Corridor medicine could help with ambulance handover delays

Matthew

Welcome to the latest edition of Health on the Line. In a few minutes, you'll hear an interview between me and Suzanne Mason, who's led a piece of work for the Confed about the urgent and emergency care pathways. A fascinating conversation, so please do listen to that.

But I'm talking to you now from the foyer of our conference, the Integrated Care System Network. Brilliant gathering. We've got 41 of the 42 ICSs here, talking about a whole range of issues. One of the things we're most interested in is how we can make an input to the work that Patricia Hewitt has been asked to do about how we get the accountability framework right for the relationship between ICSs and the centre. That's a really important piece of work and we're delighted that Patricia has asked us at the Confed to support her in that work.

The other thing of course people have been talking about is the autumn statement, and we've welcomed broadly the extra money that's been made available for health and for social care. Of course, it's not going to be enough on its own to close that yawning gap between demand and capacity in the system. But that's why we were also pleased to see a commitment at long last to a properly funded workforce plan due to be published next year.

So, these are really challenging times for the health service as we move into winter; we all know that. It's going to take a long time to get back to the health service that we want and needs. But with that extra money, with the commitment from the government to devolve more power to ICSs, there's a palpable sense of hope and possibility at this conference. So, do stay on and listen to the conversation with Suzanne Mason.

I'm delighted to be joined by Professor Sue Mason from the University of Sheffield School of Health and Related Research. Suzanne joined Sheffield University as senior clinical lecturer in 2001, was promoted to reader in 2007, a personal chair in 2010. She now divides her time between the university and as director of research and development at Barnsley NHS Foundation Trust.

And one of your main research interests, Sue, is evaluating complex interventions in emergency and urgent care. And the reason why we're speaking today is that you have written a report we'll be publishing in a few days’ time, which is our contribution to the review of urgent emergency care being undertaken by NHS England. So that's what we're going to focus on.

But first of all, Sue, how are you?

Sue

I'm very well, thank you. Thank you for inviting me to speak today.

Matthew

It's our pleasure. Just because before we get into you see, tell us more about what you do, because you have quite a complex role. Tell us about how the different bits of it work together.

Sue

So, I have a role at the university, as you are saying, basically leading a lot of research around urgency and emergency care and trying to improve patient outcomes and service delivery within urgent and emergency using really good robust evidence-based evaluation.

But I also am clinically trained in emergency medicine. So that's my area of interest, my background. I've just recently given up clinical work for family reasons, and now I'm focusing on research, developing research in the Barnsley Hospital Trust, which is a relatively new role for me, but really exciting to be able to try and grow research in a small organisation that's really challenged, but is also really keen to give the best for the patients. And so that's been a really enjoyable experience for me.

Matthew

Let's go straight to the report that we'll be publishing very soon. What are the top line conclusions that you reach in the report?

Sue

After speaking to lots of people reading around the subject and obviously with my background, I think the problem that we're facing at the moment is that we just have a system in urgent care that's not fit for purpose. It's not set up to service the needs that are out there in the population at the moment, which are many people with complex needs, both mental health but also physical health needs. Lots of people who have long-term conditions have exacerbations of those long-term conditions and need support when they have a problem.

And the system we seem to have at the moment is very much focussed on delivering to the most acutely unwell patients. So, it measures acuity; its performance is measured on addressing the acuity in the population. But a lot of what we're currently seeing is not life threatening. Obviously, that's some of our work, but it's not life-threatening emergencies, time-critical problems. The vast majority of it is more urgent care, which needs a timely response that the system that set up at the moment for that is not really geared towards the outcomes that those patients are looking for.

Matthew

So, this is something that we hear a lot. And indeed, just the other day there was a report from Scarborough Acute Trust, which suggested that only around a third of patients being conveyanced to the emergency department there were patients who really needed to go to the emergency department.

Now, I've been in quite high-level meetings, where what has been fascinating to me has been really a quite a strong divergence of view. So, one view, which I guess is probably the most prevalent view, is, how do we stop people going to ED, calling ambulances, who don't need to?

There is, however, a kind of minority view, which I've heard, which is, well, we've had this problem for a long time. The whole point about emergency departments is they're always open. It's going to take a long time for us to be able to sort out access to primary care, for example. Perhaps we just need to accept this. And actually, what we need to be focusing on is what do we do when people walk through the doors of emergency department? How can we effectively triage them through to a to urgent care?

Where do you stand on that debate?

Sue

I think we do need to have a whole culture shift right through from the public understanding and perceptions of how they use the system through to how professionals use it.

My feeling is once the patient's turned up in the emergency department wanting to be seen, it's possibly too late to address that because that's just going to cause frustration. And actually, it's often harder to turn a patient around and send them away than it is just to see them there and then.

I think we need a system where we can deal with the need earlier and at the moment those systems consist of either calling the GP or the 111 service or the 999 service. And at the moment none of those seem to be addressing that need, and patients turn up in the emergency department because the lights are always on. They know that they will be seen there, but it's often not the right place for them and that's one of the reasons that we've become overloaded with work - one of the reasons, there are many others - and some sort of navigation system needs to be developed that allows us to use the whole range of services that are out there accessible that patients find very confusing and difficult to know what to do and what to do for the best for them and their family.

Matthew

So, I guess there's a kind of long-term and a short-term element to this isn't there?

There's a long-term vision is that patients get the care they need when they need it and that that we would have a primary care service that was able to provide the levels of access that the public want. I think we sometimes overstate how difficult access is to primary care. Most people who get through to their GP will be seen on the same day if they need to be and nearly everyone within two weeks. But nevertheless, there are issues around primary care access that when people do contact 111, they will get the right advice and only be directed to emergency services when it was necessary, where ambulance services were more able to offer people help over the phone or in their home and not conveyance people to emergency departments unless they needed to, where emergency departments were really effective at triaging and redirecting people to urgent care if that's what they need.

All of that, we can kind of see what that whole system might look like and many of the kind of recommendations in the Fuller Stocktake apply to elements of that system. So that's the kind of vision we would have.

But there's a short-term problem. And the short-term problem is a system which has more demand than it can cope with. And my experience quite often when I speak to people and speak to leaders, is that they will say initially that the problem is this problem of too much demand. But very often if I push them, they will then say, well, my part of the system ends up taking more risk than other parts of the system.

To what extent do you think it's necessary when we think about how we act in the short term at least, to deal with the problems that we've now got, that we have a kind of what's sometimes referred to as a shared truth about where risk lies in the system.

Sue

I think that's very important. And I think that that's something that because we don't look at things from the problems, particularly from a system perspective, on the whole, in the NHS, we don't consider where risk is best held and shared, and certainly in managing potentially the short-term problem, we need to be realistic about the fact that we are holding a lot of risk and look at where it's most effectively spread.

I'll give you an example, which won't go down well with my emergency department colleagues, but at the moment the biggest problems for the ambulance services is handling the delays; that's the single biggest thing that they want to have dealt with. If they have that dealt with, I think they felt they will feel more able to cope with the immediate problems that they're facing over the winter.

So, in my view, why don't we just deal with handover delays and get that sorted?

One of the biggest reasons we now have handover delays is because during covid we stopped having corridor medicine in the emergency department because of infection control. So, the problem was pushed further down the line. Patients were held instead of in corridors, they were held in ambulances.

Now, I know of one ICS that's looked at this from a systems perspective and said, you know what, we're better off holding that risk in the emergency department and removing those patients from ambulances and actually putting them in the emergency department. The risk is less to the health system and the patients within that system. If we have patients in corridors in the emergency department and then release the ambulances to deal with a patient who's been on the floor for 12 hours. And that's the perspective that that ICS has taken. And they're now encouraging that that practice.

Now, it's not perfect. It's not a solution in the long term, but for getting us through the next few weeks and months, it may well be something that systems should be looking at in terms of how they're managing that risk and holding it within the system.

Matthew

Yes, and I think that NHSE is encouraged, I think they refer to the North Bristol model, encouraging hospitals to expand corridor care, but also possibly have patients sitting outside wards in beds, outside wards, using space to do that. I understand that as something which addresses the fact that the greatest risk is delayed ambulance response times. I think most people would say that is the single biggest risk in terms of patient harm. But of course, the danger is that we end up undercutting the future, by the way in which we respond to the short term. So, what we do is we have more beds, we try to expand what acute can do, new emergency departments are built, bigger emergency departments. But that in a sense is a pattern we've seen a lot in the health service, which is we have a systemic problem. It's most, excuse the pun, acutely seen in the acute sector. And so the resource ends up going into the acute sector when actually if we want the broader solution, we'd be looking at investing across the rest of the system. That's a bit of catch 22.

Sue

So, I completely agree. And obviously the quick fixes risk is saying, well, we don't need to do the big the bigger plan, the longer-term plan would, as you say, invest in those other areas that really don't touch the emergency department. The knock-on effect is that they're not able to do their role and execute their jobs. So, I think it's very difficult in terms of short-term fixes because when we'll be tempted to leave the system to fail, but that's also leaving patients of risk and staff vulnerable in the longer term. There's no doubt that what we need is an expansion in that capacity and to fix the social care problem. I mean that those are probably the two biggest things that the NHS could deal with at the moment and in the longer term. To deal with the flow problem and the demand.

And my understanding, hearing evidence recently at the House of Lords from Ministers and NHS England, is that they really don’t have a very robust plan for how they're going to do that. They talk about 7,000 more over the winter, but many of those virtual and trying to recruit international staff to fill the social care gap, which is significant. And I think probably that is not going to be sufficient.

So, I think that, you know, at the moment it feels a little bit like there's a lack of robust, strong leadership and a clear vision for how we're not only going to get through the next few weeks, but how we're going to get through the next five to ten years.

Matthew

So, my experience, complex problems rarely have a single solution. And I think if you look across the pathway, there are various parts of the system that we need to explore without, as it were, blaming. Ambulance conveyance and rates vary. I was in Wales recently where their conveyancing rates are very, very high, and in other parts of parts of England they're lower. So that's part of this story isn't it; we have understand why it is that some ambulance services find it easier to find alternatives to taking people to emergency departments. Do you have any reflections on that?

Sue

I think there's a mixture of issues there. I think some of it is down to skill mix and some of it down to the individual ambulance services themselves. And I think that there are a number of challenges in ambulance services where I think there's a tendency to have embedded in some antiquated values, which I think need to be addressed. Having said that, I think there's a skill mix issue amongst ambulance workers in some parts of the country whereby there is insufficient clinical decision makers who can treat and leave a patient at home. But indeed, the other issue we see often is that there is a lack of pathways open to paramedics. So, whilst they may wish to leave a patient at home, having referred them on to another service that's going to respond, I think there's a lack of that happening uniformly and at scale across the country.

Now we're evaluating an urgent care hub model where a number of urgent care homes have sprung up around the country, which are delivering multidisciplinary care. And paramedics can refer patients into that, knowing that they will get a two-hour response to the needs of that patient, which means that they don't have to transfer into hospital, that they can leave them at home knowing that the community response will be there. And those hope models seem to be taking off some of the heat from ambulance services and also from primary care when GPs often can't get through to the hospital on the phone. And they also need a timely response to a problem that they're facing at that moment. And so there are pockets where there's good practice. What we're not seeing at the moment is that being rolled out in a uniform manner. But also with insufficient flexibility for that to address the particular needs of those populations, which may be around their health inequalities or the level of deprivation within them. So, I think that there are solutions out there. It's just that we're not seeing that, we may see it in the strategy that's coming out, but we're not seeing that being sort of rolled out sufficiently robustly and rapidly at the moment.

Matthew

And what about 111? Do you feel that in a sense it is there to provide alternatives to 999 enabling people to get reassurance or advice or to be redirected in ways which don't then result in an ambulance coming out. What's your view of how well the 111 service is doing that job at the moment?

Sue

I think 111 is really struggling at the moment. So, we have to look back at what originally was NHS Direct, which was run by nursing staff. So, it had that clinician first contact with the patient over the telephone. That was the intention. It then morphed into basically a call centre with call handlers who have very little clinical training or experience and use this sort of algorithmic approach to calls. It's created basically a new demand in the population, and I think it's serviced any existing need or demand that's there. All the evidence shows that it hasn't reduced demand on emergency departments or ambulance services. And we also know that the level of calls coming through are very low-level calls that very low acuity, where the 75 per cent of them do not need an emergency department or 999 response. So again, it's back to this thing of it's servicing some sort of need in the population, but it's certainly not that emergency needs that's going to really change outcomes.

My view is that the money put into 111 and the resources put into it could very well be used in a different way. But I feel that we're probably stuck with this. I can't see any minister who's going to say, let's just scrap it. So, what do we do with it? Well, what we probably do is increase the number of clinical call handlers who are that clinician first response that patients need. And certainly, work done by ourselves on some of our 111 data have also down in the south-east has shown that having, for paediatric calls, having a clinician first really changes the outcome. And those clinicians are able to reassure parents, get sensible advice, and then the call is dropped. So, there's no onward referral. And that would appear to me to be a much more efficient way of delivering the telephone service rather than the very risk averse nature of the service. By its very nature, it has to be risk averse at the moment, which means that that too many calls are being referred to the ambulance service in the emergency department, which are avoidable.

Matthew

And I wonder whether another element of this series is that most people, if they need to see a GP, they will see a GP on the same day if it feels like that's necessary and overwhelmingly within two weeks. But the problem often is actually just getting through to the primary care centre, the GP surgery. And I know one of the things NHSE is looking at is, is how we can just make sure that the phone gets answered quickly. Because actually if the phone is answered and you're told someone will phone you back or you're told that you can get an appointment at a certain point, that will reduce the number of people who give up, who give up because the phone isn't being answered or who have heard so often that it is hard to get through to your local GP practice, that they don't even bother and they phone 111. So, we have to look at multiple points of entry into the system to see how we could do better to give patients just the initial response, which can quite often be enough not for them to end up then kind of bouncing around the rest of the system.

Sue

The reality is that people need to speak to somebody who has some knowledge, not just clinical knowledge, but some knowledge of the system in which they're living and to be to be able to signpost sensibly. And one of the problems with 111 is that the directory services that they have is often not detailed enough and they're not up to date enough to be able to provide that sort of sensible advice for callers. I think being able to respond to a call quickly is important, although if calls are being dropped, one could question whether they should be phoning in the first place. But that's probably another conversation. And I think primary care really struggle with that. And so, I think finding ways to have a timely response and be able to then provide sensible signposting advice and clinical support is absolutely vital if we're going to have a sort of call before you come approach, I think is what you are sort of alluding to.

Matthew

So, let's step back and think about the system as a whole. And what's clear, I think from our conversation and from your report that we'll be publishing in a few days is that we need a system response to this. And that has to include social care, which of course is out with the work the NHS will be able to do on this. So, actually, before we get into think about the systems, let's just talk about the social care dimension, because I think that's one of the important points you want to make in your report, which is that any attempt to resolve the problems in the urgent emergency pathway that doesn't confront the difficulties of social care is really kind of failing to address the situation as a whole.

Sue

Absolutely. It's 160,000 job vacancies in social care at the moment. And then with the new cap coming in, that workload will actually be increasing. So, the number of people that they will have to become responsible for will actually go up. And yet the sort of pool of resources is reducing.

I think there's also there are also challenges in social care in the way that community care liaises with hospital discharge systems. And some of the people I interviewed for the report were very keen that, again, it's back to the risk sharing, isn't it, that, you know, they have a greater input into planning that discharge for individual patients. There are some models of this around the country, I think, that have been quite successful. I think Swindon is one of them where they're having daily sort of boardrooms with those patients who are ready for discharge for some reason can't go home. And having local council and social care input into planning that and then ensuring that that happens in a more timely way.

But that, again, comes down to the whole thing around we need a system, a joint approach, and unfortunately, we can't separate health from social care. With the ageing population we have. They are integrally linked and it's absolutely essential that that is a seamless link without the saving that there are there is the barriers there preventing patients from moving from hospital to home. And at the moment it would appear that's created a lot of the flow issues that we have. So, yes, I would say that is front and central to what needs to be dealt with by ICSs, but also the NHS level.

Matthew

And you and I are speaking today and hopefully by the time this is broadcast it will have changed. But we're now, I think, six weeks since the government announced £500 million for a delayed discharge fund, most of which was slated to go to topping up domiciliary care wages to helping systems with the biggest kind of challenge around patients for discharge. Six weeks later, we still have no idea how that money's going to be spent and is supposed to be there to help with winter pressures as well. You know, it's mild today, but winter is certainly here. So, it does suggest a kind of lack of urgency, which is which is slightly worrying.

So just to just kind of end our conversation, I want to talk about systems and places as well. We are the organisation that represents ICSs and we're very proud to do so as well. And I think one of the things we always want to emphasise and our ICS leaders do as well is that we want a different kind of leadership from ICSs. Both through ICPs kind of partnership body but also through ICBs and that is a form of leadership which is really about empowering, facilitating, problem solving, adding value, not a kind of bureaucratic regulatory controlling layer.

 And when you look at something like UEC, you can see the power of having a body whose primary role is to enable the kind of ecology of the local system to work effectively, to bring people together, to use hard tools like data, but also soft tools like intelligent process and effective relationships to make the system work as a whole. But my worry is, and the worry of other ICS leads, is that if NHSE, DHSC lean on ICSs to become bodies which do a great deal of regulation and control, responding to kind of central targets, they won't be able to do this kind of facilitative enabling system management work, which could be their kind of USP. What's your view on that?

Sue

I think there's a huge risk here that the ICSs are being given a big agenda, but that they, as you say, they won't be allowed to evolve and to evolve their systems in the way that we all really would love to see happen. And I think the risk is that we will be shifting blame. So, it will be used as an opportunity to shift blame when things fail onto the ICSs, to beat them over the head with a big stick, rather than encourage that sort of, as you say, the evolution of good practice, of innovation and trying to develop the service that their local populations need.

So, regulation in some way should sit with the ICSs. Yes. I mean, in terms of the risk sharing that we've discussed, I think absolutely. But, you know, CQC needs to step up and become and, they're starting to do this, become more responsible for the regulation of systems. And I think that the ICSs need to be left to deliver the services that are needed in the way that we need to see them evolve and that needs to be a very clear mandate given by NHS England and parts of health down to them in order that there isn't that confusion. But it is a concern that I have that eventually they'll just sort of retreat and be beating each other over the head with sticks and also being beaten themselves with sticks. And that's not something that, as we know, isn’t helpful.

Matthew

I agree. I feel that the danger is that we are underestimating the radical possibility presented by public sector bodies whose primary role is to empower and enable systems to work rather than, as it were, to control. And when I talk to acute leaders, that's what they want. For example, they want systems to solve problems for them. They don't want systems to be second guessing what they're doing because we're already subject to CQC, regional oversight and national oversight. So many years ago, when I worked at the RSA, I wrote a set of blogs about public sector collaboration, place-based collaboration. I said that we invest in bricks, but we don't invest in cement. You know, we invest in pistons, we don't invest in oil. And actually, that's often what is missing. And so if ICSs were freed up to enable systems to work more effectively together, they really could be making a huge difference. And also speak to a very different kind of model of public sector leadership. And certainly what we're doing at the Confed, working with ICS leaders is to explore how we can develop that kind of different style of working well.

Sue, it's been absolutely great talking to you and thank you for doing the piece of work that you've done for us, which will be published in a few days’ time. We'll publicise it widely; it’ll be on our website. So, thank you.

Sue

Thank you.