Just over ten years after the Francis Report revealed the full extent of the appalling systems failure that had taken place when Mid Staffordshire Hospitals Foundation Trust slashed staffing levels and quality of services in a bid to wipe out a £10 million deficit, the Royal College of Emergency Medicine convened a Crisis Summit on Emergency Care in the House of Lords.
RCEM President Dr Adrian Boyle summed up the aim of the gathering as seeking to “build political will to address problems that will take more than an election cycle to fix”.
A large invited audience crammed in to the Attlee Room on March 28 to hear a distinguished panel of speakers including Health Foundation Director of Research Anita Charlesworth, College of Paramedics President John Martin, British Geriatrics Society President Prof Adam Gordon, Society of Acute Medicine President Dr Tim Cooksley, Dr Camilla Kingdon, President of the Royal College of Paediatrics and Child Health, and two politicians, Labour’s Shadow Health and Social Care Secretary Wes Streeting and LibDem Lords health spokesperson Lord Allan.
The event began with a general introduction, emphasising that 2022 had been the worst year ever for the emergency care system, with one in ten of the most serious Type 1 patients waiting 12 hours or more from their time of arrival to admission, with 60% of 12 hour waits affecting patients aged 60 and above.
By contrast performance on the 4-hour target to treat and admit or discharge A&E patients slumped to a record low of 49.6% in December, compared with the initial 95% target. Dr Boyle emphasised that none of the most serious signs of crisis in emergency care were visible in 2013: there has been a rapid decline.
A series of case study examples of the ways in which the NHS is currently failing emergency patients was then given, beginning with a very clear summary by a patient, Becky Goddard-Hill, of the shockingly poor treatment she had received in Nottingham, and how this has had serious long-term consequences for her health.
Members of the panel gave similar concise real life examples of ways in which their services have been failing to work together to meet patients’ needs.
Noting the ineffectiveness of the government’s now routine annual belated injection of around £400m to address winter pressures, with the money not released until January, and then inevitably consumed on agency and locum staff, the RCEM invited a further round of short contributions from the panel focused on which three changes they see as essential to remedy the problems.
Most speakers focused on staffing issues – recruitment and retention – with the paramedic emphasising upskilling paramedics to provide more treatment outside hospital, and the acute care specialist stressing the need to reduce bed occupancy levels and improved links between GPs and hospital care.
Prof Adam Gordon called for a shift in attitude and awareness of frailty, with better triage at the front door of emergency departments and reversing almost two decades of declining investment in rehabilitation services.
Camilla Kingdon argued for improved coordination of GP and emergency services, with a focus on empowering parents, improving NHS 111 response to child health, greater ring-fencing of the child health workforce, and underlined the rapid increase in child and adolescent mental health problems.
Anita Charlesworth returned several times to the fundamental problem of the lack of both capacity and planning in the NHS, which was not the result of Covid, although the pandemic had exacerbated problems.
She argued that the NHS had “run too hot” for too long, with far too much focus on short term efficiency savings and not nearly enough on resilience: the result was too few beds, with high occupancy levels, and too few staff.
The threat was that numbers of people aged 85-plus are set to increase by a third in the next decade, with insufficient services to care for them. Former NHS England CEO Simon Stevens had recognised that numbers of hospital beds had been reduced too far: what was needed now was an increase in capacity, alongside different models of care that increase the quality of services.
Anita later followed up by emphasising that the key was building sufficient capacity in the NHS, which was hampered by a long-standing lack of capital funding: “If we had matched the levels of capital funding of the EU14 countries the NHS would have invested an extra £33 billion by now.” That’s why the backlog maintenance bill has soared to almost £11bn, and why there is not a better digital infrastructure and why the NHS lacks the numbers of scanners and other equipment other countries have.
Adrian Boyle from the RCEM emphasised the College’s campaign to “Resuscitate Emergency Care”, calling for a combination of investment and reform, the return of the 4-hour target (“it’s a terrible measure of performance – but nobody has come up with anything better”), and for “evidence-based policies” to address the crisis.
Lord Allan, who had been called out to a vote in the Lords, returned to argue for more beds in acute care and mental health, more investment in modernising and repairing buildings, and for a workforce plan which he insisted had to “be real” and include social care.
Wes Streeting limited his response to the now rather stale and limited Labour mantra of “retention, recruitment and reform,” repeating his concerns about the impact of the junior doctors’ 4-day strike after Easter, but adding that the biggest danger was not so much that the doctors walk out on strike, but more that “they walk away for ever” from the NHS if there is no proper plan to retain them. However he outlined no proposals for increased funding that would ensure that any extra doctors or other professional staff recruited through his plan would actually have jobs to go to.
Streeting argued that by “reform” he meant more ways of delivering care in “community settings” and emphasised the need to confront gaps in mental health services that too often mean police are relied upon in A&E departments where mental health patients are a threat to themselves or to others. In response to a direct question from BMJ editor Kamran Abbasi on the rundown of public health funding, Streeting promised only that more will be said about public health and prevention later in the year.
Two of the other questions from the audience focused on mental health care, with a Royal College of Psychiatrists representative warning that police are intending to withdraw from their role in mental health, and noting the problems created by siting acute mental health assessment units miles away from A&E departments.
A liaison psychiatrist followed this up by recounting a recent morning in which she arrived at an A&E department to find ten of the 17 cubicles filled with psychiatric patients, and eight patients elsewhere awaiting mental health beds – one who had been waiting six days. Her own mental health trust at that time already had 30 patients waiting for beds.
Lord Allan raised the tendency of NHS management, seeking cash savings, to make short term decisions that may seem “penny wise” but wind up “pound foolish”. The government had argued that part of the solution was to create Integrated Care Boards, but it was necessary to ensure that the ICBs invest wisely, and for example increase spending on social care.
At this point yours truly, as the Lowdown correspondent, got the chance to mention the elephant in the room, warning that the ICBs are in no position to invest – far from it: they are facing demands to make “savings” of £12bn by 2025, which will very likely mean running down staffing levels and cutting services. It was necessary to take stock of the amount of funding needed to run the NHS properly.
Lord Allan replied that he did not disagree, and Anita Charlesworth also came back at the end of the event to reemphasise the impact of the long period in which NHS funding had fallen way short of pressures.
“Running hot has run out of road,” she said. “There is no route to a better NHS that is not an appropriately funded NHS.” The NHS “can’t do magic”: it must be resourced, and we need “at least five years of rebuilding the fundamentals and sustained capital investment.”
The RCEM deserves credit for convening such an event, and its influence is clearly growing as it draws around important allies to back its campaign to Resuscitate Emergency Care.
But as the audience made for the exit it seemed a shame that none of the national news media were present to hear the moving and convincing stories of how system failures mean things are going seriously wrong for so many patients, and the authoritative arguments for policies and resources to restore the performance standards that peaked in 2010 before the long cold winter of austerity took its toll.
The RCEM itself has published important factual information and evidence, arguing strongly for increased staff as well as more beds to ensure that emergency and other acute and mental health services are given the capacity they need to improve the quality and safety of patient care.
It’s worth noting that this core sector of the NHS is one in which the private sector has made no real effort to intervene, seeing no possibility of profits to be made.
With a general election now becoming more of a tangible feature on the political horizon, it is more important than ever that campaigners use this type of qualitative information to pile pressure on to Streeting, Keir Starmer and other opposition politicians to commit to at least the decade of sustained investment in the NHS that Tony Blair’s government – whatever their other failings – eventually committed to from 2000.
The Lowdown will continue to assemble the body of evidence to support campaigning along these lines as we run up to the 75th anniversary of the NHS amid the evidence of its decline at the hands of governments in the last 13 years, and grim warnings for the future if there is no change of course.
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