Committee of Public Accounts


Press Notice No. 16 of Session 2005-06, dated 30 March 2005


SIXTEENTH REPORT: DEPARTMENT OF HEALTH: IMPROVING EMERGENCY CARE IN ENGLAND (HC 445)

Mr Edward Leigh MP, Chairman of the Committee of Public Accounts, said today:

"I welcome the Department of Health's emphasis on providing innovative emergency care services, such as Walk-In Centres, which are convenient for patients. But these new services are not taking the pressure off traditional A&E services, the demand for which continues to grow. There has been intense effort by NHS trusts, under the management of the Department, to meet the four hour target and patient waiting times in general have been reduced. But the picture is less rosy than it seems. Shortages of specialist staff mean that key patient groups, such as older people and patients with mental health problems, are still waiting the longest. And recent evidence from the British Medical Association suggests that the push to meet the target might be at the expense of undue pressure on staff, with an associated risk to patient care.

"Bottlenecks in the wider hospital system are still delaying A&E patients who need to be admitted. We must have fewer old fashioned practices, such as inefficient bed management and traditional staff schedules built around the convenience of consultants. There must also be more integrated working between A&E departments and the other providers of emergency care so that the needs of patients are fully met."

Mr Leigh was speaking as the Committee published its 16th Report of this Session, which examined demand for emergency care, timely treatment for patients and integration of services.

On an average day in the National Health Service (NHS) 34,700 people attend an accident and emergency (A&E) department, 11,700 need urgent transport to hospital by ambulance and over one million people contact their general practitioner (GP). These requests for emergency care take place against a background of four access targets outlined in The NHS Plan in 2000. The Department of Health produced a detailed strategy, Reforming Emergency Care in 2001, which set the targets in the broader context of increased capacity, reduced fragmentation, wider access and consistency of emergency services, as well as new professional roles and ways of working.

The Committee found that demand for emergency care continues to grow and the Department has focused on providing services for the convenience of the patient. It has brought in a range of new open-access minor injury and illness services, of which Walk-in-Centres have the highest profile and there are therefore a number of ways in which patients can access emergency care. These alternative services have been positively received by patients but they are mainly addressing previously unmet demand rather than taking pressure off existing A&E services and the relative cost effectiveness of all emergency care providers has not been established.

Patients identified a reduction in waiting time in A&E as the improvement they would most like to see, and the Department has been pro-actively managing NHS trust performance to ensure that, by December 2004, no one will spend longer than four hours in A&E before being discharged or admitted to hospital, unless clinically appropriate. It has used a combination of programmes to help trusts identify and implement changes, such as the Emergency Services Collaborative and the Improvement Partnership for Hospitals, together with financial incentives to drive improvements. As a result significant and sustained progress has been made towards the target, and published performance data for July-September 2004 showed on average 95.9% of patients across all acute and primary care trusts in England spent less than four hours in A&E. However, a number of trusts still have some way to go since only around 70 trusts had consistently achieved the weekly mark of 98%. From April 2005, the four-hour maximum total time in A&E will no longer be a national target but will be part of the framework of health and social care performance standards which will be assessed by the Healthcare Commission.

Some patient groups are much less likely to be seen within four hours. Avoidable peaks and troughs in the availability of beds, waiting for specialist opinion and lack of access to diagnostic services still cause delay. Undue focus on meeting the target could mean less attention is paid to the timely completion of treatment for patients, and a full range of formal measures of quality of care or care pathways provided in A&E departments has yet to be put in place. Obtaining sufficient suitably qualified and experienced healthcare professionals remains a problem and there is no accepted model for staffing A&E departments.

The modernisation of emergency care requires the redesign of work systems around patients' needs. There are some good examples of collaborative projects, but NHS trust chief executives believe there is the potential to improve joint working. As a means of securing the necessary integration of services, Emergency Care Networks (cross-organisation and multi-disciplinary groups to lead on local emergency care delivery) are a promising development. Nevertheless, many networks are still in their infancy and lack the authority and funding to bring about co-operation across the various emergency care providers. Emergency Care and Emergency Nurse Practitioner roles have been created to diagnose, treat and discharge patients with minor illnesses and injuries, but there is no national competency framework or standard curriculum.


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