To:

• Chief executive officers – all integrated care boards (ICBs)
• All acute NHS trusts and
• All type 3 providers (NHS and private providers)
  • Chief operating officers
  • Medical directors/chief medical officers
  • Chief nurses/chief nursing officers
  • Clinical directors (emergency department)

cc.

• Chief executives – all NHS provider trusts
• Ambulance services: chief executives

Dear colleague,

Thank you for your ongoing work to support front line teams and deliver high quality urgent and emergency care for patients. We are very aware that the winter period has been particularly pressurised and exacerbated by several rounds of industrial action; and would like to thank you and your teams for their outstanding leadership throughout.

We are now almost halfway through delivering the two-year Urgent and emergency care (UEC) recovery plan, published in January 2023, and centred around two key deliverables for 2023/2024.

• Patients being seen more quickly in emergency departments (EDs): with the ambition to improve to 76% of patients being admitted, transferred, or discharged within four hours by March 2024, with further improvement in 2024/25.
• Ambulances getting to patients quicker: with improved ambulance response times for Category 2 incidents to 30 minutes on average over 2023/24, with further improvement in 2024/25 towards pre-pandemic levels.

Significant progress has already been made, with four-hour performance better in every month this year compared to the same month last year; and category two ambulance response times in December significantly improved in comparison to last year.

However, there is more to do to ensure that the NHS delivers in full on these key public commitments by March 2024, and that plans to achieve these standards are implemented in full, as set out in the operational planning reset which took place in November 2023.

The UEC recovery plan establishes a programme of transformative improvement across the entire urgent and emergency care pathway and this work should continue at pace. In addition, and in the immediate term, it is also essential that every ED operates as effectively as possible to achieve planned performance levels this year, even with the current constraints many are experiencing.

Given this, we are writing today to ask that as a priority, ICBs and trusts review internal systems and processes to support their ED teams, ensuring as a priority that the initiatives described at Appendix A are in place.

We are aware that the best performing trusts and systems follow these approaches routinely, but a reminder that these priorities are (evidenced) ways in which consistent application delivers results. They are also the areas that we will place a particular focus on in terms of our oversight and support offers, which will include:

• Access and instructions to optimise Getting it Right First Time (GIRFT) UEC data, supporting identification of opportunities at system level related to the five initiatives set out above. These resources can be accessed through the Summary Emergency Department Indicator Table (SEDIT). If you have not already registered to the OKTA/Insight platform, please register at apps.model.nhs.uk/register. Once registered, login to your account using this link apps.model.nhs.uk/products. Scroll down to the bottom of the “Insight” home page and then press the button to “request access” to the SEDIT. Alternatively, please try this link SEDIT: Launch – Tableau Server (england.nhs.uk) which is bespoke for SEDIT access.
• National Workshops (multiple locations). NHS England national and regional teams will be running a series of workshops to expand on the five initiatives, including case studies supporting rapid implementation. Attendance is for an executive sponsor and a representative of the UEC pathway delivery triumvirate (operations, medicine, nursing). The sessions will also provide space for providers to discuss their plans, constraints and support needed, whilst learning from one another. A summary of the events is set out at Appendix B below.
• Virtual drop-in sessions. NHS England will facilitate support and connection between colleagues as challenges are worked on together. This will include access to subject matter experts.
• Improvement support pack. The support pack at Appendix C includes resources and materials to assist with delivery of the initiatives outlined in this letter. A series of UEC improvement guides have also been designed for providers and systems to consider embedding as good practice to reduce handover delays. Resources include key principles for ED leaders to help create a positive culture and enable change.

In addition to the support offer, we as a Midlands region will continue to work closely with all systems and providers to ensure improved access for patients across the UEC pathway. The Midlands regional team will;

• Maintain a performance focus on delivery of 4 hour and Cat 2 trajectories through a planned oversight meeting. Tier 1 systems [Shropshire, Telford and Wrekin (Shrewsbury and Telford Hospitals)] will be coordinated by National and regional colleagues, Tier 2 [Hereford and Worcester (Worcester hospital), Staffordshire and Stoke-on-Trent (University hospital North Midlands), Lincolnshire (United hospitals Lincoln & Boston), Northamptonshire (Northampton and Kettering hospitals)] will be led by the region (Regional Director and Regional Chief Operating Officer) and Tier 3 (Coventry and Warwickshire, Black Country, Birmingham and Solihull, Joined Up Care Derbyshire, Nottingham and Nottinghamshire, Leicester, Leicestershire and Rutland) will be coordinated by the regional team and systems. These interactions will oversee delivery, identify exceptions and agree recovery actions with systems and providers where required.
• Continue to work with ICBs and providers to share good practice aligning support offers.

We would like to thank you in advance for your ongoing focus on delivering improved access for patients across the UEC pathway.

Finally, colleagues are reminded that providers with a Type 1 Emergency Department who can achieve better performance in the second half of the year are still able to access a share of a £150 million capital fund in 2024/25 to be used for local improvement projects

We hope this provides a clear way forward for the remainder of 2023/24, however should you have any further questions on the details included in this letter, or any of the individual components, please contact your NHS England Regional Performance and Improvement Director in the first instance.

We would like to thank you in advance for your ongoing support. We will be in touch in due course, with regard to next steps for your system and organisations.

Yours sincerely,

Sarah-Jane Marsh, National Director of iUEC and Deputy Chief Operating Officer, NHS England.
Dale Bywater, Regional Director – Midlands, NHS England.

Appendix A: Five priority ED improvement initiatives

1. Streaming and redirection: A competently trained member of clinical staff should perform an initial assessment within 15 minutes of a patients arrival and be able to stream and redirect appropriate patients to an alternative service in line with the CQC Patient First framework. This is a tool providing practical solutions for all ED leaders to support good, efficient, and safe patient care. Planning for discharge from hospital services also should start at the point of initial assessment in ED.

2. Rapid assessment and treatment (RAT): RAT is the most intensive form of initial assessment and incorporates both streaming and triage. A competently trained member of clinical staff should perform a rapid assessment within 60 minutes of a patients arrival to ED to reduce delay and support immediate referral where appropriate, and / or the initiation of required diagnostics and first line treatment. Where a specialty opinion is required, this must be available in a timely way.

3. Maximising the use of Urgent Treatment Centres (UTCs): All UTCs should be compliant with UTC standards and principles and where possible co-located with EDs and open for 24 hours a day.  UTCs that are not co-located should be open for a minimum of 12 hours per day 7 days a week.

4. Improving ambulance handovers: EDs should ensure prompt assessment by a trained clinician as part of the ambulance handover process and perform regular care rounds which include fit to sit assessments. There should be adequate seated and cubicle capacity to meet the needs of patients, and executive oversight of the ambulance handover position must be in place, with timely escalation and associated actions to resolve delays. There is now clear evidence that timely handover is a whole hospital leadership issue and it must be approached as such. Planning to safely reduce avoidable conveyance: aims to support ambulance services, systems, and commissioners to safely reduce the number of patients conveyed to EDs.  Leaders should familiarise themselves with the objectives and deliverables set out in the guidance and test where there is potential to go further.

5. Reducing time in department: We know that having too many patients in an ED is a serious risk to patient safety. Again, regular executive and senior clinical lead oversight is imperative so that all patients approaching the maximum waiting times are highlighted for escalation. It is also crucial that Same Day Emergency Care (SDEC), acute frailty services and other ambulatory capacity is not used for bedded care otherwise it is not possible to maintain flow. Use of ambulatory facilities also enhances the opportunity to discharge patients either to their usual place of residence or to a specialty bed.

Appendix B: ED improvement workshops in February 2024

Further details to follow.

1. Title: ED Improvement Workshop 

2. What is it? 

• Four events will be hosted, focussing on ED performance improvement.  
• Events have been grouped by NHS region. 
• Please attend the event for your region.  
• If you are unable to attend on the preferred date, please consider attending one of the other sessions. 

3. Dates, times, and venues:  

• For colleagues based in the Midlands:
  • Date: 20 February from 9.00am – 5.00pm
  • Venue TBC
• For colleagues based in London and East of England:
  • Date: 27 February from 9.00am – 5.00pm
  • Venue: Mary Ward House (27), 5-7 Tavistock Place, London, WC1H 9SN 
• For colleagues based in the South East and South West:
  • Date: 28 February from 9.00am – 5.00pm
  • Venue: Ambassador Bloomsbury, 12 Upper Woburn Place, Bloomsbury, London, C1H 0HX 
• For colleagues based in the North East and Yorkshire and North West:
  • Date: 29 February from 9.00am – 5.00pm
  • Venue: Metropolitan Hotel, King Street, Leeds, Yorkshire, LS1 2HQ 

4. Registration:  

A link to register will be provided, along with the agenda and event details in our follow-up communications. The registration link includes venue, location, timings, dietary and access requests. 

5. Who should attend?  

• NHS providers: one executive sponsor and one member of the UEC Pathway triumvirate. 
• Integrated care board’s (ICBs): Ideally the accountable individual/s for delivery of the 4 hour standard.  
• Regional UEC leads 
• ECIST regional and national leads 
• GIRFT leads 
• National UEC leads.

Appendix C: Improvement tool/resources

If you would like access to any of the documents described above, please contact us at england.universalsupportoffer@nhs.net

Publication reference: PRN01107