Comment / Emergency response

28 May 2013

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Accident and emergency departments grabbed the headlines last month with concerns about rising attendances and longer waits for patients. We should know what to expect with NHS media coverage, but the search for simplistic causes and even more simplistic conclusions was notable.

It was the historic changes to the GP contract that was undermining local out-of-hours arrangements, we were told. Others pointed to marginal rate remuneration  robbing providers of the necessary resources to respond to this wave of demand. This was an interesting side track.

In most cases, inappropriate attendance at A&E (one that would be better handled in another part of the system) shouldn’t lead to an admission – the exception often being overnight attendances for the elderly, where lack of support at home for the patient may push providers to admit.

Others questioned recent and ongoing plans to restructure A&E services, in some places potentially requiring the closure of existing facilities. Given rising demand, how could the NHS consider this?

The reality is rarely so straightforward. Data is vital to understanding past and planning future performance. And transparency is clearly the right approach. But there is a job for local organisations in understanding their patient flows. Communication with the public is vital for ensuring appropriate use of the right services in the right setting and understanding how reorganised services in some cases may be the solution to these and other issues, as well as addressing quality and financial issues.

Like many others, my trust, Salford Royal, has faced real difficulty sustaining A&E performance. Yet we know how hard staff are working to ensure they are doing all they can to fulfil promises to patients.

Activity over the past 10 years has risen significantly, but our analysis for the past year is that absolute numbers have not been the key issue. Our local hypothesis shows a change in acuity levels of patients presenting at the front door of the hospital and ever more complex discharges slowing egress out of our hospital as the real challenge. These are the causes of our key pressures.

Clearly, demographics are changing and medical advances creeping up. But perhaps a long winter means the system gets pressurised for longer, with all the attendant consequences. Our interest should be focused on those changes and our knowledge should be contributing to the redesign of our system to meet the needs of future patients.

But organisations will not find solutions on their own. We value the strong relationships we have with our local clinical commissioning group and the city council to find answers rather than apportion blame. Salford has an exciting pilot project to integrate health and social care. The aim is to avoid the crises for patients that create the pressure that slows down flow, which in turn consumes resources. The critical factor will be trust built up by all the collaborators. And the goal should be for a different payment mechanism that rewards prevention. It is good to see Monitor and NHS England encouraging local pricing experiments, with a particular interest in integrated health and social care.

Data is vital to mapping our way forward. But we need to ensure we understand what we are looking at. And we need to take time to keep the public involved in the discussion, whatever the current headlines.

Knowing the business

As part of my theme for the year – ‘Knowing the business’ – I called on finance staff to get out of their offices and experience working on the front line – and I called on finance directors to support these activities.

I am keen to hear from those of you who have taken up the challenge. Let me know what you did, your experiences and any initial learning points.

Contact the president at [email protected] 

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