AUEC0004

 

Written evidence submitted by Healthwatch England

 

 

 

Healthwatch England submission to Public Accounts Committee inquiry, Access to urgent and emergency care

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.

 

  1. 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.

 

  1. 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

  1. Over the last four 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:

 

 

  1. We also recently reviewed patient sentiment about access to all services, including UEC, as part of an (as yet unpublished) briefing for NHS England to inform the NHS 75th anniversary. This shows that 53% of all feedback shared with Healthwatch about UEC was negative in 2022-23, up from 47% negative sentiment in the pre-pandemic period in 2019-20.
     
  2. Overall, Healthwatch is observing a decline in public confidence in services and hearing more evidence of people’s problems in accessing UEC. We are calling for a longer-term ambition from the government to return to previous levels of service, especially A&E waiting times, as well as the introduction of other patient experience indicators we know are important to people. We also urge the government to finally publish its NHS workforce plan (and any associated funding increase) given its importance in underpinning all pandemic recovery plans, including that for UEC.
     
  3. How access problems are Impacting on patients
    People in England tell us they are experiencing delayed ambulance response times, long and uncomfortable waits in A&E, poor access to GPs that can drive them to turn to A&E, being unaware of alternative services like 111 First and overall decreased confidence that UEC services will be there for them when they need them most.
     
  1. Ambulance delays

Out of all UEC services, ambulance services have attracted the highest level of negative feedback (58%) heard by Healthwatch in the past 18 months. Our national poll in September 2022 showed only 38% were confident that an ambulance would turn up in a reasonable time if they called for one.
 

  1. 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)

 

  1. 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.
     
  2. A&E confidence and experience
    Our 2022 poll showed only 37% of adults thought they would be seen at A&E within a reasonable time, although confidence was much higher (68%) in the quality of care people felt they would receive at A&E.
     
  3. People have described experiences to their local Healthwatch of waiting in unclean or crowded A&E departments without access to proper food or

pain relief, lack of communication on waiting times and observing stressed and over-stretched NHS staff.

 

  1. Case study
    “While I was sitting in line, there were a lot of elderly people, small children, people with blood on their heads, there were people who vomited right in the waiting room next to me, who also sat waiting for 5-6 hours.”
    (As told to Healthwatch Greenwich)
     
  2. Case study
    “Firstly I want to say that my comments here are in no way a criticism of the staff in A&E. Every member of staff was kind, polite and professional despite working under immense pressure. The system is on its knees. Sick patients were helping others (complete strangers) to the toilet and buying cups of tea for people with no money. An elderly couple in their 80s had been there since 10am and were still there at 9pm when I left. There must have been more than a dozen ambulances waiting to discharge patients.

(As told to Healthwatch Norfolk)
 

  1. Using 111 as an alternative
    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 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 were trained to a level to deal with more patients during the first point of contact.
     
  2. Our project found people became frustrated with the service if they had to make repeated attempts to get call-handlers to accurately understand their problems, arrange swift care or join up with other UEC services:

 

  1. 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)

 

  1. 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 as 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)

 

  1. 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).

 

  1. The national poll we conducted for our 111 project found 80% of respondents were not aware that NHS 111 could reserve appointments for patients at GPs and 73% were not aware they could reserve patient time slots at A&E (a function known as NHS 111 First).
  2. This is important, as 60% of people who were previously unaware of the service told us that knowing this information made them more likely to call NHS 111 the next time they had an urgent medical problem.
  3. Those who had heard of the new appointment-booking services offered as part of NHS 111 First, were most often told about it by friends and family (21%), through TV (18%) or by call handlers once they had already called 111 (14%). This shows that word of the new service is slowly spreading.
  4. However, awareness of NHS 111 First based on posters (7%), radio (8%) and news stories (9%)) was low, suggesting that an improved media and communications strategy might encourage more people to use NHS 111 ‘first’ when seeking urgent medical care.
  5. Accessing GPs before going to A&E
    Systemic workforce shortages and pressures within primary care can leave people feeling they have no agency in getting help for urgent problems from local primary care services and are left with no choice but to go to A&E instead.
    Healthwatch Devon, Plymouth and Torbay[5] 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.

 

  1. A separate survey by Healthwatch Plymouth[6], completed by 140 people attending an urgent treatment centre in autumn 2022, showed 9% had gone because they hadn’t been able to access primary care.  Comments from people showed that many felt they were in the wrong service for their need:
    “Would have preferred to be able to see local GP rather than waiting a long time at the walk in.”
    “Would have preferred to have been seen at local GP surgery.”
    “Should have been my GP.”
    “I feel I should have been able to access a GP.”
    “Did an online request for e-consult with GP but got no reply so self-referred.”
    “Had to come in as not able to get GP appointment.”

 

  1. Over the 2022-23 Christmas period, Healthwatch was also contacted by a health professional who did everything in her power not to go to A&E when she experienced uncontrolled bleeding. She rang 111, rang her GP and spoke to a pharmacist, but repeated missed attempts to help her early left her having to go to hospital. She eventually waited for 14 hours for a hospital bed in a corridor with no curtain, bell or privacy.

 

  1. The role of the 4-hour target

 

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.

 

  1. Our 2019 submission to the government’s review of the target included findings of an online poll that showed people thought the 4-hour target was less important (81%) than:
     
  1. The national poll conducted for our 2022 report also showed 41% of people believed that A&Es rarely or never meet the 4-hour waiting time target, while 48% didn’t believe people would be assessed within 15 minutes of arrival.

 

  1. The NHSE National Review of Clinical Standards[7], 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:

 

Following this review, the government confirmed in autumn 2022 that it planned to retain the 4-hour target.

 

 

 

  1. Discussion and recommendations

 

We welcomed the government’s decision – which accepts a principle we have long called for – to start publishing data from April 2023 onwards on 12-hour waits in A&E, from a person’s time of arrival at the department rather than from the point of a doctor’s admission.
 

We also welcomed many elements of the NHSE urgent and emergency care recovery plan published in January 2023, which sets out concrete ambitions to ensure that ambulances and emergency departments see people more quickly.

 

Yet, at the same time, the national performance target against the four-hour waiting time standard was lowered from 95% to 76%. While the 4-hour target is no longer due to be phased out, the fact that it hasn't been met for so long still suggests need for greater clarity for patients on what they can expect from UEC services.

 

 

 

  1. Healthwatch England wants to see the following:

 

  1. The UEC recovery plan’s successful implementation will rely on significant improvements in the workforce to deal with the large number of vacancies and the different ways the NHS will need to work. The NHS workforce plan is still not yet published and that plan is crucial in showing the numbers of staff required to provide services and how the NHS will meet that need. As identified in the Hewitt Review[8] of integrated care systems, social care also faces severe staffing issues, and a complementary social care workforce plan is needed to ensure people can be discharged when ready from hospital and free up flow of new patients admitted from A&E.

June 2023

 


[1] What people have told us about Urgent and Emergency Care Services, Healthwatch, 2022

[2] Is NHS 111 First making a difference?, Healthwatch England, 2021

 

[3] What matters to people using A&E, Healthwatch England, 2020

[4] People’s views on A&E waiting times, Healthwatch England, 2019

[5] Emergency Department Survey Report, Healthwatch in Devon, Plymouth and Torbay, 2021

[6] Urgent Treatment Centre survey findings, Healthwatch Plymouth, 2022

[7] Clinically led review of urgent and emergency care standards: Measuring performance in a transformed system, NHS England and NHS Improvement, 2021

 

[8] The Hewitt Review, Department of Health and Social Care, 2023