Analysis

Emergency departments one of the weakest parts of healthcare system, report finds

Care Quality Commission recently published a report presenting the weaknesses in emergency services in England.
CQC report

Rising attendances at emergency departments (EDs), lengthening waiting times and increasing numbers of admissions are well documented. So it perhaps comes as no surprise that those pressures have started to hit the quality of care EDs are able to provide in England.

Figures released by the Care Quality Commission (CQC) show urgent and emergency care is now one of the weakest parts of the healthcare system.

The regulators 2015-16 annual state of care report, presented to parliament last month, showed 57% of urgent and emergency services were rated as inadequate or requiring improvement. Medical services hampered by delayed discharges scored nearly as badly with 56% falling into these two categories.

57%

of urgent and emergency care rated as inadequate or requiring improvement

...

Rising attendances at emergency departments (EDs), lengthening waiting times and increasing numbers of admissions are well documented. So it perhaps comes as no surprise that those pressures have started to hit the quality of care EDs are able to provide in England.

CQC report
Failings in other areas of health and social care are creating pressures in emergency departments. Picture: iStock

Figures released by the Care Quality Commission (CQC) show urgent and emergency care is now one of the weakest parts of the healthcare system.

The regulator’s 2015-16 annual state of care report, presented to parliament last month, showed 57% of urgent and emergency services were rated as inadequate or requiring improvement. Medical services – hampered by delayed discharges – scored nearly as badly with 56% falling into these two categories.

57%

of urgent and emergency care rated as inadequate or requiring improvement

By comparison just 13% of GP practices were deemed not good enough and just over one quarter of social care services.

Safety – a major concern

In particular, safety in EDs was highlighted as a major concern by inspectors because of overcrowding, ambulances having to queue, delays getting patients into resuscitation bays, waits for vital equipment and poor hygiene practices.

But rather than criticise EDs, the CQC is pinning the blame on cuts to council-run social care services and taking the unprecedented step of calling on government to pump more money into the system.

Chief executive David Behan says figures show the number of people accessing social care has fallen by one quarter in the past 4 years, leaving 1 million people with care needs going without any sort of support.

He also says the squeeze on fees paid by councils to providers has started having an affect on the market with providers handing back contracts and the number of residential and nursing care beds beginning to fall.

‘The fragility of the social care market is beginning to impact on people who rely on these services and on the performance of secondary care,’ Mr Behan says. ‘We are reaching a tipping point.’

Painting a picture

The warning is particularly pertinent as this marks the first year the CQC has a fuller picture of what is going on in hospitals – the report covers the findings from 85% of all acute trusts.

But if the evidence gathered by the inspection body is not enough, the scale of the problems have been further emphasised by figures on ambulance handover times obtained by the Labour party using the Freedom of Information Act.

Handovers to ED staff are meant to take place within 15 minutes of the ambulance arriving. But data from all ten ambulance trusts in England showed the number of handovers taking longer than 30 minutes had risen by 60% in the past 2 years to nearly 413,000. Meanwhile, the number taking over an hour had nearly trebled to 76,000.

RCN professional lead for acute, emergency and critical care Anna Crossley says it has become a vicious circle whereby the pressures on EDs have resulted in units struggling to recruit staff, which in turn makes it even more difficult to keep up.

‘There is an immediate shortage of nurses and doctors in the speciality due to these pressures which is making recruitment and retention of staff a challenge,’ she says.

133

NHS trusts running 187 EDs were inspected

But can the entire blame be laid at the door of council cuts? Cliff Mann, the past president of the Royal College of Emergency Medicine, who is now working as the ED national clinical adviser for NHS England, believes not.

Dr Mann says investment in social care will only do so much. ‘Access to GPs and mental health care is also a problem and EDs are a popular brand – people will always come because they know they will get seen whatever time of day or night. We need to do much more to co-locate services at EDs.

‘We could take out 30% of patients from the system this way. That would make a huge difference.’

Linsey Sheerin, a member of the RCN’s emergency care association, agrees greater co-location of services could help.

But she says: ‘It is really a sign of the ageing population and rising demand and not enough money to go round.’

And she points out that it is not just an England-only problem. Ms Sheerin, who works at Belfast’s Royal Victoria Hospital, says pressures are being seen across the UK. ‘In Northern Ireland we have the integrated health and care model – there is one pot of money – so in theory it should work. But only three quarters of patients are seen in 4 hours. The pressures are clear for all to see.’

 

How one area is getting it right

The partnership between the NHS and care sectors in the London borough of Sutton was highlighted as an example of excellent practice by the Care Quality Commission.

Through NHS England’s vanguard programme, GPs have been employed to carry out visits to care homes with each resident now receiving 6-monthly check-ups.

District nurses work with care home staff training them in dementia, falls prevention and diabetes. Medicine reviews are also regularly carried out.

All this has helped reduce visits to EDs by 10%.

But when a resident does need to go to hospital they are sent with a red bag containing information about their health conditions, supplies of medicine and a change of clothes. Within 48 hours someone from the care home visits the individual to start planning discharge. Average length of stay has been reduced by a third to 8 days.

 

12,000 beds short

Hospitals may be 12,000 beds short of what is needed, experts are claiming.

The Nuffield Trust warning comes after it carried out a review of patient flow through hospitals.

It found that bed occupancy rates, which are now topping 90% – well above the recommended 85% level, were hampering the ability of staff to get patients through the system, causing delays in EDs.

It said the official figures were even likely to be an underestimate of the true picture because of the practice of measuring bed occupancy at midnight, particularly as there had been a 17% rise in so-called zero-day patients in the past 5 years through increased use of day surgery, short stay and admission on the day of surgery.

Coupled with the rising rates of admissions generally, this had left hospitals short of beds. There are more than 100,000 acute beds – a figure which has remained pretty stable for a number of years.

The report called on hospitals to redesign rehabilitation and discharge processes, noting that while only one in ten patients stayed in hospital for longer than a week these patients accounted for nearly two thirds of bed usage.

Nuffield Trust chief executive Nigel Edwards says: ‘Helping the longest staying patients to leave hospital sooner should be a priority, although it will be difficult with the social care system on its knees.

‘We should be realistic about what hospitals can do when they are this full, and how hard it will be to free up space again.’

 


Further information

State of Care 2015/16 (CQC report)

Understanding Patient Flow (Nuffield Trust report)


Nick Evans is a freelance journalist

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