Calls for improvements in emergency care

The Healthcare Commission has called for a new drive to improve the system for delivering urgent and emergency care across England – after a comprehensive review found that gaps remain in some services, despite overall progress being achieved.

The watchdog reviewed all urgent and emergency services – including ambulance services, A&E, out of hours GP services, NHS Direct, urgent care provided by GPs, walk-in centres and minor injuries units.

A rating for each service was awarded, within 152 localities, while three themes were assessed in each PCT area: how services are accessed and delivered; how they work together to provide effective care; and how they are managed.

The commission found that the majority of services are performing well – with 60% of PCT areas scoring the top two ratings. Thirty-three percent of local areas are rated as “best” performing (50 areas) and 27% as “better” performing (41 areas). Twenty-two percent are “fair” performing (33 areas) and 18% are rated as “least well” performing (28 areas).

Urgent and emergency care services have received significant local and national attention in recent years. The Government has set a range of targets and introduced new services such as NHS Direct and NHS walk-in centres. As a result, significant improvements have been achieved, the Commission concluded.

For example, the review found that the number of people dealt with within four hours in A&E has increased from 91.2% in 2003/04 to 97.9% in 2007/08. In addition, the number of category A (immediately life threatening) ambulance responses arriving within eight minutes has increased from 74.6% in 2002/03 to 77.1% in 2007.

These improvements have been made at the same time as there has been an increase in the numbers of people using emergency services. In 2007/08, there were 19.1 million visits to A&E and urgent care centres, compared to 16.5 million visits in 2003/04.

The review also showed that it is important for PCTs and healthcare providers to work more closely together to address gaps in the system. It said that PCTs and the Government must now drive improvements through the whole system to ensure people get the right care as quickly as possible.

People in the best performing areas are more likely to get the care they need promptly and have their needs met effectively. Those in the worse performing areas tend to have weaker GP out of hours services, wait longer for care and services are less likely to meet the needs of people with disabilities or long-term conditions.

Anna Walker, the Commission’s chief executive, said: “Urgent and emergency services are to be congratulated for the work they have done to improve access to services. There have been real improvements in the number of people getting urgent care quickly. “But more could be done to get these services working together so that the right care is provided at the right time and in the right way.

“People often don’t know which services to use, and too often have to repeat their story time and again because services don’t always share information effectively. Navigating between services can be difficult and confusing for patients and this can have a real impact, especially on people with more complex needs, such as older people and people with disabilities. Integrating services across a local area will help address these challenges.”

Key findings

On access and delivery of care, the report said that access to individual urgent and emergency services is generally good, with most people able to get an ambulance in an emergency and get A&E care within the four hour maximum. However, services still fall short in some areas, often where there have not been national targets.

The review found that 97.9% of patients who visit an A&E department or urgent care centre were dealt with within the target four hours, although this varied from 100% in the best performing units to 90% in others.

In response to calls where there was an immediately life threatening situation (category A), 77% of ambulances arrived within the eight minute target. However performance varied between different areas from 61% to 94%.

For urgent but not life threatening calls (category B), in two thirds of PCT areas, fewer than 95% of these calls were reached within the 19 minute target. Although category B patients may not be in immediate danger of dying, they may still be in need of urgent medical attention or be in severe pain.

When the Commission checked on the quality of care for a particular group – such as children with a fractured limb who present to A&E – the results varied widely. In the best units 100% of children in the audit received pain relief within an hour but in the worst performing units only 20% received pain relief within the target time.

The provision of services for disabled people in A&E departments and urgent care centres was variable. For example, only 54% of units had a hearing loop in place for hearing aid users, and of these a third did not test it regularly. Forty-one percent of units produced information for patients in “easy read” formats suitable for people with a learning disability. Only 38% of units had undertaken an audit of facilities for disabled people that had involved disabled people.

In 65% of areas, out of hours GP services met the requirement that they start telephone assessments within 20 minutes of a patient’s initial contact if a patient’s needs were urgent, and within 60 minutes otherwise. In some areas, less than 80% of assessments are started within these timescales.

NHS Direct exceeded the target for starting telephone-based assessments within 20 minutes for urgent calls (priority 1) and 60 minutes for other urgent calls (priority 2) in 95% of cases. It achieved this for 98% of priority one, and 99% of priority 2 calls.

The report also found that there is great variation in how ambulances get back on the road after delivering a patient to A&E. The proportion of ambulance journeys where the ambulance was back on the road within 15 minutes varied from 95% at some A&Es to less than 10% at others. The Healthcare Commission will be working with the Department of Health, ambulance Trusts and hospital Trusts to determine the reasons for these variations.

In some areas, more needs to be done to ensure that patients do not attend A&E when other appropriate services, such as out of hours GPs, could be used. For example, in some areas over 50% of visits to A&E could be avoided if other services were used.

Only 44% of out of hours GP services had arrangements to divert calls made to GP surgeries during the out of hours period. This means that patients who need urgent care outside of normal working hours may have difficulty getting through to the correct service, which can be distressing if they are anxious about an urgent situation.

Important information on patient care is often not shared between different parts of the urgent and emergency care system. For example, only 20% of A&E departments are able to receive electronic data from ambulance services and only 30% of urgent care centres reported that all GPs in their area were able to receive electronic information about their patients. In 75% of areas, out of hours GP services had access to care plans for vulnerable people and those with long-term health conditions. These care plans are normally held by GPs and describe what action should be taken if there is an emergency and details of any medication prescribed. Systems to share care plans with ambulance services and A&Es are only in place in around 12% of areas.

Management

The Commission assessed how well services are managed by PCTs as commissioners of urgent and emergency services. Overall, 30% of PCTs performed well across the managerial aspects of the review (this includes establishing networks, planning services, monitoring performance and engaging with patients and the public), 40% scored poorly and the remainder were in between. In particular, many PCTs (74%) could be making better use of data on the performance of individual services in order to determine where further resources are required. For example, only 30% of PCTs monitored levels of patient safety incidents in A&E departments. In addition, 73% of areas had conducted public awareness campaigns to improve understanding of when to use particular services, but only 40% of these campaigns had been evaluated.

Recommendations

The Commission made seven recommendations to PCTs and Government in order to improve the way services work together. PCTs should:

• Work with patients and the public to plan and deliver services, especially for people with more complex needs.
• Have a clear plan for the delivery of integrated urgent and emergency care services across their area.
• Ensure that they make effective use of information and collect whole-system data to inform the development of services.

The commission called on service providers to:

• Fully engage with PCTs in addressing the results of this review.
• Assist in the design and collection of whole-system data.

The Government was urged to:

• Ensure the organisational stability that PCTs and providers need to effectively plan future services.
• Support the integration of services and simplify the way services are accessed, for example, through piloting of a single telephone number for urgent care services. A single telephone number has the potential to ensure fewer people attend the wrong services.
• The Government also needs to use consistent terminology to describe different types of services and make clear what each service provides. This should help patients know which particular service they should attend.
• Review urgent care targets, which at the moment only measure individual parts of the system, and support the development of a whole-system approach, which measures performance from the time a patient seeks care to the time they receive it.

The Commission will be working with those organisations in the “least well performing” areas to develop plans to improve their performance. Responding to the report, the Royal College of Nursing (RCN) issued a statement criticising the “unrealistic” four-hour waiting time target. It called for the current target of 98% to be reduced to 95%, to ensure service delivery is not “compromised”.

Dr Peter Carter, chief executive and general secretary of the RCN said: “The review highlights some gaps in the delivery of emergency care, particularly the need for further integration of primary care Trusts and healthcare providers. This can only be achieved if there is less bureaucracy, more investment in services and a commitment to recruiting and retaining staff. We know that well-staffed and properly organised acute and emergency care saves lives.”

A survey by RCN, conducted earlier this year, showed that 75% of nurses said that patients were regularly admitted to inappropriate wards just to meet the four-hour target. Fifty-nine percent felt that the responsibility to meet the target lay primarily with nursing staff, as opposed to other clinical colleagues.