Public Accounts Committee
Monday 2nd November 2026
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15:34
Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
Order, order! Welcome to the Public Accounts Committee on Monday, the 2nd of November 2026. Since 2014, A&E departments at the national level have failed to meet their constitutional target of 95% of patients should be discharged, transferred or admitted within four hours of arriving at A&E. In addition to this proportion of patients waiting in A&E for over 12 hours or more has tripled from around 3% before Covid 19 to around 10%. Last year, 256 and in May 26th of this year, during any 24 hour period, almost 3000 people were waiting on corridors. Not only have wait times, but also costs are rising, too.
The cost per patient in NI has increased by a third from £211 in 2018 19 to £280 in 245. Overall spending in A&E also increased from £4.3 billion in 1819 to 6.6 in 245. This represents a wholly unacceptable level of care, with the increase in long waits and rise of corridor care significantly impacting safety patient safety. Analysis by the Office of National Statistics estimates that patients waiting in A&E for 12 or more hours are twice as likely to die as patients waiting for two hours. So today we will therefore be challenging NHS England and the department.
DHS on A&E waiting times. Patient experience in hospital as well as rising costs, costs and flow within hospitals. So we have a very senior team here with us today. Would each of you like to please introduce yourselves? Starting with you, Permanent Secretary.
The cost per patient in NI has increased by a third from £211 in 2018 19 to £280 in 245. Overall spending in A&E also increased from £4.3 billion in 1819 to 6.6 in 245. This represents a wholly unacceptable level of care, with the increase in long waits and rise of corridor care significantly impacting safety patient safety. Analysis by the Office of National Statistics estimates that patients waiting in A&E for 12 or more hours are twice as likely to die as patients waiting for two hours. So today we will therefore be challenging NHS England and the department.
DHS on A&E waiting times. Patient experience in hospital as well as rising costs, costs and flow within hospitals. So we have a very senior team here with us today. Would each of you like to please introduce yourselves? Starting with you, Permanent Secretary.
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15:36
Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
Thank you all very much. I think Doctor Emma and Professor Tim this is your first time at the committee. You are very welcome. And I'm I hope at least the committee, even if you don't enjoy it, it will enlighten things for you and us. So I'm going to start, I think, hopefully you've been warned about Anna's top of the session question. Maybe not. Anyway, so Anna will, will will, will.
And you'll have to do your best to answer us, please. So.
And you'll have to do your best to answer us, please. So.
15:37
Anna Dixon
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Anna Dixon
Chair, and before I go in, I guess I should just declare a potential conflict of interest, having worked myself at the Department of Health previously. So we had UN previously at the time that the reorganisation of the NHS England was announced. Obviously, the health Bill is currently passing through to give the sort of legislative abolition of NHS England, as it was debated in the House of Lords. There was quite considerable discussion about the transition plan and the costs of transition, and I just wondered if you had any update for us here at the Public Accounts Committee as to your current estimates of the cost of the reorganisation associated with the abolition of NHS England.
15:38
Catherine McKinnell
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Catherine McKinnell
So I will come back to the committee and confirm the latest, if that's okay. I know I don't want to give you something on the hoof, but I can confirm is that, as the Secretary of State said at the dispatch box, remain totally committed to the abolition of NHS England and the creation of the new Department, and further information will be coming in due course.
15:38
Anna Dixon
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Anna Dixon
Okay. Would be grateful. I think you're back with us for another one on ICB reorganisation. So it may be if you can make sure that we've received any information ahead of that hearing, we could include a further question. And can you just clarify and this may be for you system. I think this has been reported in the news about the possibility of needing to create a separate arm's length body, because it's not possible to absorb all staff, particularly those on senior salaries, into the Department of Health and put them on civil service pay grades. Could you just provide clarity on on that?
15:39
Speaker 1
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Speaker 1
Yes. So some said we we will be making or Secretary of State will be making some more announcements on this in the very near future. It's still been subject to debate very recently. And one of the key points is not just on the terms and conditions things. It's about alignment with the Devo principle and philosophy. So it's not fixed yet. It'll be communicated very soon.
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15:40
Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
That's very helpful. I think just for the record, my clerk did say that you had been warned of that question, I think. Thank you. Thank you anyway for those answers. And we look forward to hearing further on Anna's inquiries. Just before I bring Rupert in, I'd like to raise an important issue that was raised both in the Nao report and by the Royal College of Accident and Emergency. I think that's what they call themselves, Royal College of Emergency Medicine, they say, and I think this evidence you've had sight of this evidence because it was published a week or so ago, paragraph one.
There were around 16,000 excess deaths in England associated with long waits in emergency departments. And the Nao in paragraph 1.9 on page 19 delves down into this a little further. They say 12 hour waits are associated with higher mortality. This is clearly a very difficult situation and a sad situation. What do you intend to do to try and reduce that.
There were around 16,000 excess deaths in England associated with long waits in emergency departments. And the Nao in paragraph 1.9 on page 19 delves down into this a little further. They say 12 hour waits are associated with higher mortality. This is clearly a very difficult situation and a sad situation. What do you intend to do to try and reduce that.
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Speaker 2
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Speaker 2
Thank you. Chair. So just to acknowledge initially, so behind every one of those numbers is obviously a patient and a family. And I think we are all in complete agreement. That's completely unacceptable. That's not what we want to see or what we want to deliver. So our focus is absolutely on eliminating and abolishing all those long waits. It's a complex system , and the predominant causation of patients residing in corridors or any other treatment escalation space, as they're called. So places that are not suitable for clinical care are essentially flow problems with flow. All of those patients that are currently in a corridor should be in a hospital bed.
That's the bottom line. So the question is, why can't they get to those hospital beds and in a timely and safe fashion? And the cause for that is that delay all the way through the system, particularly at what we call the back door. So the back of the hospital. So it's that flow through the hospital system and encouraging a timely discharge, timely hospital processes and timely exit from A and E, and then also timely system processes around the hospital to support that.
That's the bottom line. So the question is, why can't they get to those hospital beds and in a timely and safe fashion? And the cause for that is that delay all the way through the system, particularly at what we call the back door. So the back of the hospital. So it's that flow through the hospital system and encouraging a timely discharge, timely hospital processes and timely exit from A and E, and then also timely system processes around the hospital to support that.
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15:42
Speaker 1
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Speaker 1
Can I just add to that as well? So first of all, we all we are all in agreement. This is a good report. It's a very good balanced view. It emphasises we've got to look at the whole system rather than parts of the system. Hopefully this afternoon will explain what we're doing about all of that. And we've had some really useful challenges from new ministerial team, especially on discharge and the impact of discharge and rebalancing the plan. But probably what we'll try to mainly convey is very this is all very complicated, and especially in the context of all the things we've had to do in the last year around financial turnaround and improvement and various various settings, etc.
. And this year, the main thing that set us off course has been quite a strange increase in demand from the early part of the year, which was still struggling with. But at no point will we be disagreeing with the content or the balance or the tone of the report. I think it's a very good report and very helpful for the service.
. And this year, the main thing that set us off course has been quite a strange increase in demand from the early part of the year, which was still struggling with. But at no point will we be disagreeing with the content or the balance or the tone of the report. I think it's a very good report and very helpful for the service.
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Rupert Lowe
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Rupert Lowe
Thank you, chairman. And I echo your the now's great report, as usual, has helped us understand this better. I do come across this quite a lot in my constituency in Great Yarmouth with the James Paget Hospital, where we do have issues with A&E. So. So I'm quite aware that it is a. It's a major problem across the country, I guess. I mean, my first question really is given, given that in your constitution, in the NHS Constitution, you actually promise 95% within four hours in terms of A&E type one, A and E. You last met that target in 20 1314, and it appears you now have an interim target, which is 85%, but not until 2829.
So I guess the question I've got for you is, in which year will you meet the 95% that is in your constitution?
So I guess the question I've got for you is, in which year will you meet the 95% that is in your constitution?
15:45
Speaker 1
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Speaker 1
Want me to take that? So you've rightly pointed out it's a long time since the NHS has delivered this standard. So the way my memory looks at this is in the run into Covid, we'd had a long period of steady decline. Then we had the Covid event and we've struggled since then to get back to normal levels. The report acknowledges some progress since then, but as I described at the beginning, given all of the other competing challenges, the overall resource position, etc., we've tried throughout to set stretching targets and objectives for the service, but not so stretching beyond reach.
And therefore everybody gave up. We when we when the last plan was published, we didn't because there was an uncertain medium term financial position. We didn't commit to a time at that point to deliver in the standard overall, we absolutely. That's what we're aiming for every day. But from where we are now, it's not going to be in the next the next couple of years. It's going to be a longer time frame than that.
And therefore everybody gave up. We when we when the last plan was published, we didn't because there was an uncertain medium term financial position. We didn't commit to a time at that point to deliver in the standard overall, we absolutely. That's what we're aiming for every day. But from where we are now, it's not going to be in the next the next couple of years. It's going to be a longer time frame than that.
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15:46
Speaker 1
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Speaker 1
No we haven't. We will just about go into further discussions about planning and stuff for next year and objectives for next year. So we haven't set a date for complete delivery of that overall standard. And as I say, part of that is about the demand growth that we've had this year. That's not, of course, a little bit.
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15:46
Rupert Lowe
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Rupert Lowe
I mean, it did concern me, Jim, again, when I when I read, you know, your own analysis, basically it's saying the Nao says we need 115 to 120,000 beds and you've got around 103,000 I think. Is that right? Yeah. And in the Nao report says you haven't actually costed the gap. So if you've costed the gap you really can't be that serious about delivering on that on that 95% target. Can you.
15:47
Speaker 1
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Speaker 1
Well we'll know what the cost of award is. And the cost of those beds are what we've not what we haven't got is a realistic prospect of being able to secure that overall level of resource. And we're all trying very hard to shift patterns of care. So people who are currently being treated in beds, aren't treated in beds, are treated nearer the home and through eastex and utcs and in neighborhoods, etc.. So all of those things are currently being considered again. But if we said the only plan was to open 15,000 extra beds, we couldn't afford it and we couldn't staff it.
So we do. There's an imperative as to how quickly we can change the pattern of care. One thing that doesn't come across through strongly in the report is the implementation of same day emergency care across the service, which has had a has materially reduced our reliance on beds in the last few years. So when you you're right in that if you look at where we are now doing as performing as we are now, and with clinical systems that we've got now, we need a lot more beds. What we're trying very hard is to find alternatives to that through shift in the model of care.
So we do. There's an imperative as to how quickly we can change the pattern of care. One thing that doesn't come across through strongly in the report is the implementation of same day emergency care across the service, which has had a has materially reduced our reliance on beds in the last few years. So when you you're right in that if you look at where we are now doing as performing as we are now, and with clinical systems that we've got now, we need a lot more beds. What we're trying very hard is to find alternatives to that through shift in the model of care.
15:48
Rupert Lowe
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Rupert Lowe
I mean, again, as the chairman says, it's pretty shocking that statistic about people being twice as likely to die if they're waiting for 12 hours rather than for two hours. So it does strike me. It's quite important to try and meet that target. And then with regard to corridor care, which is a major problem still, are you now collecting data each month on how many people are actually in corridors waiting to be treated?
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15:49
Speaker 3
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Speaker 3
Yeah. So I was asked to get involved in trying to resolve this issue of corridor care September of last year, bringing the methodology and the clinical leads to bear to try and make a big difference. We've gone live now with a new definition of 45 minutes in a designated space, and that is being measured. There is some discrepancy between what we say is corridor care and our Kem, and we think some of the answer is somewhere in the middle. I think we're probably unreported at the moment. But the critical thing for me is it's the risk of these patients that they they have in the corridor and the corridor care piece, where people are in the corridor can occur at any part along the pathway.
You don't have to be admitted to end up in the corridor. And what's really important as we tackle this is to tackle the areas where there's the greatest risk. And if you look at the patients in the corridor, 60% are over the age of 65. And that is the real risk to us that these patients frail multiple co-morbidities. And they're the ones that we've really got to we've got to really try and manage first. We've got to get out the corridor as quickly as we can. Now, in the last year, we've worked very hard with 45 trusts.
21 is what we call a further, faster cohort. They were just about managing, and then we worked with the 24 tier one trusts who were not managing at all. And what we did is we brought our clinical leads, we got the data and we went into help because when you look at corridor care, the issue is the whole pathway. And often when we went to these trusts, they were silo working. Everybody's going to work doing, trying to work really hard, doing a good day's work. But what we found was it was silo working. What we needed was everybody to own the problem, both all the clinicians and also the management teams.
So we did a lot of work with the 21 trusts and we improved four hours. We improved ambulance handovers, and we reduced the 12 hour wait and therefore corridor care. And on the tier one, which was the issue where it's really the back end, that was really the problem. We reduced the 12 hour breaches by almost 12%, so we knew that our methodology would work. And what we then did, we worked with nine providers and six trusts to focus on corridor care, and we were able to reduce that by 50 to 60%. So we know the methodology we've got is right.
And we're absolutely been working with 40 trusts this year. We just agreed with Emma and the regional regional COO's on the 40 trusts. We're going to use all our efforts on this winter, and I hope that we can make a significant impact. But it's hard yards. It's going to be at trust level, working with the trusts, changing cultures, behaviours, getting the whole team to work as one right from the front door, right through to discharge. But we're on our way , and I think we're seeing change in behaviours that I think is going to make a difference.
You don't have to be admitted to end up in the corridor. And what's really important as we tackle this is to tackle the areas where there's the greatest risk. And if you look at the patients in the corridor, 60% are over the age of 65. And that is the real risk to us that these patients frail multiple co-morbidities. And they're the ones that we've really got to we've got to really try and manage first. We've got to get out the corridor as quickly as we can. Now, in the last year, we've worked very hard with 45 trusts.
21 is what we call a further, faster cohort. They were just about managing, and then we worked with the 24 tier one trusts who were not managing at all. And what we did is we brought our clinical leads, we got the data and we went into help because when you look at corridor care, the issue is the whole pathway. And often when we went to these trusts, they were silo working. Everybody's going to work doing, trying to work really hard, doing a good day's work. But what we found was it was silo working. What we needed was everybody to own the problem, both all the clinicians and also the management teams.
So we did a lot of work with the 21 trusts and we improved four hours. We improved ambulance handovers, and we reduced the 12 hour wait and therefore corridor care. And on the tier one, which was the issue where it's really the back end, that was really the problem. We reduced the 12 hour breaches by almost 12%, so we knew that our methodology would work. And what we then did, we worked with nine providers and six trusts to focus on corridor care, and we were able to reduce that by 50 to 60%. So we know the methodology we've got is right.
And we're absolutely been working with 40 trusts this year. We just agreed with Emma and the regional regional COO's on the 40 trusts. We're going to use all our efforts on this winter, and I hope that we can make a significant impact. But it's hard yards. It's going to be at trust level, working with the trusts, changing cultures, behaviours, getting the whole team to work as one right from the front door, right through to discharge. But we're on our way , and I think we're seeing change in behaviours that I think is going to make a difference.
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Rupert Lowe
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Rupert Lowe
And that's not a winter month, is it? So that's no. Okay. So so I mean, are you going to publish a plan on how you're going to deal with it? Because I always think when I'm running something, a plan written down with, with, with an actual sort of structured approach to it is better than just words around a committee. So are you going to have a plan published? Because I really do think this is quite serious.
15:52
Speaker 1
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Speaker 1
We've used in the last year and some of it's referenced in the report, the model Ed model discharge. So when we've got a bit more reliable data over a longer period of time, I'd expect Tim and colleagues to produce a model approach to eliminating corridor care. I'll just the point I was going to make as well. So there's absolutely a harm issue, but we shouldn't lose sight of the dignity issue as well. So a patient could wait a long time and not suffer harm, but still have a horrible loss of dignity. So I just want we should acknowledge that that's a thing that we're all very focused on.
And colleagues are very.
And colleagues are very.
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Catherine McKinnell
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Catherine McKinnell
If I may just also, just to confirm, I mean, the Secretary of State and the ministerial team have been very clear. There is there is no tolerance at all for corridor care. And the challenge from the ministerial team, and certainly the Secretary of State is for a plan to come back in terms of eradicating it over what time period, by when and who's doing what. So in terms of the answer to your to your question are very clear.
15:53
Rupert Lowe
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Rupert Lowe
Okay, now I've just got two , two other quick questions. So so one thing that also concerned me was it doesn't appear there's a correlation between how much money you spend and how successful you are. It seems you've heard a lot of money at this issue and it hasn't got better. So you've mentioned some things that you're intending to do. I mean, is there a is there an actual better approach than just hurling money at it than you're aware of now? I mean, you've had a chance to look at it. I mean, how are you going to solve it?
15:54
Speaker 1
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Speaker 1
I think the answer is the report is, is looking at the whole the whole of the system. It is right, factually correct. That post Covid, there were 2 or 3 years of significant investment in the in the workforce in this area, but generally across the NHS. That's partly what we've been dealing with in the last year, trying to, you know, trying to address that. Last year was the first year in 12 years we haven't had a workforce growth first year in 11 years. We haven't had to make a call on the Treasury Reserve. So there's a correction going on there.
And I, I mean, clinical colleagues should speak up. I don't think the answer is more money into Eddie. You know, we've definitely got discharge problems. We've definitely got social care investment problems. And we want to do more in, in neighborhoods. So it's more about how we address the whole thing. I think, again, what this report proves and our performance data proves is all of these things are connected. And if we squeeze one part of the balloon without changing other parts of the thing, it's just going to pop out somewhere else. And I think you can see that day to day, and especially in some of the places that Tim and Emma work with regularly, we're part of the system is being fixed, but not the whole of the system.
And that's really what we've got to try and do in this next couple of years.
And I, I mean, clinical colleagues should speak up. I don't think the answer is more money into Eddie. You know, we've definitely got discharge problems. We've definitely got social care investment problems. And we want to do more in, in neighborhoods. So it's more about how we address the whole thing. I think, again, what this report proves and our performance data proves is all of these things are connected. And if we squeeze one part of the balloon without changing other parts of the thing, it's just going to pop out somewhere else. And I think you can see that day to day, and especially in some of the places that Tim and Emma work with regularly, we're part of the system is being fixed, but not the whole of the system.
And that's really what we've got to try and do in this next couple of years.
15:55
Speaker 3
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Speaker 3
So can I add to that? So from the clinical perspective, last week I was visiting 22 Pcns across five regions, and this was a part of a programme that we've been doing now for two years. And what Pcns had done was. primary care, primary care. No, sorry about that. And so we met all the GPS. And what we found is that since we've given them the head space to look at their population, if you like, and using neighborhood and community services, what they've been able to do is look at the most vulnerable people. So they've looked at the people with multiple co-morbidities, frailty, mental health issues.
And those patients, if I may say, were frequent attenders, either in the Ed or in the GP surgery and universally across the 22 Pcns and the five regions, there was a 20 to 30% drop in Ed referrals. As a consequence of that, we've then add to that the care homes. There are care homes that have frequent referrals to Ed when others don't. And again, working with GPS and providers, they are now aware that of the the top three care homes that have the highest number of referrals. So we can work with those in a clinical way to make sure the patients are managed in the right place and get the right care they need and using the community services.
Secondly, with the ambulances, we're working with all the ambulance trusts. I've included Wales in that because on the west part of England, with Countess of Chester and hospitals like that, there's a lot of patients coming from Powis into England from there. And again, we've asked them to do five things this year to standardise, which they're working very hard to do around call before convey here and treat , make sure that we we stream patients and we're going to have the maximum handover time of 45 minutes, but we want it less than that. And also how we manage patients that don't need to come to the Ed that evening, but can come tomorrow, and how we keep them safe in the community.
All of that feeds into the front end of the pathway because as I've said, if we're going to get this right, it's the whole pathway that we have to resolve. And so I think we are making progress there. And as Emma says, we're working at the back end of the whole pathway within the acute trust to try and make sure that we have a we have a better winter in terms of flow.
And those patients, if I may say, were frequent attenders, either in the Ed or in the GP surgery and universally across the 22 Pcns and the five regions, there was a 20 to 30% drop in Ed referrals. As a consequence of that, we've then add to that the care homes. There are care homes that have frequent referrals to Ed when others don't. And again, working with GPS and providers, they are now aware that of the the top three care homes that have the highest number of referrals. So we can work with those in a clinical way to make sure the patients are managed in the right place and get the right care they need and using the community services.
Secondly, with the ambulances, we're working with all the ambulance trusts. I've included Wales in that because on the west part of England, with Countess of Chester and hospitals like that, there's a lot of patients coming from Powis into England from there. And again, we've asked them to do five things this year to standardise, which they're working very hard to do around call before convey here and treat , make sure that we we stream patients and we're going to have the maximum handover time of 45 minutes, but we want it less than that. And also how we manage patients that don't need to come to the Ed that evening, but can come tomorrow, and how we keep them safe in the community.
All of that feeds into the front end of the pathway because as I've said, if we're going to get this right, it's the whole pathway that we have to resolve. And so I think we are making progress there. And as Emma says, we're working at the back end of the whole pathway within the acute trust to try and make sure that we have a we have a better winter in terms of flow.
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Rupert Lowe
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Rupert Lowe
And that's exemplified, isn't it, by this £2 billion in less than a year as a result of people being in hospital for longer than they need to be? Yeah. So my last question really on performance, and this timing involves senior executives and their pay. And I came across the Taxpayers Alliance rich list for the NHS for 26. I have to say, Jim, you came out pretty high up. Looks like you were making out like Dick Turpin at the Newcastle NHS, but I. But I looked up the best and worst performing trusts by any waiting times.
Humber teaching came out top East Cheshire came out bottom. Now for me as a businessman, the key here is it doesn't appear that there's any correlation between the pay and rations of the people who do very well, and the pay and rations of people who do very badly indeed. The person in East Cheshire in a year, the pay went from 172,000 to 370 7500, even though they remained as the worst performing trust for A&E waiting times for the second consecutive year. So is there now a correlation? You do mention in the report that there's an intention to link performance to pay, which must be one of the things you probably need to do to get this problem sorted out.
So has that happened number one? And number two, how many people have underperformed and therefore been penalised since you introduced that rule?
Humber teaching came out top East Cheshire came out bottom. Now for me as a businessman, the key here is it doesn't appear that there's any correlation between the pay and rations of the people who do very well, and the pay and rations of people who do very badly indeed. The person in East Cheshire in a year, the pay went from 172,000 to 370 7500, even though they remained as the worst performing trust for A&E waiting times for the second consecutive year. So is there now a correlation? You do mention in the report that there's an intention to link performance to pay, which must be one of the things you probably need to do to get this problem sorted out.
So has that happened number one? And number two, how many people have underperformed and therefore been penalised since you introduced that rule?
15:59
Speaker 1
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Speaker 1
There's a link to the oversight framework. And in certain segments, this is our way of looking in the rounded organisations and segmenting them . High performer right through to lowest performer and in the lowest categories of performance other than where there's a need to change a team and encourage people to come in to run the organisation. Some of the organisations you've mentioned have had lots of turnover over the years. It would generally be the case that if you're in those lower categories, you couldn't receive a pay rise. That was the intention. It is, as I say, complicated.
If you've had a lot of churn and then you've got to pay the market rates to encourage a chief executive and an executive team to join an organisation in trouble.
If you've had a lot of churn and then you've got to pay the market rates to encourage a chief executive and an executive team to join an organisation in trouble.
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Speaker 1
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Speaker 1
The the action has always been that there was a policy agreed last year that if you're in the lowest segments, you wouldn't earn the pay rise, the annual pay rise. You couldn't just automatically reduce anybody's salary, but you would withhold pay awards until performance was on an acceptable level. That was that has been applied. It is being applied, as I say, with the exception of if you've got an organisation where a team of board is changed and you need to encourage people to come in, you've got to pay appropriate market rates for them to go into that organisation.
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16:01
Clive Betts
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Clive Betts
About frailty and what could be done to improve it. I understand and I understand you've been to see the project. So they referred that to me, that there's been a net saving of about £600,000 per annum as a result of the work done to improve frailty amongst the patients. That's net the cost is, I think initially 350 saving is nearly a million. I understand now the ICB say they can't find the money to continue the project next year. Come on. What's going on? We've got a project that's actually delivering savings, but the the initial funding to deliver those savings is now beyond the ICB at local level.
16:02
Speaker 3
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Speaker 3
So I was there on Friday , and the all the Pcns in Sheffield and Rotherham had done extremely well in terms of what we're talking about. And these these patients with complex needs, reducing the referrals. And in addition to that, two of the two of the trusts, Barnsley and Rotherham, are really, really good in terms of very low numbers of 12 hours and corridor care. They are doing extremely well. To be fair, we had a very good discussion about their their impact and they'd all done. And when you bring all the 22 pcns together and look at the data.
The data is very powerful about how we're going to solve this problem. And so there was a discussion with the ICB, and I have to say , the Icbs were very open and very fair about taking this away, looking at the evidence and then deciding on whether they were going to continue it. And the, the, the message I got from the, the ICB in Sheffield was that they were going to do all they could to make sure it continued. And we highlighted the fact that the clinical staff gone from being where they were just about managing to now, could see real light at the end of the tunnel.
We're really keen. This continued. And so we've asked them they've been given money to show the evidence of what they've done. They're going to produce the evidence across the 22 Pcns, and I think the evidence there is very powerful for it to continue.
The data is very powerful about how we're going to solve this problem. And so there was a discussion with the ICB, and I have to say , the Icbs were very open and very fair about taking this away, looking at the evidence and then deciding on whether they were going to continue it. And the, the, the message I got from the, the ICB in Sheffield was that they were going to do all they could to make sure it continued. And we highlighted the fact that the clinical staff gone from being where they were just about managing to now, could see real light at the end of the tunnel.
We're really keen. This continued. And so we've asked them they've been given money to show the evidence of what they've done. They're going to produce the evidence across the 22 Pcns, and I think the evidence there is very powerful for it to continue.
16:03
16:03
16:04
16:04
Speaker 1
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Speaker 1
So generally on a weekly basis, I get 2 or 3 of these. Often there's a. There's something behind it about the. ICB wants a bit longer on the data to be able to prove its case. Occasionally there's a complete misunderstanding of how the financial flows work, but if I can get the facts, I'll. I'll pick it up with the ICB.
16:04
16:04
16:04
Matt Turmaine
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Matt Turmaine
No, it's quite all right. I'd like to go back to Corridor Care, if I may, for a moment. West Hart's teaching Hospitals Trust in my patch, which runs Watford General Hospital in desperate, desperate need of rebuilding as part of the NHP. And I'm sure you know that. Nevertheless, the team on the ground at that hospital is fantastic and they have eradicated corridor care in that particular setting. So I know a couple of secretaries of state have been to see them and talk about it. I just wanted to know if you could tell us a little bit about when you have that best practice.
What are you doing to share that across the system? Thank you.
What are you doing to share that across the system? Thank you.
16:05
Speaker 2
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Speaker 2
And then we'll pass around. So, so thank you. And several of us have also been to visit West Hearts and they are a fantastic team. I would second that. And I actually took my team from Homerton as well. And we're a high performing trust. But to go and learn for exactly that reason, and I know since then they've actually done several visits. So I think there are lots of good ingredients there. And I think we absolutely have to learn. And the question is then is what do we share and how do we share it across the patch?
From a delivery perspective, there are a couple of things. I think to me, it's number one, it's an exact engagement and it's very clear, certainly from their chief nurse how engaged she is. I'm sure many of us have met her and she's fantastic. And the fact that she got down and spent time in A and E understanding what the challenges to the barriers are, and then made a commitment at exec level that it was going to be no more, that it was a red line for them. And then the questions were, once you've done that, how do you unpick that?
And there's lots and lots, as I say, that they have done there. They focused exactly, as my colleagues have said, from both the front door all the way to the back door. So some of the front door good examples that they've done is called before, convey what's called called before convey. So what they're trying to do, if patients particularly are frail, there is a combination of the ambulance team and the hospital team coming together to say, is there an alternative in their patch that that could be offered to? And certainly we're learning across how do we lift and shift some of that?
Secondly, in the A and E itself, how do you take, as I say, the model that we've done? So we've learned from them. We've they have been round the table for several of our models, particularly model D and model discharge. So how do we take that good practice of seeing that front door, the streaming, the assessment and the flow through a in itself? Thirdly, that hospital part. So particularly around that discharge, again, they have come together with their providers and particularly for their frail, most vulnerable population. How do you ensure a timely discharge? And they have really focused again , there and again, what we've done is we have parted part of part of the frailty.
What we're also trying to do is take three examples of which West Hearts is one. And we have put people together with other good providers and say, how do we replicate this? So we're taking very specific providers with providers to provide that peer support at a local level. And then probably more to Professor Briggs, how do we take it as a an overarching how do we take it as a get it right first time, which is exactly what girth is designed to do?
From a delivery perspective, there are a couple of things. I think to me, it's number one, it's an exact engagement and it's very clear, certainly from their chief nurse how engaged she is. I'm sure many of us have met her and she's fantastic. And the fact that she got down and spent time in A and E understanding what the challenges to the barriers are, and then made a commitment at exec level that it was going to be no more, that it was a red line for them. And then the questions were, once you've done that, how do you unpick that?
And there's lots and lots, as I say, that they have done there. They focused exactly, as my colleagues have said, from both the front door all the way to the back door. So some of the front door good examples that they've done is called before, convey what's called called before convey. So what they're trying to do, if patients particularly are frail, there is a combination of the ambulance team and the hospital team coming together to say, is there an alternative in their patch that that could be offered to? And certainly we're learning across how do we lift and shift some of that?
Secondly, in the A and E itself, how do you take, as I say, the model that we've done? So we've learned from them. We've they have been round the table for several of our models, particularly model D and model discharge. So how do we take that good practice of seeing that front door, the streaming, the assessment and the flow through a in itself? Thirdly, that hospital part. So particularly around that discharge, again, they have come together with their providers and particularly for their frail, most vulnerable population. How do you ensure a timely discharge? And they have really focused again , there and again, what we've done is we have parted part of part of the frailty.
What we're also trying to do is take three examples of which West Hearts is one. And we have put people together with other good providers and say, how do we replicate this? So we're taking very specific providers with providers to provide that peer support at a local level. And then probably more to Professor Briggs, how do we take it as a an overarching how do we take it as a get it right first time, which is exactly what girth is designed to do?
16:07
Speaker 3
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Speaker 3
Yeah. So what we've tried to do is we know now what works. And for me, the, the West Hearts thing is all about leadership. And it's the CEO, the CMO, chief medical officer, and the chief nursing officer. Those three have driven that trust into the place it is today. And so if they can do it, we can do it everywhere. What we've tried to do is try to set standards with what we call the girth clinical operational standards, setting the time when patients come in, when they're seen and then flow through the hospital. We've produced documents about reducing length of stay because we now know how to do that, about how we can improve discharge, how we can use the discharge lounge more appropriately.
So you get ten in there, ten patients there before ten. And then we've got a USC improvement guide building on such as West Hearts and others that are doing things really well. Now we've got those. We've got the teams to go out there with these trusts we're helping, and what we want them to do is adopt and embed all these processes. So I think that's what's going to be different this winter. This is what we want them to do. We don't really want it to be optional because we don't want to lose the learning of places like West Hearts and others.
Medicine, Tunbridge Wells, other Northumbria nor Newcastle where Jim is and what have you. There's some really, really good work out there. You just need to scale that up and then help. And that's what we try and do is help trust clinicians and operational teams, then embed it that, and that's how we're going to improve the flow of patients.
So you get ten in there, ten patients there before ten. And then we've got a USC improvement guide building on such as West Hearts and others that are doing things really well. Now we've got those. We've got the teams to go out there with these trusts we're helping, and what we want them to do is adopt and embed all these processes. So I think that's what's going to be different this winter. This is what we want them to do. We don't really want it to be optional because we don't want to lose the learning of places like West Hearts and others.
Medicine, Tunbridge Wells, other Northumbria nor Newcastle where Jim is and what have you. There's some really, really good work out there. You just need to scale that up and then help. And that's what we try and do is help trust clinicians and operational teams, then embed it that, and that's how we're going to improve the flow of patients.
16:09
Speaker 1
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Speaker 1
And just to add to that, with the help of the Corridor Care Coalition, we've had a couple of events. West Hearts give a very powerful presentation, a nursing colleague, I think, at the first event, and because of their physical constraints, what we found is what's most helpful is people go and see them because it's I mean, it is the sort of place where if you see if they've solved it, it must be soluble everywhere because they've got really terrible physical constraints that they're working with. But and it is an absolute leadership commitment throughout the organisation.
But I think what struck me in the event was just the, the, the power of the nursing voice on standards and compassion and doing the right thing for patients, etc. some took that away and it it's helped their journey. Others are still really struggling with it and haven't quite got off the ground yet.
But I think what struck me in the event was just the, the, the power of the nursing voice on standards and compassion and doing the right thing for patients, etc. some took that away and it it's helped their journey. Others are still really struggling with it and haven't quite got off the ground yet.
16:09
Catherine McKinnell
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Catherine McKinnell
Just a bit to add, I know the trust very well from a very long time ago. The other bit that the leadership have done is worked very well with the local system and local partners, so they are a very good example of a very practical neighbourhood health and care in practice, which they've been doing alongside the internal flow and leadership elements.
16:10
16:10
Speaker 3
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Speaker 3
But yeah, so we're going to work with 40 trusts this winter that we've agreed with the regional Coos and also with Emma deploying the team with these, with these documents and what have you, plus the knowledge and the challenge, but the support to enable that whole pathway to be entertained along with the work we're doing with ambulances and primary care.
16:10
16:10
Catherine McKinnell
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Catherine McKinnell
I may just also add Secretary of State recently announced the investment in urgent treatment centres and the capital, with a further 25 new or expanded urgent care sites to be opening before winter. So it doesn't it's not necessarily about the model of care, but it is about supporting in terms of capacity constraints as well.
16:11
16:11
16:11
16:11
Speaker 1
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Speaker 1
It's mainly because the. Because of that complexity of the system and lots of things needing to be fixed at the same or similar times, the. The more the organisations with the most stubborn problems generally, generally have more of a discharge problem in a bed capacity problem, which is a really stubborn thing. It's a it's a complicated thing to unblock. It involves partners, it's very expensive, you know, etc. so that that would be if we could solve it tomorrow, overnight, we would solve it tomorrow overnight. But we have to do it at a pace that we can afford with partners, making sure every part of the system works together.
16:12
16:12
Speaker 1
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Speaker 1
Yeah. So it's a, it's a , it's a version of what we saw in West Hart, a leadership commitment to basically saying, we're just going to do absolutely everything we can within our power to eradicate this in places where it has been possible, probably where there's been much less of a discharge problem or social care interface problem, it has been more down to the leadership effort and everybody pulling together clinical, operational, administrative, everybody just pulling together to eradicate it. Yes, I think what we're I think what Tim's describing is a process whereby it doesn't work unless there's a leadership commitment that is that focused and that driven to try and eradicate it.
16:13
Speaker 3
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Speaker 3
Yeah. So let me give you two examples where we've gone to help trust that had a real problem, BHUT, which is in going east out of London, they we were asked to go to there because they had 55 patients in the corridor and were struggling to move those patients. So we got a commitment from the leadership, from the medical director, the chief nurse and the CEO that we were going to have this say, this is just not acceptable. We're going to do something very different. And over three months we were able to clear the corridor.
Now, there's been a little bit of slippage back since that time, but on the whole, they are doing very, very much better. So it just shows, I think, what can be achieved. And the other example I would give you.
Now, there's been a little bit of slippage back since that time, but on the whole, they are doing very, very much better. So it just shows, I think, what can be achieved. And the other example I would give you.
16:13
Speaker 3
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Speaker 3
So it was it was the agreement by all that this was unacceptable, that we had to do something really different. Because when you went to the corridor, again, patients over 65 in unacceptable places, and everybody agreed that this was no longer acceptable. So the triumvirate, the chief executive, the chief medical officer and the chief nurse said, right, we're going to do this differently. And we were able to support them with the the implementing the clinical operational standards, how we're going to get discharges out, what we're going to do at the front door. And we were able to make a really big difference.
What was amazing was the morale in the hospital improved so much afterwards, and they could now see that there was a way out of this. I was just going to give you one other example, which is in East Kent, William Harvey. Again, they had patients. They made, I think it was made the news. They had patients in the cost of coffee corridor, which was just totally. They realised that. So they asked us to go and help that. And again, with exactly the same scenario, this is unacceptable. The triumphant leadership, giving them the tools and also support from my team to help them, they clear the corridor.
So again, just shows how working together and this work we're doing in NHS can make a big difference.
What was amazing was the morale in the hospital improved so much afterwards, and they could now see that there was a way out of this. I was just going to give you one other example, which is in East Kent, William Harvey. Again, they had patients. They made, I think it was made the news. They had patients in the cost of coffee corridor, which was just totally. They realised that. So they asked us to go and help that. And again, with exactly the same scenario, this is unacceptable. The triumphant leadership, giving them the tools and also support from my team to help them, they clear the corridor.
So again, just shows how working together and this work we're doing in NHS can make a big difference.
16:15
16:15
Speaker 3
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Speaker 3
It's it was it's a mixture. I have to say. In the early days, I think we were asked to go in, but now we are welcomed with open arms. And in fact, I think we've got too many people asking for our help than we've got capacity for at the moment. But we're hoping to just reorganize the teams. But no, we've never been refused. When we've offered help, everybody said, yes, please.
16:15
16:15
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16:16
16:16
Speaker 1
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Speaker 1
Sorry, he's been he's just started this week, appointed a few months ago. And his job is to try and shift us away from annual surveys into, into a world where we're much more actively measuring experience in a real, real time way. Some organisations do this around the NHS, but try and do it systematically across the whole of the service so that will. He'll have a plan within a few months as to how we're going to go about that.
16:16
Catherine McKinnell
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Catherine McKinnell
And then and then just to build on that for the creation of the new department as part of the transformation, we have a very clear challenge set by the Secretary of State to ensure that how Jacob puts things together, he has the patient voice right at the heart of it. Obviously, the decision around the move, not the move of Healthwatch, the abolition of Healthwatch, to make sure that we truly are taking the patient voice. So the the stuff that's being done, a lot of stuff, the information is being taken locally to make a difference. We have obviously patient complaints that come through reviewing those from a departmental perspective, but the Secretary of State has charged us very clearly with giving Jacob, obviously more than a day to start.
How do we best ensure that we have the patient voice at the centre, citizen voice and family voice at the centre of the stuff that the department does on a daily basis. So I suggest if we can come back with further details on that when he's been imposed.
How do we best ensure that we have the patient voice at the centre, citizen voice and family voice at the centre of the stuff that the department does on a daily basis. So I suggest if we can come back with further details on that when he's been imposed.
16:17
Speaker 1
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Speaker 1
And there was an example started in Northumbria, but continued after I left, I tried to connect patient and staff experience with length of wait as well. So we'll share that with you after after this, if you wanted to see it. And it's that kind of approach we'd like to try and bring to this setting. What that work found was that patients were often more tolerant than you'd expect them to be, as long as they were communicated with and could understand what was going on.
16:17
16:18
16:18
Speaker 2
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Speaker 2
So just to add from a sort of a day to day A and E perspective, we know and we can see hands down that if you communicate and you're clear with the patients, they can see what's going on. So they understand the situation around them. And as long as they know what's happening, they can see what's happening to them. They're actually relatively comfortable and assured. It's when they can't see, they can't understand what's going on, or they wait for extended periods of times with no information in that void. That's where we see most of our complaints.
And I've answered many, many complaints in my times. And that is a hands down standard thing.
And I've answered many, many complaints in my times. And that is a hands down standard thing.
16:18
16:18
Catherine McKinnell
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Catherine McKinnell
Thank you. I'm just going to going to add that none of us are complacent at all about the impact on individuals, as Jim said, both from a dignity perspective and a harm perspective. So I wouldn't want any member of the committee to feel that we are either complacent or not focused on it in terms of the things that need to be done. I think the particular learning is making sure, as Jim said, around the whole system approach, and I'm sure we'll come on to social care a bit, a bit later, but I just want to finish, you know, there's no complacency at all from any of us around the impact on individuals and families.
16:19
16:19
Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
Can I ask you, the president of the Royal College of Emergency Medicine, who I'm sure you know? Well, Doctor Higginson did an interview for LBC, which was headed A and E, facing perfect storm ahead of winter as leading medics warn only 3% prepared for severe pressures. And indeed, he says that the number of people admitted to A&E was 44,000 or nearly 45,000 in August, but in September it was 50,500. So what preparations are you making for a you know, particularly if we get a severe outbreak of something like influenza, to be able to cope with that.
On top of this, quite a distinct increase in summer demands.
On top of this, quite a distinct increase in summer demands.
16:20
Speaker 2
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Speaker 2
Thank you. So I'll start, if I may, chair. So, as you rightly say, I know doctor very well, and he's right to say that we've had a really difficult summer. I think that's the first thing to say. So certainly from an attendance perspective in A and E it has been higher than anticipated and is is maintained. And even in September now it continues. So that we know demand at that front door is a problem. The the good news where I would suggest that some of the investment that we've made and a lot of the work we've made at the front door is working for things like our same day emergency care and our urgent treatment centres.
That increase in attendance is not translating to increase in admissions and hospital. So that is a good thing to take out of some of the work that's been done. That aside, it does because of the flow and the the challenges we've already alluded to at the back door mean we have what's called less operational headroom going into winter, which which is what he's rightly flagging, because the capacity and the hospital and the occupancy of the hospital at the moment is very high and higher than we'd like it to be going into winter. From winter itself, we have done a lot of preparations we've prepared earlier than than usual.
There's there's a lot going on. We've gone out for bringing up some of the previous points on culture. We've gone for board assurance statements about how is the how are the trust and the icbs, the integrated care boards and the regions all assured by their plans? And what does that include? For example, how do we look after our frailest population during winter? How do we ensure primary care is there to meet people's needs? How do we ensure people are vaccinated, particularly from the children's perspective and also from our staff perspective? So all the way through, how do we prevent the things we can prevent, particularly for things like influenza?
Then we come into perhaps preparing the hospitals is another way of looking at it. So how do we we are focusing heavily now on discharge, and we have done since the beginning of September, so that we can clear out as safely as possible some of our hospitals to recreate some of that headroom. So over December, we've created some new data looking at data and discharge delays so we can understand the challenges of what's going on, get some of those foundations right. We've published, as it said in the report, not only the model ID, the acute care pathway, but also the model discharge.
So how do we ensure patients flow safely entirely through our hospitals. And we're working incredibly tightly with social care, particularly about how we can enable that process at the end for hospitals and social care, to work closely together to ensure that we can improve that discharge process at the end there. So we're trying to create some of that additional headroom. Then the third, perhaps I'd bring the committee's attention to is what I call the process, particularly from an NHS England perspective. So we have started that and we've started that formally this week. So that's a couple of fold.
That is, we do every Monday a weekly clinical brief, and that is sharing to the clinicians such as ourselves and the operational teams out in the hospital what is going on, because we assume that information is out there. But often it's not. So even this morning we shared what is flu doing? What is Covid doing? What is the occupancy doing so that people are sighted on what's likely to come, and particularly over the next couple of weeks, so you can be prepared. Secondly, then we've got a coordination cell. So we've got what's called a winter cell, where we're coordinating everything so that we can aim that we only add value.
And thirdly, then how we escalate people in trouble and add support, but also de-escalate so that we're not there to create noise. So there's a huge amount of, of planning, testing for and rigor already gone into this place.
That increase in attendance is not translating to increase in admissions and hospital. So that is a good thing to take out of some of the work that's been done. That aside, it does because of the flow and the the challenges we've already alluded to at the back door mean we have what's called less operational headroom going into winter, which which is what he's rightly flagging, because the capacity and the hospital and the occupancy of the hospital at the moment is very high and higher than we'd like it to be going into winter. From winter itself, we have done a lot of preparations we've prepared earlier than than usual.
There's there's a lot going on. We've gone out for bringing up some of the previous points on culture. We've gone for board assurance statements about how is the how are the trust and the icbs, the integrated care boards and the regions all assured by their plans? And what does that include? For example, how do we look after our frailest population during winter? How do we ensure primary care is there to meet people's needs? How do we ensure people are vaccinated, particularly from the children's perspective and also from our staff perspective? So all the way through, how do we prevent the things we can prevent, particularly for things like influenza?
Then we come into perhaps preparing the hospitals is another way of looking at it. So how do we we are focusing heavily now on discharge, and we have done since the beginning of September, so that we can clear out as safely as possible some of our hospitals to recreate some of that headroom. So over December, we've created some new data looking at data and discharge delays so we can understand the challenges of what's going on, get some of those foundations right. We've published, as it said in the report, not only the model ID, the acute care pathway, but also the model discharge.
So how do we ensure patients flow safely entirely through our hospitals. And we're working incredibly tightly with social care, particularly about how we can enable that process at the end for hospitals and social care, to work closely together to ensure that we can improve that discharge process at the end there. So we're trying to create some of that additional headroom. Then the third, perhaps I'd bring the committee's attention to is what I call the process, particularly from an NHS England perspective. So we have started that and we've started that formally this week. So that's a couple of fold.
That is, we do every Monday a weekly clinical brief, and that is sharing to the clinicians such as ourselves and the operational teams out in the hospital what is going on, because we assume that information is out there. But often it's not. So even this morning we shared what is flu doing? What is Covid doing? What is the occupancy doing so that people are sighted on what's likely to come, and particularly over the next couple of weeks, so you can be prepared. Secondly, then we've got a coordination cell. So we've got what's called a winter cell, where we're coordinating everything so that we can aim that we only add value.
And thirdly, then how we escalate people in trouble and add support, but also de-escalate so that we're not there to create noise. So there's a huge amount of, of planning, testing for and rigor already gone into this place.
16:23
16:23
16:24
16:24
16:24
Speaker 1
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Speaker 1
Not really. No. We've actually had quite a significant growth in demand in urgent care. So roughly 6% this September compared to last September, which is pretty significant when you're on fine margins. But we've also had a significant growth in elective demand this year as well, which were struggling with not quite as high, But we've also had a significant growth in elective demand this year as well, which were struggling with not quite as high, but similarly a problem for us. Our main. We've looked at everything. It's just trying to work out whether there's a. geographical or a kind of disease pattern issue.
It's fairly.
It's fairly.
16:25
16:25
16:25
16:25
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16:25
16:25
16:25
Sarah Olney
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Sarah Olney
16:26
16:26
Sarah Olney
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Sarah Olney
Go there and the default is always go to A&E. So certainly I can come back on some of that. So looking at the increase in demand, there hasn't. There has been a. significant spike over summer in the use of. 111 in the region of approximately 11%. However, that has not translated to an increase in 111. Going over to A&E and that has stayed about the same, which is about.
16:26
16:26
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16:26
16:27
Sarah Olney
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Sarah Olney
Why is performance not improving? Shall I start? So I think it's it's absolutely fair to say there's been a significant increase in resource into the e C so the urgent emergency care sphere. And I think this does. demonstrate that over the last couple of years there has been significant improvement in performance as the report rightly pulls out. However, that has plateaued. So I think it rightly demonstrates that an. investment is required but is not the only answer.
The some of the some of the how it has captured.
The some of the some of the how it has captured.
16:27
16:27
16:27
16:27
16:28
16:28
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16:28
Speaker 2
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Speaker 2
Expensive use of agency. And it's part of that equation that may be a saving. Then let's use the agency. But actually the costs per patient have gone up significantly. I think. 2018 for six years onwards, the cost rose by. £69 per patient allowing for inflation. So lots more money going in and not better .
16:28
Sarah Olney
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Sarah Olney
Service at the end. Not right is it? No. So if I may coming on to the cost per patient. Absolutely. We acknowledge the cost per patient has gone up and then has started to plateau again over the last couple of years. That doesn't surprise me, if I'm honest, being there and an A&E and I'm sure it won't surprise Tim either. The. It is evidenced and also evidenced in the report. The patients coming through to A&E now are much more complex, and that's estimated to be about. 2 to 3% increase in complexity per year.
And the reason that that's happening is the lower complex patients. We are managing to see an alternative environments either the same day emergency care, as I said, in urgent treatment centres by primary care, etc.. So you are you result in that more complex patients coming through to the A&E. The evidence, I think, in the report was welcomed with that. If you saw the increase in diagnostics, particularly on. CTS and.
And the reason that that's happening is the lower complex patients. We are managing to see an alternative environments either the same day emergency care, as I said, in urgent treatment centres by primary care, etc.. So you are you result in that more complex patients coming through to the A&E. The evidence, I think, in the report was welcomed with that. If you saw the increase in diagnostics, particularly on. CTS and.
16:29
16:29
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16:30
16:30
Sarah Olney
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Sarah Olney
Is the system not picking them up a long time before? So I think it depends a little bit on where they are. Part part. Absolutely. And that is exactly our intention, particularly about frailty. Can we manage people in a different way? And that's what Neighborhood health is here to deliver. Some of it is changing how we've worked in emergency medicine over the last couple of years. Perhaps an example, if I may.
So a particular change that's happened is what's called silver trauma. So trauma in the elderly population.
So a particular change that's happened is what's called silver trauma. So trauma in the elderly population.
16:30
16:30
Sarah Olney
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Sarah Olney
If you'd come in having had a fall from standing and you were, for example, 80 years or plus, you probably would have got some X-rays, you would have had a review and some X-rays. Now we know that that was insufficient. And guidelines have suggested we treat people very, very differently. So now in what's called silver trauma, you get a CT scan, which is nearly all of the body. And we've picked up several injuries in that way. So we are we're investigating people in a much more thorough manner .
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Sarah Olney
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Sarah Olney
There is a highlight. I'm. A previous example I've got is there is a campaign. I don't know if anybody's seen it called think aorta. When it is publicised. There is no doubt that that comes to the forefront of your mind, and therefore you are more likely to do an investigation. Another example is particularly on cauda equina. So we know from when the HSB set out their investigation. I think it was in.
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Speaker 3
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Speaker 3
How people are actually treated in the department, what happens when a decision to admit is made, how it actually supported with with partners through through primary care and social care? So the, the important bit is for us as DHS to ensure collectively with NHS England, of course, is to make sure that people are doing the things that actually really do make a difference. Hence all the model documents that have been described in the way.
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Sarah Olney
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Sarah Olney
That that potentially can cause harm. So it's up to the individuals. We, however, are and do support the guidelines which surround us. And some of those guidelines have changed. So for example, I'll bring it back to that. Severe trauma is a guideline. Our nice guidelines have changed. So the expectation is that we do follow .
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Speaker 1
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Speaker 1
Especially younger clinicians coming through when they've decided to not. investigate and something goes wrong, it's pretty impactful on them as well. So that does it just behaviour. So it's not to say that this growth in. diagnostics has gone without any scrutiny or any oversight at all. It is being challenged.
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Speaker 2
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Speaker 2
It's just very, very hard to get the balance right. It's done. During the junior doctors. dispute they weren't around in A and E and the consultant stepped in. There were fewer. referrals from A&E upwards, more decisions were taken at A and E. Is that that sort of reflection of perhaps that, again, junior doctors without as much experience tend to pass things up and into the system.
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Sarah Olney
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Sarah Olney
A more experienced doctor probably won't. So I'll answer that for me. I was working during the E, so I can I can certainly comment. There are probably a couple of different layers there. Definitely. As consultants we are more. experienced and therefore are more likely to make different decisions to our junior colleagues.
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Sarah Olney
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Sarah Olney
The process in most agencies, if I see a patient in A&E, I will then call one of my colleagues, such as the medical colleagues and the patient is referred through the system. A lot of people, staff particularly collated within EDI. So it's actually several other consultants there. So you could easily have a conversation with a colleague that I wouldn't need to refer, because the colleague was here because they were .
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Sarah Hall
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Sarah Hall
Emergency care. And first to start with, the questioning is an addiction. Please. Thank you very much, chair. I'd like to come back to the issues of hospital flow, in. particular the related issues of bed occupancy and delayed discharge. So firstly, on bed occupancy, the report notes the increase from.
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Matt Turmaine
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Matt Turmaine
You think, Professor Briggs , is a safe occupancy level? Yeah, I can say about 85%. I think that's very reasonable. But if you look at the data, what it also shows is that about. 14.7% of all the bed days that we have are are taken up by patients who are ready to go home. And if you're in hospital for a long time, again, there's risk of harm.
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Matt Turmaine
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Matt Turmaine
Loss of mobility, etc.. And so what we've got to do is to make sure that we use every bed available for the right patient. So for me, the part of this, this whole issue is about getting this flow right is making sure we've got our discharges. And one of the things we've been trying to do as part of the, the whole programme of the bringing the right standards is, is having the ward round, starting on time, having board rounds in the afternoon, identifying the patients that are likely to go home tomorrow morning and making sure their discharge summaries are done, their.
toes and really important is transport. That's another really big issue. And making sure the discharge lounge, which is is available now in many, many.
toes and really important is transport. That's another really big issue. And making sure the discharge lounge, which is is available now in many, many.
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Sarah Hall
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Sarah Hall
Either more beds, which was the direction that my colleague was going in earlier, or eliminate the. 4.7 million lost bed days, which is the number that I have here. Which of those two? Well, I mean, obviously it's both. And but how much do you think you can eliminate through eliminating. 4.7 million to .
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Matt Turmaine
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Matt Turmaine
Get down to 85%? And how much do you think we are short of capacity? The second part of the question, I don't know, but one of the things we're doing at the moment is we're working. It's called the Rio, which is working in the Midlands, which is working across six trusts in the Midlands. And what we're aiming to do is eliminate the. P0 I patients go home or P once they need a bit of support, the hospital related delays and really trying to remove those barriers to discharge, because those are absolutely crucial. And what we want to try and do is by doing that, achieve 80%, 80%.
occupancy by Christmas Day and then sustain that in the first week of January. So I think it's both parts. I think one of the things we've got to make sure is every bed is used for the right reason, and that's why we're working with this group, which if it works well and we're already, for instance, seeing the percentage beds occupied by long stay patients is reducing in relation to all other trusts in the Midlands region, which is and they're improving at a greater rate. So we're making progress there. But no, I understand that we've got a certain bed base, we've got an increasing.
occupancy by Christmas Day and then sustain that in the first week of January. So I think it's both parts. I think one of the things we've got to make sure is every bed is used for the right reason, and that's why we're working with this group, which if it works well and we're already, for instance, seeing the percentage beds occupied by long stay patients is reducing in relation to all other trusts in the Midlands region, which is and they're improving at a greater rate. So we're making progress there. But no, I understand that we've got a certain bed base, we've got an increasing.
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Sarah Hall
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Sarah Hall
And there is a there is a need probably for more beds as well. It sounds like quite a lot of that, focusing on the sort of what's within the control of the hospital to accelerate delayed discharge. What I mean, I think permanent secretary, you sort of. preempted how much of this is down to the lack of social care, how much is down to the lack of other. intermediate or step down care? And what plans are you putting in place to ensure that there is more seamless? Join up at that back door .
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Speaker 3
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Speaker 3
With community health services, social care and other provision. If you're okay, I'm going to ask Emma to describe how we are. We have joined up in terms of planning and execution from a particularly with our social care colleagues. From a department perspective, I'll just if I just start today, it's about a third of delay. People waiting for discharge is around social care for social care.
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Speaker 3
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Speaker 3
That would be not the right thing to say. So there is a final bit I'd add, and then I'll just hand over to Emma. Is that from a department perspective with the Secretary of State, a clear. focus on a very on a regular basis, weekly, if not more often, in terms of what are the reasons for the delay, what is happening from a discharge perspective? And we go through on a weekly basis, both in terms of attendances, what's happening from a from a flu, from a weather.
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Speaker 3
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Speaker 3
I just and also be interested what the other two thirds are made up of just on end of life care and hospice, again, as both as part of this, but also, of course, as part of our work around social care reform and the National Care Service, looking particularly at end of life. And what does that mean in practice for .
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Sarah Olney
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Sarah Olney
People at end of life? Do you want to talk about our processes? No thank you. Thank you, Madam Secretary. So as the Permanent Secretary says, the Secretary of State has has brought us all together. So we're all very much around the table. And we're using winter as that leverage to bring that and make that start. So it's very clear that the planning and the winter is across the system and is expected to bring all partners together. And likewise, so from the top, all the way down to the bottom, if you like, the expectation is collaborative working.
We know when people collaboratively work, we get much better outcomes. So those board assurance statements that I mentioned earlier, the expectation is that local authority, etc. around that table, there's also some very specific examples, perhaps going from a national level. So we have declared a. focus on discharge because we know that's what's going to get us through this winter and we've done it together.
We know when people collaboratively work, we get much better outcomes. So those board assurance statements that I mentioned earlier, the expectation is that local authority, etc. around that table, there's also some very specific examples, perhaps going from a national level. So we have declared a. focus on discharge because we know that's what's going to get us through this winter and we've done it together.
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Sarah Olney
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Sarah Olney
What we are doing is hosting regional we're hosting weekly regional. calls where we look at two acute and one community provider. And again, that is us coming together to say, what are your blockers and how can we, if everybody's around the table, how can we cut through some of those barriers and deliver? And then, as Tim then alludes to, there's much more local level, some of it the Rio in the Midlands, but also we've got what's called Dag, which is the discharge and admissions group, which is a.
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Sarah Hall
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Sarah Hall
We are we are taking a much more collaborative approach at looking across the part that sounds positive in terms of working together, but the incentives aren't there, are they, to actually collaborate? So age UK was suggesting in their briefing on Corridor Care that part of the. deterioration in from. March 2022 was that special arrangements for funding social care and discharge that were there in the pandemic came to an end. Do you think that does play a part? And are the arguments to, you know, change the.
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Speaker 3
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Speaker 3
Fund to be able to get people out quicker? I think I was just about to talk about the Better Care Fund for precisely that reason. So the incentives may may be different from a local government perspective and a health perspective, but there is the poor budget in terms of the better care fund , and from both at a national and a local perspective, there is a very clear expectation about what the Better Care Fund is to be used for and how that actually works through in. practice . As clearly as part of our work, to look at how we can better support social care in terms of social care reform, we're looking at what else do we need to do to make sure we've got the right levers from a national perspective and a local.
perspective to support, if it's over and above the better care fund, and how do we actually make the Better Care fund have teeth .
perspective to support, if it's over and above the better care fund, and how do we actually make the Better Care fund have teeth .
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Sarah Hall
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Sarah Hall
Okay. Because obviously at the moment we're spending money on failure, aren't we? 2.7 billion estimated costs of delayed discharge. So we've heard a few of the steps that you've been taken to try and reduce that spend and that cost of failure around the third that may be connected with social care. But can you just say if there's any other big blocks in the other. two thirds and .
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Sarah Olney
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Sarah Olney
How you might be addressing those? I think there are one of the important ones is probably hospital discharge. So there's different ways that you can cut up some of this data. And I think one of the simplest things that we've sort of said is at least. 22 to 23% is within the capability of the hospital, what's called pathway zero. So no immediate changes to care, but just pure process. And that for us is a massive, massive focus. So there are a large amount of patients that go through there. Their delays are relatively low, but at accumulative level then that starts to add up.
So it's about 9000 patients with a three day delay on average. So the question is how do we reduce that. And that comes back to what Professor Briggs has said, which is about making sure the board rounds, making the decision, making sure the paperwork is done on time, making sure those. logistics are all done, the transports ready and booked.
So it's about 9000 patients with a three day delay on average. So the question is how do we reduce that. And that comes back to what Professor Briggs has said, which is about making sure the board rounds, making the decision, making sure the paperwork is done on time, making sure those. logistics are all done, the transports ready and booked.
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Sarah Hall
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Sarah Hall
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Matt Turmaine
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Matt Turmaine
NHS just forget like what, what works? Well, I think that I think Covid has had a big effect on the health service without a shadow of a doubt. And I think some of the learning has been lost, both the operational side and also clinically. And so I think the great thing we have with the Gerf program is people respect it, got the right clinical leaders who we can go back out there now and redo that and relearn it. The key will be to embed it. And this is what myself and Emma really, really trying to do to make sure that it sticks and we actually get that flow right.
And those discharges, I think we now have a programme and working together that we can make this work this time. And I think it's really important it does. So that's where we are. And I think as we go forward in winter with the 40 providers, we're .
And those discharges, I think we now have a programme and working together that we can make this work this time. And I think it's really important it does. So that's where we are. And I think as we go forward in winter with the 40 providers, we're .
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Speaker 3
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Speaker 3
Going to trust, we're going to be working with, we hope that we'll see significant progress, if I may. So just just to add, Jim's talked about this before at the committee around around the muscle memory and setting the. expectations and NHS England holding every single leader within the NHS to account for what is you know, this is the national standard.
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Speaker 1
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Speaker 1
The Health Foundation thing. But we're putting a lot of emphasis in trying to rebuild. capability and the curiosity in the board and the hunger to try and find a place that's done it better, improving something where the evidence is either here or abroad. Emma and I had an interaction over the weekend on email as well, about whether we like it or not. A large part of our. workforce has only worked in this kind of context. They haven't worked in a four hour world necessarily. They haven't worked in a world where it's been anything other than a slog to try and find beds for patients.
I can remember what it was like, and I remember, you know, how lovely hospitals were when there were free flowing and Eds were empty. But that's not the experience that a lot of our staff have ever had. And the other bit just just as a check on the the problem with macro stats versus local stats, we often default to the discharge thing being a social care problem. That was never really my experience as a hospital leader. Our council partners were brilliant in the North East generally, and whereas in other parts of the NHS, social care is a really big part of the part of the problem.
So we have we have to have a nuance between our overall national.
I can remember what it was like, and I remember, you know, how lovely hospitals were when there were free flowing and Eds were empty. But that's not the experience that a lot of our staff have ever had. And the other bit just just as a check on the the problem with macro stats versus local stats, we often default to the discharge thing being a social care problem. That was never really my experience as a hospital leader. Our council partners were brilliant in the North East generally, and whereas in other parts of the NHS, social care is a really big part of the part of the problem.
So we have we have to have a nuance between our overall national.
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Sarah Hall
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Sarah Hall
Differences and variation as well. Otherwise we'll solve solve the wrong problem. One final question, if I may, to Jeffrey, and I'll start with you, Sir Jim, but please feel free if there's anybody else wants to come in. And really is about data and technology. So I went to visit the Bradford Royal Infirmary to their amazing. I guess it's a bit like air traffic. control with a. Basically data screens showing who's coming in to A and E, all the flow through the hospital and who was being discharged. And so they could. anticipate as demand was coming in through A&E, they could be sending people to say, right, these are ready to discharge.
Can we accelerate them going out? So they were able to in one place. It was very calm in there actually. I've never like gone with the days of screaming down the phone if we've got a bed, have we got a bed from somebody? It was all very calm and wonderful. So I was like, I mean, the results are not too bad. They've got 83% A&E performance for our performance. It's not the worst. But how much does a model like that in terms of, you know, being able to have real time data, a control centre effectively for the hospital?
I have no idea how widespread it was. It looked really to be brilliant. So how much can is is that sort of tech and data something that .
Can we accelerate them going out? So they were able to in one place. It was very calm in there actually. I've never like gone with the days of screaming down the phone if we've got a bed, have we got a bed from somebody? It was all very calm and wonderful. So I was like, I mean, the results are not too bad. They've got 83% A&E performance for our performance. It's not the worst. But how much does a model like that in terms of, you know, being able to have real time data, a control centre effectively for the hospital?
I have no idea how widespread it was. It looked really to be brilliant. So how much can is is that sort of tech and data something that .
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Speaker 1
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Speaker 1
Also can help get down these delayed discharges? So it's not it's not the only thing. So again, in my Northumbria experience at that time, the trust was quite poorly developed from a technology point of view, although it did have bed management technology which was hugely valuable. Bradford are generally one of the top ten performers in the weekly ed stats, so they're actually .
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Speaker 1
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Speaker 1
And they come and come and visit. If you haven't recently, it's great. Yeah, absolutely. In the command centre is really impressive when you see it. Lots of people are trying to either replicate that. So they've got an EPR instance that's similar to them that can replicate a lot of it, and then others are using adapted approaches. But if you if you haven't got live data on your, your bed occupancy and who's ready to go and all those things, you know, you're going to really struggle. So it absolutely has to be , has to be part of the plan.
But that. technology without the leadership will, without the clinical and operational alignment, without the whole system being in sync with each other isn't going to get you there either. And I've seen a bit of that at times where people have put the technology in and think that would solve it. But if you if you haven't got a good relationship with .
But that. technology without the leadership will, without the clinical and operational alignment, without the whole system being in sync with each other isn't going to get you there either. And I've seen a bit of that at times where people have put the technology in and think that would solve it. But if you if you haven't got a good relationship with .
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Tristan Osborne
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Tristan Osborne
Fantastic job there. Thank you chair thank you. Anna. Chris. Thank you very much, Mr. Chairman. Many of my questions have already been answered, but I am going to focus on a couple of areas. So I represent Medway and Kent, the Kent and Medway. ICB has challenges and Medway Maritime as well. So my question is just. around the ageing. The over 65 population in my area has grown by. 25% in ten years. We know that those people are much more likely to go into hospitals. The bed population has not grown in a similar guise. Similar. The the care home capacity in the in the local community hasn't either.
So the hospital struggles . Can I , can I ask if you I know you've mentioned alluded to this question, have we modelled which parts of the. country have some of these process problems and which potentially is in the North East, and how many are related to. specific care problems in those localities? Do we .
So the hospital struggles . Can I , can I ask if you I know you've mentioned alluded to this question, have we modelled which parts of the. country have some of these process problems and which potentially is in the North East, and how many are related to. specific care problems in those localities? Do we .
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Speaker 1
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Speaker 1
But when when there's a cause for. concern that Emerald come in on this. We have an approach called hearing where we'll we'll look at an organisation and a system. And then the first step is a diagnostic. So what's going on here. Where do we think this system is out of balance. Can we bring data and insights and then connect to somewhere else in the country that has a similar problem and has been able to solve it. So it's not a one size fits all thing. It's all it has to be quite tailored. The system you've described has.
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Speaker 1
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Speaker 1
That are really multifactorial. So it is one of a handful of most worrying places in terms of all the problems they've got to solve. But I can assure you it is very tailored. There's a lot of data analysis goes in initially to just try and work out exactly what's going on, and then try to help with .
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Sarah Olney
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Sarah Olney
Targeted support and intervention. Anything you want to add, Emma? No, no. Probably not. Maybe a little. Sorry. Having said that. So there's a degree of absolutely. We look at very specifics because everybody is not the same. Everybody's population is not the same. Everybody's needs not the same. Everybody's A and E is different. So the question is we try and do two things. One from a model. What can we take that does what can we do once, but what actually needs completely nuanced? And we try and balance exactly that. And certainly when it comes to specific support, it very much depends on population needs, primary .
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Tristan Osborne
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Tristan Osborne
And there's a clear plan going forward, which I'm really impressed with. So there is change coming, and I think there's this confidence in that ecosystem about that. I just wanted to put that on the record. My second question is just around the fact that you're right. In parts of the country, the care system, which represents a third of the discharges, is extremely. expensive and has also seen a reduction in the number of beds. Is there any nuance around perhaps supporting some icbs around expanding some of that community capacity? Because we have ostensibly a privatized care model in our area, it's extremely expensive for the council.
Councils are struggling financially. Is there, is there is there a dialogue with M, C H, MH CLG and others just around? How do we build that capacity? And my second part of that question is just around. There is a proposal by the NHS to move more into. neighbourhood at the moment. Obviously a lot of people entering primary are in hospitals are secondary care. There is a concern that as you take money out of hospitals and move it into neighborhoods, that they won't have the capacity to deal with these challenges.
Councils are struggling financially. Is there, is there is there a dialogue with M, C H, MH CLG and others just around? How do we build that capacity? And my second part of that question is just around. There is a proposal by the NHS to move more into. neighbourhood at the moment. Obviously a lot of people entering primary are in hospitals are secondary care. There is a concern that as you take money out of hospitals and move it into neighborhoods, that they won't have the capacity to deal with these challenges.
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Speaker 1
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Speaker 1
And it has that. Has that been fully gone through? Yeah. I'll take the second one of it, sorry, and I'll dodge the social care. Mhclg one for some, but the neighborhoods thing is, is one of our core priorities. And it's, it's, we absolutely need to be. shifting people who are in hospital and care for them more locally wherever possible. That's what the whole philosophy is about. But also in a value for money way. There's a huge tension every day about, do we just take a lot of money out of the hospital sector and invest in that, and then hope that it stems the flow?
We've done that before over over my career and it hasn't worked. And we've ended up with double running. Or can we stimulate things with financial mechanisms? Hopefully in the next couple of weeks, we'll meet a group of GPS who want to take more risk in outpatients, for example, where they think they can shift out the outpatient model. That would then free up resource to allow them to start investing in other things. But importantly, it reduces the burden of work in the hospital sector. I've just left the discussion earlier on about this, actually, and I get played back to me a lot about what do we do with the stranded costs.
And in the hospital sector, when people have lost income because they've lost work, I honestly think that would be a lovely problem to have , because every hospital in the country is just absolutely full of the gunnels. So I'd like us to take a bit of risk on shifting.
We've done that before over over my career and it hasn't worked. And we've ended up with double running. Or can we stimulate things with financial mechanisms? Hopefully in the next couple of weeks, we'll meet a group of GPS who want to take more risk in outpatients, for example, where they think they can shift out the outpatient model. That would then free up resource to allow them to start investing in other things. But importantly, it reduces the burden of work in the hospital sector. I've just left the discussion earlier on about this, actually, and I get played back to me a lot about what do we do with the stranded costs.
And in the hospital sector, when people have lost income because they've lost work, I honestly think that would be a lovely problem to have , because every hospital in the country is just absolutely full of the gunnels. So I'd like us to take a bit of risk on shifting.
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Speaker 3
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Speaker 3
I think realistically, that's a few days down the path. And then in your in your first question, answer your first question. Yes, it's a summary. So obviously linked through to the Casey Commission. And what does the future around the National Care Service look like in practice? Obviously not waiting for that, although that has been brought forward. Definitely. As part of our winter planning, we work very closely with the other government department. In fact, they're part of the winter team. And in terms of what can we what do we do locally in terms of understanding capacity locally, there is a a piece of work that we're just looking at at the moment, which is obviously around with ministers around social care reform for workforce.
What does that actually look like from a capacity perspective? What does that look like in terms of supporting our.
What does that actually look like from a capacity perspective? What does that look like in terms of supporting our.
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Tristan Osborne
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Tristan Osborne
The future of how the funding around care home sector? Okay. And just my last question is I'm conscious of time. So you may are there any data gaps here? So is there anywhere where we need to be much more cognizant of data where we have data weaknesses? I think some of your answers have alluded to the fact you might need to improve some of the data collection, or the data collection needs to be standardised better. For instance, you mentioned about bed. How do we define bed blocking, for instance, is there a is there a national definition around that that every hospital is working to.
Because if there isn't, then how do we know that the data is really salient and. And just lastly, on the seven day.
Because if there isn't, then how do we know that the data is really salient and. And just lastly, on the seven day.
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Tristan Osborne
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Tristan Osborne
Obviously that could be how do we get hospitals into a seven day service sort of process? Because obviously they have the staffing and they have the capacity potentially in terms of the building, but how do we get the operational elements to get to that point so that we can have more efficiency with .
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Speaker 1
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Speaker 1
On discharge delays, the. There's a bit of. subjectivity and. blurriness at times. That would be really nice to be really definitive. And some of that's our data, but sometimes it's just complicated patients where it's hard to tell, is this a social care problem or a health problem? People need something and we need to get better at tightening that data up. I would also love a scenario.
I think this is referenced in the.
I think this is referenced in the.
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Speaker 1
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Speaker 1
Where at every stage of the pathway were clear how long every stage should take and whether actually complying with it. We're nowhere near being able to do that, and not even not just setting the standards, but having the technology that could work in that kind of real time. There's no one in the world able to do it yet, but that within the next few years, I would have thought that would that would be possible and within, within reach. So we're working with the data that we've got.
We're trying to refine it as much as we can,
We're trying to refine it as much as we can,
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Speaker 3
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Speaker 3
But there's always going to be a bit of, you know, a bit of blurriness in it. I think, I mean, to go back to the question was earlier asked about patient. experience from a from a patient or family perspective. They just expect us to know from across health and social care and within the hospital what's actually what's actually going on. So it's not really a very good answer for any of us to say to any member of the family. Well, actually, it's because of this. So there's always a need to make sure that we've got the the most joined up data.
possible and that everybody agrees on the data. So you've got past the argument. Well, actually, it's not a social care delay. It's this this day we do have data on those patients with no criteria to reside, which is a is a terrible expression, but which is kind of breaks down where the delays .
possible and that everybody agrees on the data. So you've got past the argument. Well, actually, it's not a social care delay. It's this this day we do have data on those patients with no criteria to reside, which is a is a terrible expression, but which is kind of breaks down where the delays .
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Sarah Olney
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Sarah Olney
From one trust to another to another? So there's, there's two in there. So with regards to the corridor care definition, there is a clear. definition that is available for all there. There is naturally some local interpretation on that. And we know that that is happening. And certainly that is a conversation that goes on particularly amongst clinical and operational bodies from a what you define as a bed blocking. There is no definition there as such. But what the team have explained, what we've got. recently is a new acute discharge. SitRep is what it's called, which defines what the patient requires.
So from the point of view, you are ready for discharge. What do you now need. And it's what's called pathway based. So it's needs based. It's not perfect, but it does give us an idea how many patients might not have any needs to go. No care needs additional needs to go home. So on pathway zero all the way to the opposite end of pathway three, where you might need a care home, because it gives an idea about where we would be best to focus,
So from the point of view, you are ready for discharge. What do you now need. And it's what's called pathway based. So it's needs based. It's not perfect, but it does give us an idea how many patients might not have any needs to go. No care needs additional needs to go home. So on pathway zero all the way to the opposite end of pathway three, where you might need a care home, because it gives an idea about where we would be best to focus,
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Speaker 1
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Speaker 1
Looking at those delays and the bed potentially that has lost during that time. Just sorry, just that as well. So I think on this discharge thing, I can't. overemphasize the need for all partners to work together. There's nothing worse than if you're a family member on the end of it. And it sounds like health and social care are arguing about whose problem it is. We just that needs to be as joined up as it can be in the best places. Really deal with that properly. I think I would also come back to the crowding point earlier on.
I'd love to have us have a crowding metric, and we've talked about that, see if we can construct something together that I think would be really useful for us in trying to make the.
I'd love to have us have a crowding metric, and we've talked about that, see if we can construct something together that I think would be really useful for us in trying to make the.
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Speaker 3
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Speaker 3
Improvements in this area as well. Thank you very much. Just the other point I was going to make was . it's pathway based. We don't use the expression bed blockers. I wish I no , no no no no no no, I know absolutely no. Because you were saying yourself because it's an individual within that bed and it's, it's an making somebody feel as if they're in the wrong place is that was the definition previously.
But as Emma said, it's. understanding the pathway delays for the reason. Because .
But as Emma said, it's. understanding the pathway delays for the reason. Because .
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Speaker 1
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Speaker 1
As Jim said right at the beginning, the dignity of the. individuals involved as well. And the corridor care metric was started from scratch with the coalition as well. So Tim and I have all been to this, this, this hospital, which I'll not name, but we was an outlier, had terrible. visible patients on corridors. When I went to see them, there were no patients on.
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Matt Turmaine
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Matt Turmaine
A start and try and take a stand and start shining a light on it. Can I just say about the seven day hospital? One of the conversations we're having is because discharges fall off for the weekend. And what's going to be absolutely critical this winter is we maintain that on a Saturday and Sunday, because what happens otherwise trust then are blocked up by the Monday. Don't free up until the Tuesday, Wednesday. And we've got to change that. So conversation ongoing about making sure the discharge lounge is open at the weekend, making sure we get the ward rounds done at weekends again, the board rounds.
So we make sure it becomes a seven day hospital. And we absolutely maintain our. discharges during the weekend. That which means on the Monday, you start afresh and you .
So we make sure it becomes a seven day hospital. And we absolutely maintain our. discharges during the weekend. That which means on the Monday, you start afresh and you .
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Matt Turmaine
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Matt Turmaine
Why are they not doing the same thing to get people out on a Friday before the weekend? So that's part of the. conversations that Emma and I are having with individual trusts, systems and what have you. Again, I think it's part of the relearning. And I think what we've got to do is just make it become business as usual, which it hasn't been. And so but I think people are now beginning to. understand the need for this discharge lounges at weekends, being open is going to be critical. And what they mustn't do is get bedded by patients that come in the night before.
But if we can get that right and then get the. clinicians and the teams coming in to do the ward rounds and also. discharging by nurse led discharge .
But if we can get that right and then get the. clinicians and the teams coming in to do the ward rounds and also. discharging by nurse led discharge .
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Matt Turmaine
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Matt Turmaine
Thank you. I'm Matt Tamhane, please. Thank you . Chair. I'd like to talk about the delivery patterns. And Sir Jim, if I could direct my question to you, that would be great. The Nao report says that the main objective of the two year. 2023 plan was to deal with reduced patient flow through. hospitals resulting from increased bed occupancy rates, which NHS saw as the key.
driver of falling A&E performance.
driver of falling A&E performance.
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Speaker 1
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Speaker 1
I think the way so this is the 23 plan was before my time in this role, but from memory, the team were very focused on long ambulance waits as well. And actually, to be fair, made a pretty significant improvement in category two performance with sustained that through last winter also. So it was as stated in the plan. But then after the plan was.
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Speaker 1
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Speaker 1
There's a really big focus on category two performance and handover delays, which did improve fairly dramatically. What we're now doing is just trying to take a more rounded approach and a more tailored approach, as we've discussed there before as well, and make sure that in particular. organisations and systems were focused on what the .
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Speaker 1
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Speaker 1
Plan did deliver. Yeah, a lot of what it was supposed to do. Yeah, I would hope so. I've described before the we're trying to deal with an awful lot, you know, and I think when you when you look at it, you sit back from all of this. What local leaders are trying to deal with is, I think, often. understated the level of.
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Speaker 1
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Speaker 1
The. financial turnaround they're trying to trying to pull off the delivery of or improvement of standards across elective urgent care, the big shifts, you know, etc.. There's an awful lot that we're trying to do at the same time compared to other times in NHS history. We're trying we're trying to improve at a rate that's much quicker than ever before in a much tighter fiscal context. The economy is much tighter than it was in the last time we made big improvements, you know? So we're all cognisant of that and just trying to, you know, keep the right pace, keep things as stretching as we can, but also not so .
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Sarah Olney
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Sarah Olney
I used to be the Chief Operating officer Thompson. So probably crosses both. So that probably stems all the way down really from again that grip and control which I think we've hopefully alluded to. So yes, it's about resource. Yes, it's about mapping out that pathway, but it's also about getting hold of your data. It's about. understanding what your flow and your patterns look like and what that means. And that's all the way down from executive and from board to down to the individuals on the ground. And some of that hopefully comes by the the models that we've alluded to.
So again, the. expectation is comply or achieve by other means. So for example model ID it is there. It has come from the learning. So how are you implementing it if you are not achieving. And likewise again through that grip and control that we've alluded to across that next 72 hours. So what's the board round look like? The expectation for you to discharge the patients, etc.. And then .
So again, the. expectation is comply or achieve by other means. So for example model ID it is there. It has come from the learning. So how are you implementing it if you are not achieving. And likewise again through that grip and control that we've alluded to across that next 72 hours. So what's the board round look like? The expectation for you to discharge the patients, etc.. And then .
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Speaker 1
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Speaker 1
Doctors affected the performance of these two plans? So a really good point. And potentially going into another industrial action soon with consultants, which is. terribly difficult to manage, is everybody will be aware. When you look back at last year, it is easy to forget that we had a lot of rounds of industrial action with resident doctors. Now we saw in the event, as colleagues have pointed out, performance improves short term, but then over the longer period you pay, you pay the price, you know that you get.
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Speaker 1
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Speaker 1
Afterwards as things start to settle down and everyone starts to, you know, get back into balance, etc.. So it's hugely. disruptive from a performance point of view, no question about that. I think the biggest issue though, is it squeezes headroom, leadership headroom, clinical headroom for innovation. All of the things that were that are highlighted. And we've talked about today. Absolutely everybody you meet will want to do them. You know, very, very rarely meet anybody who is arguing about whether patients could be in a different setting or whether we could improve discharge, or it could be more seven days.
It's just really hard to do when every every few weeks you've got to strike. So there's the headroom impact. You know, how people got the time in the head space to do it. There's the financial. impact and then there's the actual performance impact, the short term gain for longer term. deterioration over time. You weigh all those things up .
It's just really hard to do when every every few weeks you've got to strike. So there's the headroom impact. You know, how people got the time in the head space to do it. There's the financial. impact and then there's the actual performance impact, the short term gain for longer term. deterioration over time. You weigh all those things up .
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Speaker 1
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Speaker 1
Ensure that they're getting the right care in the right place? Yeah, I'll bring bring Emma in in a second. But you're right, Anna, and especially when you look at very long waits, is a very big proportion of those patients are mental health patients. And Hugh, you know, it's a wrong place for them. It's not the right environment for them.
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Sarah Olney
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Sarah Olney
But Emma do you want to pick this up? Certainly. So mental health patients are obviously very vulnerable and particularly, as you rightly pointed out, have an extended long stay in A&E. And I suspect there's a significant. proportion of patients in those. 24 hours are probably mental health patients. It's all the way through the path really. So again, we've invested how can we how can we prevent those patients escalating to this need so that they don't require an A&E?
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Sarah Olney
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Sarah Olney
A and E is the last place anybody should end up. So what does that look like, for example, then things like crisis cafes and community. healthcare in primary care. So how do we make sure people are as well as possible all the way through? Certainly. Then when people are either heading towards A&E. How do we ensure we've got the collaborative pathways, right. So for example, mental health in A&E, we've also got mental health lines on one, one, one and also with the 999. So how do we make sure that individual goes to the right and the safest place that they can do once in A&E?
Care and safety is obviously paramount. So how do we look after that individual, and how do we also make sure that they get the needs they want most a and E's now have what's called a psychiatric liaison service. So a direct.
Care and safety is obviously paramount. So how do we look after that individual, and how do we also make sure that they get the needs they want most a and E's now have what's called a psychiatric liaison service. So a direct.
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Sarah Hall
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Sarah Hall
Expectation is that that is a synchronous review. So you don't wait for one person, followed by the other people employed by the mental health trust. Who are they? Usually people who are employed by the mental health trust co-located in the e D yes. And does it actually count as a place of safety? I mean, is it set up to meet standards to allow people to be.
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Sarah Olney
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Sarah Olney
There are there are. variations in standards. So A and E by definition, in most AA and E's is declared as a place of safety. Not necessarily the same thing as saying have we got a safe environment for an individual? So I would certainly say from a noisy A and E, that is far from ideal, from a poor patient that is acutely disturbed during that time. So what we're trying to do very much is say, what does a mental health A&E and what does other things look like that we could get those individuals to the right place.
A lot of the delays that go on for these individuals are because of the. complexity of, of, of their needs, plus also the, the mental health beds that's required and some of the process .
A lot of the delays that go on for these individuals are because of the. complexity of, of, of their needs, plus also the, the mental health beds that's required and some of the process .
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Sarah Hall
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Sarah Hall
But there are also delays around the process for those individuals as well. So we're good to actually get the data on that if possible. I mean, I respect your personal opinion, obviously, Emma, but it would be good to get that. And then sorry, on a different topic, in the evidence we received, we heard, and I think you talked about some of these other units you used some acronyms in. And there seem to be widely used, but I don't actually know what they stand for.
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Sarah Olney
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Sarah Olney
Which is where you might see more minor illnesses, minor injuries, and is part of what we call the left shift from A and E. So how do you take some of the lower acuity patients out of A and E to reduce crowding very much on the area on the clock, apologies and performance rate is high. At least. 96% of people are seen within the four hours. There is then what's called same day emergency care. So that is almost the other end if you like. So in A&E, if I was thinking of admitting a patient, I might see if they could instead be seen in the same day emergency care where their care might be.
coordinated in a much faster fashion, both from a consultant level. So they get the consultant's review, they get the.
coordinated in a much faster fashion, both from a consultant level. So they get the consultant's review, they get the.
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Sarah Olney
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Sarah Olney
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Sarah Olney
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Sarah Olney
You now might get that if you can walk and go home. safely through a same day emergency care system. There's then a new area in model Ed, which what's called iMac as well, which is. extended emergency medicine, which is specifically to remain under A&E. So that might be if I'd seen a patient and I wanted an additional blood test that I think that, again, that they could go home with, that they might remain in me under that time.
So they'd remain in the in the .
So they'd remain in the in the .
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Sarah Hall
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Sarah Hall
Out in the next couple of weeks to just say, can everyone just comply with these standards? I mean, innovation, great. As long as it's for the right reasons, getting people safe, care in the right place, and whether it's on the clock or off the clock. I mean, in a way, the main thing is that people are doing the right thing and not being driven by the target, and they're driven by safety and quality. So can you give assurance that this.
proliferation of different models and different units is, is still .
proliferation of different models and different units is, is still .
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Speaker 2
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Speaker 2
Questioning, Clive, please. Yes. Just do follow ups. We've talked quite a bit about the need to have a whole system, end to end approach in hospitals to the challenge of A and E, amongst other things. Refer back to my colleague Anna Dixon's comments about the system in Bradford, where there is a, you know, a controlled position where the management of the hospital can see where everyone is, what the delays are, what the obstacles are.
And look at every patient.
And look at every patient.
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Speaker 1
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Speaker 1
Many trusts don't have that. Why? Because they don't have the the technology infrastructure. We're going through a process of. everybody installing an EPR, which is one of the core electronic patient record, one of the core. fundamentals that allows us to start being built out. The system in Bradford. As I understand it, it did involve quite a significant investment. So not every not everywhere can afford to do that. And we can't afford to do it all nationally, everywhere. And also in an ideal world, you wouldn't just have the. hospital data and all that. You'd have what's going on in primary care, what's going on in the social care system as well.
I honestly think, Clive, over the next sort of five years. Definitely ten years, this will be built out. It'll be everywhere. It'll just happen organically. But we can't. We haven't got the resource and the technology fundamentals in every .
I honestly think, Clive, over the next sort of five years. Definitely ten years, this will be built out. It'll be everywhere. It'll just happen organically. But we can't. We haven't got the resource and the technology fundamentals in every .
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Speaker 1
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Speaker 1
Been there 5 or 6 years, I think now as well. From memory, every bed, every patient. Yeah. It's a well it's a well. established way ahead of nearly everybody else in the, in the in the NHS because they made some early moves when they put an EPR in. That's some again, from memory, some technology. investment from the technology companies to try and prove the case. But that's not the case everywhere. And you've heard before, you know, we're trying to get everybody up to a basic .
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Speaker 1
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Speaker 1
Going to take time. There'll be a central drive to do that. There is. But it's if every hospital I mean, I think again, I'd be guessing it's maybe. 4 or £5 million to do that in But also, even if we had the money, we have to bear in mind what everybody else is trying to cope with, all of the things that people are trying to deliver at the same time. There's a .
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Speaker 1
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Speaker 1
Can actually absorb . without it. It's hard. It's harder thinking about some of the improvements. It's harder. But there are simple bed management systems around that are really effective, and people are using them really. effectively to, to, to, to manage flow with good performance. So it's not, it's ideal and it definitely would enhance the ability, especially if we could do it across the .
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Speaker 1
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Speaker 1
Hospitals got to manage management systems in place in everywhere has a has a version of. And it could be. Yeah. Well, it means different things to different people. I've lived in a, in an environment in Northumbria that had a had, as I've said before, didn't have a big mainstream EPR, had a brilliant bed management system. I went to Newcastle hospitals that had a well, very well known EPR, but didn't have a digital bed management system. It was very much old school in the way that that was developed and couldn't. The EPR couldn't cope with a bed management system being attached to it.
So because of our. infrastructure being built over time and .
So because of our. infrastructure being built over time and .
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Clive Betts
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Clive Betts
Everybody's got a different inheritance, it's very complicated. It's a big problem, needs addressing. Yeah. Just about the the join up then across the piece, perhaps permanent Secretary or yourself, sir Jim would answer. And that's about trying to get local leaders generally together to address the issues, particularly the interface between the health service, social care, public health, right across. I think, you know, my comments in the past about the Icbs withdrawing from this process and the importance of actually having named officials in the NHS who can link with that named. counterparts in social services and public health.
It's worked really well in Sheffield in the past. It's been pulled apart .
It's worked really well in Sheffield in the past. It's been pulled apart .
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Speaker 1
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Speaker 1
Now and get addressed properly across the piece. Absolutely. And as Emma has described, all of our local winter planning processes should be whole system. So we obviously start in the NHS, but locally you'd expect all partners to be working together. Everything we're talking about with regard to neighbourhoods, for example, and our work in frailty , etc., were really clear. No single. organisation can deal with that by themselves. We've discussed before when your ICB changes happened, there's a your view strong view was there was a loss of focus in place. Secretary of state, last week in a conversation about our operating models being very, very clear with us that.
arrangements at place, however, they are developed and delivered partners working together, mainly health and social care, working together with other partners has to be a core.
arrangements at place, however, they are developed and delivered partners working together, mainly health and social care, working together with other partners has to be a core.
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Matt Turmaine
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Matt Turmaine
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Rupert Lowe
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Rupert Lowe
On the various NHS trusts, which I think is one of the points they made. And listening to this very useful debate today. My question to you is, so when an NHS trust doesn't follow your. recommendations and it basically falls short with regard to the amount of hours, say 24 hours, people have to wait and it falls outside your guidelines. I mean, what .
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Speaker 1
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Speaker 1
Exercise those powers very carefully. Have you ever used them? We're in the process of using it somewhere now in. England on another matter. So these things do happen. Generally our intervention will involve removal, removal of key individuals, removal of a board. implanting a turnaround director, etc. but these powers are used as a process to go through. You have to have the legal instruments in place.
But as I say, as of today, a set of actions were initiated last week to. enforce some clinical. change where we .
But as I say, as of today, a set of actions were initiated last week to. enforce some clinical. change where we .
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Speaker 1
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Speaker 1
Got the power of censure over those people who are failing to deliver, but it can't be the first tool you get out of the box and it's all in this area. Everything we do is about managing risk. Everything that local leaders do is about managing risk. There's a real. chance we increase increase risk by not knowing the .
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Speaker 1
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Speaker 1
Nuances and operational and clinical systems well enough. And I think also there's a point here about . our whole model only works if boards do their job. And you know, we need to really build board capability and capacity over time , because in all of these things, there's a natural inclination, obviously, from our point of view, that we have to solve every problem nationally. It's not can't, can't work like that. Everything has to be solved locally with a few things resolved nationally,
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Matt Turmaine
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Matt Turmaine
What we've seen now is trust. Build a. dashboard where they can monitor real time, whether patients are being seen at the right time and, and find out the reasons why that doesn't happen. And then there's the conversation with the chief medical officer about why it's happened and how we prevent it happening again. And I think that'll be quite.
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Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
It's going to make them, I hope, quite a difference. Rupert, thank you for asking that question. I don't want to get anybody into trouble, but there was exactly the same question I was going to ask about my own trust. I visited one of my local hospitals. I'm not going to name it in the early summer. And they did have some capacity, admittedly, but they had a delayed discharge payment patient who had been .
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Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
That hospital for 120 days, 120 days. And I checked it. I didn't believe I'd heard correctly. Now I see my trust is at the lower end of the four for our target at 63%. Does seem to me that somebody needs to pay some attention somewhere. Yeah. Will do. Thank you. Could I just, while you're sort of on your feet metaphorically, Jim, we you will recall in our earlier hearing on hospital building programmes, had some discussion about the number of beds. Given the evidence we've got in this report from the. Now that another 9 to 14,000 beds would make a huge difference to this whole matter, have you altered or are you do you have a different policy .
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Speaker 1
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Speaker 1
On new hospitals and the number of beds that new hospitals are going to provide? We haven't got a new policy on it, but we in various board sessions over the summer, especially relating to the new urgent and elective care strategy, there's been a really big focus on that strategy and the impact it has. And then the read across into the hospital estate and what that might mean in terms of capital .
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Speaker 1
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Speaker 1
To make sure that all of these things are in sync. We're not saying this is going to shrink over there, but it's actually going to grow over there. There's quite a lot of. realignment to do in all of that. And then the main thing I worry about that is we get too carried away about how much change we're going to pull off, and then start making heroic assumptions that turn out to not be possible, because we've done that a lot over the last.
20 or 30 years. So being again,
20 or 30 years. So being again,
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Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
Need to be very, very sensitive to local demographics, etc.. Thank you very much for that answer. Professor Tim, last question to you. You were or are, I think, still leading the get it right first time programme. Can you say what effect that's having? Is it having a beneficial effect? And perhaps combine that answer with how .
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Matt Turmaine
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Matt Turmaine
In in solving this problem? He wants a quick answer, Tim, as well. I would say yes, I think they're getting it right. First time is respected by all clinicians, operational teams, respected by all the regions and the advice that we give people. Listen. And the great thing about it is we look at the data and then we offer support and help. As regards virtual wards, I think they also have a role in helping us with.
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Matt Turmaine
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Matt Turmaine
Either step up or step down from primary care or indeed from secondary care. Again, this is where technologies come in. I think. technologies for remote monitoring can make a big difference, but I think it has to be all things together, like virtual wards, hot clinics, discharge planning. All of those together .
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Speaker 4
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Speaker 4
Their relative is likely to be discharged? Can I hand over to Emma on that? Thank you. I don't know specific answers on that, but I think the expectation is that good. communication throughout is obviously absolutely paramount. And we'd say not only with relatives and. patients knowing what's going on, but also our partners, for example, in social care. So to come back to the original point, I think we need to start planning discharge, including those.
conversations with patients, relatives. partners right at the beginning of their journey, and then .
conversations with patients, relatives. partners right at the beginning of their journey, and then .
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Catherine McKinnell
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Catherine McKinnell
Decision making. Thank you very much, permanent Secretary. Of course, I just wanted to this pains me, but the reason that gift works so well is evidenced by today's clinically led. So if you take what Emma and Tim do, it's clinically led with data. And this is kind of relentless focus on the clinical leadership and the data associated with it. And the secretary of State is very clear with us around the importance of clinical leadership doesn't even need to be said.
But the importance of clinical leadership .
But the importance of clinical leadership .
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Geoffrey Clifton-Brown
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Geoffrey Clifton-Brown
Leading the change that you see set out today as examples. Thank you for that clarification. This is a huge subject, which I have no doubt we will want to return to. Lots to be done. We will take very carefully your evidence and have a look at it. Produce a report with recommendations which I hope you will seriously consider. An uncorrected version of the transcript will be available in the coming days.
You're all very busy people. We do appreciate your appearance here this afternoon and the evidence you've .
You're all very busy people. We do appreciate your appearance here this afternoon and the evidence you've .
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