COMMONS

No clear strategy for tackling lack of specialist A&E consultants

04 March 2014

Public Accounts Committee publishes its 46th Report on emergency admissions to hospital and chronic shortage of specialist A&E consultants.

The Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts, today said:

"Any attempt to improve emergency admissions services in the NHS is being completely stymied by the chronic shortage of specialist A&E consultants.

Nearly one fifth of consultant posts in emergency departments were either vacant or filled by locums in 2012.

There are also major problems in training enough doctors in emergency medicine. In 2012, only 18.5% of first year of higher training posts were filled.

What we found amazing is that neither the Department nor NHS England has a clear strategy to tackle the shortage of A&E consultants. 

With many hospitals struggling to fill vacant posts for A&E consultants, there is too much reliance on temporary staff to fill gaps. This is expensive and just does not offer the same quality of service.
 
Struggling hospitals, such as those placed in special measures, find it even harder to attract and retain consultants. There are currently no incentive payments to make working in these hospitals a more attractive prospect.
 
So, we raised with the Department the possibility of paying consultants more to work at struggling hospitals.
 
You could also make greater use in A&E of consultants from other departments, or mandate that all trainee consultants spend time in A&E, or make A&E positions more attractive through improved terms and conditions.

The slow introduction of round-the-clock consultant cover in hospitals – which will not be in place before the end of 2016-17 – is also having a negative impact. More people die as a result of being admitted at the weekend when fewer consultants are in A&E.
 
Changing this relies on the British Medical Association and NHS Employers negotiating a more flexible consultants’ contract, and neither the Department nor NHS England has direct control over the timescale or details of these negotiations.

Emergency admissions to hospitals have increased by 47% over the last 15 years at a time when budgets are under pressure. Bed occupancy rates across hospitals continue to rise year-on-year and the ambulance service is also under stress.

Hospitals, GPs and community health services all have a role to play in reducing emergency admissions – but financial incentives to make this happen are not in place.  Attempts to ensure patients are treated without coming to A&E are not working.

While hospitals get no money if patients are readmitted within 30 days, there are no financial incentives for community and social care services to reduce emergency admissions.

Both the Department of Health and NHS England struggled to explain to us who is ultimately accountable for the efficient delivery of local A&E services, and for intervening when there are problems.

Without clear accountability and responsibility it is much more difficult to achieve the changes needed to improve the situation."

Margaret Hodge was speaking as the Committee published its 46th Report of this Session which, on the basis of evidence from the Department of Health (the Department) and NHS England, examined emergency admissions to hospitals in England.

In 2012-13, there were 5.3 million emergency admissions to hospitals, an increase of 47% over the last 15 years. Two thirds of hospital beds are occupied by people admitted as emergencies and the cost is approximately £12.5 billion. NHS trusts and NHS foundation trusts, primary, community and social care and ambulance services work together to deliver urgent care services. Since April 2013, A&E services have been commissioned by clinical commissioning groups, which are overseen by NHS England. However, it is the Department of Health (the Department) that is ultimately responsible for securing value for money for this spending.
 
It is not clear who is accountable for the performance of local urgent and emergency care systems, and for intervening when local provision is not working effectively. The Department accepts that it has overall responsibility for the urgent and emergency care system. But it discharges its duties through arms-length bodies, and both the Department and NHS England struggled to explain to us who is ultimately accountable for the efficient delivery of local A&E services and for intervening when there are problems. Delivery is fragmented, and the health sector does not consistently work together in a cohesive way to secure savings, better value and a better service for patients. Urgent care working groups, which have been established to create better integration, have no powers and are overly reliant on the good will of all those involved. A tripartite group, accountable to the Department and comprising NHS England, Monitor and the Trust Development Authority, is intended to oversee the performance of aspects of the urgent and emergency care system, including urgent care working groups. However, it is unclear under what circumstances the tripartite group would intervene at a local level.

Recommendation: In response to this report, we expect the Department to: Confirm that it is responsible for the overall performance of urgent and emergency care; and Set out how it will challenge local performance, step in when this performance is substandard and enforce beneficial local changes to save money and provide a better service when local agreement cannot be reached.

Financial incentives across the system are not aligned, which undermines the coordination of care across the system. All parts of the health system have a role to play in reducing emergency admissions, including providers of social, community, primary and secondary care. However the financial incentives to limit A&E admissions are not working across the whole system. Hospitals get no money if patients are readmitted within 30 days and a reduced rate if they admit patients above an agreed limit, but there are no financial incentives for community and social care services to reduce emergency admissions. A new ‘year of care’ funding model is being piloted that aims to promote the integration of services for patients with long-term conditions by providing funding per head of population for the totality of their care, both in and out of hospital. From April 2015, the £3.8 billion Better Care Fund is intended to ensure better integration between health and social care. However, £2 billion of this funding will have to come from additional NHS savings, mainly in the acute sector, on top of the 4% savings the NHS already needs to make in 2015-16.

Recommendation: The Department, NHS England and Monitor should review the overall system for funding urgent and emergency care, including the impact of the ‘year of care’ funding, to ensure that incentives for all organisations are coherent and aligned.

Neither the Department nor NHS England has a clear strategy for tackling the chronic shortage of A&E consultants. Many hospitals, and especially those facing the greatest challenges, struggle to fill vacant posts for A&E consultants. There is too great a reliance on temporary staff to fill gaps, which is expensive and does not offer the same quality of service. The Department told us that it was working with the College of Emergency Medicine and Health Education England to increase the supply of emergency medicine doctors. Solutions may include the greater use in A&E of consultants from other departments, mandating that all trainee consultants spend time in A&E, making A&E positions more attractive through improved terms and conditions, and providing financial incentives for consultants to work in more challenging hospitals. But we are not convinced that the Department has a clear vision of how to address either the immediate or longer term shortage of A&E consultants.

Recommendation: The Department and NHS England should urgently develop and implement a strategy which considers all available options and addresses the immediate and longer term shortages of A&E consultants. 
 
We are not convinced that additional funding from the Department to support A&E services during winter has been used to best effect. Trusts receive additional funding from the Department to support the additional workload they face in winter. The Department allocated £250 million to help 53 struggling urgent and emergency care systems prepare for winter in September 2013, and further funding of £150 million was announced in November 2013. The Department acknowledged that the allocation of this funding so close to winter was not ideal as it means that hospitals cannot plan ahead and instead resort to more expensive temporary solutions, such as engaging agency staff to meet demand. The Department plans to release the £250 million winter fund for 2014-15 in the first quarter of that year. However, the Department said it was difficult to assess where the money could best be allocated to address real need rather than rewarding failure.

Recommendation: The Department should evaluate promptly the impact of additional winter pressure money allocated for 2013-14 and the timing of when the money became available, and use this analysis to inform the early and effective allocation of this fund in 2014-15.

We welcome the proposed shift to 24/7 consultant cover in hospitals, but are concerned about the slow pace of implementation and the lack of clarity over affordability. The introduction of round-the-clock consultancy care will start with A&E services, but will not be in place before the end of 2016-17. Round-the-clock hospital services are intended to reduce weekend mortality rates and make more efficient use of NHS assets and facilities. However, its implementation will rely on the British Medical Association and NHS Employers negotiating a more flexible consultants’ contract, and neither the Department nor NHS England has direct control over the timescale or details of these negotiations. The Department and NHS England are also uncertain about the likely costs of moving to 24/7 consultant cover, which early evidence suggests could increase hospital running costs by up to 2%.

Recommendation: The Department should act with urgency to establish the costs and affordability of this measure and develop a clear implementation plan.

Commissioners and urgent care working groups lack the quality data needed to manage the emergency care system more effectively. Those who manage urgent and emergency care services need a clear understanding of demand, activity and capacity across the system. However, performance management is hampered by poor quality data. For example, the NAO reported concerns that the current measure for delayed discharges from hospitals to social care does not accurately reflect the scale of the problem, and figures for the time spent by patients in ambulances upon arrival at hospital before being handed over to A&E departments are not reported consistently. In addition, information across local urgent and emergency care services is not available in one place so that the public can easily make comparisons and hold their local organisations to account.

Recommendation: NHS England should ensure that reliable information is available across the urgent and emergency care system and that local information is published collectively in one place.

Further information:

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