, through our advanced care practitioner programme, and they are a small but important minority of our membership.
Q26 Rachael Maskell: We have talked about the back door, but I would like to talk about the front door. According to the data, in December 2022, we saw 1,439,000 people—an increase—but there were only 378,000 admissions. That is where the data took us; about one in four patients is being admitted and three in four are not. How do we address the people who come to emergency departments but do not need admission? Is there another pathway they should be following? If so, why isn’t that happening?
Dr Boyle: There are some patients who go to emergency departments entirely appropriately and are subsequently discharged. It is almost impossible for anyone who gets severe chest pain, for instance, to know whether they are having a heart attack, so there will always be a number of people whom we discharge. That is right and proper.
As regards how we manage people who could be looked after elsewhere, the key thing to do is to improve NHS 111. There is a lack of clinical validation and access within NHS 111; 50% of calls to NHS 111 have some form of clinical input, but an awful lot of them are just people following an algorithm. Call handlers who are just following a computer-generated algorithm are necessarily risk averse.
There is good evidence that if you get clinicians involved with NHS 111 you can reduce the number of people who are directed to an ambulance, a GP or an emergency department. Triage, which is what NHS 111 is supposed to do, is a skilled, difficult clinical activity that requires a degree of clinical risk-taking. The biggest gain, and the simplest thing to do, would be to increase clinical support to NHS 111.
Q27 Rachael Maskell: Would you say that that is going back to the NHS Direct model that was first established in that space?
Dr Boyle: Yes. NHS Scotland, which is equivalent, has 100% clinical input to its calls. There is a different mechanism. It is difficult to compare data between the two, but it seems that having clinical input leads to more self-care.
Q28 Rachael Maskell: Often people look to the acute sector as the place to go. I note that my own area of York has set up a diversion route for paediatrics to be assessed outside the hospital. Of 1,300 patients who attended that, only three were referred on to the emergency department, with one admission. What more can be done with assessment in the community?
Dr Boyle: Probably quite a lot. Good healthcare systems have strong roots in good primary care. We know that access to primary care is important to people. Generally, people value being able to talk to their GP. We also know that our GPs are under enormous pressure and that we have not increased the number of full-time equivalent GPs. Improving access to primary care would help.
Q29 Rachael Maskell: Given that the Government are handing out money, how much of that money should be put into primary care services, as opposed to secondary care?
Dr Boyle: That is a difficult question. In Scandinavia and other parts of Europe, the most cost-effective healthcare systems in the world are highly rooted in primary care and have strong primary care. In the least cost-effective systems—the US is an example that is really not cost-effective—their primary care offer is very fragmented and difficult.
Q30 Chris Green: In your view, why has performance for emergency departments, in terms of the four-hour wait, fallen so much since 2010?
Dr Boyle: There is a variety of factors. The biggest fundamental factor is the way that we are able to manage flow for admitted patients. The four-hour target, when it came in, provided a very simple metric: “We have to try to do this,” and it generated a lot of push to move people through emergency departments. It had some undesirable factors, by getting people to focus on quick wins and directing the most senior doctors to go and see the people who had the least wrong with them, which feels wrong, but it was simple and it was well understood.
As we have lost beds in our healthcare system—we have lost beds faster than almost any other European country; we are right at the bottom of the table in terms of the number of beds per population—people get stuck and cannot move into our hospitals. We have also taken out, with the rise of minor injury units and urgent treatment centres, a lot of the people who would have been discharged. The denominator has changed.
We are also doing a lot more for our patients. We are doing many more CT scans. These things take time. There are many more treatments for things like stroke thrombolysis and there are transfers to higher levels of care. Medicine is becoming more complicated and time-consuming.
The pandemic disrupted everything. It made our use of in-patient hospital beds more difficult because of infection control. Not only the number of beds, but the actual way you can use the beds, has become much less flexible. With the introduction of the clinical review of standards, which was a plan to try to come up with an alternative to the four-hour target, a lot of places were left in a performance vacuum. The signal that seemed to be coming from central Government was that the four-hour target was over and there would be something new. But nobody quite knew what they were aiming for, and that led to a performance vacuum for chief operating officers and CEOs.
Q31 Chris Green: There are a number of concerns in emergency departments themselves. Within broader society, attendance has gone up over the years. Pressure from society is increasing, whether it is from increased population or various other factors. Are there any particular cultural aspects? There is people’s understanding of A&E and what it is there for; people’s appreciation of GPs and what they are there for; and the certainty of getting a GP appointment or the certainty of society thinking, “It’s four hours. You are in A&E and you are going to get seen in four hours.” That is a guarantee you do not have with GPs. Are there cultural things in society that need to be corrected as well?
Dr Boyle: Possibly. There is some evidence from work done by the Sheffield School of Health and Related Research, where they looked at health-seeking behaviours. They identified a particular blip, where there is an increase in working-age adults attending emergency departments between the hours of six and 12.
My personal experience is that people now try really hard not to come to emergency departments, and they try very hard to access healthcare in other ways. They will have phoned NHS 111 and been directed to A&E and say, “I really didn’t think I needed to come to an emergency department, but NHS 111 sent me,” or they may have struggled to get access to a GP. Some of this is not necessarily about cultural behaviours, but about creating a system that is responsive to people’s needs. If there are blocks elsewhere, people will find ways round their blocks.
Q32 Chris Green: In emergency departments themselves, with new types of treatments, sometimes involving equipment of different sorts, are the buildings physically fit for purpose? If you bring in more kit and you are doing more treatments and more activities in the A&E, do many of them—if they have a legacy footprint—need a significant expansion in size?
Dr Boyle: Again, it comes down not to building bigger departments; bigger departments would be a problem, and better flow would be much better. That said, many emergency departments that I walk around look pretty dilapidated. They have spread through bits of the hospital. Certainly, there was a feature, during the early stages of the pandemic, where, to increase clinical space, we took over other areas. There are emergency departments—King’s Lynn in Norfolk keeps coming up in the press as a department that is held up by girders because bits of it are falling down—where there has been a real lack of investment in emergency department estate over the last 10 years.
Q33 Chris Green: Integrated care systems have been set up and rolled out across the country. Is the funding and what they commission a significant part of the solution in getting people out of A&E and into the hospital more broadly, and then out of the hospital and into care? Do you think the ICSs are going to make a significant contribution to that?
Dr Boyle: I don’t know. We will have to see how it works. The idea that there is system oversight is welcome. One of the problems we have always had is the lack of system oversight. The proof will be in the pudding and what it actually looks like at the end.
Q34 Chris Green: That is not very reassuring for quite a significant change. There is so much pressure on the system broadly across the national health service. There are particular things that are apparent at the moment in emergency departments. We see the build-up of ambulances and a significant change in terms of responsibility that happened fairly recently. It is a kind of “Wait and see.” I did not get the expectation that the new local leadership will be able to deliver the changes we need.
Dr Boyle: When you have been looking at performance graphs for as long as I have, you become a little bit wary.
Q35 Dr Johnson: First of all, I definitely endorse what you say about 111. As a student I worked for a company on Teesside that was providing the out of hours GP service. The out of hours calls that would be taken by 111 now were taken by a small number, two or three GPs, with help from call handlers. There were far fewer people having to come in for appointments as a result. They could just turn up for prescriptions and things.
What other solutions are there? We can see that there is a problem and a difficulty. What other solutions are available? What would you do if you had a magic wand and plenty of money?
Dr Boyle: That would be a terrible thing. The first thing is to increase the capacity of our hospitals and decrease the occupancy. Our analysis last year suggested that this winter we were going to need 14,000 beds. There was a bit of quibbling going on within NHS England, who came up with a figure of 7,000.
We are a little bit sceptical about virtual wards as a solution. I know it is an attractive option, because it looks very cheap, but actually unless it is properly evaluated we are not going to know whether it works. A lot of this is about making sure that we have more capacity, and that we use that capacity better, which means reforming social care. It is starting very much at the back door.
There are absolutely things that can be done at the front door to try to improve matters. Certainly, it is about increasing clinical support around NHS 111, but also looking at various clinical validation tools in the ambulance service is helpful. There are certainly things that could be done about improving that. We have to get into a situation where we routinely evaluate the interventions we are doing. It is very easy to come up with a good idea and make it into a policy, but then actually not evaluate it and know whether it has worked.
Q36 Dr Johnson: That seems like a very good point. You talked about the four-hour wait. I am afraid I disagree with you. I do not think the four-hour wait is very well understood. I think the majority of people in the press report it, and people in my community understand it as the wait to see a doctor. It is actually the clock from your arrival in the department to leaving the department. I do not think that is very well understood. Do you think there are any targets that could be used and, if so, what would you target?
Dr Boyle: The one thing we would say is abandoning the 12-hour decision to admit target and having an end-to-end, time of registration to discharge target. Currently, the NHS England performance figures that you get each month report 12-hour decisions to admit. The decision to admit can be made several hours after a patient has been in a hospital. It also does not include people who have been in the department if they are not admitted. There is a whole bunch of people who are missed by it. We think actually having 12-hour stays measured from time of registration, regardless of whether somebody is admitted or discharged, would be a more meaningful metric. It is more patient-centred and it is easier to understand. A lot of managerial time is wasted on validating what the decision to admit time was.
Q37 Dr Johnson: Essentially, it is the four-hour target made a 12-hour target only for people who are admitted.
Dr Boyle: No. In terms of what I am asking for, no. We would say a 12-hour length of stay target. It is the same, alongside a trajectory to improve the four-hour target performance. We need to have the two. The reason you need the two is that once somebody stays more than four hours there is a waning of attention, so you need that second bit of focus: “This person is coming up to being in the department for 12 hours. What are we actually doing about it?”
Before Christmas we surveyed the clinical leads of all our departments. We have a WhatsApp group where we can all communicate; 90% of clinical leads in England reported patients staying more than 24 hours in the department in the preceding week.
Q38 Dr Johnson: You have talked about how, before people get to A&E, 111 can be improved to help A&E, and I understand and support that. You talk about how the flow out of the back door into the hospital through social care and other things can be improved. I support that too. Is there anything that A&E itself can do that you think it does not do well at the moment, or could do better or could be supported to do better, as opposed to just what happens before and after people arrive?
Dr Boyle: That is a good question. It would be better if we were able to look after our staff and get to do our initial assessment earlier. One of the things that I am concerned about is that the time to initial assessment is getting worse. It is helpful for us to get in early and initially assess. It is much better for patients. It is also much safer.
Q39 Dr Johnson: Are you talking about triage or first medical assessment?
Dr Boyle: Different department designs lend to different types of models. Certainly, we have some support for the idea of having a senior doctor going out and assisting with triage. That is certainly helpful. It is helpful that you reduce unnecessary investigations, but also that you stream people to other levels of care. That can definitely be helpful.
Q40 Chair: That is very interesting. You have a WhatsApp group of clinical leads in emergency departments.
Dr Boyle: Yes.
Q41 Chair: I thought the Tory MPs’ WhatsApp group was lively over Christmas, but I imagine that one was not to be repeated.
Dr Boyle: My phone was quite hot.
Q42 Chair: I imagine it was. Could I do an advert? Last week this Committee launched a major inquiry into prevention of ill health. We started this session with me talking about demand. If you think about the groups that present to your members in emergency departments, frail and elderly falls that end up being picked up by an ambulance, or brought in if possible, are probably quite a big number. There will be people who are experiencing a mental health crisis, acute or otherwise. I know from being out with the ambulance service that they make up a number of people admitted.
Would you give us some thoughts on the overall prevention of ill health to drive down that demand and the numbers that are coming in the front door as a longer-term measure? Would you concur that that is absolutely critical to the survival of the NHS? We are spending some £185 billion a year on the NHS, which is a significant amount of GDP. Clearly, we could double that and people would still say it was not enough. Would you give us some reflections on the prevention agenda?
Dr Boyle: Yes. I can only talk about the patients that I look after. There are absolutely prevention opportunities. Some of it is about making sure that we have places we can signpost to people. We already do quite a lot of work about health promotion in terms of harmful drinking. Alcohol generates quite a lot of my patients. Being able to identify patients and direct them to services or even to a website that tells them how to safely cut down on alcohol we see as important for the work we do. There is good, randomised control trial evidence that doing that reduces subsequent attendances.
Among other things that we get involved in, we advocate violence reduction. We share information, when someone has been assaulted, with community partners. This requires system-level thinking and engaging with other partners outside the health service, sharing information with the police and so on about where assaults are occurring.
There are limited bits, even in emergency doctors, in our responses; our training is all about dealing with very sick people. We get it, and we are supportive of anything for improving the health of the nation through preventive care. We recognise that we have bits within that.
Q43 Chair: Surely, going back to Mr Green’s question about ICSs and the system approach, that is why they have been created. A lot of things to do with health aren’t anything to do with the portfolio of the national health service. There are many other players.
Going back to the frail elderly, the falls and them then coming in through the front door, there is a two-hour community response target in the long-term plan for frail elderly for falls. Is that even remotely being met?
Dr Boyle: I don’t know. That would be—
Q44 Chair: But you must recognise those presentations at the front door.
Dr Boyle: I look after a lot of very elderly people who have spent a long time on the floor. One of the things that has happened over the last year is that the number of people being brought to us by ambulances has dropped. The paramedics have become incredibly motivated not to bring people to hospital and to try to do stuff. If you look at the data, the number has dropped by about 20%.
I am aware that there is an awful lot that the paramedics are doing that I simply do not see, and does not come to me. I see lots and lots of people who have had what we call long lies on the floor—the frail and elderly who have been on the floor for an awfully long time. I do not know how much of that could be prevented. Hopefully, people pick them up quickly.
Q45 Chair: Lots of work goes on in the fire service, for instance. They do a lot of work in the health space these days, working with frail and elderly people to fall-proof homes, as much as they can, to make sure that is prevented in the first place.
Finally, what are your reflections on the current ambulance strikes? Obviously, the data shows how the number of calls has significantly fallen off during those strikes, with pandemic levels of drop-off, as the public refrain from using those services unless they are urgent emergencies and life threatening, which is of course what an ambulance is for. What are your reflections on that, and some of the stuff that was flying around in the media yesterday about the high number of calls to the ambulance service that have absolutely nothing to do with the ambulance service?
Dr Boyle: That is interesting. Certainly, the effect of disruptions, whether it be industrial action or a lockdown, is that there is a sudden drop in demand.
Q46 Chair: Is there a learning in that?
Dr Boyle: There is learning in that. Some of the learning we had is that people who should have sought help during lockdowns did not seek help. One of my anxieties about all of the recurrent problems we are having at the moment, and the media stuff, is that it is discouraging the right people from seeking help. We know, for instance, that the time to angioplasty for people who were having heart attacks got an awful lot worse and then dropped off during lockdown.
I do not know what is going to happen with the ambulance service, but we worry that there will be people who do not want to make a fuss and do not want to bother. I have personal experience from members of my own family. They are desperate not to go into hospital and not to bother people.
There is always the blunt thing where, yes, you suddenly get a reduction in demand, but is the risk that there will be some vulnerable people within that? One of the things that we learned in the ambulance strike was the value of increased clinical support. The discussions I have had with various ambulance medical directors is that providing increased clinical support to people taking calls and dispatchers led to many better decisions. It was not sustainable at the time, but we learned a lot. Going back to the point about NHS 111, if you get clinicians involved early, you can make better and more cost-effective decisions.
Chair: Dr Boyle, thank you so much for your time and for coming in and speaking to us. There is obviously huge public interest in this, and there is huge interest among Members of Parliament, as you would imagine. Thank you very much.
Witnesses: Chris Hopson, Professor Redhead and Dr Diwakar.
Q47 Chair: We have heard from the president of the Royal College of Emergency Medicine, who obviously practises on the frontline as well as representing his members. Now, on schedule, we move to our second panel, which is NHS England.
We have an illustrious line-up, starting with Chris Hopson, chief strategy officer at NHS England. It is nice to see you again, Chris. Thank you for coming in. We have a return for Professor Julian Redhead, who has been in this Committee relatively recently. He is the national clinical director for urgent and emergency care. Dr Vin Diwakar is the medical director, national transformation and medical directorates at NHS England. I hope you have a big business card, Dr Diwakar.
Chris Hopson, thank you for coming. Let me start where I almost started with Dr Boyle. I made it very clear in the lead-up to this session that we would be asking Dr Boyle to show his workings-out. I think anyone watching would agree that he showed his workings-out. He referred to some academic papers and some papers from the college. He went through it in quite a lot of detail. It is all there on the record.
When that happened at the start of the year, over the Christmas and new year holidays, you said that NHS England does not recognise these figures, so the question for you is: show your workings-out. Why don’t you recognise those figures?
Chris Hopson: There are three different things going on. The first issue is the pressure on the urgent and emergency care pathway. We know that the NHS has been under an unprecedented degree of pressure on that pathway. We know that has led to significantly longer waits than we have seen before and we know that those longer waits are associated with poorer outcomes.
As I think you know, Chair, the key principle in urgent and emergency care is to triage as quickly as possible, treating the sickest patients first and doing all we can to reduce harm and avoidable mortality. It is worth noting that without the 7,000 extra beds, bed equivalents or virtual wards, and without the extra 1,000 111 and 999 call handlers, the community fall service, the respiratory hubs and the system control centres that we have added this winter, those pressures would have been significantly greater.
The second issue is that at the same time—Chair, you quoted these figures in your earlier questioning—we are seeing higher levels of excess deaths over the winter months. Those higher levels of excess deaths are not unusual. That will obviously reflect flu, cold weather snaps and covid. In addition, again as you know, in July 2020 SAGE said that they too expected to see higher levels of mortality as a result of covid—for example, the higher levels of cardiovascular mortality that the chief medical officer has recently pointed to. Again, as you know, we are now seeing similar levels of excess mortality in countries like Germany. The context around those excess deaths makes it very difficult to analyse or identify the exact cause of those excess deaths. It is right, as I said when I did my interview, that experts at the ONS, supported by the chief medical office and working with the chief medical officer, continue to analyse the reasons for that higher level of excess death.
The third issue is that obviously, when you combine the two, which is the link between the pressures on the urgent and emergency care pathway and the higher levels of excess mortality, the widely quoted 300 to 500 a week figure that is, as you have heard, based on a study in the Emergency Medicine Journal suggests a link to delays in admitting patients from emergency departments and all-cause 30-day mortality. The key phrase is “suggests a link”. As Vin and Julian, who are the expert clinicians, can explain in more detail, that figure of 300 to 500 cannot be definitive and does not give a full and certain picture. That is why both I and our chief medical officer, Sir Steve Powis, said we did not recognise that figure, while at the same time—this is really important—specifically acknowledging the recent extreme pressures in urgent care and recognising that longer waits are associated with poorer outcomes.
Q48 Chair: I understand what you are saying. Professor Redhead, on a clinical pathway, you heard our conversation about full capacity protocols—moving people out of the emergency department away from harm on to wards. We heard about the Bristol example. Are you enticed by that?
Professor Redhead: It is important that we understand where risk sits across a whole system. There is risk sitting in the ambulance service; there is risk sitting in A&E; and there is risk sitting in the ward, as well as in the discharge pathways. How do we at individual and local level balance those risks so that we do not have too much risk in one area and not balance it with others?
In certain systems and in certain places, the movement of patients from the emergency department, which may be overcrowded, with corridor care and not necessarily enough staff to deal with that number of patients, into a different environment where there may be better care provided, albeit not optimum, can sometimes be a better place and a better risk management than others.
Q49 Chair: Chris, have you been shocked by this winter so far? There is some suggestion that the flu is peaking. There are 100 times as many people in hospital with flu as there were this time last year. Going back to my supply and demand analogy, if it was 100 times the number of people in this room, it would be cosy. Have you been shocked by what you are hearing from emergency departments across the system, for which you are the chief strategy officer? To put it bluntly, if you were on Dr Boyle’s WhatsApp group, would you be surprised by what you were seeing?
Chris Hopson: We know that the service is under pressure. You just need to talk to frontline clinicians and chief executives, as we all do every day of the week. The consistent story that you hear, which is why I use the phrase, is “an unprecedented degree of pressure”. Obviously, again as you know, we prepared for this winter. We prepared for it earlier than we had done before. I gave you the list of things that we did; in particular, as I said, we are adding 7,000 beds or bed equivalents.
This winter, the issue was always going to be the degree to which we saw prevalence of both covid and flu, and the degree to which they combined. We are obviously not through winter yet, but to make the really important point, which I do not think has come out enough, what happened is that, interestingly, both covid and flu peaked so far on 29 December, when we had 9,500 people with covid in our hospital beds and 6,500 people with flu in hospital beds. As you know, Chair, we had around 12,000 people who were medically fit to discharge, but we were unable to discharge them. If you add that together, 28,000 of the approximately 100,000 beds that the NHS has were effectively occupied by a combination of covid, flu and medically fit to discharge patients.
As you heard earlier, that gives the NHS a very significant problem of patient flow, which means that you get a back-up right the way throughout the system. You get the ambulance waits. You get the inability on ramps. You get the inability to promptly convey to hospital.
There is no doubt that when we were looking at future scenarios, it was the combination of the two things. There are the absolute levels of numbers of covid and flu patients that we saw, but also the fact that they both hit at exactly the same time. That is why we used the phrase “twindemic”.
Q50 Chair: Of those three, I think even your harshest critic would suggest that the NHS and the Government have done very well in rolling out the covid vaccine. That has prevented huge numbers of admissions—I am sure you could put a figure on it—from going into the acute sector. The flu vaccination roll-out—I am sure, again, you can give us the figures—has been good this year, but there are many people who are getting very sick with flu. I have seen people in the acute setting who are relatively young and not suffering comorbidities who have been hospitalised by the strain of flu that came this year.
The third string of that, though, where people may be less generous towards you, is around the preparedness for those in hospital who are clinically fit, who do not need to be there but who are missing either a care package or a care home place. We talked with Dr Boyle about domiciliary care and its role in that.
Where I am struggling is that on 4 January you had your summit. On 6 January the Secretary of State announced the extra £250 million, which is only until the end of March, to unblock, hopefully, those bed-blockers. Maybe you could give us an update on how that is going. It doesn’t sound like, “We prepared well for this winter.”
On the other two, people get sick and that is the human condition. We do as much as we can through vaccination and preventive measures. I wear a mask on the tube. I never used to, but I don’t want to get flu, so I do. That is my choice. Lots of people have changed their behaviour. It is that third bit about discharge that I, and many people, are struggling to be generous to you on. Is that fair?
Chris Hopson: We have a health and social care system. If you actually look at the discharge issue specifically, discharge is a combination of issues in ensuring that transfers to other NHS care are dealt with as effectively as possible. You know that we have been doing a whole load of work over the summer and the early autumn in our 100-day discharge challenge to reduce the level of care inside NHS care. We have had good progress there.
Obviously, exactly as you were implying, we have discharges to both domiciliary care and care homes. Clearly, that is the responsibility of the social care system, which the NHS does not control. You will know that one of the big arguments for the creation of the integrated care systems, which became statutory bodies in July, is the opportunity for health and social care to work together more effectively and to try to create an integrated system, but you have an NHS and a social care system.
Q51 Chair: Yes, in theory, we have a health and social care system, but in practice, I wonder. Even with the ICSs, maybe I doubt it. Why do I say that? It is because we do not have a national tariff for trusts to negotiate with the care system to move people out. In Winchester, which I represent, they have to deal with Hampshire, but they have people who live in Southampton, a different social care local authority. I am sure you heard the head of Care UK on the radio earlier this year saying that maybe it is time to think about a national tariff that breaks down that barrier. I often hear that one of the complications is that a switch from one local authority to another slows the whole thing down, and they have a whole new group of people to talk to, so do we have a health and social care system?
Chris Hopson: Your identification of the need to ensure that the join between health and social care works as effectively as possible is absolutely right. As I say, that is precisely why integrated care systems have been created. I could point you to a whole series of examples right the way across the country where the creation of those systems is actually improving the discharge position.
Fundamentally, if you talk to those who work in the social care system, as I know you do, there is a set of very difficult issues in the social care system—for example, availability of staff and pay rates in social care, particularly in the domiciliary care sector. Those, unfortunately, are not the responsibility of the NHS. We found, in a number of different systems, ways in which the NHS can assist social care, both local authorities as commissioners and providers, in trying to address those issues, but ultimately in the end they are the responsibility of the social care system.
Q52 Chair: They are not your responsibility, but they are your problem.
Chris Hopson: I completely agree.
Q53 Chair: That is not a great place to be, is it? To have something that is not your responsibility, but is your problem, is a hospital pass—no pun intended.
Chris Hopson: Which is precisely why, as I said, the creation of the integrated care systems allows the opportunity for us to address these issues in a way that we have been unable to before, and we are making progress in so doing.
Chair: We could go on with this for a long time. I was going to bring Rachael in later, but I think this is pertinent. I can read her mind.
Q54 Rachael Maskell: I want to come back to you about the surprise. We knew that there was going to be a spike. We predicted it, first of all, for last year in flu and covid. It came this year, so we were saved last year. Why wasn’t there more preparation in place for last year instead of leaving it to August and then an announcement in January this year?
Chris Hopson: As I said, we prepared earlier than we have done before this year. We put in a whole series of different things to prepare. The issue that you can never be sure of is exactly what levels of covid we should expect. If you remember, the pattern over the last year has been a series of waves. We did not know what was going to happen with flu. As the Chair has already said, we have seen several years of much lower levels of flu. I should be bringing in my clinical colleagues here, rather than saying I am a clinical expert because I am clearly not.
We have seen lower levels of flu, significantly because of social distancing. We did not know what the levels of flu were going to be this year. We did prepare, but there is absolutely no doubt that the levels of absolute demand that we have seen in relation to covid and flu were at the higher levels of our estimates. It is the fact that they both happened together. Vin, is there anything more you want to add on the preparations that we made?
Dr Diwakar: First, the preparations for winter start at the end of the previous winter. We issued our first winter planning letter at the beginning of August, and then we had a further winter planning letter giving instructions to systems as to what they should do in October, when we saw the modelling that was showing what was potentially coming down the line in December. Nevertheless, it was right at the worst end of our scenario that the numbers of in-patients with covid and the numbers of in-patients with influenza would peak on the same day in December in the middle of the Christmas period. Secondly, we had the impact of the cold snap about two weeks beforehand. That leads to a rise in respiratory infections a week later, and a rise in heart attacks a week later still.
Then, of course, we had the challenges of prevention, as the Chair talked about. During the covid pandemic many people, for a variety of reasons, were unable, for example, to have their blood pressure checked. We had a job to do in the post-pandemic period in order to catch up. We recommend that anyone over the age of 40 has their blood pressure checked. In the last data produced, which was in March 2022, about 75% of people in the eligible groups had had their blood pressure checked. That is an improvement on where it was a year before, when it was 65%, but is still not as good as where we want it to be, which is where it was pre-pandemic.
Similarly, we have a NICE stated target to optimise blood pressure control. About 65% of people had optimum blood pressure control in March 2022. That was better than the 48% a year before. We are putting a lot of effort into what we have been doing in the subsequent year to improve blood pressure control even more. We should see those results in March 2023 when they come out. For example, community pharmacists can now check blood pressure. We know that over 600,000 people have had their blood pressure checked through community pharmacy, so that will have an impact down the line.
When you take those things together, you have the infectious diseases, the cold snap and the impact of being unable to maximise our preventive activities. You have industrial action. That led to an unprecedented range of pressures that all came on the service in December, which resulted in some of the challenges that we saw, despite our best efforts with some of the things that we did over the summer and autumn period that Chris has already mentioned.
Q55 Rachael Maskell: Mr Hopson, I want to come back to you. We have already heard that bed occupancy is consistently far too high, and therefore not safe. That was not prepared for to try to free up bed occupancy. In fact, the Secretary of State made a call in January to try to clear 2,500 of those beds. That is not preparation in advance of winter. We know that winter is always cold. We know that there is always a rise in respiratory conditions. That was not properly prepared for.
When families gathered together at Christmas, with the risk of infection spreading, as we have seen consistently through the pandemic and learnt much from that, there should have been an expectation and a risk of infection spreading. I note the date; very significantly, it was 29 December, after families had gathered. That was not properly prepared for. What preparations went forward in the light of the fact that all of these risks could have been predicted, and yet were not addressed until January, after that Christmas spike?
Chris Hopson: If you don’t mind, I disagree. I think we did prepare. As you heard, we prepared earlier than we had done before. I will take the first point, and then I will ask colleagues to join in on the rest.
We identified significantly in advance that we did not have sufficient bed capacity inside the NHS to match what we predicted was likely to happen in relation to covid and flu. That was precisely why from August, in that first planning letter, we had asked our individual ICSs to send us back a capacity plan that looked at demand and capacity available. That identified a need to add 7,000 extra beds.
We made funding available to enable that capacity to be added. We agreed with each individual integrated care system exactly what pattern of extra capacity they wanted. In some places they wanted extra or acute bed capacity. In some places they wanted virtual ward capacity. In some places they wanted intermediate step-down, step-up care capacity. We agreed a plan with each individual integrated care system that we then funded, and that capacity has been added and is continuing to be added over the period. In fact, if you look at the NHS bed numbers that we currently have open, they are significantly higher than last year. Vin or Julian, do you want to pick up the other issues in terms of not just the capacity?
Chair: I am conscious of the time. We have a hard stop at 11.30. I will let Rachael determine who answers her questions.
Q56 Rachael Maskell: I think the answer has been given. It seems that it is too late in the day. Obviously, these things do not come on stream immediately. It takes time.
I want to ask one final question about international comparators. We keep hearing that the UK is an outlier and we are given specific reasons for that. I would like to know what comparators you are making with other countries. How do we fare? What additional steps are they taking that could assist our systems if we were to adopt them?
Chris Hopson: Clearly, the NHS is a learning system and we do everything we can to ensure that we learn from other national systems about the ways in which we can improve the quality of our care. The observation I would make, and it is an important one, is that the NHS in the UK is not unique in the scale of pressures that we are currently facing. If you look at what is currently going on in, for example, the American, the Canadian, the French and the German systems, we are seeing similar levels of pressure. Every single advanced western healthcare system is seeking to deal with the combination of growing demand, particularly as we see the baby boom generation come through and have greater need for healthcare as they reach their years when demand for healthcare increases, and at the same time we are all dealing with the impact that we have seen of covid.
As you know, and it is very obvious, it is important not to look at the urgent and emergency care pathway in isolation. It is important to look across the whole piece. As well as the pressures we are dealing with on the urgent and emergency care pathway, we have a very significant elective backlog, significantly caused by covid, which we are also having to work through at the same time. Every single advanced western healthcare system is also struggling with the impact of covid.
Q57 James Morris: Notwithstanding the explanation that you have given for the situation that currently exists, Mr Hopson, the facts of it are that performance within emergency departments has been deteriorating for quite a long time. What do we do now in order to arrest that deterioration in performance?
Chris Hopson: As we said before, and as you heard earlier, there is a combination of different things that we need to do. As the Chair has already referred to, we will shortly be bringing out our urgent and emergency care pathway plan, which will look at a number of different things.
If I were to pick out three or four things, the first is that we know we need to make the extra capacity permanent. Effectively, if you look at the planning process and the planning document that we issued just before Christmas, we have asked integrated care systems to ensure that capacity is made permanent.
Secondly, you know that we are working on a long-term workforce strategy, where it is absolutely vital that we get the right size and shape of workforce with the right skills in the right place. We know we need to tackle discharge. Again, as has already been pointed out, an extra discharge fund has been made available at short notice, and we are obviously seeking to maximise the benefits of that. Fundamentally, if we are unable to tackle the issue of freeing up capacity as a result of being able to discharge medically fit patients promptly, it causes back-up through the rest of the entire system. I know people have said that to you several times. There is a combination of different things that we need to do.
Q58 James Morris: Do you think the four-hour target has run its course? Is it having an unintended negative consequence in the management of patient flow through emergency departments?
Chris Hopson: Both Vin and Julian have been working on that in detail, so would you mind if I ask one of them to pick it up?
Dr Diwakar: I will pass to you, Julian, as an emergency man.
Professor Redhead: Colleagues will know that there was a clinical review of standards led by Steve Powis. Those are still there as potentials that we might be able to use as mitigating or balancing measures towards a four-hour target.
The four-hour target has been useful in the past. I think it still provides a basis for how we go forward to ensure that we provide timely care to patients. As we know, there are always ways that departments will try to make sure that they are achieving that target. We need to make sure that they are achieving the target as well as providing the great patient care that I know they want to give, and that certainly the clinical staff absolutely want to give.
Q59 James Morris: Incidentally, when would we expect the plan to be published? I think you said “shortly”.
Chris Hopson: That is a matter that we would need to agree with Government. I am not in a position to give you a definitive date, but hopefully shortly. If you were to say, “What do you mean by shortly?”, I would expect it to be in the next fortnight or so.
Q60 Chair: Is that complete, as in with the independent assessment?
Chris Hopson: I am sorry, I thought you were asking about the UEC plan as opposed to the workforce strategy.
Chair: The workforce plan.
Q61 James Morris: I was talking about the emergency—
Chris Hopson: Okay, so that is the emergency plan. Chair, in relation to the workforce strategy, as you know, we have agreed that the numbers that we are putting in the workforce strategy will be independently verified. Yes, when we publish, the assumption we are currently working on is that that will have been through independent verification. If the question is, “When will that be published?”—
Q62 Chair: Yes, that is the question.
Chris Hopson: The answer to that again is that it is a matter of discussion with Government. If you were to ask me, “What do you mean by that?”, I would probably say within the next two months as opposed to the next two weeks.
Q63 Chair: Who is doing the independent assessment?
Chris Hopson: I don’t know that. I think we are in the process of agreeing that, or have just agreed that, with Government. As you know, the Chancellor announced in the autumn statement that we were going to be doing the workforce strategy, and it said that there would be independent verification.
Q64 Chair: Don’t you think Parliament should know who is doing the independent assessment of such an important thing?
Chris Hopson: I can certainly find out for you, Chair, and if you wish me to send you a note—
Chair: I wish it.
Q65 Lucy Allan: Chris Hopson, I recognise that some trusts perform better than others when it comes to meeting urgent and emergency care targets. I am the MP for Telford. On the front page of my local paper today is quoted an emergency care doctor who says, “it is chaos, like a war zone…there are patients everywhere they can be squeezed, in cupboards and blocking fire exits…Every patient who dies, who we might have saved had they been seen sooner, leaves us feeling traumatised.” The article goes on to pages 4, 5, 6, 7, 8, 9 and 10, and is written by a very respected journalist. Do you think, Chris Hopson, that senior management in NHS England are complacent?
Chris Hopson: Absolutely not. I think we recognise, as we have said publicly, including today, the scale of pressure that the NHS is under, particularly on the urgent and emergency care pathway. As I said earlier, we talk to senior leaders and clinicians every day of the week. We are deeply aware of the consequences of that pressure for both our patients and our staff. I certainly would not describe us as complacent. We have been working incredibly hard both to prepare for winter and to manage over the winter period, complicated by the fact that we have also had industrial action.
Q66 Lucy Allan: Why would this trust be coming bottom in the rankings of meeting targets? It is fourth from bottom. What is this trust doing wrong that prevents it from meeting the targets that other trusts are capable of meeting in urgent and emergency care?
Chris Hopson: Would you mind if I asked one of my colleagues to basically explain a little bit about the mechanics of why you would see some warranted variation in urgent and emergency care performance?
Chair: If they are succinct, yes.
Dr Diwakar: The first thing is that we know there is variation across the country. We take that very seriously. We know, for example, that in the trusts that are struggling the most to reach the standards, we have a pretty intense peer review regime. Not only do we speak to them on a regular basis and ask how they are doing, spreading good practice and identifying some of the things that they could do differently when we compare them with the trusts that have the best performance, but there are a number of visits that colleagues, for example on discharge, are taking around the country in order to spread good practice.
If we take discharge as one of our key challenges, in summer last year we had identified 10 things that every trust should be doing in order to optimise the discharge of patients. We took the 10 things that we had developed from the 14 trusts with the best discharge profiles and then we set a 100-day challenge for the NHS for everywhere to implement them in their trust. You can see a statistically significant reduction in the numbers of patients who were in hospital, who would have been medically safer at home for reasons within the control of the hospital over that period, and that has been sustained. I think we take those very seriously.
As Chris said, for any system the real challenge in getting flow, which is what the emergency medicine consultant and the newspaper articles are reflecting, is for flow to happen. That is partly about discharge. It is partly about proper processes within the trust. It is also about making sure that patients who attend hospital are only there if they need the facilities of hospitals. We have already talked a bit about prevention. For example, we think that urgent community response services are really important. They take 20,000 calls a week, I think, although I will have to check that. They have a significant impact.
Secondly, we have put in place community fall services across England. We think that those will avoid around 55,000 visits. When I have been out with ambulance services, you go to see patients who have fallen. They do not need the very specialist skills of a paramedic. What they need is someone to support them, get them off the floor, check that they are okay, speak to their normal caregiver and give an urgent community response.
Q67 Chair: What percentage of them are meeting the two-hour wait? We set that out in the long-term plan, if you remember.
Dr Diwakar: Yes, I remember you asked that question.
Q68 Chair: That’s an unfair question. Could you find that out and write to me?
Dr Diwakar: Yes.
Q69 Lucy Allan: Quickly, if I may, to what extent is the challenge in accessing GP care impacting on the flow issues that emergency and urgent care systems experience?
Professor Redhead: In terms of GP care, there are two aspects. I think Adrian alluded to some of this. One is around prevention, being able to take blood pressures and make sure that patients are in a preventive state so that they do not become unwell. It is making sure that those things are there.
The other side of it is to do with urgent care as opposed to emergency care. A number of patients who have urgent care needs rather than time-critical or potentially time-critical interventions and emergency department skills will come to A&E rather than to the GP for access to that care. They add to the burden in the emergency department.
Q70 Lucy Allan: Do you recognise a correlation between GP practices that are struggling to see patients and overburdened urgent and emergency care systems?
Professor Redhead: It is complicated. The data I have seen on this is complicated because it also depends on how distanced a GP practice is from an emergency department, as well as deprivation index and things like that. It is never straightforward. I have not seen anything personally that absolutely says that poorly performing practices lead to increasing A&E presentations, although you can surmise that it makes sense that there will be, to a degree.
Q71 Lucy Allan: Where else would they go?
Professor Redhead: Patients want to be seen by a doctor. If they cannot access primary care because of the pressures that there are on the primary care system, it will inevitably mean that they seek that care elsewhere.
Chair: Indeed. We have eight minutes for two colleagues. Taiwo Owatemi will go first.
Q72 Taiwo Owatemi: Thank you, Chair. I am particularly interested in the early intervention and improving primary care aspect that you were speaking about with my colleague. You have just said that GPs are under a considerable amount of pressure. We heard from Dr Boyle that we need to be able to improve our NHS 111 services.
What discussions are being had to relieve the pressures on GPs—for example, bringing in other healthcare professionals such as pharmacists? I declare that I am a pharmacist. What is being done to improve the current NHS 111 service to help it to achieve its full potential?
Dr Diwakar: First, on general practice, the biggest intervention that we have made in recent years has been the additional role scheme. There are 19,000 new roles that have been put into general practice. That includes, for example, physiotherapists, first contact practitioners, nurses and paramedics, as well as social prescribing, which of course supports people to access non-healthcare aids that are important preventive measures.
It is also true that workforce for general practitioners themselves is very challenged at the moment. Retention of general practitioners is a real challenge at the moment and it is an area that we are particularly focused on. Even within those limits, pre-pandemic, GPs were delivering about 310 million appointments a year. They delivered 345 million in the last full year, so general practice is working pretty hard at the moment.
NHS 111 takes a significant amount of demand, both from general practice and from emergency departments. I cannot remember the number off the top of my head, but 111 takes something like 17 million calls a year. That has gone up 30% over the last five years. Only 11% of the patients who call 111 are directed to an emergency department. Those calls, as Adrian reflected, are validated by a clinician. We are increasing the number of clinicians in 111 to validate those calls. The challenge with the validation process is that the majority of those individuals are general practitioners. Obviously, if you are in a system, you have to get the balance right about where you deploy general practice for best effect.
Q73 Taiwo Owatemi: I know you cannot see Adrian’s face at the back, but I think on some of the points you have just raised he would beg to differ about whether or not they are being validated by a clinician. Does that happen across all the healthcare systems in this country, or is that what we would expect to happen?
Dr Diwakar: Absolutely. That data about the number of calls that are validated is tracked as internal management data by NHS England. In my previous role I was the medical director of the London region. I used to look at that data on a regular basis. As I say, 11% of patients come through to emergency departments from 111. Some of those patients can be booked in directly to general practice.
Of course, as with any NHS service—indeed with any service—there are always areas we are looking to learn from and improve. For example, in 111 itself, calls are monitored. Supervisors sit next to the call handlers and look at how they are dealing with the calls. You have the clinical validation process and NHS Pathways, which is a triage system, and the only triage system of its type in the world. It learns because anything that happens is then investigated, and changes to protocols are made by a clinical expert group. On top of that, on a regular basis they undertake reviews of whole pathways. Most recently, they undertook a review of the cardiac pathway and changed some of the parameters.
There is always room for change and improvement. There is continuous improvement going on in 111 services all the time. Nevertheless, at the moment I think they take a load from the service. We are putting in more clinical validators, but inevitably if you are in a system you have to balance where you put your resource.
Q74 Taiwo Owatemi: I am completely aware of the time, but I want to make this last point. You are right that there are always areas of improvement, but some of these initiatives need to be reviewed on a constant basis.
When I speak to some of my pharmacist friends who go into GP surgeries, half of them tell me that all they are doing is repeat prescriptions and the other half tell me that they are seeing patients, and in some situations the GPs see them as an extension of themselves. Surely, both extremes are not what the role was designed for. My advice is that some of these initiatives need to be reviewed on a daily basis to ensure that they are effective and achieving what they were designed to achieve.
Dr Diwakar: I absolutely agree with you.
Q75 Dr Johnson: I will try to fit this in quickly. We have heard about how external pressures—the spikes in covid and flu and problems with flow in social care—are causing difficulties. You used the phrase that it is your problem but not your responsibility, and therefore it is difficult for you to fix.
I accept that those things are true, but I want to know a little bit more about what you are doing. We hear about, for example, some people waiting in hospital for several days for a specific scan. How are you prioritising or changing the hours of scan availability to make sure that you maximise the use of that asset?
In pharmacy, we hear about patients staying in hospital because they are waiting for their take-out medication. Sometimes they stay an extra night in hospital waiting for take-out medication. How are you using the virtual ward? We know that improved hospital care and improved hospital nutrition will reduce the length of patient stay. We know that if people have not had their OT and physio assessments, they are not discharged until they are done.
What are you doing within the bit that is your responsibility to try to resolve these problems? It is very easy to say that it is all because of social care flow or something that is happening before they get there, or that the wrong people are coming or whatever. Actually, what are you doing on the bit that is your responsibility?
Chris Hopson: Before we finish, can I say something on industrial action, if that is okay?
Chair: Who do you want to answer that question, Caroline?
Dr Johnson: All three of you, but specifically Chris. Julian is looking very keen to answer it, so perhaps Chris and Julian.
Chair: Pick one.
Professor Redhead: I cannot remember the question now.
Q76 Dr Johnson: What is being done within the bit that is your responsibility? I get that there are external pressures, but what about the bit that is your responsibility?
Professor Redhead: The discharge taskforce that was set up, and is led by Sarah-Jane Marsh, has been working very closely on that. As colleagues may know, we have divided different processes to look at different pathways. Pathway zero is where it is wholly internally within the hospital’s ability to care for those patients. Through Lesley Watts there was a 100-day challenge specifically around that group of patients, with a number of challenges to those trusts. We have seen a drop in the number of patients who are waiting for things on that pathway zero, so there have been improvements.
That is not to say that there are not always improvements we can make, and we continue to try to work with trusts to make sure that they are following all the things that you have just correctly pointed out, because they are all issues that we should be addressing, as well as working with our colleagues in social care, community care and mental health to improve the position for discharge across the whole system. That is why the ICS is important. We have heard that already. Things like the control centres and how clinicians come together across the pathway to help solve those issues are very important as well.
Dr Diwakar: One final thing is that you mentioned diagnostics. Of course, we are putting in new community diagnostic hubs across England. They should draw some of the planned activity away from the acute trusts and would provide the capacity in the acute trust to focus on exactly the patients you mention.
Q77 Chair: Finally, Chris Hopson is going to tell us that he has solved the industrial dispute. Excellent news.
Chris Hopson: Unfortunately not. We have not really talked about the impact of the industrial action. I want to draw the Committee’s attention to the fact that next month will see a step change in the action arising from the dispute between the trade unions and the Government. We expect 6 February to be the biggest strike day in NHS history for five reasons.
First, we are going to have nursing and ambulance unions planning co-ordinated industrial action across the country. Secondly, the nursing stoppage will last for two days rather than one. Thirdly, the numbers of trusts affected will go from 44 in December and 55 in January to 73 in February. There is now a shorter gap between the strikes, and in this particular case the strike days start on a Monday, which effectively makes it difficult to deploy the discharge of patients to improve flow, as we have done in previous strikes.
I want to make the point that we are now entering a new and more difficult phase in the dispute. That said, we are doing all we can to make sure that those who need care receive it, as we have done so far. If you don’t mind, I particularly want to stress that it is incredibly important that any patient who has a life-threatening emergency calls 999, and for any other urgent care please use 111 online.
Chair: Thank you; well said. That is a good public health message. Chris Hopson, Dr Vin Diwakar and Professor Julian Redhead, thank you very much for coming in. That is the end of this topical session.