Rescue boards are set up in England to deal with “significant deterioration” in A&E departments

BMJ 2013; 346 doi: (Published 10 May 2013) Cite this as: BMJ 2013;346:f3065
  1. Matthew Limb
  1. 1London

NHS England has announced steps to tackle rising pressure on hospitals’ accident and emergency departments that has sparked anxiety among regulators and ministers.

It has set up a national support plan with Monitor, the economic regulator of the NHS, and the NHS Trust Development Authority, which provides support and leadership to NHS trusts. The plan requires local urgent care boards to be formed to ensure that “recovery and improvement plans” are in place for each hospital accident and emergency department by 31 May.

The boards, led by NHS England area teams, will work with clinical commissioning groups, hospitals, and local authorities to meet demand, fix problems, and improve performance against national targets. They will also examine the quality of ambulance services, the NHS 111 urgent helpline service, and out of hours services and the effectiveness of primary and community care services.

NHS England said on 9 May that the performance of hospital emergency departments had “deteriorated significantly” over the past six months.

In the final quarter of 2011-12 a total of 47 of 152 providers (31%) failed to meet the 95% target for patients arriving at emergency departments to be seen and discharged or admitted within four hours. In the final quarter of 2012-13 this proportion had doubled to 94 of 148 (64%).

NHS England said that long waiting times in emergency departments not only delivered poor quality in terms of patient experience but also “compromised patient safety and reduced clinical effectiveness.” It said that increased numbers of acute admissions were putting pressure on beds. Several factors were at work, and another review would take place to examine the causes in more detail, it said.

There was a “general consensus,” NHS England said, that patients were “presenting more ill and hence more likely to need admission and have longer stays.”

The College of Emergency Medicine welcomed the announcement of a support plan but said it needed to study the proposals. A college spokesperson said, “The concept of creating urgent care boards which oversee the whole care pathway is welcomed as this is a whole system problem. Our fellows and members will look forward to being involved in this.”

The plan emerged a day after David Prior, the newly installed chairman of England’s hospital and care services watchdog the Care Quality Commission, disclosed his worries to a conference on integrated care held by the health think tank the King’s Fund in London on 8 May.

He said that emergency department admissions were “out of control” in large parts of the country. More had to be done through better funded and coordinated approaches in the community, he said, to prevent patients, including large numbers of elderly people, having to be admitted as emergency cases.

Prior said that primary care in particular was in “bad shape” and suggested that GPs should not have been allowed to opt out of their responsibility to provide out of hours care.

He said, “If we don’t start closing acute beds, the system will fall over.” He said that a fragmented health and social care system and financial incentives that were “all wrong” mitigated against achieving the integrated approach that could improve the quality of care for people with long term conditions.

David Oliver, a King’s Fund visiting fellow and former national clinical director for older people, told the same integrated care summit that frail elderly people were poorly served by current services: they needed better diagnosis, proper treatment plans, more rehabilitation beds, and to be more fully involved in their care.

Describing what he said was the “existential challenge” for health bodies, he asked, “How do you take capacity out of hospital provision when people are still piling in through the doors?”

NHS England said that local recovery and improvement plans should consider, among other things, strengthening GPs’ out of hours care and primary and community care for frail and elderly patients and measures to support care homes to avoid emergency admissions.

The care services minister, Norman Lamb, told the King’s Fund conference that the government would be publishing a new “framework” document next week to support integrated care and would ensure that it became normal and widespread practice. He gave few details but said that it would include support for “pioneer” communities to develop new care models and advice to organisations on overcoming barriers to more coordinated working, on pooling budgets, and on establishing partnership agreements.

He said that out of hours care was variable, was too often inadequate, and forced people to seek emergency treatment.

Prior said that the Care Quality Commission would reinforce efforts to develop integrated care and would “always be on the side of people who use services.”


Cite this as: BMJ 2013;346:f3065