Healthwatch England – Written evidence(AES0006)

Healthwatch England submission to House of Lords Public Services Committee Inquiry on Access to Emergency Services, due 26 oct

About Healthwatch

1. We are the independent statutory champion for people who use health and care services. Our job is to make sure that those who run local health and care services understand and act on what really matters to people.

2. A local Healthwatch exists in every area of England. We support them to find out what people want from health and care services and to advocate for services that work for local communities. Local Healthwatch also act as our eyes and ears on the ground, telling us what people think about local health and social care services.

3. We use the information the network shares with us and our statutory powers to ensure the voice of the public is strengthened and heard by those who design, commission, deliver and regulate health and care services.

Our work on urgent and emergency care

4. Over the last three years Healthwatch England has produced four major reports on Urgent and Emergency Care (UEC) based on the views of more than 22,000 people, including:

• Findings published in September 2022[1] of a national poll exploring confidence in UEC services and feedback from 3,000 people to local Healthwatch since the end of 2020
• Research published in February 2020[2] to inform the National Review of Clinical Standards on UEC, based on 330 A&E patient interviews in six pilot areas testing proposed new targets and analysis of 6,000 free text comments collected via the NHS ‘Friends and Family Test’
• A submission in March 2019[3] to the government’s review of the four-hour A&E target, based on a national poll and views shared by 6,500 people with local Healthwatch in the preceding two years
• Data published in March 2021[4] from national polling on views of NHS 111, plus feedback from 400 users of NHS 111 in the preceding six months shared with local Healthwatch.
   

5. This evidence is outlined in more detail below in response to the inquiry’s specific questions. But overall, Healthwatch is observing a decline in public confidence in services and hearing more evidence of people’s problems in accessing UEC.

Our response to key inquiry questions

6. Question 1. What are the main challenges facing emergency health services in the UK? How are these challenges affecting service user?

People in England tell us (as our remit covers only England, not all the UK) that they are being affected in many ways. We most recently highlighted these, in our 2022 report based on 5,000 shared views, showing that people are affected by:
 

• Delays of many hours for ambulances to arrive, sometimes for serious symptoms
• Frustration caused by lack of communication on ambulance arrival times
• Uncomfortable waits on trolleys in A&E corridors, in some case for up to 23 hours
• Waiting in unclean or crowded A&E departments without access to proper food
• Observing stressed and over-stretched NHS staff
• Decreased confidence in UEC to be seen quickly in an emergency
• Poor access to GPs, prompting people to go to A&E instead
• Being unaware of alternatives, like NHS 111 First, which can reserve urgent GP or A&E appointments for people who need to be seen.

7. Case study
   “My Mom had a fall at home. I called an ambulance and Mom was left on a cold kitchen floor for 21 hours until the ambulance came the following day. Even though I telephoned 999 five times and basically told them that I thought Mom had fractured something I was told stop ringing unless anything changed in her condition. … Mom has osteoporosis of the spine, hips and knees and I advised them of this but still she was left on the floor.”
   As told to Healthwatch Shropshire, December 2021

8. Out of all UEC, ambulance services received the highest negative feedback (58%), according to views shared with local Healthwatch between December 2020 and August 2022.
    
9. Our 2022 report also details a national poll we commissioned of over 2,000 adults, that found only 38% were confident that an ambulance would turn up in a reasonable time if they called for one and only 37% thought they would be seen at A&E within a reasonable time. Confidence was much higher (68%) in the quality of care people felt they would receive at A&E.

10.        When we explored in this poll whether people’s confidence in UEC had changed over the pandemic, most (58%) said it had, and of these, 72% said it had decreased. There were major differences between age groups in changed confidence: 90% of over-55s whose confidence had changed said it was for the worse, compared to only 60% of under-55s.  The top cause of decreased confidence in UEC was NHS stories in the media, followed by experiences of family or friends or people’s own experience of using UEC.
     
11.        People who had been admitted to hospital after seeking urgent help were more likely to say that their confidence in UEC had increased over the pandemic.

This suggests that the service is getting it right for those in greatest need, but this point is getting lost in current reporting on effectiveness of services.

12.        Question 3:  Where and when should decisions of whether someone should receive an emergency health response be made? Who should be making those decisions?
    
    Joint decision-making between clinicians and patients is the bedrock of good care, as confirmed by the duty to involve patients in the NHS Constitution[5].

13.        People tell us they want to be listened to as experts on their own health. This is particularly important when a person with an ongoing condition contacts UEC services to report a serious deterioration in their health.

14.        This does not always happen, according to our NHS 111 project that we reported on in 2021. Some people told us of frustrating or repeated attempts to get call-handlers to accurately understand their problems, arrange swift care or join up with other UEC services:

15.        Case study
    “After an extremely long conversation where I had to give so much information, I then had to go through the whole conversation again when passed on. Frustrating, upsetting and a waste of time.”
    Woman, Birmingham, aged 65-79

16.        Case study
    "I was told by 111 that they would e-mail my doctor with all the details [about severe pain symptoms] and the doctors would be in touch immediately. Waited a long as possible, maybe 20 minutes. No call, so I called my doctor. The doctor had not received an e-mail or knew anything about it. They suggested that I call 111 again. Started trying to do that, got asked all the same questions with the same responses. In the end [I] call 999, who came within minutes. … If I get to the point of needing help [again], 111 will be missed out and 999 will be my go-to service. Then I know I will get attended to sensibly and with knowledge."
    Man, Rotherham, aged 65 - 79

17.        Case study
    “I called 111 for advice …. I gave full details and thought they would be able to give guidance on the phone, but they booked me an appointment at A&E. A&E were not interested & sent me home, saying nothing to worry about. They seemed surprised 111 had sent me."
    Woman, Oxfordshire, aged 25 - 49

18.        People were more likely to rate their experience of NHS 111 as ‘very good’ (69%) if the call handler was able to confidently and quickly advise them on their health issue, according to a national poll for our 2019 NHS 111 project. Satisfaction fell to below half (42%) if the call handler advised them to go back and contact their own GP or dentist themselves. This shows the potential of NHS 111 to become a more effective part of the UEC pathway if its call handlers are trained to a level to deal with more patients during the first point of contact.
     
19.        Joint decision-making on whether people need urgent help could also be improved if barriers were removed for disabled people trying to contact services, according to a project we have been running on the impact of the NHS Accessible Information Standard (AIS).

20.        The AIS[6] was introduced in 2016 to compel services to arrange communication support to people with learning disabilities and sensory needs when contacting services, getting information or receiving treatment.

21.        We surveyed 605 people between February and May 2022, who live with needs such as hearing loss, mental health challenges and learning disabilities.

22.        Only 10% said they got the support they needed to understand healthcare information, contact services or communicate with staff. More than one in five (22%) had been refused support after requesting help and over one-quarter (27%) had not been able to contact the service.  One in 10 people said they struggled to access NHS 111 or A&E because of communication problems[7].

23.        Communication barriers are particularly frightening for seriously unwell people. A deaf couple described to the Deaf charity SignHealth (one of our AIS campaign partners) how they had had to wake their hearing child in the middle of the night to help them communicate with paramedics before they took the father away to hospital. When he had to re-attend A&E in the future, the couple paid privately for a video interpreter to ensure they had a better experience[8].
     
24.        To find out how well NHS trusts comply with the AIS, we made Freedom of Information requests between September and December 2021. Of 139 trusts who responded, only one-third (35%) said they fully complied[9]. While only a small number of ambulance services responded, their comments (unpublished to date) indicated a varied approach.

25.        Two ambulance trusts told us that while they could comply with the AIS for NHS 111 or non-urgent patient transport, they could not comply with the AIS for 999 calls at the first point of contact, without lengthening emergency call durations and increasing waiting times, due to a lack of resources. However, they did say they assessed communication needs further into the patient journey.

26.        Our evidence shows there are opportunities that can be taken to remove communication barriers to aid joint decision making on whether a person needs an emergency health response. But there are also systemic workforce shortages and pressure that remove people’s agency altogether – such as not being able to access urgent GP appointments and feeling left with no choice but to go to A&E instead. As our 2022 report highlights, Healthwatch Devon, Plymouth and Torbay found that more than half of patients at one emergency department they visited in 2021, had gone there because they couldn’t see their GP.

27.        Question 4. a) How far are the targets set for emergency health services helpful for driving good practice and processes which benefit service users?

When the four-hour A&E waiting time target was introduced in 2004 it helped to significantly reduce lengthy waits faced by many patients. But 18 years on, people feel other measures are more important.

28.        Our 2019 submission to the government’s review of the target including findings of an online poll that showed people thought the 4-hour target was less important (81%) than:
     

• High quality patient treatment (95%)
• Assessing patients quickly on arrival at A&E (95%)
• Prioritising the order of A&E patients by the urgency of their cases (94%)
• Highlighting how A&Es monitor if patients get worse while they wait (91%)
• Ensuring staff can support people while they wait, such as giving pain relief (91%)
• Giving people estimated wait times on arrival and any changes to this time (88%)
• Publicising waiting times of A&E and alternative services to help inform people’s decision to go to A&E (85%).
   

29.        Our 2022 report confirms people are concerned about their comfort, dignity and pain relief and not just the overall wait time:

Case study
“Triage service appalling. [I] was considered ill enough for admission. No bed. Treatment [was] sporadic and a total of 24 hours spent in A&E finally requesting to be allowed home as was in too much pain and discomfort to remain sitting on a hard chair any longer. Traumatic experience which was largely due to poor communication, lack of staff, poor triage system, and overcrowded accommodation. A truly shocking experience.”
Comment from woman, aged 65+ to local Healthwatch, August 2022
 

30.        A national poll conducted for our 2022 report also shows 41% of people believe that A&Es rarely or never meet the 4-hour waiting time target, while 48% don’t believe people will be assessed within 15 minutes of arrival.  Latest data[10] shows only 71% of all A&E patients were seen in 4 hours, the lowest since records began.
31.        However, the 4-hour target will remain, according to health secretary Thérèse Coffey[11], in response to a question from the shadow health secretary in the House of Commons in September 2022.

32.        Her comments came a year after the NHSE National Review of Clinical Standards[12], which was informed by Healthwatch England evidence, recommended replacing the 4-hour target with a ‘basket’ of 10 measures that could better capture people’s experiences, such as:

• Proportion of people contacting NHS 111 who receive clinical input
• Percentage of patients receiving an initial assessment within 15 minutes of arrival at A&E
• Critical time standards, such as treating people with life-threatening conditions within one hour of arrival at hospital
• Average waiting times for those sent home from A&E with less serious conditions.

33.        While we believe that the four-hour target can be a useful indicator of performance, we would support national reporting on additional measures, including some of those recommended by the clinical standards review. This would give patients a more detailed picture of what is happening at different parts of the pathway and may help rebuild public confidence that the NHS will be there for them in their hour of greatest need. As our 2022 research showed, people with direct experience of UEC had increased confidence in services.
     
34.        To date, there has been no further detail from the Department of Health and Social Care on whether the review’s recommendations will be adopted.

Our recommendations

35.        We note that there are no quick fixes to reducing delays in ambulance arrival times, handovers and admissions and improving urgent access to GPs, against a background of systemic workforce and pandemic pressures.

36.        While these fundamental issues are addressed, we urge the government to support the NHS to take immediate action to:

• improve communication to patients, such as estimated ambulance arrival times
• treat A&E patients with dignity, with access to food, water, seats, clean facilities or pain relief if needed
• comply with the AIS so disabled people can communicate urgent health needs
   

37.        We also recommend that the Department of Health and Social Care clarify how, or if, it plans to implement the Clinical Standards Review’s recommendations for a new basket of measures, possibly running alongside the existing 4-hour target for a set period.

24 October 2022