Urgent and emergency care recovery plan - what to look out for next winter
In January 2023, the Department of Health and Social Care and NHS England recently published the Delivery Plan for Recovering Urgent and Emergency Care Services. We regularly hear from people who have had difficulties trying to access the services they need, so here’s what improvements you can expect in the next year, and what that will mean for you.
The NHS has committed to:
- Increase capacity, to help deal with increasing pressures on hospitals which see 19 in 20 beds currently occupied.
- Grow the workforce, as increasing capacity requires more staff who feel supported.
- Speed up discharge from hospitals, to help reduce the numbers of beds occupied by patients ready to be discharged.
- Expand new services in the community, as up to 20% of emergency admissions can be avoided with the right care in place.
- Help people access the right care first time, as 111 should be the first port of call and reduce the need for people to go to A&E.
The aim of the delivery plan
Two ‘ambitions’ are highlighted:
- Patients being seen more quickly in emergency departments: with the ambition to improve to 76% of patients being admitted, transferred or discharged within four hours by March 2024, with further improvement in 2024/25. (This is a reduction on the previous target which was 95% in 4 hours. The lack of a longer-term plan to return to that standard is a concern.)
- Ambulances getting to patients quicker: with improved ambulance response times for Category 2 incidents to 30 minutes on average over 2023/24, with further improvement in 2024/25 towards pre-pandemic levels.
We know that the NHS already has severe workforce shortages – the report lists vacancy rates as being 11.8% - and these ambitions will rely on an increased workforce. In the current climate where the NHS faces sustained industrial action, that is likely to be incredibly challenging.
Our view
One positive aspect of the plan is that, in the section about why a plan is needed, it includes what will be delivered for patients and the public. This includes some of the actions we have called for:
“We recognise that patients want better communication on time spent in A&E, want a better understanding of how to access the right care to avoid multiple handovers between services, and want greater continuity of care so that they do not have to repeat their story as they go through the system.”
Some elements of the plan have been challenged:
- The promise that “there will be 5,000 more staffed, sustainable beds in 2023/24” will include 4,000 temporary beds being made permanent and 1,000 new beds.
- The plan for 800 new ambulances is framed in terms of tacking issues other than handovers. As this is part of “improvement and replacement” of the fleet, it’s not entirely clear how many of these ambulances will be ‘additional’ rather than ‘new’. In response to a Freedom of Information request from the BBC, eight (out of 11) ambulance trusts reported that they were planning to order 655 replacement ambulances in the period 2023 – 25 and 51 new ones.
- The schemes to support mental health crisis response are included but these have already been announced separately recently.
Staffing
What is proposed?
The report includes an extensive section on workforce. This relies on the yet-to-be-published workplan – and doesn’t take account of the likely impact of current industrial action on staffing. The plan also has a role for volunteers.
“We also know that volunteers can play a crucial role delivering care, as seen so clearly during the COVID pandemic, and we want to further build on this in roles across health and social care.”
Volunteers have had a long history of supporting the NHS and were particularly valuable during the pandemic. The plan sees them having a role across both health and social care, particularly through the expansion of the Volunteer Responders programme.
Our view
The 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 has been delayed, 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, social care also faces severe staffing issues, and a complementary social care workforce plan is needed.
While volunteers have a role in various services, one of the criticisms of the Volunteer Responders scheme during the pandemic was that it set up something new, potentially at the expense of valuable local infrastructure. The Volunteer Responders programme has relaunched the Check-In and Chat service developed during the pandemic. Any evaluation of this programme needs to consider the impact on voluntary, community, faith and social enterprise organisations and infrastructure in local areas, including whether there are opportunities to work with them.
Alternatives to urgent and emergency care
What is proposed
The plan sets out an increase in capacity for ‘step-down’ services, which help people move from hospital to more appropriate settings for their needs and helping to reduce the pressure on hospitals. Local areas are expected to develop ‘integrated care transfer hubs’. The plan identifies core elements of the basis of an effective hub rather than setting out how they will be delivered.
The section on ‘expanding care outside hospital’ looks designed to have a significant impact, although – like so much in the plan - it is likely to be affected by workforce challenges. Care outside hospital is seen as particularly valuable in relation to falls, older people living with frailty and people experiencing a mental health crisis. The plan includes improved use of Urgent community response (UCR) teams, which operate twelve hours a day, seven days a week, with the expectation that they will reach 70% of patients within two hours. This approach is expected to lead to more referrals to community services rather than ambulances. Although £77 million is allocated for community health services, this development will still rely heavily on the workforce plan.
The plan includes the expansion of ‘virtual wards’, both in terms of capacity and use. The longer-term ambition is to reach 40 – 50 virtual wards per 100,000 people. Different areas are developing different ways of working, so there is a commitment to “a data-driven approach to peer review that supports implementation”, building on successful implementation.
The section on ‘making it easier to access the right care’ emphasises the importance of people using NHS 111. Again, the plan talks about testing different models, so we don’t yet have a clear view of what this might mean in practice. We are concerned that there doesn’t seem to be a focus on involving patients in this area of work – especially as we keep hearing about negative experiences of NHS 111. Pre-booking into A&E via 111 First was formally rolled out nationally last year, but the promised patient evaluation never materialised.
Our view
Providing alternatives to urgent and emergency care will not only help services, but in many cases enable people to maximise their independence. While the ambition is welcome, we would expect to see more detail about the implementation. The plan emphasises building on good practice where it is developed, but without a clear method of identifying and disseminating good practice. We would expect the people’s view of the service to be taken into account in deciding best practice, but that isn’t clear from the plan.
The variety of support for people with mental health issues is highlighted, but it’s unclear how well people will be informed about the options available to them.
What does the plan mean?
The plan does cover many of the issues that people are raising with us and that are regularly covered in the media: delayed discharge, ambulance response times and waits in A&E. Some parts of the plan are longer-term and people may not see improvements immediately, so it’s important that people are kept fully informed about what to expect.
We are particularly interested to hear about experiences of virtual wards. We are pushing to see an evaluation done before the roll out is stepped up ahead of next winter, so any insight would be valuable.
The plan sets out expectations, but it recognises that much of the implementation will be designed at a local level meaning that responses may vary in different areas, even if they are working to the same targets. The plan is not clear about how everyone will be involved in these changes, so we will be working locally and nationally to make sure that people and communities are properly involved. An important aspect of this will be how well any changes are communicated – for example, if you had a bad experiences of NHS 111 locally, any campaign will need to take account of that. This is an area where we can offer support to local systems.
In considering how well this plan is working, we will be interested in the local picture:
- Are targets being met?
- What has been the impact – of meeting or not meeting the target – on patient experience?
- Did in-patients have an estimated discharge date? (And what did it mean for the patient?)
