Recommendations & Conclusions
15 items
2
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
NHS England’s improvement plans rely on better staff recruitment and retention to address significant shortfalls in the NHS workforce, but we are not convinced that NHS England’s current approach will achieve its very optimistic assumptions. NHS England has identified a potential shortfall of 260,000 to 360,000 staff by 2036–37, compared …
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NHS England’s improvement plans rely on better staff recruitment and retention to address significant shortfalls in the NHS workforce, but we are not convinced that NHS England’s current approach will achieve its very optimistic assumptions. NHS England has identified a potential shortfall of 260,000 to 360,000 staff by 2036–37, compared with a current shortfall of approximately 150,000 full-time equivalents. It intends to address this through ramping up recruitment, improving retention, and reforming work and training practices. NHS staff are currently experiencing very high levels of physical and mental ill health, particularly in the wake of the COVID-19 pandemic, with the most recent 5% sickness absence rate reported for 2022–23 above the long-term average of 4.2%. NHS England estimates that the rate of staff turnover in the health service was 9% in 2022–23. NHS England hopes to retain 130,000 staff who would otherwise leave the NHS over the next 15 years and stated this will be cost neutral. However, the realism of the assumptions underpinning this aspiration seems highly doubtful, given NHS England has identified multiple dependencies on other factors and unknowns. Recommendation 2: NHS England should write to the Committee within six months to provide an update on progress with reducing staff shortfalls and improving retention rates. This update should include details of action it has taken and an assessment of whether its original assumptions have proved accurate. 6 Access to urgent and emergency care
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Government response AI summary
The government agrees with the recommendation, highlighting the positive impact of the Exemplar programme on staff retention and outlining the NHS Long Term Workforce Plan's projections to reduce leaver rates. NHS England will also submit its full cost estimates for the plan as part of …
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HM Treasury
3
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
The quality of patients’ access to urgent and emergency care depends too much on where they live, particularly with wide variation in ambulance response times. There is significant regional variation in the performance of services for urgent and emergency care. For example, in 2021–22, average ambulance response times for the …
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The quality of patients’ access to urgent and emergency care depends too much on where they live, particularly with wide variation in ambulance response times. There is significant regional variation in the performance of services for urgent and emergency care. For example, in 2021–22, average ambulance response times for the most serious incidents varied from six minutes 51 seconds for the London ambulance service to ten minutes 20 seconds for the South-West ambulance service, and average 999 call response times ranged from 5.4 seconds for the West Midlands ambulance service to 67.4 seconds for the South-West ambulance service. The length of stay in the worst performing areas for discharging patients when they are medically fit is over double that of the best performing areas. Local management of systems and digitisation are likely to play a critical part in patients’ access to services, but one in ten trusts still lacks an electronic patient record and only four trusts have an electronic bed management system that could be described as first class. NHS England only has plans to upgrade 16 further systems, but it is working with the Department on a business case to expand this capability. NHS England has identified where there is good practice and poor performance but is weak at implementing and rolling out best practice more widely. Recommendation 3: As part of its Treasury Minute response, NHS England should clearly set out the causes of variation in performance, and the specific initiatives it takes responsibility for to bring the worst-performing organisations closer to the standards being achieved by the best.
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Government response AI summary
The government agrees and describes initiatives under the UEC recovery plan to standardise processes, increase referrals, and provide targeted support to challenged systems to reduce performance variation. NHS England commits to writing to the Committee in February 2024 to detail the underlying causes of this …
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HM Treasury
4
Recommendation
Seventy-Third Report - Access to urgent…
Accepted
Not enough is being done to tackle delayed discharges, which cause inefficiencies both within hospitals and more widely across the care system. Delays with discharging patients when they are medically fit for discharge reduces available bed capacity, which in turn slows admissions from A&E departments, which in turn slows the …
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Not enough is being done to tackle delayed discharges, which cause inefficiencies both within hospitals and more widely across the care system. Delays with discharging patients when they are medically fit for discharge reduces available bed capacity, which in turn slows admissions from A&E departments, which in turn slows the rate at which ambulances can hand over new patients, which then reduces ambulance capacity and therefore the timeliness of ambulance responses. More patients are remaining in hospital when they no longer need to do so. In Q4 of 2022– 23, there was an increase of 12% in patients remaining in hospital despite no longer needing to, compared with the same period in 2021–22. Each unnecessary delay is a bed that cannot be released for a new patient. While a proportion of delayed discharges can be attributed to problems discharging older patients from hospital into adult social care, NHS England acknowledges that the challenge does not lie entirely in social care and more work was needed in the hospital sector. Recommendation 4: As part of its Treasury Minute response, the Department should set out what it is doing to address delayed discharges caused by constraints within hospitals, problems in NHS community services, and shortfalls in social care.
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Government response AI summary
The government agrees and states the recommendation is implemented, detailing an investment of an additional £1.6 billion by 2025 and outlining a wide programme of measures from the Urgent and Emergency Care recovery plan to tackle delayed discharges, including new care transfer hubs and improved …
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HM Treasury
1
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department) and NHS England about access to unplanned or urgent care.1
Government response AI summary
The government agrees and outlines a comprehensive plan to improve patient flow and urgent care, including boosting bed capacity, implementing digital tools, increasing paramedic numbers, and introducing care transfer hubs and discharge funding through the Urgent and Emergency Care recovery plan.
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HM Treasury
7
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
The pandemic has also had an impact on NHS staff absence rates. NHS England pointed to mental health conditions and anxiety, musculoskeletal conditions and respiratory conditions that were affecting NHS staff.14 We asked whether NHS England has a percentage measure to assess how far staff sickness impacts on NHS productivity, …
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The pandemic has also had an impact on NHS staff absence rates. NHS England pointed to mental health conditions and anxiety, musculoskeletal conditions and respiratory conditions that were affecting NHS staff.14 We asked whether NHS England has a percentage measure to assess how far staff sickness impacts on NHS productivity, and it told us that any reason for staff being off sick would have an impact on their ability to care for patients.15
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Government response AI summary
The government agrees with the committee's finding, stating that the NHS is making progress in recovering lost productivity and reducing staff absences through ongoing efforts, the Long Term Workforce Plan, and incentive schemes, with a target implementation date of April 2024.
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HM Treasury
9
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
The Department told us that when looking internationally, demand for health across OECD countries goes up around 4% a year and improving productivity had to be one of the ways of meeting that demand. Alongside an increase in productivity, increasing the supply of services, improvements to public health in order …
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The Department told us that when looking internationally, demand for health across OECD countries goes up around 4% a year and improving productivity had to be one of the ways of meeting that demand. Alongside an increase in productivity, increasing the supply of services, improvements to public health in order to reduce demand, and developing new technology would be crucial to improving performance in the NHS.18 NHS England also told us that effective electronic management systems could improve patent flows within hospitals and increase overall productivity.19 As an example, NHS England pointed to four organisations in England that have implemented fully functional electronic bed management systems, allowing them to track patients and bed occupancy in real time.20 NHS England told us that it planned to work with a further 16 trusts this year to implement this system that it knows works well. The initiative will not be funded by new money but will be paid for from capital identified in existing budgets from both NHS England and hospital trusts. We asked whether NHS England had done an analysis of the costs and benefits in productivity terms. NHS England told us that productivity benefits would be part of the business case it is discussing with the Department for rolling out electronic bed management systems more widely, but could not yet be confirmed 11 C&AG’s Report, para 4.13 12 Q 1 13 Qq 1, 2 14 Qq 2, 28, 29 and 118 15 Qq 27, 28 16 Qq 3, 4; NHS England, NHS Long Term Workforce Plan, June 2023 17 NHS England, NHS Long Term Workforce Plan, June 2023, page 71 paragraph 8 18 Qq 119, 121 19 Q 52 20 Qq 48, 50 10 Access to urgent and emergency care because the business case has not been formally approved.21 In written evidence after the session NHS England informed us that it expects the main productivity benefit from this system will result from better visibility of bed capacity leading to more informed decision- making, in turn reducing the down time between a bed bei
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Government response AI summary
The government agrees and is implementing digital tools like electronic bed management systems and System Control Centres, aiming to improve patient flow and productivity with a target implementation date of April 2024. They are also boosting capacity with 5,000 extra beds.
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HM Treasury
14
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
We and past Committees have repeatedly expressed concerns about variations in patients’ experience of health and care.32 The C&AG’s report highlighted considerable differences in both service performance and access across geographical areas and providers. Proportions of the most serious A&E patients waiting less than four hours in March 2023 ranged …
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We and past Committees have repeatedly expressed concerns about variations in patients’ experience of health and care.32 The C&AG’s report highlighted considerable differences in both service performance and access across geographical areas and providers. Proportions of the most serious A&E patients waiting less than four hours in March 2023 ranged from 53.3% in the Midlands to 62.1% in the South-East.33 We asked, for example, about the average length of discharge delays in Gloucestershire which is double the national figure. NHS England acknowledged that Gloucestershire is one of the areas it worked most closely with in an attempt to tackle systemic issues, but that similar problems will be replicated across the country.34
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Government response AI summary
The government agrees with the committee's finding and states NHS England is actively working on improving and standardising UEC processes, providing targeted support to challenged systems. NHS England will write to the Committee in February 2024 to detail the underlying causes of variation.
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HM Treasury
15
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
In 2021–22, mean Category 1 ambulance response times varied from six minutes 51 seconds for the London ambulance service to ten minutes 20 seconds for the South-West ambulance service, and average 999 call response times ranged from 5.4 seconds for the West Midlands ambulance service to 67.4 seconds for the …
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In 2021–22, mean Category 1 ambulance response times varied from six minutes 51 seconds for the London ambulance service to ten minutes 20 seconds for the South-West ambulance service, and average 999 call response times ranged from 5.4 seconds for the West Midlands ambulance service to 67.4 seconds for the South-West ambulance service.35 We asked what could be done to address differences between ambulance services. NHS England accepted that ambulance response times were not at all where they needed to be over the winter. It added that ambulance services covering large rural areas, for example the services in the south-west and east of England, were particularly challenged and disproportionately affected by problems stemming from the flow of patients elsewhere in the system.36 It also told us that while all ambulances services worked in partnership with their local systems to develop solutions to treat more people in their homes and reduce admissions to hospital, there was variation in how this was being done.37
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Government response AI summary
The government agrees with the committee's finding, stating NHS England is working to tackle unwarranted variation in ambulance performance through the UEC recovery plan, providing targeted support to challenged systems, and will provide an update in February 2024.
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HM Treasury
16
Recommendation
Seventy-Third Report - Access to urgent…
Accepted
There are differences in the capability of individual trusts, including around management, clinical leadership, and technology, that must be addressed to reduce variations in patients’ access to and experience of services.38 We asked witnesses how the worst performing trusts were being brought up to the standards of the best.39 The …
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There are differences in the capability of individual trusts, including around management, clinical leadership, and technology, that must be addressed to reduce variations in patients’ access to and experience of services.38 We asked witnesses how the worst performing trusts were being brought up to the standards of the best.39 The Department said tackling variability and importing best practice was one of its biggest priorities and NHS England told us it worked more closely with those systems that it has identified as the most challenged, of which there are currently seven, to provide extra help and support including financial assistance.40
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Government response AI summary
The government accepts the recommendation and states NHS England is actively working to reduce unwarranted variation in trust performance, focusing on the most challenged systems by providing maximum support, national experts, and improvement teams, with a target implementation date of February 2024. NHS England will …
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HM Treasury
17
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
NHS England described several different initiatives that it had piloted to improve services, for example around electronic patient records and workforce flexibility measures.41 It also informed us that it had recently launched a new programme of work 32 Committee of Public Accounts, NHS ambulance services, Sixty-second report of Session 2016–17, …
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NHS England described several different initiatives that it had piloted to improve services, for example around electronic patient records and workforce flexibility measures.41 It also informed us that it had recently launched a new programme of work 32 Committee of Public Accounts, NHS ambulance services, Sixty-second report of Session 2016–17, HC 1035, 27 April 2017; Committee of Public Accounts, NHS continuing healthcare funding, Thirteenth report of Session 2017–19, HC 455, 17 January 2018 33 C&AG’s report, para 11 34 Q 57 35 C&AG’s report, para 11 36 Qq 63, 64 37 Q 71 38 Qq 52, 84 39 Q 66 40 Qq 49, 65, 124, 125 41 Q 47–48, 88–91 12 Access to urgent and emergency care specifically to identify variation and provide tools to make improvements.42 NHS England pointed to examples where NHS bodies were trying new approaches and identifying good practice, although cautioned that there were limits to the extent and pace at which these could be rolled out more widely.43 NHS England told us, for example, that there are four places with first-class electronic bed management systems providing information needed to manage patient flows in real-time.44 We asked why similar systems would be rolled out to only 16 more trusts by the end of the year. NHS England noted that there were several dependencies beyond the core technology, such as the availability of expertise and differing levels of organisational maturity within systems, that made this challenging and said it felt 16 trusts was the right number to focus on for the current phase.45 Delayed discharges
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Government response AI summary
The government agrees with the committee's observation, stating that NHS England is actively working to tackle unwarranted variation in performance through the UEC recovery plan. They commit to writing to the Committee in February 2024 to detail the underlying causes of variation.
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HM Treasury
18
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
The different services for urgent and emergency care are highly connected and interdependent, meaning that issues in one service impacts throughout the rest of the system.46 If the NHS is unable to discharge patients from hospitals when they no longer need to be there it means that people waiting in …
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The different services for urgent and emergency care are highly connected and interdependent, meaning that issues in one service impacts throughout the rest of the system.46 If the NHS is unable to discharge patients from hospitals when they no longer need to be there it means that people waiting in accident and emergency departments (A&E) cannot be moved into wards, which in turn prevents ambulances from handing patients over to A&E and attending to new incidents.47 Maintaining the flow of patients throughout and between different urgent and emergency services is critical to ensuring that the system as a whole functions effectively.48
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Government response AI summary
The government agrees with the observation and outlines an additional £1.6 billion investment over 2023-25 for care services and measures within the Urgent and Emergency Care recovery plan aimed at tackling delayed discharges and improving patient flow.
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HM Treasury
19
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
The number of patients staying in hospital despite no longer needing to be there averaged 13,623 across Q4 of 2022–23, an increase of 1,505 or 12% compared with 12,118 during the same period in 2021–22.49 We asked NHS England why delayed discharges had increased, and it told us this was …
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The number of patients staying in hospital despite no longer needing to be there averaged 13,623 across Q4 of 2022–23, an increase of 1,505 or 12% compared with 12,118 during the same period in 2021–22.49 We asked NHS England why delayed discharges had increased, and it told us this was partly due to the more complex needs of the population creating greater demand for domiciliary and rehabilitation support.50
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Government response AI summary
The government agrees with the observation and details an additional £1.6 billion investment over 2023-25 to commission care services, alongside measures in the Urgent and Emergency Care recovery plan to tackle delayed discharges.
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HM Treasury
20
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
NHS England told us that the reasons why patients might experience delays in leaving hospital could be divided into four categories. For one group of patients, accounting for around 20%, the delays are related directly to activity in the discharging hospital.51 NHS England told us it was largely the responsibility …
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NHS England told us that the reasons why patients might experience delays in leaving hospital could be divided into four categories. For one group of patients, accounting for around 20%, the delays are related directly to activity in the discharging hospital.51 NHS England told us it was largely the responsibility of the leadership within these hospitals to improve their processes, so patients are better supported to leave when they are ready.52 Between 25% and 30% of patients leaving hospital need short-term packages of care, which are a shared responsibility between the NHS and local government. A further 25% of patients need to go into NHS community settings, which is another part of the NHS.53 The smallest group, by number, are patients needing nursing or residential care, but we were told that these people can wait the longest, sometimes up to four or five weeks from when they are ready to leave hospital.54 42 Q 125 43 Q 88–90 44 Qq 46–48 45 Q 87, 89 46 Q 111 47 Qq 45, 111, AUEC0001 48 Q 63, AUEC0003, AUEC0005 49 Q 37; C&AG’s report, para 1.13 50 Qq 2, 38 51 Qq 44, 98 52 Q 99 53 Qq 102–104 54 Q 105; AUEC0006 Access to urgent and emergency care 13
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Government response AI summary
The government agrees with the committee's finding and states the recommendation is implemented, citing an additional £1.6 billion investment and a comprehensive programme of measures from the Urgent and Emergency Care recovery plan to tackle delayed discharges, improve processes, and increase social care capacity.
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HM Treasury
21
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
We have previously noted that the fragility of the adult social care provider market was exacerbating the difficulties in discharging older patients from hospital.55 NHS England agreed that there is a clear challenge in social care. Different solutions are needed in different parts of the country, but health and social …
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We have previously noted that the fragility of the adult social care provider market was exacerbating the difficulties in discharging older patients from hospital.55 NHS England agreed that there is a clear challenge in social care. Different solutions are needed in different parts of the country, but health and social care services must work together to tackle problems with delayed discharges from hospital.56 The Department noted that social care remains primarily the responsibility of local government, but that recent changes due to the Health and Care Act 2022 had increased its oversight and awareness of the sector, and provided a better basis for shared solutions between local government and the NHS through the move from Clinical Commissioning Groups to Integrated Care Boards.57 However, NHS England acknowledged that the challenge with delayed discharges does not lie entirely in social care and more work needs to be done in the hospital sector.58
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Government response AI summary
The government agrees with the committee's findings, stating the recommendation has been implemented through an additional £1.6 billion investment and the Urgent and Emergency Care recovery plan, which funds services for rehabilitation, improves discharge processes, and increases adult social care capacity to address delayed discharges.
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HM Treasury
22
Conclusion
Seventy-Third Report - Access to urgent…
Accepted
NHS England told us it had instructed the NHS to speed up discharge processes, for example by minimising waits for supporting services such as transport and medications. It was also asking hospitals to monitor patients more closely to assess whether they needed to remain in hospital. We asked whether this …
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NHS England told us it had instructed the NHS to speed up discharge processes, for example by minimising waits for supporting services such as transport and medications. It was also asking hospitals to monitor patients more closely to assess whether they needed to remain in hospital. We asked whether this approach was working.59 NHS England told us that there were some good examples across the country but accepted that there was more to be done, particularly in terms of reducing variations between different places, and ensuring that patients are discharged from hospital to the right place and at the right time.60 55 Committee of Public Accounts, Discharging older people from acute hospitals, Twelfth Report of Session 2016–17, HC 76, 22 July 2016, page 5, paragraph 3 56 Qq 57, 105; AUEC0001, AUEC0003, AUEC0005, 57 Qq 105, 128 58 Q 57 59 Qq 38, 41 60 Qq 2, 38, 42 14 Access to urgent and emergency care 3 NHS workforce
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Government response AI summary
The government agrees with the committee's finding, stating the recommendation has been implemented through an additional £1.6 billion investment and a comprehensive Urgent and Emergency Care recovery plan to tackle delayed discharges, improve processes, and increase social care capacity.
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HM Treasury