Trust chief executives in England have until March 2018 to bring A&E performance up to the required target of seeing 95% of patients within four hours.
It’s a tall order given the parlous state of the system, where ambulances are turned away from A&E departments and surgeons are left "twiddling their thumbs" because delayed discharges mean there are no beds for patients after surgery.
The Spring Budget committed £2 billion to social services to ease pressure on the NHS and £100 million to set up GP triage units in A&E. But critics, who say the extra cash smacks of gates closing on empty stables, have also asked where staff will be found for these new triage centres. Then there is the problem according to the Royal College of Emergency Medicine (RCEM) of a shortfall of some 2,200 emergency care consultants.
Western Sussex Hospitals NHS Trust is regularly hitting the 95% target and has done so by radically redesigning emergency care by creating the 67-bed Worthing Hospital Emergency Floor (EF).
The EF cost £6.5 million and was developed in partnership with the Royal College of Physicians (RCP) whose Future Hospital Commission report , written in 2013, concludes that care should come to patients, but also found it is not unusual for patients – particularly older people – to move beds several times during a single hospital stay.
RCP Fellow Dr Roger Duckitt, a consultant physician in acute medicine at the Trust, leads the EF project. He explains just how different it is: “The EF is an acute medical unit, combined with an acute frailty unit, combined with an acute surgical unit. Its function is to accept patients from A&E and from GPs, who have been referred into secondary care for further assessment, diagnosis and treatment. It embraces many of the principles of acute medicine, including looking for alternatives to admission, development of ambulatory pathways and early senior input into the decision-making process.”
To that end, the EF focuses care around the patient, who will receive treatment led by one consultant, from a multi-disciplinary team, in a single setting. It is designed so patients benefit from the expertise of medical doctors, surgeons, social work and elderly care specialists working together who previously operated in different departments.
The aim is to provide better, faster and safer care to help reduce hospital stays. It is hoped that most people should be discharged in less than 72 hours. Indeed, a significant proportion will be admitted and treated without the need for an overnight stay in the custom-designed Ambulatory Care Area (ACA).
Duckitt says the impact of the EF on surgery was “phenomenal”. “After opening in December 2014, our first look at the data in May 2015 showed a 28% increase in the number of surgical patients going home within one day, and a 22% reduction in surgical admissions. This was largely achieved by seeing most surgical patients in the ACA but there was also a 9% reduction in the number of patients referred to surgery who then breached in A&E.
“Overall, we were able to support the flow of patients out of the A&E department, and since opening, our A&E department has been much more able to manage the rising number of attendances – and Western sits in the top 10 A&E's for four-hour performance.”
Duckitt says feedback from patients has been “overwhelmingly positive” with few significant incidents. But the “million-dollar question” is, can the EF be replicated across the NHS? “I believe that it is worth exploring. There are over 190 Acute Trusts. The Society for Acute Medicine Benchmarking Audit 2016 identified that Western is the only one with all three streams of adult admissions (med/surg/elderly) coming into a single combined unit.
Anne Crofts, Partner at DAC Beachcroft, says the EF at Western Sussex Hospitals NHS Trust is a great example of how designing services around the patient can create efficiencies throughout the system. “We know that elderly frail patients are some of the most likely to enter through A&E and some of the least likely to be discharged quickly for all sorts of reasons. Bringing the right expertise to the patient in a focussed team rather than expecting the patient to navigate through the system has the clear potential to free up time and resources and lead to better outcomes,” she adds.
As the Spring Budget announced a cash boost, new figures revealed that A&E performance against the four-hour target was just 85.1% – the worst since monthly reporting began in 2010.
RCEM President Dr Taj Hassan, called the figures "deeply worrying". But he was encouraged by the new cash as a sign of intent "to begin fixing some of the problems".
He is in favour of primary care services co-located around the emergency departments rather than having a GP triage patients in an Emergency Department (ED).
“As such, this scheme should be the first step towards co-locating more services, including frailty teams and out-of-hours mental health, around the ED. By creating a hub of services, patients can be swiftly directed to the treatment or service most appropriate for their needs, without the need to travel elsewhere or book another appointment."
The College estimates that some 15-20% of patients could be better treated elsewhere. “While GP streaming works well, and is cost effective in bigger systems, this is not necessarily the case in medium and smaller departments,” he says.
In general, Hassan says tackling the A&E crisis requires more acute care beds and a push to reduce the shortfall of 2,200 emergency medicine consultants.
“The College is working with NHS Improvement to develop a funded programme that will focus on expanding and supporting the emergency workforce, and establishing a more cohesive clinical operating model to support the system through the next year.”
Dr Hassan ends unequivocally: “Stakeholders are working closely together to make the best of a bad situation, it is clear that a lot more will be required if our departments are to meet and maintain performance of 95% again by March 2018. Only then will we begin to get back to the exemplary levels of safety and quality of service our patients deserve.”