26
Examination of witnesses
Karin Smyth, Sarah-Jane Marsh and Dr Fenella Wrigley.
Q21 The Chair: Good morning, and welcome to the third session of the Public Services Select Committee. I particularly welcome the Minister, Sarah-Jane Marsh, and Dr Fenella Wrigley. Before we move to questions, I am chairing today in an interim capacity in the absence of Lord Bradley. This session will be streamed live on the Parliament website and a transcript will be taken. That transcript will be available immediately following today’s session and sent to you as witnesses to allow you to come back with comments or small corrections. I also remind colleagues that if they have not declared their interests today, please do so before asking questions. Minister, can you introduce yourself, followed by the two other witnesses?
Karin Smyth: Thank you, Chair. I am Minister of State for Health, particularly secondary care. This title covers urgent emergency care and ambulance services. I am very pleased to be here this morning.
Sarah-Jane Marsh: Good morning, everybody, I am the national priority programme director for urgent and emergency care for NHS England and the Department of Health and Social Care.
Dr Fenella Wrigley: Good morning. I am the national medical adviser to NHS England’s ambulance team and chief medical officer for London Ambulance Service. I remain a practising emergency medicine consultant.
Q22 The Chair: Thank you very much for giving up your time to be here today. I turn to the first question, and will aim this initially at the Minister. We have heard from witnesses that the roles of ambulance services and paramedics, and the expectations placed upon them, have progressively evolved far beyond stabilising patients and transporting them to hospital. How would you define the current role of ambulance services within the urgent and emergency care system, and what do you consider to be their optimal role?
Karin Smyth: Thank you, that is a great question to get us started. I am really pleased that we are looking particularly at ambulances, because this is a long and complex pathway. The traditional and public view, which I think you have heard about, is that ambulances are about flashing lights, picking people up and scooping them in. But they are a critical part of the entire pathway, and how they change is fundamental to how we will change the health service to be responsive and focused on people wherever they are, whether in their homes and communities, and support them as close to that as possible. Then the highly specialised services in hospitals can be used for what they were always intended to do. As we transform them, their role is critical.
I will come to my colleagues to explain this in detail, but to be clear: the changes made, particularly since we have been in office—although I would say that—have transformed the way that those services work. I hope we will get on to some of that. We have seen such great improvements this year and people are seeing that. I go out myself to listen to Hear and Treat’s mental health support, across the country and in my own constituency. Shining a light on this from within the committee is very good, as they are leading some of that transformation. Perhaps Dr Wrigley can speak to the clinical specifics.
Dr Fenella Wrigley: As the Minister said, the ambulance service has moved forward significantly, particularly in the past 10 years. The image of ambulances picking patients up and taking them directly into hospital, with minimal intervention and care, is something of the past. Paramedicine has grown enormously as a health profession. The ambulances have a highly skilled, highly knowledgeable clinical workforce that goes out to the patients. We know that 999 is very often the first point of contact for a patient entering the health system. It could of course be via 111, or via a GP, but a lot of patients ring 999. That first interaction is critical in understanding the requirement for a rapid triage and supporting the patient or caller at the end of the phone.
The ambulance service maintains a responsibility, as a category 1 provider under the Civil Contingencies Act, to respond to major incidents, cyberattacks and pandemics. This is something we work on collaboratively across the whole system. There is also a time criticality for some groups of patients, such as those who call with symptoms of a stroke or sepsis, or who have been involved in a road-traffic collision, or who have chest pain. Time is of the essence for that patient, but so is the outcome. Knowing that we arrived there in time to make a difference is so important, as is getting those patients quickly into definitive care.
However, the bigger group of patients are the 60% who have called 999 because they are struggling with something, such as breathing or their mental health. The ability to perform a clinical assessment after that rapid triage means that we can send the right response—a bespoke response—to help them, rather than simply sending an ambulance. We can then navigate them and refer them into the available neighbourhood and community teams, so that patients who actually need to go to the emergency department are taken there. That is what has transformed the service over the past 10 years, and continues to do so as we support the rollout of the 10-year plan.
Sarah-Jane Marsh: I will not repeat anything—I will probably go to the end of the question where you asked what the optimal role is moving forwards. Obviously, they fit within a UEC system, and the two big components of the way we want to see that moving forwards based on what we saw in the 10-year plan and so on is that wherever possible, we are able to triage and support people as close to home as possible. That may be done in a remote way over the phone, or in a neighbourhood health centre or an urgent treatment centre. The ambulance service has clearly got a really important role to play, not only in navigating patients to those alternative services but in being able to provide some of those services as well due to the clinical skills that Fenella has outlined. I think as we move forward, we will want to see a greater role for the ambulance service there, and we are starting to see that emerge—I am sure we will get into this topic as we go through the session.
The second is that we want to really change the way we look after older people in this country. We want fewer people brought to hospital and having extended stays in hospital with delays around discharge and so on, and the ambulance service has an important role to play in the way that it works with care homes, with urgent community response, community nursing and so on, to be able to support patients to stay at home whenever it is possible.
We have come a long way, and what Fenella has outlined gives us a lot of the infrastructure to be able to do this, but we want to make these further sort of advances over the next couple of years in the way that we deliver urgent and emergency care, and we see the ambulance sector as crucial to that. We have come a long way, but I think there is more to aim at and more opportunity.
The Chair: That is great, thank you. I have a follow-up question; I think you have almost answered it, but I will ask it anyway just in case there is anything you would like to add. Would it be beneficial for the role of ambulance services to be reviewed and clarified?
Sarah-Jane Marsh: I do not think so in a formal sense, in isolation, because, as I said, it is an important part of the system. As we move forward and we want to work in this more integrated way around the needs of local people and place, it is important that ambulance services are part of those local, regional and national conversations, and we are constantly thinking and evolving as other parts move forwards. I do not think review or clarifying in isolation would be appropriate at this point, but it absolutely has such an important role.
Karin Smyth: I add that the 10-year plan gives us the guide for the service as a whole—I wrote down “evolved” to myself as well just as Sarah-Jane said it. There is amazing, great leadership and experience across the service. We say we want to take the best to the rest, so on a sort of formal review, I would not think that is advised by the experts, but I would not see that as necessary at this time. There is a lot going on in the service. We want to take that best where it is going and learn from the front line and build that up rather than imposing things downwards. So that is where we would be on that.
Q23 Baroness O’Neill of Bexley: I was delighted to hear what you said. I am an ex-council leader until 5 November, and I constantly argued with the NHS locally; all the conversations with councils were about discharging and getting elderly people discharged, and my argument was, “Let’s stop them going in to start off with”. The ambulance service does not actually connect up with councils that well. I just wonder whether you could put that on your radar so that when those discussions are happening about avoiding elderly people going into hospital, that conversation can be had with councils up front rather than at the other end, where it is about getting them out of hospitals.
Sarah-Jane Marsh: I agree with you a million per cent. We often find with patients who are in hospital for long stays that there was never a clear reason to admit them in the first place; there is just a general sense they were not able to cope—all the stuff that you will absolutely know. A lot of the strategy, as the Minister said, is to try to avoid people needing to go in in the first place, and ambulance services are often the first point of contact for that. They are working increasingly closely with primary care, community services, care homes, and so on. We have some examples—I do not know whether you want to come in here, Fenella—of where that then links in with social care as well. Obviously, they have those established relationships, often through community services and so on. To go back to the Minister’s point, what we do not have at the moment is that consistency. I agree with you that as we move forward, we need to see that full multidisciplinary work, but I think we have some examples emerging around the country, Fenella, of where that is very much the case.
Dr Fenella Wrigley: A lot of it is around being able to share information so that the ambulance crew, who are likely to have never met the patient that they are going to go and assess—that is the key thing; they are going to assess the patient, not necessarily to convey them—and actually have eyes on what has happened to that patient. What is the patient’s wish and what do they want to happen, what is their family’s wish, and what information do we have from the general practitioner and the clinicians that are looking after the patient day in, day out? If they go in blindfolded, to a degree, with nothing to be able to look at and see, they see somebody who does not look very well but actually may be able to be looked after in their care home. So there are two things, about sharing the notes, making sure that they are accessible, and making sure that there are people to be able to jointly make that decision with, so through single point of access or integrated care hubs, which includes social care and healthcare, to do the right thing for each patient.
Baroness O’Neill of Bexley: I think I am right in saying that social care information would not be there, would it, so is that a missing part of the jigsaw?
Dr Fenella Wrigley: On the summary care record, the social care information is not there, but for urgent care plans it will indicate whether it has been uploaded, what the care package is, what the patient’s preferences are, and who to contact, if they have a social worker. That is particularly important not just for our elderly population but for our mental health patients, because they end up in an emergency department, which is very often the wrong place, and then we miss the opportunity to be able to look after them in a safe environment at home.
Karin Smyth: I will take away this point about discharge to formally thinking about it. There is a very live discussion about the roles of neighbourhoods and local authorities working in neighbourhoods, and mayoral authorities at ICB level—it is a democratic world that we are all involved in. That is to be resolved; it is always difficult, but we are very much looking at neighbourhoods as a centre, and obviously local authorities have a role in different parts of local authorities, not just discharge. Perhaps to be more explicit about that in some of our thinking is a helpful point.
Q24 Baroness Watkins of Tavistock: Just to declare my interests, I chaired the paramedic grandfathering board for IPC, so I am really into everything you are saying. I am also a fellow of the Royal College of Nursing. You talked about mental health; we really would like to know whether you think we should have mental health emergency areas right across the country. We have got the development of some new centres that seem to be really applauded, but, again, it does seem to be up to commissioners about whether they need that or not.
Sarah-Jane Marsh: I am happy to go first. Fenella, I know you have some experiences of this. The needs of people with mental health issues to access urgent care are escalating, as you will know very well. In an ideal world, there is co-ordination that does not involve ringing 999, because we know that is not the best experience that we would want for people. Where that does happen, if we can get the expertise in the right place at the right time, that is massively helpful.
We have the mental health response cars in some parts of the country, where we have dedicated teams that go out. There is really good evidence that they are able to support and often de-escalate and not need to take the patient somewhere. But if they do, and/or it is a standard ambulance, having those centres—they look different in different parts of the country; some people have specific areas inside A&E, adjacent to it or in different areas of the community—is fundamental to being able to support people in the appropriate way. It is a little bit like when we were talking about the older person that potentially gets in hospital for a period when they did not need to be admitted. This can also happen with mental health patients getting stuck at the front door of hospitals. That is not a great environment or a great set of outcomes.
But again, I agree with what you are saying. We have some brilliant examples. Most places in the country have got something, but we have not necessarily got a systematic approach and an evaluation of what works best, and therefore absolute clarity about the right of everybody in the population to be able to access a certain something. We are doing more work on that, because we recognise the importance of it. It is important—the Minister and I were discussing this—that all these things are, to a degree, flexed to local circumstance, because in some places people will be very comfortable with being close to a hospital, or adjacent to it or whatever, whereas in other areas that would not be appropriate. We are talking about a service specification and an ability to access that, rather than a place, a building or a room in a particular location, which might be quite constraining for local circumstance.
Karin Smyth: That arose in response to colleagues looking around the country. In our 10-year plan, we made a deliberate commitment to coastal and rural communities in particular, because they are underserved. It is often difficult to get people to be working, or to get services or buildings. It is absolutely important that we have the right clinical model, but, as Sarah-Jane says, we need to flex that to respond to people where they are in different parts of the community.
Q25 Lord Mohammed of Tinsley: I just want to carry on the theme that we have been talking about: your vision, your 10-year plan, and the role of ambulance services. For me, it is about priorities, targets and performance measures. Where do you see it going forward from where we have come since, say, 15 years ago? Then, it was very much turn up and very quickly transport to a hospital, whereas now a lot more time is given at the scene, and then there is a decision made on whether to take or not. How does that align with your NHS policies, priorities and target performances?
Karin Smyth: As Lord Bradley knows—it is good to see you on the screen—I was on the board of a primary care trust during the 2000s. I think targets are good and helpful. As a Government, we are very clear that that is what the public expect. They are there because they demonstrate that need to be publicly accountable, and we recognise that is also good for patient safety. I will move on. I know there is a discussion around what sort of targets people should have at different times, but we are committed to those going forward, because we think that is what the public expect, quite rightly. We are very keen to look at what works clinically in different sorts of settings at different times as well.
Sarah-Jane Marsh: I will say a few things about the suite of things that we measure, or how that might evolve. Then I can ask Fenella to talk about some of the clinical measures, because we are also obviously wanting to think about the outcomes. The Minister talked about the importance of time-based targets and the link between access, experience and outcomes for patients. These will remain a critical part of how we work with ambulance services. We have set ourselves the standard, certainly for category 2, of getting back to the constitutional standards as quickly as possible. It feels like one of the most important things to the public.
However, we also work with ambulance services, and a performance manager is held to account on a range of other indicators that describe and assess performance against some of the areas that we have talked about. These are things such as Hear and Treat, the number of patients that at first contact can be supported over the phone, or See and Treat, where patients can be supported in their own home or redirected elsewhere. This is a better outcome for those patients but also frees up resources for those who need the category 2 response. We take those very seriously as well.
I want to call out, as with all the other services across the NHS, the experience of people working in the service and the culture. We had some issues with ambulance services that were quite high profile—some cultural issues, sexual safety and so on. Therefore, we have been focused on cultural indicators as well, to make sure that the people working in ambulance services have an appropriate experience. We have talked about community response, being able to redirect into UTCs and “call before you convey” with care homes.
We need a broader set of indicators to see that the strategy in the round is effective. As we do further work on neighbourhood health and delivery of the 10-year plan, we will develop a suite of indicators that sit as part of that, within which I am sure that ambulance services will have an important part. There is a commitment to the time and to looking more broadly. I think Fenella will say a few words about what we do in terms of clinical outcomes and where we might take that in the future.
Dr Fenella Wrigley: I think we would all agree that for the patient, their relatives and the clinical staff, the time target and the patient outcome are very important. Achieving a time target but the outcome being poor for the patient is not supporting that development of improving patient outcomes. We currently report on cardiac arrests within ambulance clinical outcomes, looking at the number of patients going into cardiac arrest whose heart can be restarted. Locally, within ambulance services, it is looked at in more detail, to see how quickly the basic life support starts and how quickly a defibrillator gets there. Seven minutes, if your heart is not beating, feels like an awful long time, but what are the measures beforehand? How quickly is the phone picked up, how quickly do we give advice to the bystander and how quickly do we get a defib to them?
The Utstein comparator looks at how the outcome is significantly better if somebody witnesses the cardiac arrest and starts chest compressions. Therefore, the faster that we get there, the closer we will get to some of the international outcomes for our patients who are in cardiac arrest. What then is the 30-day outcome for patients? How many can be discharged from hospital and returned to their normal living? That is really important.
Equally, for our stroke patients, each minute means neurones in our brain that are being lost. If somebody is having a stroke and needs a clot-busting drug, how quickly we get there remains very important. However, equally important is the ongoing matter of when they arrive at hospital, how quickly the scan is done and how quickly that drug is given. For those patients who need a thrombectomy, with a little basket to remove the clot, how quickly does that happen? The brain is being harmed in each minute that we lose.
We have introduced a metric to measure elderly fallers, how quickly we get there, what we do and how we assess the elderly faller to make sure that we are not conveying people who do not need to be conveyed but, equally, that we are not inadvertently leaving people at home who are at risk of further falls. That is important.
The other measure is heart attacks. With patients who get chest pain and the ECG tracing of their heart shows that they have got an ST elevation MI, this means that they have a critical ischemia going on in one of their vessels. How quickly do we get them to a heart-attack centre so that the cardiologist can do that intervention, to open up that vessel again?
Those are all our sickest patients—and hugely important—but as we go into the 10-year plan and the neighbourhood, we need to be looking at the measures for patients in care homes and linking back in the ambulance data with the urgent and emergency care data to know that the decisions being made met the patient’s wish, but also gave the right outcome for that patient. It may well be that they were supported compassionately and with dignity in the latter days of their life or it may be that they were given antibiotics, recovered and are happily still living their life in their care home. As Sarah-Jane said, we are working towards a bigger suite of measures to be able to provide that feedback as assurance, but also to assure our clinicians that those decisions they are making are the right ones.
Lord Mohammed of Tinsley: Obviously, we have heard evidence previously. One question I asked of a panel was, if there was one thing you could ask a Minister, what would it be? They said that the feeling was that too much emphasis is given to measuring time in terms of cat 1 and cat 2 response times. I think it links into staff morale as well. I get the more serious cases, the heart attacks and strokes, but if I was in this profession, I would like to know how well that patient I looked after recovered. How can we devise a mechanism to feed that back? Ambulance staff get to A&E, and once they have discharged, they clean the ambulance, press a button, get the next job and off they go. Very rarely do they find out what happened.
Karin Smyth: I will bring in the experts on this. It is an important point. On my last outing with the service, we went from driving along the road, very calmly chatting about service with them telling me what is going on, to going to a major incident and going through. You see that. Then they are on to the next job. It is really hard work, and they see people in the worst circumstances. I absolutely take that.
This is a bigger question. As we develop into neighbourhood services generally, we will need to look at, and are looking at, different metrics. As you rightly say, for staff outcomes, morale is obviously critical, but so is public confidence. We all know that levels of public satisfaction as well as staff satisfaction are low. Thankfully, they are seeing a bit of an increase, but that is our responsibility in terms of accountability. That is why I am so firm about that metric by which we have come into office. People expect to have those constitutional standards.
We will be clinically led to look at things sensibly. The move into neighbourhoods and these different models mean that the entire pathway is different. It is good that you are looking at it. I welcome any help I can have on explaining what things mean. It is true for diagnostic centres. It is true for different ways of bringing technology closer to home and patients being at home and, as you rightly outline, in this sort of sphere as well. The team are looking very much at those, and we will as a Government work with them to see what is sensible. But we also need to have that conversation with the taxpaying British public to explain that. Things like this help with that.
Sarah-Jane Marsh: I think we are saying the same things, which is that it is a “both and”. We need to, as we move forward, have a greater focus on outcomes, but the times themselves are important to the public. They are also important to the operational response. The way that ambulance services are responding is the most real-time data that we have in the NHS. There is a central dashboard. We can see every five minutes how ambulance services are coping and how many patients are on a stack waiting for a call. This becomes particularly important in winter when we can have backlogs of patients waiting and so on. The time part of this has to be front and centre. It is a little bit the same with the four-hour target in the emergency department. It does not mean that just because someone has been seen, treated and discharged within four hours, it was the best outcome, but we know that as waiting times go out, outcomes also deteriorate. I sympathise with where we are coming from and we need to do more, but it will not be at the expense of a really tight focus on response times.
Lord Mohammed of Tinsley: Let me I be clear. It was not that they wanted time to be taken. They did not say, “Do not measure us on time”, but they also said, “Do not look just at time. Please look at the outcome”.
Karin Smyth: We agree.
Q26 Baroness Pidgeon: I wanted to pick up on something. You have talked about developing the suite of indicators that go alongside your 10-year plan, but by when are we expecting them to be published? Will you review how long each category is? You are saying that you want to stick to times—I understand that and the public understand that—but your focus is actually changing to where you are treating people. So should you not be revising that and reflecting on the right time band against which you want to measure services, deciding whether that is in A&E or the ambulance services?
Sarah-Jane Marsh: The work is ongoing at the moment. I do not know the precise date, and I would not want to give it falsely. There are a lot of working groups and a very live conversation is going on at present. That is how we measure—however you describe it—the left shift of resource or people from hospitals into the community. There are some direct measures for the way that we do that—in terms of patients who have had an admission avoidance—and then there are also more outcome-based approaches, such as asking whether we are able to look after people for a year of care in a very different way.
We have just set off on our plans for this year, 2026-27. The NHS put a series of plans together, but we did not ask it, for this year, to say how it would perform against this new suite. So we are getting something prepared so that it can be embedded into next year’s planning process.
We are doing work in the here and now around the category 2 and 3 times and precisely which patients should fit into which category. We have had a lot of focus on categories 1 and 2, but Fenella has been leading some work on category 3 patients as well. That is complementary, but it is moving forward more quickly than the broader question of how we measure whether we are effectively delivering neighbourhood health services.
Dr Fenella Wrigley: Category 2 makes up around 50% of the 999 calls. It includes everything from a patient who, as we have talked about, is ringing up with chest pain that is a heart attack—and where time is of the essence to get a good outcome when the patient gets to the definitive care—through to somebody on a warm day struggling to breathe because there is a lot of pollen outside or it is very warm on the Tube and they have not got water with them and feel a bit faint and dizzy.
At the point of the 999 call, when the non-clinical call handler is assessing that, the patient may well be struggling to breathe or be feeling faint. They may have passed out and be lying on the floor being assisted by people. So the triage system is very sensitive to pick that up—and rightly so, because if the patient is not breathing as well, we absolutely need to get the ambulance there as quickly as possible.
The work that we have done, being supported by all the ambulance services, is to differentiate within that category 2. If we put a clinical assessment on the back end of the person who is normally fit and well but has found that the pollen count is very high today, and we give them some advice, then the ambulance remains free for the patient having a heart attack. We can then give them advice about Pharmacy First or being able to use their inhaler in additional time. We could give the person who has fainted some water, keep on the phone with them as part of a clinical conversation for a few minutes, and then recategorise them to the right place. So that is the piece of work that we have been doing to make sure that the right patients are getting ambulances.
There are innovations going on around learning for our clinicians. For the patients they have attended, an app is now available in some ambulance services so they can go back in and see what happened to their patients. For example, if they took a patient to hospital because they thought they had broken their hip, they can go back in 24 hours later and see what happened. Maybe they had an X-ray and the app said they had broken their hip, they did some blood tests and they are having that mended. Alternatively, maybe they did not break their hip, which gives the clinician time to reflect on that and ask, “Could I have done something different with that patient? Could I have called out a community falls team? What could I have done?” That process enables them, because they have had direct clinical contact with that patient, to go back in and see what has happened. That then reinforces their confidence to make those, at times, quite difficult decisions.
Baroness Pidgeon: But some of your metrics will need to change as you are doing this work. Spending a bit longer so that that person does not go in an ambulance to hospital would be the right outcome for them and right for the management of your service, but it might be that it would take a little bit longer.
Karin Smyth: That goes to my earlier point. It is a dynamic system, because, as Dr Wrigley said, we have Pharmacy First and other options. Neighbourhoods will look that differently. That is why looking at the whole piece—one bit is connected to another—is an important part of what we keep trying to do.
Q27 Baroness Coffey: Minister, Dr Wrigley and Ms Marsh, you very kindly wrote to us about the warm transfer: automatically going from 111, if it says you need an ambulance, to the local ambulance trust. I did not quite understand the answer that was sent to us, but by and large it seems that an ambulance has to go. You were just talking about dispatching. In the 10-year plan, there is a reference to people phoning 111 being more likely to get an ambulance sent to them. It is perhaps less than what is there; that is going back to a paper by the Nuffield Trust in 2017. Perhaps you could explain more what the real risks are of not allowing the 999 operators to be able to undergo potentially extra very brief clinical trusts, as opposed to the algorithm that they have gone through on 111. It feels like you are more likely to get an ambulance sent to you than not if you phone 111, and that is frustrating for some of the trusts.
Dr Fenella Wrigley: As you are aware, there are two systems that can be used in England and the UK to triage 999 and 111 calls. One is an international tool called MPDS, which is a rapid triage to identify the ‘big sick’ patients, and one is NHS Pathways, which is able to quickly identify the ‘big sick’ patients but also then uses a clinical algorithm with non-clinicians—so health advisers—to take people through a reductive process to identify whether they need an ambulance or whether we can pass them into a system that does not. A huge number of patients who call 111 who are not category 1 or category 2 undergo a further clinical assessment before the patient is passed into the ambulance dispatch queue. Over 85% of patients are clinically validated that they need that ambulance, because we may end up saying to the patient, “You need an ambulance”, but a clinician talking to them is able to navigate them to a different place. A very small number of category 3 and category 4 ambulances come across from 111.
On category 2, part of the work that we did in 2017 with the ambulance response programme and looking at all of the time targets aligned as best as possible two very different triage systems. One is a clinical triage system and one is a rapid triage system to be able to identify. The category 2 patients come into the ambulance 999 stack, as you just described. Since we have been doing the work on revalidating the patients in category 2, the ambulance service clinicians in the 999 control room will be able to call those patients back and give them exactly the same service as if somebody had rung 999, not 111.
Baroness Coffey: When will that be operational from?
Dr Fenella Wrigley: It is in place, but it is dependent on the number of clinicians who are there. What we cannot do is delay a category 2 ambulance being dispatched if one is available. If somebody comes through with chest pain, we do not have enough information at that point to say that they are not having a heart attack. It is about being able to increase that number. The reason why they do not get that validation done in 111 and why they are passed through to 999 is that the patient who rang 111 instead of 999 needs equitable access to that emergency ambulance. If they are all in the stack together, the clinician can pick them out, quickly ring them back, determine that we can manage that patient with a further clinical assessment or say, “Actually no, you sound like you’ve got crushing chest pain, you’re sweaty, you feel sick, we need to get an ambulance to you”, and dispatch one to them.
Baroness Coffey: To confirm my understanding: if the 999 provider, whatever ambulance trust it is, has enough clinicians on the category 2, it could then make a change, but it depends on the number of clinicians?
Dr Fenella Wrigley: Yes.
Baroness Coffey: Do you see a difference in which trusts are brilliant at it and those which do not have quite that confidence?
Dr Fenella Wrigley: The process of doing category 2 streaming, as we call it, and segmentation—to be able to navigate and then do that clinical assessment—is new. Ambulance services are focused on building up the number of clinicians. Sarah-Jane has talked about the operating plan that each ambulance service has put in, and one of the areas is: “How many clinicians do you have in your 999 and what do you expect to be able to deliver?” It will continue to increase.
Sarah-Jane Marsh: Briefly, I understand the frustration sometimes from colleagues in other sectors because you remember the one patient who came who probably could have gone through the “triage and”, without a line of sight to the 25 or whatever who did not. That is often the feedback that we see. It can be more of an issue at night or out of hours. It is almost the Swiss cheese and where it is cut that there were not necessarily some of the community services. We still see too many frail and older people in particular brought to hospital out of hours overnight because the things that would have worked in the day were not in place. That is another area of focus. These things need to be as 24/7 as they can be.
Q28 Baroness Watkins of Tavistock: You have partly answered some of my question, but I will still read it out. We have heard how variations in the availability, accessibility and consistency of primary and urgent care services both drive demand for ambulance services and emergency departments and make finding alternative care harder for ambulance services. For example, an ambulance service told us that because it had seven different ICBs, even though it had one central commissioner, it can be a matter of a mile and a half meaning that it cannot take somebody to something. Could you therefore explain the commissioning framework for urgent and emergency care and how more accessible and consistent alternative care can be achieved between ambulance service areas?
Karin Smyth: I understand that problem. I think it was a problem in a specific area—I think it might have been Yorkshire.
Baroness Watkins of Tavistock: It was the South Western Ambulance Service.
Karin Smyth: Okay, south-west as well; I know there are couple. Boundaries are currently across my desk. It is a forever problem. ICBs understand the problem. We have had this lead commissioner policy and framework. They will continue to be responsible for that. ICBs are changing footprints. We recognise that you need expertise on some of these to make sure that that happens. That is how we are going to continue. One always strives for consistency across the country. It is a human system, based on humans talking to each other. As a former commissioner myself, I know they are human beings and do a great job in very difficult circumstances. We continue to hear that. I will let Sarah-Jane pick up on the specifics.
I understand why it is a frustration for people at the front end. I also understand, as services have come together over a larger footprint—the south-west is my own area—that it is very varied. That area covers my own city of Bristol out to rural parts of Devon and Cornwall. The ability of the lead managers to manage that and of the service to respond to that, we are very live to on that larger footprint. But we will be continuing that lead commissioner overall framework. I will let Sarah-Jane pick up on the specifics.
Sarah-Jane Marsh: Thanks, Minister. I will come at it in two ways. We have how we get as much consistency as we can in what ambulance services themselves do and try to reduce unwarranted variation. We also have to ensure that we have consistency in the alternative services, which is probably what ambulance services themselves are raising. On the consistency within ambulance services, this year we have created an ambulance commissioning framework to support all the ICBs and the lead ICB commissioners on what the building blocks of what a good ambulance service looks like and to support them in their commissioning function.
We have seen commissioning to that specification happen this year as part of the planning round. That is picking up lots of the issues that we have heard on this panel where we have good examples of practice going on in single points of access, control rooms and so on, and how we standardise that, as well as make sure we do basic productivity measures such as turnaround times on scene.
Then there is the broader question that we started to touch on around the neighbourhood health framework. We have an implementation programme looking at several sites across the country at the moment. That is essentially gathering evidence about some of the interventions or the community infrastructure that really supports that consistency, so we can increasingly start to move into the community the resources that we currently have locked in acute hospitals and so they can be accessed directly.
There is also strategic commissioning, which I am sure you have heard about in other forums, which is a really important part of that. It is basically asking how we use the resources of this population differently to provide this set of services for ambulances to then link in with. That is a big focus of this year and is in development to be a more fundamental part as we go into next year’s planning. So I am more confident that we have a clear answer to how we get the consistency in the ambulance services. Then the second part is coming as part of that broader left-shift framework.
Karin Smyth: To add to that, the thing we have not touched on is the 45-minute handover. Certainly, in my first few months in post as a way in which to go forward and seemingly a good outcome and metric, working as I went around various trusts, it is fair to say that there was a bit of pushback and people were not overly happy about that. That often happens. Part of that is for me to be consistent as a Minister in talking with chief executives and clinicians at the front end of an ED, and to the ambulance trust, to say, “Well, the evidence looks like that is working and is successful. We want to see that happening consistently across the country”. That helped with reinforcing the clinically led message that that is what we expect to see because it looks like a better outcome if it does not prove to be the case, as we said in our earlier conversation. We are content to be led by the clinical evidence and outcome to see if we need to change that. But that is an important message that the Secretary of State and I give when we make visits across the country and see things not working—or hear from the front line about what is wrong with it. That adds to that and we then take that back.
Baroness Watkins of Tavistock: How much do you think you have involved ambulance expertise and urgent care leaders in the setting of these standards?
Sarah-Jane Marsh: I am confident, in all our national work, that we absolutely do that through the national ambulance team. We work closely with the Association of Ambulance Chief Executives. We see ourselves as an extended team working together. When it comes to how involved ambulance services feel or how engaged people feel in individual places and relationships with ICBs, there is variation. We see some ambulance services embedded in those initial conversations. In some places in the country, they lead strategy and are not just not just engaged in it. That is absolutely a leading part of that. In other parts of the country, it is less consistent. It is important for ICBs as strategic commissioners to engage ambulance services as these things evolve. But from a national perspective, we would not produce any strategies or anything without working directly with colleagues who have all the front-line expertise.
Karin Smyth: Certainly from the political side, the government side, I have addressed conferences, met people regularly and absolutely recognise that it is important. As I and the Secretary of State have said, we make sure that we are out with crews but also in control rooms to talk with people and hear that directly. That is really important. As I said at a recent conference, to Sarah-Jane’s point, in some places people are leading this with phenomenal expertise in out-of-hours care. From my own experience as a commissioning manager previously and in 111, for example, this is about bringing people forward. We have new people coming into the service as well as people who are steeped in it. We want to learn from that. We do not want to top-down it. So there is an opportunity there for them to lead, particularly in neighbourhoods and in some of the expertise we are seeing at the moment.
Q29 Baroness Nichols of Selby: I think you can see that we are as passionate as you about this, because we have from the very beginning seen that there is a huge amount of work that the ambulance service can do to help the improvements in the NHS. On some of the reforms that have come through, as a public sector worker, there have been so many changes—as you well know, Minister—and they have never really been able to finish one before starting something else. However, we got evidence from people saying that they are now seeing some of those improvements come through, so it is again turning to reviews, if you like, and we have covered that quite a lot.
We are aware that there are a number of ongoing reforms, which you have talked through with us, in respect of the ambulance service and commissioning, including contract and funding reform, and scope for ambulance commissioning to transfer to various other commissioning agencies. Can you explain the Government’s work and aims in these areas? We might be looking at the commissioning to transfer it to the Office for Pan-ICB Commissioning. We have talked about that an awful lot.
Karin Smyth: Correct me if I am not on the right track. I think this is in addition to my previous comments—I think I pitched in around that sort of lead commissioner role. The allocation continues to go to ICBs on a population basis—that does not change. It is a needs-based formula. Everyone has a disagreement with formulas. We are always willing to hear people’s ideas, but that is what that is, and that comes from core ICB allocations.
One of the things that I think is generally recognised as really helpful that we have been able to do, partly from the Chancellor’s first Budget, is to be very clear on capital and revenue allocations. We have a four-year capital allocation period in which people will be able to plan more consistently about how the money comes forward. I think that is universally well recognised. You cannot now do capital to revenue transfers and then a three-year funding envelope for that revenue. We have obviously had some improvements in some of that capital spend and got it out the door very quickly because that is important for everybody. Does that answer that question? I can go into more detail on that if that is helpful.
Baroness Nichols of Selby: No, I am content with that, if others are. I suppose the follow-up question is that it has been suggested that the ambulance service would be better commissioned on a regional basis in line with the national standards and outcomes. What are your views around that?
Sarah-Jane Marsh: We are trying to strike a balance here. I understand where the question is coming from because it is important that we get national consistency. It is a national offer to the public. There is evidence about what works, and we want to see that applied consistently. That was partly the purpose behind the framework. At the same time, places around the country look very different, and inside a region things look very different. We also need there to be flexibility to be able to bespoke commissioning arrangements to a set of local circumstances. At the moment, I think we have got that balance about right. I am sure there are other ways to do it, but we have got that balance about right. We need to keep thinking about how that might evolve. Other things are changing around the way we think about commissioning for neighbourhoods and so on.
The ambulance service is clearly different from other services. We work on things such as major incident response, for example, on a national level because we need to. We do not have any immediate plans to change anything in the here and now. We think it is working well and probably better than it has done in previous years—I think that most people would agree—but we will continue to think about the question and work with the ambulance sector on what is best for it as we move forwards, and do whatever is the right thing as strategies evolve.
To my earlier point, the ICBs are now on a larger footprint with that lead commissioner and that expertise—we need to recognise that. I recognise that that sort of movement causes concern when there is that level of change, but we are keen—[Interruption.] This is a real-life emergency—
Baroness Coffey: That alarm is PMQs starting.
Karin Smyth: It is all happening; a lively end of Session. I have lost my train of thought now.
Essentially, we want to get a bit of stability into the system. Commissioners will commission, and we want to hold on to that expertise. We understand that there is variance, but there are some things that we need to hold on to. As Sarah-Jane said, that is a more settled position than perhaps it was some time ago.
Baroness Nichols of Selby: I understand the point that it is based on population, but I come from North Yorkshire, which is the largest shire county in England, and it is often very difficult because of the metropolitan areas within Yorkshire. That is where we sometimes we get that sort of conflict, and I think that is where the public need to have a better understanding.
Karin Smyth: I have visited the call centre just outside Wakefield and, having seen that geography and knowing that part of the country—although that is in south-west Yorkshire—I would take the point that every geography has its challenges. As people move around, we need to learn from that and use everything at our disposal to be able to make that work.
Q30 Baroness Shawcross-Wolfson: We have heard from the ambulance services that we have spoken to about the tools that they need to do the job better, particularly as the job is evolving, as we have discussed, to a more community-based, triage-based service that supports patients in their homes. Some things that have come up have been referenced in this session: better access to care records; access to information about local services and the ability to refer into those local services; and having the right professional expertise, whether that is the ability to prescribe or having mental health specialists available—there is quite a long list. I would be grateful to get from you a sense of what you think the priorities are for giving the ambulance services these additional tools. In terms of delivering those tools, what is your plan, and what sort of timeframe are you looking at?
Dr Fenella Wrigley: As we want to look after more patients in the community or in their own home, it is important that the ambulance service clinicians are seen as what is called a trusted assessor. You may have heard that phrase from other colleagues who have given evidence, but it means that, when they have done an assessment, they are able to refer a patient directly into, for example, a falls pathway or a community pathway to do the right thing for the patient. As an ambulance sector, we also need to be feeding back when those pathways are not available. That is not as criticism but to help, from a commissioning point of view, how we increase the times that those services are available.
For example, when the two clinicians on an ambulance team make a referral for the first time into a falls pathway, if that is not successful, then they will have reduced confidence about doing so the next time. In an emergency department, if a new resident doctor tries to refer to the medical team or surgical team and gets a little bit of pushback, they have a registrar or consultant who can support them and help push that conversation forward. Having a single point of access is absolutely critical to be able to make sure that ambulance clinicians can have that discussion. It is not about passing over responsibility; they are autonomous, highly skilled clinicians. They need to be able to say, “I am thinking about referring this patient into such-and-such, but is there anything else I should have done before I do that? How do we do that?” So that is one area.
The other area is access to notes, where seamless transfer of information is really critical. The summary care record gives us really key information in an emergency, such as who the GP is, whether there are any ongoing clinical problems and whether there are any allergies, which can be life-changing if that is not known. We need to know what the situation is for the patient right now. For example, the urgent care plan, which we talked about earlier, might say that the patient has been diagnosed with a heart problem or with cancer, and the plan is this; or, if they are a respiratory patient with worsening lung disease, for example, their normal oxygen saturations might be at a level that might look alarming to an ambulance crew who had never met the patient before, but if they can see that, actually, a level of 90% for that patient is okay, then confidence builds up. Being involved in that is really important for us.
Finally, expanding the scope of practice for our paramedics includes prescribing, enabling the training of more paramedics to go through non-medical prescribing courses, and giving them access to the support in order to complete that training. This means that although they may have a large number of drugs under Schedules 19 and 17, they are not restricted in what they can administer. They are then providing very patient-centred and individualised care for patients. Those would be the key things.
The golden thread running throughout is that the ambulance service needs to be a collaborative partner in all the discussions around the development of neighbourhoods, of the urgent emergency care reforms and of the 10-year plan. They should not be seen as vehicles but as clinicians, and as part of that community as we take things forward.
Karin Smyth: You asked about investment. We made an additional investment of £26 billion into the NHS as a result of the Chancellor’s first Budget. The taxpayer knows and understands that time and money is tight. Obviously, things have become more difficult economically since that time, especially given what is happening in Iran and so on. However, that was intended to give certainty around revenue spending and capital over a period of time. That included things such as technology and access to the tools that staff deserve in order to do the job that they are being asked to do.
To an earlier point about morale, we know that working with poor equipment, or not having the basic equipment to do the job and the transfer, as Dr Wrigley has said, is really poor for morale. We are asking them to do a lot. So certainty around planning and urgent and emergency care, as well as electives and getting down those waiting lists, are very clearly the Prime Minister’s primary target. That means that they are the Secretary of State’s and my primary target too. That is why we want to look at the whole pathway, of which this is critical, as Dr Wrigley has outlined.
Baroness Shawcross-Wolfson: That was very helpful. You gave three quite clear priorities. In terms of the timing, if we were running this session again in a year’s time, would you expect to see significant progress on all three? Would you expect to be saying that we ought not to think about this in one-year shifts but in 10-year shifts? How are you thinking about the phasing and delivery of those changes?
Dr Fenella Wrigley: We know that, in March, the frameworks for neighbourhood delivery and development were released. The ambulance service is part of that delivery. We call the single point of access and the care and community pathways “alternatives” because they are alternatives to the emergency department, but for the majority of patients they should be the first port of call rather than the emergency department.
Over the next 12 to 18 months, as neighbourhoods develop, those will progress well. We know that there are 27 sites being supported to take this forward and to deliver 12 hours a day, six days a week. That is a really good step forward, because it means that there will be consistency in pathways that people can work with together.
As the Minister said, the intelligence about what is needed comes from the front line. I was in west London yesterday and the key things that came up were patients who were at the end of their life, such as care-home patients, and patients who need a catheter changed. Why do they need to go to an emergency department to have that done? Why can we not take it to them? That is where the information comes from in order for us to have these conversations and to do that. Paramedic prescribing will take longer, but it is about doing things cohort by cohort, so that advanced and specialist practices are able to support them. They need to have training time, and they very often need to be supported with clinicians in hospitals, or in primary care, to be able to get that experience of prescribing.
Currently, around 1,600 of the 20,000 paramedics in ambulance services are prescribers. That sounds really small but, if we had been talking three years ago, it would have been a few hundred, so we are making really good progress, and it will enable them to take individualised care better. But that will be in the longer term.
Lord Mohammed of Tinsley: How many paramedics do you envisage at some point in future will be able to prescribe? You now have 1,600. Out of the 20,000, will it be 5,000 or 10,000?
Dr Fenella Wrigley: I think we will be looking at about 50% of paramedics doing some sort of specialist training, which might include prescribing. We need specialist paramedics who are able to go out and, as was talked about, assess mental health patients, assess children, become specialists in critical care for our sickest patients, and become specialists in trauma, urgent care and primary care to support the neighbourhood. The cohort where patients will benefit most is urgent and specialist care, so a percentage of that 50% will become specialists. The core job of going to emergencies and being available for major incidents absolutely remains.
Q31 Lord Faulkner of Worcester: Thank you very much for coming in this morning; it has been a really interesting session. I want to ask you about the relationship between the 111 service and 999. We have had some evidence that the efficiency of both would be improved if they were merged. Is this under active consideration in the department? Am I right in thinking that there has been a review of 111 and, if so, are you going to publish the findings?
Sarah-Jane Marsh: A review was undertaken; it was committed to in the urgent and emergency care recovery plan. I want to be clear that it was an operational review, not a strategic one. In essence, it was looking at what we could do to help 111 perform better. There are some broader strategic questions, as part of the next iteration of the urgent and emergency care strategy, which the Minister might want to say something about.
I will focus on that particular review. We work with a series of stakeholders to say, “How can we make the current 111 system better?” There were four planks of that. The first was about how we use technologies to improve efficiency and outcomes: things such as AI-driven natural language processing, which lots of call centres of course use. We have pilots going on in relation to that. There is also the link between 111 on the phone and 111 online and in the app. So there is a whole group of things that are technology-related.
The second was about the key performance indicators that we use for 111. We know, for example, how important it is that we answer the phone quickly and, if we commit to calling someone back, we make that call quickly because, if people are holding on the line and they are concerned, they are more likely to put the phone down and seek an alternative. So there are key standards around things such as call answering and callback.
The third plank was having sufficient clinical capacity: we touched on this in response to an earlier question. It is important that, if a patient can benefit from a clinical callback, there are enough clinicians as part of 111 to be able to do that in a timely way. We have seen a big improvement in that.
The fourth area is the importance of looking after the 111 workforce, which we probably do not talk as much about. We have people working in call centres and people working remotely and we need to make sure we have models that are fit for the future.
That review was adopted and shared with stakeholders and we have been working to implement it. But it was an operational review and I think the first part of your question was a bit more strategic, as in “Do we want something different from 111, moving forwards, and how does that work alongside 999?” We will keep that under review as we move forward.
Lord Faulkner of Worcester: When I was young, there was no 111; it was all 999.
Karin Smyth: Yes, I remember being a commissioner when we started the move to 111.
More broadly, I am not particularly minded at this moment to add more change to one part of the system. Obviously, the 10-year plan is the guide for how we see both provision and the commissioning landscape for the future, and there is quite a lot in there as we work through it. For me, part of this conversation—and I am genuinely happy to be corrected by the expert leading this in the field—is that that sort of rigidness, and how the public think about 999 and 111, have moved on in terms of perception, delivery and the improvements that have been made to both. As we look at the future, which is coming at us fast, in line with the 10-year plan—we talked earlier about evolving on the ground and learning from what works—we can see that, in different parts of the country, people are doing very innovative things around 111 and out of hours more generally and community. I am a big fan of what goes on in the community and the different models that I have seen and heard about from the team. We want to use the innovation on the ground and that enthusiasm for working together to produce something.
At the moment, in relation to adding something formally into that, the internal review has some clear lessons, as Sarah-Jane said. As I hope you have a sense of, as an operational management team we are very much in touch with the front line. As I said in a previous session, I have been really impressed by how the clinical and managerial leadership know and understand what goes on round the country. I test people by asking them, “What happens in X?”, because MPs stop me all the time to say, “This is happening in town or city X or Y”. I do not think I have come away from clinical colleagues or Sarah-Jane without them knowing what that is. I am not saying the problem is solved, but the awareness is there. We want to keep learning from that going forward, but I am not minded to do anything formal at the moment.
Lord Faulkner of Worcester: Are you happy with the way the private sector contractors are handling 111 in the areas where they do that?
Sarah-Jane Marsh: Again, as with everything, there is variation across the country, but some of our best and most innovative performance comes from private sector partners; in other places, the ambulance service runs it and we also get some great outcomes. As the Minister said, it is a mixed model, and we need to learn from the best. I do not think a one-size-fits-all would be sensible at this time. As with everything, we keep situations under review and think about what works best in local situations. There is obviously a big link between 111 and primary care; we are exploring the link here with ambulance services, but it is important that we also think about 111 from that perspective too.
Karin Smyth: Clearly, for strong commissioners, it is important when any provider is not performing that we are clear that that is unacceptable for the public and it is an unacceptable use of taxpayer’s money. We expect whoever is commissioning that service to do so in a very strong manner. If there is any underperformance, be that in the private or the public sector, they should take action on behalf of the public to rectify that.
Sarah-Jane Marsh: For example, I feel we should highlight the response to the meningitis B incident. When that happened in the south-east, 111 came under an enormous amount of pressure, as did 999, and our service providers down there were brilliant. It was unprecedented; it had to be a very fleet-of-foot operational response. We have got some brilliant partners across the country.
Dr Fenella Wrigley: Just to reassure you, the important thing for the patient is that, wherever they first make that first port of call, whether it is 999 or 111, if their care can be provided better at the other one, it is a seamless transfer and they do not start again from the beginning each time they make contact. In the work that Sarah-Jane has alluded to, you come in and are navigated to the right place to get the right care first time, not bounced around to find the right plan.
Lord Faulkner of Worcester: But there must be distressed callers who, having had a go at, say, 111 but do not feel they are getting the response, then dial 999 themselves. Does that create confusion in the system?
Dr Fenella Wrigley: If a caller rings 111 and they are distressed and require an ambulance, it is electronically passed straight through into the ambulance dispatch stack. If a caller is advised that they do not need an ambulance, there is a small risk that they might decide to ring 999. But actually, once they have been through the triage, with the way the systems are set up they still would be in a lower acuity and would be guided back into the right place, so far fewer bounce by making two calls than is thought. But if a patient calls because they have a problem, and if 111 with a GP is available and nurses are able to manage that remotely and quickly, they are seamlessly transferred through so that the patient gets the best experience.
The Chair: I am pleased to say that we are running nicely to time. We now have our final question, from Baroness O’Neill.
Q32 Baroness O’Neill of Bexley: You made reference earlier on to your responsibilities around major incidents, so I want to ask: how often are major incident preparedness sessions undertaken in emergency departments, and how resilient and prepared is the system?
Sarah-Jane Marsh: I will go through this methodically, because it is really important that we get this right. Ambulance trusts and NHS trusts, obviously with the emergency departments, are within our category one responders, as we said earlier. As a result, they are legally required to assess the risk of emergencies occurring; maintain, review, and exercise emergency and major incident plans; co-operate and share information with partners; and participate in multiagency planning and preparedness. That is really important. Every trust board will be considering those responsibilities and assuring itself that it executes them.
On top of that, as NHS England, we set clear expectations about what we would expect people to do in terms of the live exercise, in part of what I have just described. There should be a communications exercise at least every six months to check that all the stand-up arrangements are there so that, if a major incident is called, all the contacts, communications and things will work. I know from working in a trust myself that we would not necessarily know that was coming, but we are testing so that, when we go into action, things will be answered and responded to.
Then there should be a tabletop exercise at least once a year, getting people together to work through different scenarios with live feeds to see how they would respond and what would the gaps be. Then there should be a live exercise every three years with things that are actually acted through. These are quite complex to organise and of course they take a significant amount of people away from delivering services. We change those exercises and scenarios, so people are thinking about different areas as well.
Then there is the post-exercise analysis, so we are absolutely clear what the lessons learned from that are. It is then the job of the regional teams and ICBs to assure that that has happened within trusts. We do an annual exercise where we get everybody to sign off, which goes all the way up to the NHS England board as well. Then we do a series of national and regional preparedness exercises, which cover things such as pandemics, mass casualty incidents, cyber disruption—which is increasingly a risk that we have to manage at present—infrastructure failure and overseas casualty reception. Those are just a handful of things that we have been doing over the last year or so. There was a big cross-government exercise, Pegasus, which the NHS played a full role in as well. There is a legal requirement to take this area responsibly. We have oversight of that from NHS England, and we participate in that exercising as well.
It is fair to say that the nature of those different risks is changing. This is something we keep thinking through, as well as how it changes at a particular point in time. Cyber, as we have described, is something we have needed to deal with. In some of those incidents, we end up losing access to records, for example, and there is not always a paper back-up. That is also a really important thing that we exercise through.
There is always a balance between delivering services and preparing, but this is something that services take really seriously, and there is an annual cycle of exercising of different dangers.
Baroness O’Neill of Bexley: Do you involve all partners in that?
Sarah-Jane Marsh: Yes.
Baroness O’Neill of Bexley: Just thinking back to our earlier conversation, would you include social care people?
Sarah-Jane Marsh: Yes, 100%—in some of the NHS-led exercises, and in multiagency exercises as well, our social care colleagues would absolutely be there. Exercise Pegasus is a really good example of where social care was absolutely front and centre of the response, because we were immediately going to our learning from Covid and what we thought the key issues were in the first few weeks of that. So, yes, all partners—education and whoever else—need to be there.
Baroness Coffey: I would be really grateful for any analysis you have on the correlation and causality of the link between the number of advanced medical practitioners and See and Treat—trying to reduce the conveyance. If you have that by trust, it would be really helpful in trying to understand that. I know we are asking for a bit of information.
I want to go back to what Dr Ian Higginson talked about last week, which is discharge. He said that you can do as much as you like to stop them trying to get there, but the real problem is discharge. If you look at the NHS analysis for just last month, there are 276,512 lost bed days due to discharge delay. There are 2,591 people who are still in hospital, ready to be discharged three weeks later. There is a huge variation between council and hospital. Barking and Dagenham obviously has this out of the park; Sheffield, Reading and Gateshead are struggling. So what are you doing to try to work through and get that best practice?
By the way, I am not particularly blaming the council; it is sometimes a combination with the hospital. The data is very helpful, but trying to pull it together into analysis is quite challenging. That, for me, is trying to answer Dr Higginson’s question about how we help patients who do not need to be in hospital to get home.
Karin Smyth: Just so that you are clear—you referenced a number of places where some things are working well—it is variable and there are others available. I think I said at the beginning that it is good to focus on this part of the pathway, because it often does not get attention because of some of the changes that are happening. Sarah-Jane and I were at the other end, in the Select Committee on corridor care, so we know that this is a very pressurised service and system. The point of the urgent and emergency care pathway, and my oversight of that, is absolutely to be looking at the entire pathway. I absolutely understand, having heard this before, where others are coming from in looking at either end of the pathway, but I assure you that we are absolutely looking at the entire pathway.
I use the balloon analogy—others use others—of where the bulge comes out somewhere. We have seen a lot of that in corridor care, which is completely unacceptable. That is why we are taking action on it. But, overall, we need to help the system with the pressure that comes out wherever it comes. That is our overarching look, and that is why the pathway is so important. I am going to pass on to Sarah-Jane for the specifics of what is happening in different places.
Baroness Coffey: Just very briefly, before you move on to Sarah-Jane, I have a supplementary point. The 2022 Health and Care Act introduced discharge to assess. It would be useful to see, perhaps in your answer or a written follow-up, who is doing that really well and where it is perhaps not quite working as hoped.
Karin Smyth: We can do that.
Sarah-Jane Marsh: Obviously I work closely with Dr Higginson—and we agree on some topics and not others. I do think that there is a big link between some of these discharge delays and the admissions and avoidance we talked about. That is not necessarily the low acuity patients who could have gone to a UTC, but some older people who can often stay in hospital for multiple weeks and who could have been supported. Nevertheless, I totally agree that there are issues with discharge.
We think about them in two broad groups, as was alluded to. There are the ones who are within the hospital’s control. They are the majority; some 86% of people leave hospital without any support package at all. It is about being able to do that in a timely way, as early in the day as possible, and about getting people’s drugs and transport—all those things—ready. Then there is the other group of patients who need community support in their own home, in nursing homes et cetera. So there are a few different things. The data itself is a really powerful tool, and we have moved on quite a bit with that. We have the discharge-ready date, so we can see the length of the delay. It is about not just who is delayed but whether that goes beyond 48 hours, 72 hours and so on.
We use two main tools to help and support. Our getting it right first time—GIRFT—team works really closely with the organisations where the in-hospital part of that is an outlier or an issue that is causing patients to be in corridors. It is active in around 30 trusts in the country at the moment, and we are starting to see some really good results from that. We need to do more of that. That is about making sure that patients are reviewed inside the hospital, often in a timely way, and that decisions are made and care moves forward.
We have a discharge support group with colleagues from adult social care and the NHS working together, looking at where the relationships between the NHS and the councils are not doing some of the best practice that has been described. Again, we see huge amounts of variation. We published a document called Model Emergency Department a few months back, capturing what best practice in an emergency department looked like. We are currently midway through a model discharge document for exactly the same reason: to capture exactly what the best practice looks like on all parts of the pathway, and then how we use the data most effectively to see that those things are improving. That was one of the commitments that we made to colleagues in the Royal College of Emergency Medicine when we did the model ED: we absolutely understand that we will not solve all the problems at the front door unless we also have a real eye on the problems inside the hospital and with discharge.
The Chair: I am conscious that we are almost at the end, but we have one final question from Baroness Watkins.
Q33 Baroness Watkins of Tavistock: I want to come back to your description of the preparation for major incidents, which was really clear. But the narrative we have had is that we are not convinced that everybody has done their three-year live exercise. That is particularly because Covid quite naturally interrupted some of that. Can you assure us in writing that that is actually happening?
Sarah-Jane Marsh: We got the assurance returns back from the NHS, so we will interrogate those and give you a clear number of trusts that have made the commitment. Equally, we will say whether they have a date this year so that we know whether they are in catch-up and whether there is anything outstanding.
The Chair: Thank you so much for your time today. That was a really successful session, with lots of insightful information. We will send you a copy of the transcript. If there are any amendments to that, please get back in touch with us.
