Sustained improvement needed to tackle pressures in unscheduled care services

12 Sep 2013 - 12:00am

Rising demand, workforce challenges and problems with patient flow through acute hospitals have combined to place significant pressure on unscheduled care services in Wales.

In recent years there has been a general deterioration in performance against key service targets, although the most recent data shows some encouraging improvements, which now need to be sustained. Those are the conclusions of a report published today by the Auditor General for Wales.

The report describes the progress that has been made since a previous Auditor General report on the same subject in 2009. It recognises the commitment shown within the NHS in Wales to improve unscheduled care services but it highlights that waiting times at hospital emergency departments have generally increased over recent years, and too many patients, in particular older people, spend longer than 12 hours in these departments. Some of the key challenges that existed in 2009 are still apparent - namely the need to develop a more holistic, joined-up approach to unscheduled care services, and the need to help patients better understand the complex array of unscheduled care services so that they access the most appropriate treatment for their needs.

Important work to better understand demand for unscheduled care services has shown a marked rise in A&E attendances for patients aged 85 and over during 2012-13. These patients typically have complex health needs that require careful assessment and often admission. However, timely admission to a ward for these and other patients is often made difficult by problems with bed availability and the speed at which specialty doctors can come to A&E to assess patients.

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Sustained improvement needed to tackle pressures in unscheduled care services

Rising demand, workforce challenges and problems with patient flow through acute hospitals have combined to place significant pressure on unscheduled care services in Wales.

In recent years there has been a general deterioration in performance against key service targets, although the most recent data shows some encouraging improvements, which now need to be sustained. Those are the conclusions of a report published today by the Auditor General for Wales.

The report describes the progress that has been made since a previous Auditor General report on the same subject in 2009. It recognises the commitment shown within the NHS in Wales to improve unscheduled care services but it highlights that waiting times at hospital emergency departments have generally increased over recent years, and too many patients, in particular older people, spend longer than 12 hours in these departments. Some of the key challenges that existed in 2009 are still apparent - namely the need to develop a more holistic, joined-up approach to unscheduled care services, and the need to help patients better understand the complex array of unscheduled care services so that they access the most appropriate treatment for their needs.

Important work to better understand demand for unscheduled care services has shown a marked rise in A&E attendances for patients aged 85 and over during 2012-13. These patients typically have complex health needs that require careful assessment and often admission. However, timely admission to a ward for these and other patients is often made difficult by problems with bed availability and the speed at which specialty doctors can come to A&E to assess patients.

At times of peak demand, problems with patient flow through the hospital result in significant pressure being placed on A&E departments, which become over-crowded, with patients facing long waits and ambulances needing to queue outside A&E departments to 'hand over' patients. Notably, performance against ambulance handover targets has worsened over time since 2009.

Workforce issues can further contribute to pressures on unscheduled care services. Like the rest of the UK, Wales has experienced problems in recruiting doctors to work in emergency medicine. No A&E departments in Wales are able to meet the College of Emergency Medicine standards for consultant presence on the 'shop floor'.
There can also be problems with the recruitment and retention of doctors to work in primary care out-of-hours services.

The report highlights opportunities to tackle the pressure on unscheduled care by better management of demand. Specific areas for attention which are highlighted include: increasing access to urgent, same-day GP appointments during core working hours; enhancing the skills of ambulance staff to allow them to treat more patients at the scene or refer them to non-emergency services; and speeding up the planned development of community-based services that offer alternatives to hospital admission.

Although health boards have begun to simplify the unscheduled care system, the public still faces a complex and confusing range of options. A Welsh Government campaign Choose Well aims to persuade the public to think carefully before going to an emergency department or dialling 999 but so far it has had only a limited impact in helping people to select the right service for their urgent care needs.

The Welsh Government plans to introduce a new 111 telephone service in 2015.
This service should help patients get the right treatment as quickly as possible and reduce demand in other unscheduled care services. However, the implementation of a 111 service in England has been problematic, and the Welsh Government will need to ensure it learns from the English experience.

NHS bodies are currently engaging in debate with the public on difficult decisions about the service reconfigurations necessary to ensure clinically safe and sustainable services. Consultation plans include proposed changes to some A&E services.
The report highlights some of the arguments in favour of change but states that hospital reconfiguration plans need to be part of a wider transformation of the whole system of unscheduled care in order to secure sustainable improvements.

There is very close monitoring of unscheduled care performance by the Welsh Government and NHS bodies, with an increasing focus on the quality and safety of services. This is encouraging, although more needs to be done to capture information on patients' experience across the totality of the unscheduled care pathway and to address the gaps that exist in key unscheduled care datasets

The most recently available data on waiting times in A&E departments and for ambulance handovers is encouraging in that it shows marked improvements since Spring 2013. It will be important that these improvements are sustained through the rest of 2013 and beyond.

The report makes a number of recommendations which include the following:

  • Continued rigorous monitoring by the Welsh Government and NHS bodies to assess the impact of service pressures on quality and safety of unscheduled care services.
  •  Obtaining more comprehensive feedback from patients on the unscheduled care experiences.
  •  Improving the datasets which are used to understand and manage demand for unscheduled care.
  •  Improving communication with the public to help them select the right unscheduled care services for their needs.
  •  Producing a detailed timeline and clear milestones for the implementation of a 111 in service in 2015.
  •  Ensuring staff in emergency departments have the correct skill base to meet the needs of the growing number of elderly people attending A&E.

The Auditor General, Huw Vaughan Thomas, said today:

'While today's report shows that the NHS in Wales is prioritising unscheduled care services, factors such as rising demand and workforce challenges have clearly put services under considerable pressure, and have contributed to continued difficulties in meeting key performance targets. The report makes several clear recommendations for all the agencies providing unscheduled care in Wales, which I hope will help the NHS build on the improvements suggested by the most recently available data.'

Notes to Editors:

  •  Unscheduled care is a term used to describe any unplanned treatment, help or advice to patients in an emergency or urgent situation. It ranges from emergency hospital treatment to help for individuals to care for themselves at home.
  • Other examples of unscheduled care services include 999 ambulance services, calling NHS Direct, or booking an urgent appointment with a GP
  •  The Wales Audit Office's mission is to promote improvement, so that people in Wales benefit from accountable, well-managed public services that offer the best possible value for money. It is also committed to identifying and spreading good practice across the Welsh public sector.