In summer 2022, following a series of coordinated inspections across the urgent and emergency care pathway in 10 integrated care systems, CQC convened a workshop to bring together leaders from across health and care. These leaders came from all sectors: adult social care, primary care, community healthcare, urgent care, acute and ambulance NHS trusts, and mental health trusts.
These clinical leaders described an urgent and emergency care system in crisis – the system now routinely sees people spend over 12 hours in emergency departments, one that is working constantly at maximum capacity, without the ability to pass patients safely onto full wards. A system where nationally ambulances now regularly queue outside hospitals, and for sustained periods of time. Although recently this was common in some major emergency departments, this scale and challenge is something never before witnessed. A system where people in the community are at risk of, and at times coming to, avoidable harm when they can’t access emergency and urgent care services. Where severe challenges to community and primary care provision mean that people are deteriorating in their places of residence, and sometimes being unnecessarily admitted to hospitals. Where social care has such severe staffing problems that it can no longer sustain the pressures put upon it.
The conclusions they came to paint a stark picture of a health and care system in crisis, with people experiencing avoidable harm as a result. The workshop focused on what the response should be: from leaders, from staff, from national oversight bodies including CQC and from government. It recognised that action is needed from all parts of the system, and identified opportunities for integrated system improvements that see partners and regulators working together for the benefit of patients and populations.
This document is the output of those discussions, created and driven by CQC’s National Emergency Medicine Specialist Advisor Forum. The forum consists of a number of senior clinical leaders who provide professional and specialist advice to CQC in carrying out its work, and who see the impact of the current pressures on people and on staff every day.
The workshop feedback was unanimous in the need to bring about change; radical and bold solutions must be urgently sought and sustainably delivered, to ensure that fears that this situation represents a worrying new status quo within the health and social care are not realised.
They were clear that solutions must not focus on the NHS alone – that system leaders need to move away from reactive ‘quick fixes’ such as tents in the car park or corridor care to proactive long-term solutions and to address the enormous gap in resources and capacity.
In developing their ideas and suggestions, and to ground their discussions in the huge challenges that people in need of care are facing every day, colleagues have used the story of Margaret, as told by her daughter Rachel. There are thousands of people like Margaret in England currently, living with frailty, but this could be anyone across England with an unmet health or social care need.
This document sets out what the clinical leaders believe is needed to bring about real change, centred on the following:
1. Build collaborative leadership and a strong, open and honest culture
These form the basis of effective health and social care systems, but they are not always encouraged or rewarded. Accountability is often limited to individual systems or services, without wider consideration of accountability held in other, often related systems, or between systems. What is needed is collaborative leadership, a strong, honest and open relationship with people, and a culture of learning and improvement.
2. Share the risk across and within hospitals and the whole health and social care system
The new integrated care systems need to use their autonomy and budgets to affect radical change. Margaret spent a substantial amount of time outside the places best suited to her particular needs, with the inevitable increased risk of harm at each stage. This risk can be reduced through better access to, and therefore risk sharing between, pre-hospital care, the emergency department, inpatient care and social care.
3. Optimise flow and pathways
Connecting care, resources and systems so that people can seamlessly flow from one part of health and social care to another, while maintaining safety and quality, effective outcomes and people’s positive experiences. Margaret’s journey was characterised by barriers across multiple care providers and systems. Many of the flow and pathway challenges faced now appear hard-wired: barriers to accessing social care, which result in barriers to accessing inpatient care, which result in barriers to providing elective, cancer and urgent care, which result in barriers to timely primary and pre-hospital care.
Optimal pathways should identify risk, with early support from local services, including connected pathways for frailty and social care (inside and outside the hospital).
4. Work to retain experienced and valued staff
Ways need to be found to retain NHS and social care staff and avoid them leaving for other organisations – by ensuring sustainable workloads, a work-life balance and better pay, terms and conditions, and by supporting the staff who stay. Services that are excessively supported by inexperienced or agency staff will increase the risk to people and compromise their safety. There need to be ways to incentivise staff who are willing to work flexibly across the system, including between the NHS and social care.
In support of these themes, a number of clinical leaders from the National Emergency Medicine Specialist Advisor Forum have come together and, using the outputs of the workshop, developed the PEOPLE FIRST resource, to help system leaders and service providers. Building on Patient First first developed by CQC in 2020, this new tool recognises the unscheduled care pathway as a continuum, with solutions required across the artificial divides between primary care, secondary care, community care and social care.
The aim of PEOPLE FIRST is to support everyone to design person-centred urgent and emergency care services and to drive innovation across the system.