Non-hospital care seen as key to easing demands on emergency services

NHS Long Term Plan pledges investment in fully-integrated community care, but doubts over its implementation remain

NHS Long Term Plan pledges investment in fully-integrated community care, but doubts over its implementation remain

Picture: iStock

The NHS Long Term Plan is full of praise for emergency care. It says it is to the credit of staff that they have been able to cope with the rising number of patients in the way they have.


more patients a month treated by the emergency department within four hours than five years ago

Source: NHS Long Term Plan

The number of people being successfully treated within four hours is 100,000 a month higher than it was five years ago.

But performance against the four-hour target, which measures the proportion not the total number, has dropped.

The plan says this shows that change is needed – that emergency care requires help from the wider system if it is to keep pace with demand.

Fully integrated community-based healthcare

The government proposes to do this by spending more on non-hospital care. The plan offers a ‘guarantee’ that investment in primary, community and mental health will rise at a faster rate to create fully integrated community-based healthcare ‘for the first time since the NHS was created’.

The logic is that by investing in community services, demand on emergency departments (EDs) can be curbed.

The plan makes clear that the work already done through the vanguards and integrated care systems shows this can be achieved.

‘District nursing and other community services have not trained sufficient staff to replace an ageing workforce and support increased demand’

Amanda Cheesley, RCN professional lead for long-term conditions

While emergency admissions per head are up 6.9% in the rest of the NHS, in those that have pioneered new ways of working they have been limited to 1.6%.

£6.9 billion

of the extra £20 billion the NHS will receive by 2023 is allocated for community care

Source: NHS Long Term Plan

The plan says that in the future there will be primary care networks aligned to geographies covering populations of between 30,000 and 50,000.

Multidisciplinary neighbourhood teams will be set up with a range of staff including district nurses, GPs, social care staff, pharmacists, community geriatricians and physios.

Speedy discharge

These teams will be tasked with reducing emergency admissions, supporting care homes, promoting independence and helping towards speedy discharge.

Amanda Cheesley: ‘We’ve been
talking about shifting care out of
hospital for years’
Picture: David Gee

Alongside this, the plan says hospitals will be further supported by the continued improvements to GP out-of-hours' services and the 111 service.

But even those involved in community care have their doubts about whether this will work.

RCN professional lead for long-term conditions Amanda Cheesley says that while the vision is right, she is concerned about delivery.

14 hours

Target hospitals have been given to put care plans in place for patients, including expected date of discharge

Source: NHS Long Term Plan

‘We’ve been talking about shifting care out of hospitals for years. District nursing and other community services have not trained sufficient staff to replace an ageing workforce and support increased demand,’ she says.

‘There are shortages with practice nurses, social care nursing staff and those working in public health, such as school nurses, too. That presents a problem,’ she adds.

Society for Acute Medicine president Nick Scriven says he does not think the plan will do much to ‘significantly ease the burden’ on hospitals and is worried about how much they are being asked to do given the funding situation.

Alongside the investment in community care, the emergency care system is being asked to embrace change.

The plan advocates same-day emergency care, with the ambition of increasing the number of admissions without an overnight stay from one fifth to one third.

The key to this, it says, will be the further development of ambulatory emergency care – one in five hospitals do not have these services.

Reducing demands on hospitals 

Health and social care partners have worked together in Doncaster to set up a rapid response intermediate care team to prevent hospital admissions.

The project has brought together a range of different teams and staff after a review concluded services were ‘complicated, difficult to navigate and inefficient’.

The multidisciplinary team includes emergency care practitioners, community nurses and therapists.

Unplanned admissions down

It was set up by the council and clinical commissioning group in early 2017 with the idea of providing short bursts of support to avoid patients needing to go to the local emergency department.

Ambulance crews and GPs refer into the service. The service sees a variety of patients, including those who have had falls, have dementia or have palliative care needs.

After it was launched, unplanned admissions for trauma and orthopaedics fell by 17% and ambulance journeys are down by 15% for the over 65s.


Assessment within 30 minutes of arrival

The provision of acute frailty services by multidisciplinary teams so that older patients can be provided with expert care, including an assessment within 30 minutes of arrival, will also be important.

Janet Youd: ‘We need to address
workforce problems too’

Meanwhile, the roll-out of 24/7 all-age psychiatric liaison services is being called for, and hospitals are expected to play their part in ensuring delayed discharges are kept to a minimum.

Patients who are admitted will be expected to have an agreed clinical care plan within 14 hours of admission – and that should include an expected date of discharge.

RCN emergency care association chair Janet Youd says she has concerns about just how much is being asked of hospitals. ‘We can’t get away from the fact hospital demand is growing all the time. We need to properly resource them – that means addressing the workforce problems too,’ says Ms Youd.

Change to four-hour ED target?

1 in 5

emergency admissions do not involve an overnight stay

Source: NHS Long Term Plan

The government says a workforce strategy – delayed from last year – will be published in the coming months.

But it is clear there may be other developments to come too. On the day of launch, NHS England chief executive Simon Stevens hinted the four-hour ED target may need to be changed, pointing out it did not differentiate between a ‘sprained finger or a heart attack’.

Ms Youd says any relaxation would be a mistake: ‘If we change it or lose it we will not necessarily have a record of the pressure in the system, and you risk people waiting for a long time. As soon as it was reduced from 98% to 95% we saw it slip down almost overnight.’

Ensuring same-day emergency care 

The ambulatory emergency care unit at Wexham Park Hospital, part of Frimley Health NHS Foundation Trust, has gone from strength-to-strength since 2014. Improvements include:

  • Gradual increase in staff numbers as the numbers cared for rose from an average of five a day to 30-35
  • Wexham Park Hospital now being open seven days a week. It has seen more than 20,000 patients since 2014
  • Wide range of different treatments for patients from tests and heart monitoring to intravenous antibiotics
  • Where appropriate, pagers are given to patients so instead of waiting in the unit for test results they can go elsewhere, such as the hospital café
  • Avoiding unnecessary admissions. Latest figures show more than nine in ten patients are discharged on the same day
  • A new, larger unit is due to open in the spring as part of a redesign of the emergency care system at the trust


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