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19 January 2011: NHS Ambulatory Emergency Care Conference

  • Last modified date:
    19 April 2011

Thank you [Dr John Heyworth, President, College of Emergency Medicine].

We are all immensely proud of our NHS.  In many ways it already leads the world.  The esteemed Washington-based think tank, the Commonwealth Fund, recently rated the NHS as the best in the developed world when it comes to issues of access, equity and cost.

All this is thanks to the incredible hard work and dedication of the many who make up the NHS.  That and, I will admit, the significant investment it has received in recent years.

But while we perform well in some ways, in others we have real room for improvement.  In recent years funding for the NHS has risen more or less to the European average.  But there has not been a corresponding increase in outcomes. 

Survival rates for cervical, colo-rectal and breast cancer are among the worst in the OECD. 
We are on the wrong side of the average for premature mortality from lung cancer, and heart and respiratory disease. 

And you’re more than twice as likely to die from a heart attack in the UK than in France. 

What has held us back has not been a lack of funds or a lack of skill and dedication from staff.  I believe what has held the NHS back from delivering to its potential is the system itself. 

The top-down system of management that starts from the office of the Secretary of State and flows downward through various layers of bureaucracy to the front line.  This approach has been propagated by parties of all colours throughout the history of the NHS.

It is a system that tells people what to do rather than encouraging and supporting them to do the best they can.  A system that stifles innovation and free thinking in order to achieve particular targets mandated from above. 

Targets that are often as much about getting good headlines as they are about improving care.

I believe we need to take a more nuanced and sophisticated view.  We need an approach that moves beyond process and instead makes a wider assessment of the quality of outcomes received by individual patients. 

We, and by that I mean people like me in the Department of Health, should not be micro-managing the day-to-day work of the Health Service, constantly telling you how to do your jobs.  We should instead do more to give you the support you need to excel.

Emergency care has, in recent years, received its fare share of investment.  This investment has produced a large number of well equipped Accident and Emergency Departments and has seen the 4-hour waiting time standard met in almost every case across the country.

But while this has undeniably produced results, can we honestly say that it has produced the right results?  For while time is, of course, an important factor in emergency care, it is far from the only one. 

And as well as not being the best way of improving care for patients, neither are unjustified process targets necessarily good for clinicians – undermining their clinical judgement and adding unnecessarily to already high stress levels.

But the NHS is changing.  Emergency medicine is changing.  We have already amended the threshold for the 4-hour waiting time standard to give clinicians more flexibility.  We will soon shift the focus from a single measure of time to a wider measure of the of the treatment that patients receive and the outcomes that those treatments achieve.

This is an opportunity for clinicians to really focus on providing the best care they possibly can. 

The indicators – developed by senior clinicians [including John Hayworth] – operate as a set and are both a broader and more sophisticated assessment of clinically relevant care than the old one-shot target. 

I hope they will promote discussion and debate.  These indicators are not, after all, etched in stone, but open to annual review as evidence allows us to improve their effectiveness. 

I hope they will also enable real improvements in quality.  Improvements that will be led from the front line and made on continual basis.  Not just piling on the pressure from above. 

This is an exciting time to be working in emergency medicine.  There are real opportunities for clinicians to influence the way emergency care is provided and to bring about real improvements. 

Advances in technology and medical practice means that clinicians now conduct a far greater number of investigations, and a greater level of care, prior to admission. 

They are also more able to safely discharge people for community care or self care. 

So yes, emergency care is changing.  And it needs to change.  One of the main drivers of improvements in the NHS has been significant annual increases in the budget.  While we are protecting the NHS budget, increasing it every year, because of the realities of the current economic climate, the increases will not be like those in recent years. 

This is why it is so vitally important that we improve the productivity of the NHS, releasing money, every penny of which can be ploughed back into front line care.

Across the Health Service we need to unleash the talent and creativity of staff to improve outcomes for patients and to improve the cost effectiveness of care. 

The two cannot be separated or seen in isolation.  This is not simply an exercise in saving money, nor is it about throwing cash at a problem.  We must – and we can – deliver cost effective services while at the same time improving the quality of care.

One area where we can improve a patient’s experience of the Health Service, improving the care they receive whilst also reducing costs is through a focus on Ambulatory care. 
On treating people with urgent or emergency care needs in a way that avoids admission to hospital.

Ambulatory care is to emergency care what day surgery is to elective care. 

• It is clinically safe,
• It provides a good experience of care for patients,
• it reduces pressure on hospitals,
• it makes the best use of scarce resources, and
• it provides better value for money for taxpayers.

It’s also nothing new.  It’s already widely practiced by paediatricians, and by doctors and nurses in Emergency Departments and acute medical units. 

So this isn’t about a new initiative, it about implementing tried and tested good practice, making the existing pockets of excellence the norm across the Health Service.

That in itself is a big job.  While some level of variation can be expected across the country because of local populations, it is clear that not all areas are making the most effective use of ambulatory emergency care.

The NHS Institute estimate that as many as one in six patients who are currently admitted as emergencies could avoid admission if they were managed on ambulatory care pathways.  Saving the NHS as much as £250 million a year.

The NHS Institute’s Directory of Ambulatory Emergency Care for Adults outlines forty-nine conditions that can be safely managed without overnight stays.  I would encourage all of you to use the Directory to assess the potential to reduce emergency overnight stays.

Ambulatory Emergency Care is one of the A&E quality indicators.  While cellulitis and DVT are highlighted in the implementation guide, I’m sure you will want to go further, adopting the majority of the pathways outlined in the Directory and developing still more that are important to you locally.

You all have a great deal to offer and a great deal you can learn from each other.  One of the most valuable changes with this and many other areas of care will be clear and transparent bench-marking of performance data.  You will all be able to clearly see how you are performing in relation to your peers and be free to work together to drive up standards in your own areas.

Although there is no tariff for ambulatory emergency care, I see no reason why innovative Trusts cannot work with commissioners to agree the best way to fairly remunerate ambulatory activity.  Such an arrangement could benefit all concerned, the patient most of all.

Delivering effective ambulatory emergency care is not easy.  It requires different parts of the NHS to work together, focusing on the patient journey.  It requires innovation and, most of all, it requires leadership.  But it’s a real opportunity for you to improve the care of your patients.

I’m really pleased to open a conference that offers practical support for the NHS from some leading experts in the field.  This is what we will see more and more of in the future.  Services being driven by clinical leaders, focussed not on targets that please only Ministers, but on outcomes that improve care for patients. 

Emergency care can be a difficult choice as a career.  But as challenging as it is, it is equally rewarding and varied. 

I hope that with the changes we are making –

by giving clinicians more freedom to shape services...

by ending the constant micro-management from above and...

by shifting the focus on improving clinical outcomes for patients, one of the benefits will also be to make it a more attractive field for the next generation of emergency care professionals.

So I would like to thank NHS London and the NHS Emergency Care Intensive Support Team for organising this conference and for all of their work to improve urgent and emergency care in this country.  I am sure you will have an interesting and stimulating day.  And I hope you will be left enthused and inspired to transform emergency care in your own communities.

Thank you.

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