Written evidence submitted by NHS Providers
NHS Providers is the membership organisation for the NHS acute, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS foundation trusts and trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate.
NHS Providers has all trusts in England in voluntary membership, collectively accounting for £104bn of annual expenditure and employing 1.2 million staff.
As the membership organisation for trusts and foundation trusts, we welcome the committee’s focus on understanding the core constraints the whole health and care system is facing as our members work to restore core performance standards and deliver sustainable recovery.
- The winter of 2022/23 saw historically high levels of demand across the whole health and care system. This was the case across a range of services including for mental health and community but particularly evident on the urgent and emergency care pathway where performance against core operational performance standards deteriorated.
- The impact of high demand was compounded by workforce shortages and insufficient capacity and the sustained need for better capital investment in the NHS. It remains vital that government publishes a fully funded workforce plan and improves access to capital funding to address the fundamental mismatch between demand and supply in the health and care system.
- In the delivery plan for urgent and emergency care recovery, NHS England and the Department for Health and Social Care correctly identified a need to improve patient flow, reduce high bed occupancy levels and review capacity and pathways in a number of interlinked services across mental health, community, primary and social care within a health and care system, to improve operational performance.
- In setting interim recovery targets for ambulance response times and A&E waiting times, the recovery plan correctly identified that the task of recovering core waiting times would be a long-term one, taking multiple years of sustained effort from trusts and their partners in local systems.
- Trusts are delivering clear improvements and some of the transformational ambitions of the NHS Long Term Plan, by providing more ambulatory care, focusing on prevention, and delivering more acute care in community settings via ‘hospital at home’ and other interventions.
- The ambulance sector also has an important, but underutilised, role in preventing admission and reducing conveyance rates to emergency departments. Call centres already include multi disciplinary teams to ensure patients are referred to the most appropriate service to meet their needs.
The delivery plan for urgent and emergency care recovery
- We welcomed publication of NHS England and the Department for Health and Social Care’s Delivery plan for recovering urgent and emergency care services which correctly identified that poor patient flow, compounded by a lack of physical capacity and persistently high bed occupancy levels, were key contributors to deteriorating performance standards. The plan marks a positive step forward in advocating for a more holistic approach to tackling the pressures presenting on the UEC pathway within local health and care systems. However funding available to underpin the aspirations of the plan is limited.
- Given the challenges facing the health and care system, the interim recovery targets, of improving category two ambulance response times to an average of 30 minutes and ensuring 76% of people are seen within 4 hours at A&E over 2023/24, before delivering further improvements in the following year, are proportionate. However, trusts tell us that in the context of rising demand and persistent workforce shortages they will still be challenging.
- The key enabler for achieving these targets is improved patient flow, via increased capacity and new Urgent and Emergency Care pathways as well as in NHS 111, primary care, mental health and community and social care services. The aim must be to ensure patients’ needs are met in the right care setting in as timely a fashion as possible.
- Similarly, ambulance trusts have a key role in identifying, responding to and diverting demand more effectively. For example, ambulance services have increased the proportion of calls that are closed as “hear and treat” where an appropriately trained member of call centre staff triages, offers advice and information or redirects a call to alternative service. In December 2022 over 15% of calls were managed as “hear and treat” compared to 7.4% in December 2019 (NHS England 2023).
- Trusts are also working together in collaborative models, to treat more acute and long-term care needs in the home or in community settings, via virtual wards (or ‘hospital at home’) using remote monitoring technologies.
Trust led improvement and transformation
- Our recent Providers Deliver report, looked at how trusts are taking practical steps to manage demand more effectively and improve patient flow (NHS Providers 2023). The case studies included a focus on the following:
- Same Day Emergency Care (SDEC): The SDEC model is in place across the country. An effective SDEC should see a substantial proportion of emergency care delivered without an admission to hospital. Delivering more emergency care on this basis reduces demand on A&E and reduces overall bed occupancy levels.
- Virtual wards: an important tool to deliver more acute care in the community. Virtual wards can be used to both prevent admissions to hospital and support earlier discharge from hospital. We saw that effective collaboration between acute and community trusts has seen more patients receive safe and effective acute care at home, improving their health outcomes and reducing pressure on the urgent and emergency care pathway.
- Population health analytics: we also heard from one ambulance trust how using innovative population health analytical methods allowed them to identify drivers of high demand and work with their Integrated Care Board (ICB)colleagues to put in place preventative measures. This builds on previous examples of ambulance trusts using their insight and patient data to deliver more preventative care and improve health outcomes.
- The report also highlights some of the strategic, enablers of improving patient flow. These included effective leadership, a commitment to collaboration and embedding preventative approaches to demand management.
- However, these examples, and feedback from trusts, also underline the importance of action from government to improve workforce planning and address chronic workforce shortages in the NHS and social care – there are currently over 112,000 full-time equivalent vacancies across the NHS and 165,000 in social care (NHS England 2023; Skills for Care 2022). There is also an urgent need to respond to bring forward capital investment to update the NHS estate, address the £10 billion maintenance backlog and build capacity (NHS England 2022).
- While trusts can, and will, continue to innovate and deliver high-quality effective services, the public deserve and expect more timely support. Investment is needed across the country to ensure improvements are embedded. This will require capital investment and long-term workforce planning, to create the additional capacity needed to deliver the targets of the urgent and emergency care recovery plan.
- Transformation in urgent and emergency care, including delivering more acute care remotely or on an ambulatory basis is delivering real gains in terms of access to and waiting times for care.
- The last winter showed how even in the most difficult circumstances providers were able to deliver high quality, effective care. However, in the context of very high demand and strained capacity, operational performance deteriorated substantially and too often people waited too long for vital care.
- Addressing the fundamental mismatch between supply and demand for healthcare will be key to ensuring that recovery of urgent and emergency care waiting times is sustainable. As well as effective transformation of services, including delivering more care remotely, we need to see a long-term workforce plan to address the substantial workforce shortages across the NHS.
- Prevention, admission avoidance, new pathways and transformation will help reduce demand on beds, but increasing overall bed numbers is also needed to help reduce bed occupancy levels and improve patient flow.