With the recent publication of two major reports about urgent and emergency care, it is timely to return to the topic of flow. I talk to Isabel Lawicka from NHS Providers about how ambulance services can contribute to the whole society approach to health and social care when they are drowning in demand.
I start by asking Isabel whether she recognises what Dr Adrian Boyle said about the problem of flow in hospitals in his interview with me in the August issue. She says that it does resonate with her and with NHS Providers where she is Head of Policy and Analysis. “We talk about it a lot and how those challenges manifest themselves in different ways for different parts of healthcare services.”
NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS.
“Our members have been highlighting the problems relating to flow for some time now. It is frustrating for everyone involved and it’s not the best use of resources, with a knock-on effect on ambulance availability.”
She says that NHS statistics indicate that in early January, around 60 per cent of patients who could be discharged from hospital were unable to leave because they were waiting for support from social care or community services. If there are no spaces in the hospital then it’s obvious that the ambulances turning up at A&E will have to wait with patients because there’s no room for them inside.
“The general trend is that the numbers are going in the wrong direction. Worryingly, we are now seeing it throughout the year and not just in winter.”
A week before we meet, the House of Lords Public Services Committee published its report into emergency healthcare. We talk about the report and how it pulls no punches when it states, ‘Emergency access to healthcare is in crisis.’
NHS Providers, along with a range of other organisations gave evidence to the inquiry that was launched in September 2022. I was curious about why Miriam Deakin, Director of Policy and Strategy at NHS Providers argued as part of her evidence that it was important to stop, “Just seeing the ambulance service as a sort of blue-light response.” I asked Isabel what she meant by this.
“The ambulance service has a unique role to play in transforming services, enhancing patient experience and helping to deliver care closer to home to reduce pressure on hospitals.” She says that ambulance staff are well placed to identify problems and solutions. “Ambulance staff are often in people’s homes and can help to identify what preventative approaches could help that person in future, for example older people who may fall at home.”
I wonder how ambulance services are supposed to carve out time to do preventative work when there is such high demand for their emergency response? Isabel responds, “That’s where collaboration comes in. They can’t do this on their own. Provider collaboratives under the Integrated Care System (ICS) arrangements can deliver services in a different way. It’s about making the most of integration and collaboration to be more streamlined and efficient.”
In recent times, I have seen scant references to the 2017 legal duty for emergency services to collaborate, so I was interested to see collaboration emerge as a theme in the House of Lords report and how it links it with the regulatory and inspection regime. Doing so, the report states, “Has the potential to enable and incentivise greater collaboration between police, fire and rescue and emergency health services, leading to better outcomes for patients.” Whether this is a case of ‘what gets measured gets done’, remains to be seen. The report says that collaborative approaches to emergency services delivery are ‘patchily distributed.’
The Hewitt Review
Lena Samuels is the Chair of the Hampshire and Isle of Wight ICS and she described how the relatively new ICS arrangements work in her interview with me in the October issue of EST. I ask Isabel about the review that the Secretary of State has commissioned from former Labour Minister, Patricia Hewitt to look at how the ICS is working so far.
Isabel says that NHS Providers has fed into the review and highlighted the complexity of the geography that exists in healthcare in England. “The review needs to look at the burden on ambulance trusts of dealing with multiple ICSs.” This is no surprise as there are 11 ambulance services and 42 ICS in England meaning one ambulance service will have to deal with many ICS and that has the potential to be incredibly onerous for them.
“We think the Government and national NHS bodies should reflect the interconnected nature of health and care. The review can’t suggest that we have a target for everything; there’s got to be a recognition that where you have a response target in urgent and emergency care, it relies on other parts of the system working. We need a whole system approach to meet any targets.”
A few days after our conversation, NHS England published its two-year delivery plan for recovering urgent and emergency care services. It commits to increase capacity, grow the workforce, speed up discharge from hospitals and expand services in the community. It hits all the points that we have been talking about as well as putting 800 new ambulances on the road, although the challenge may be recruiting and retaining staff to support this added capacity.
Isabel had told me at the end of our conversation that a successful health care system would have the right people in the right place at the right time. “And that’s where we go back to the start of our conversation about flow.” She’s right, but the question is whether the £1bn backing the NHS two-year delivery plan is enough to tackle the underlying problems inhibiting urgent and emergency care at a time when paramedics and nurses are striking just to earn a decent wage. Otherwise, cautions Isabel, “We will just keep coming back to the same place.”