"The Committee conducted this review in the knowledge that Sir Bruce Keogh is currently conducting his own review of urgent and emergency care on behalf of NHS England. We hope that our recommendations will be reflected in his findings. We were not convinced that the plans presented to us represented an adequate response to the challenges the system faces. We were concerned that witnesses disagreed about the nature of demand for urgent and emergency care. The system is 'flying blind' without adequate information about the nature of the demand being placed upon it. NHS England needs to establish a proper information base to allow informed decisions to be made."
"Even if the information was adequate it is unclear who is responsible for using it. We were told it is the responsibility of Urgent Care Boards, but witnesses were unclear about how many UCB’s are planned, what powers they will have, and how they will relate to other commissioning bodies – particularly the recently created Health and Wellbeing Boards whose remit also covers urgent and emergency care. The Committee is mindful of pressures which will build during next winter and is concerned that current plans lack sufficient urgency. It recommends that NHS England should ensure that Urgent Care Plans are agreed for each area before 30th September 2013."
The Committee goes on to argue that there is a requirement to restructure provision of urgent and emergency care if patient need is to be met in the longer term. Stephen Dorrell said: "It is clear that the structures established 60 years ago are not appropriate for the 21st century. We need to reorganise the way in which emergency and urgent care is delivered. Enabling primary care to assume a more active role in dealing with urgent cases is an important part of this. We recommend that NHS England, as the commissioner of GP services, should actively seek innovative proposals for community based urgent care services, including improved access to step-up/step-down residential facilities. It is also clear that emergency care in acute hospitals needs to change. There is strong evidence that centralised specialist units save lives, but proposals for change must be genuinely evidence-based and reflect local needs and conditions. We know that what works well in London is not right for many parts of rural England."
Examining the daily operation of emergency departments in England, the Committee was particularly concerned at low staffing levels in emergency departments. "We think it is extraordinary that consultant coverage for a minimum of 16 hours a day during the working week is guaranteed in only 17% of designated A&E Departments. The figure is even lower at weekends and there are high vacancy rates for senior staff and consultants leading, inevitably, to high locum costs" said Mr Dorrell.
"We know that early assessment by a senior clinician can improve outcomes and accelerate a patient’s progress through hospital, but for this to happen there must be sufficient numbers of senior staff in the emergency department. We were told that many trainees rejecting emergency medicine in favour of other specialities. It is vital that Health Education England and Local Area and Training Boards address this trend and take steps to encourage young doctors to specialize in emergency medicine."
MPs also questioned the role NHS 111 will play in the emergency and urgent care system. "It is disappointing that the decision was made to launch NHS 111 when so little evidence had been gathered to support it", said Stephen Dorrell. "We are concerned that having to speak to a call-handler and going through a laborious triage process will only encourage patients to see A&E as their first port of call."
Lastly, the Committee was encouraged by the potential of the ambulance services to provide even greater care to patients. "Ambulance services should be regarded as care providers in their own right and not a service that simply readies patients for their journey to hospital. Ambulance Trusts must invest in recruiting qualified Paramedics who are able to treat patients and avoid unnecessary trips to A&E“, said Stephen Dorrell.
"The loss of almost 5,000 nursing jobs and other staff shortages mean A&Es are routinely operating below safe levels. The Government is ignoring warnings from the Francis and Keogh Reports on safe staffing levels and taking unacceptable risks with patient care. Ministers were also warned about the 111 service but ploughed on regardless. They replaced experienced nurses with call handlers and a 'computer says go to A&E' approach. Ministers like to point the finger at hospitals but it is their own incompetence which has placed this added pressure on A&Es. They must review the 111 contracts urgently and increase the number of nurses handling calls."
"David Cameron has cut social care to the bone and hospitals are dealing with the consequences. There has been a shocking 66% increase in the number of people aged over 90 going in to A&E via blue-light ambulance and older patients are waiting longer to return home because the care and support they need is not available. Warnings do not come more serious than this from the Select Committee. If Cameron fails to act quickly, patients face another winter of trolley-waits, ambulance queues and A&E in crisis."
