Urgent care services are under major pressure. A&E waiting times reached a nine-year high at the end of last year and NHS England is set to consult NHS staff and patients on what to do about emergency and out-of-hours care following publication of the evidence base for its medical director Sir Bruce Keogh´s review in June.
Sir Bruce has already warned that because of ‘rising demand and greater costs, the urgent and emergency care system is consuming resources at a greater rate each year’.
The bald statistics show that a million more people are visiting A&E annually compared with three years ago. Last year’s harsh winter exerted additional pressure on urgent and emergency wards and the NHS missed its four-hour waiting time target from January to March.
The Commons health committee´s investigation into emergency care, published last month, has heaped pressure on the Government, with MPs saying they are not sure enough is being done to prevent the system from collapsing this coming winter.
£500m over two years
The new funding announced earlier this month – which has been sourced from NHS savings – will over the next two years be given to the minority of the 168 A&E departments in England identified as being under the most pressure. In Prime Minister David Cameron´s words, it will be targeted at ‘pinch points’ in local services.
According to a Government statement: ‘The aim is for patients to be treated promptly, with fewer delays in A&E and for other patients to get the care, prescriptions or advice they need without going to A&E.’ So, in other words, the focus will be broad.
How the extra funding could be spent
Hospitals have put forward proposals aimed at improving how their services work. These include improvements to both A&E and improvements to other services away from A&E so there are less unnecessary visits or longer stays in urgent and emergency wards.
Local initiatives could include:
* minimising A&E attendances and hospital admissions from care homes by appointing hospital specialists in charge of joining up services for the elderly
* seven-day social work, increased hours at walk-in centres, increased intermediate care beds and extension to pharmacy services to ease pressures on A&E departments
* consultant reviews of all ambulance arrivals in A&E so that a senior level decision is taken on what care is needed at the earliest opportunity.
In a separate initiative, the DH and NHS England have agreed a £3.8bn pooled fund, which will focus on joining up services, so that health and care services work more closely together, keeping people healthier and treating them closer to home. This will involve a hefty topslice of CCG budgets which could hamper their ability to realise their commissioning plans.
So will CCGs have a say in the way the extra funds are spent? Tellingly, NHS England will decide how to allocate the first £250m fund for winter 2013/14 in collaboration with Monitor, the NHS Trust Development Authority and the Association of Directors of Adult Social Services based on plans from urgent care boards around the country.
These are all national bodies. And critics are already warning that the focus may not be local enough.
Some are also warning that hospitals might not get much of the money. Instead, a lot of it will go on social care so that patients admitted via A&E can actually be discharged from hospital, unlike last winter when – as one observer put it – hospitals found they were turning into care homes.
In some areas such as Essex, the cash could go on staff – which would be welcomed by the College of Emergency Medicine and the Royal College of Nursing among others. Barking and Dagenham, Havering and Redbridge CCGs are conducting an external clinical review of A&E services at King George Hospital in Goodmayes and Queen’s Hospital in Romford, Essex because of chronic shortages of medical personnel at A&E departments.
There is also speculation that some of the money could go to primary care – perhaps on out-of-hours services which, when they turn into ‘pinch points’, can backfire on A&E. RCGP chair Professor Clare Gerada has suggested that the money would be far better spent on 3,000 extra GPs and 3,000 extra practice nurses, which she says would reduce pressure on A&E – as well as general practice.
Money for poor performance?
But apart from a potential lack of input into how the money is spent – and how it dovetails with existing CCG plans for urgent care – there is another potential problem with the handout. CCGs which have already overseen improvements in the way their local A&E departments are run are worried that their local hospitals might lose out as they are no longer seen as ‘pinch points’.
Simon Trickett, chief operating officer of South Worcestershire CCG, told the Worcester News he is concerned an upturn in performance in A&E at Worcestershire Royal Hospital could see it miss out.
He said: ’The fear for us is that in recent months Worcestershire Acute Trust has done really well and improved A&E performance substantially. We are going to be talking with the trust and making a case for Worcestershire to have some of the funding, although we do recognise that there may be a desire to target it at some of the areas of highest concern in the country.’
Sir Bruce Keogh´s review into the demands on urgent and emergency care – and how the NHS should respond – is expected to report in the autumn. NHS winter pressures normally start to build in November.