Organisation objective

• NHS Mandate from Government

Executive summary

Since the publication of the Urgent and Emergency Care (UEC) Recovery Plan in January 2023, significant progress has been made despite a challenging backdrop. Further actions have been taken to help systems prepare for winter and an improvement offer has been launched targeting areas that will make the most difference for patients ahead of winter.

Action required

The Board is asked to note the information provided in the report.

Background

1. In January 2023, we published our Delivery Plan for recovering urgent and emergency care services with two key ambitions for delivery over 2023/24:

• Patients being seen more quickly in emergency departments: 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.

2. To deliver this plan, the plan committed to improvements in five key areas:

• Increasing UEC capacity
• Increasing workforce size and flexibility
• Improving discharge
• Expanding care outside of hospital
• Making it easier to access the right care

Performance

3. Emergency department performance remains better than last year, with 73% of patients being admitted, transferred, or discharged within four hours in August 2023 compared to under 72% in August 2022. This is despite pressure on the integrated UEC pathway remaining high over summer. In terms of demand, it has been the busiest summer on record for emergency departments with overall attendances for June, July and August at 6,522,000, a 2.4% increase from summer 2022. It was also the second highest recorded number of emergency admissions over summer at 1,582,864, a 6.8% increase from summer 2022.

4. Response to category 2 calls was on average 31 minutes and 30 seconds in August, a reduction of over 11 minutes compared to the same month last year. This is despite demand for ambulance services also being high with the total number of incidents up 5.3% from last year in August 2023.

5. We have also been focussed on improving in-hospital flow by reducing length of stay and bringing forward discharge processes. In August, the average number of patients who were in a hospital bed for 14 or more days decreased by over 13% since January.

Delivery against the five key areas of the recovery plan

6. The recovery plan committed to improvements in five key areas:

• Increasing UEC capacity
• Increasing workforce size and flexibility
• Improving discharge
• Expanding care outside of hospital
• Making it easier to access the right care

7. On increasing capacity, substantial progress has been made in increasing the number of core General and Acute (G&A) beds and virtual wards available. A key aim in the UEC recovery plan was to deliver an increase of 5,000 staffed and sustainable (core) G&A beds, above original plans for 2022/23. This means that more than 99,000 core beds will be open across the country. In total there were 98,959 general and acute beds open in August, an increase from last year, 97.8% of which were core beds.

8. There were also 9,885 virtual ward beds available in August, very close to the 10,000 ambition for September, although we continue to work with local providers to increase occupancy.

9. On increasing the workforce size and flexibility, June saw the publication of the NHS Long Term Workforce Plan which set out steps to put NHS staffing on a sustainable footing to help improve patient care. Within the UEC Recovery Plan, the focus has been on increasing staffing of 111 and 999 services where we have launched a new recruitment campaign to encourage clinicians to work in NHS 111 and Integrated Urgent Care as a flexible option, including for returners. We are growing the paramedic workforce through undergraduate student intakes, apprenticeships and a focused retention improvement plan, developed in agreement with ambulance services.

10. On improving discharge, expanding care outside of hospital and making it easier to access the right care, we have been working to develop and deliver new models of care such as the Single Point of Access and integrated UEC pilots to make sure we are navigating patients to the right care first time. We have recently published a new intermediate care rehabilitation and reablement framework to help provision of high quality step-down care. Building on the work of discharge frontrunners this best practice guidance focusses on a number of recommended actions that systems should consider in partnership with their intermediate care services.

11. The Universal Improvement Offer which was launched in July also incorporates all of these areas. The offer focuses on 10 high-impact, evidence-based, and clinically-supported interventions across the integrated UEC pathway (see Annex A) that evidence shows will enable systems to make significant progress in advance of winter. All 10 learning modules began in September which have been developed in partnership with systems, including clinicians. All 10 modules have also been accredited by the Faculty of Medical Leadership and Management.

12. While the NHS has delivered on the first six months of the UEC Recovery Plan, and is in a better position going into winter than last year, risks still remain over the second half of the year. These include:

• Demand – with uncertainty over the level of flu, covid levels increasing over Summer from a low of 1,037 in July to 3,370 (as of 11th September), and the emergence of BA.2.86.
• Capacity – despite significant improvements, discharge delays remain high with ongoing challenges in social and community care.
• Industrial Action – the NHS has now faced 10 months of industrial action, meaning more than one million patient appointments have had to be rescheduled. This has required significant and ongoing work from staff across the NHS, including those working in urgent and emergency care, to maintain as much care as possible, as safely as possible. This diverts away from the clinical and operational capacity building and transformation activity required ahead of Winter.

Winter planning

13. NHS England started preparing for winter earlier than ever this year, culminating in the publication of the winter plan in July. This plan consisted of four key areas:

• 10 high-impact priority interventions drawn from the UEC recovery plan that all systems are asked to deliver.
• Clear roles and responsibilities for each part of the system so that both shared and individual organisational accountability is clear.
• System-level resilience and surge planning, to avoid systems becoming overwhelmed at times of peak demand.
• Supporting our workforce to deliver over winter.

14. Since the winter plan was published, progress has been made against all three of these areas. The 10 high-impact priority interventions have been incorporated into the universal improvement offer described above, and systems are in the process of submitting their winter planning returns which will take account of the roles and responsibilities outlined in the winter publication. Systems have also been asked to encourage the uptake of flu and covid vaccines amongst their staff and to take steps to improve the wellbeing of their workforce.

15. It also included a new incentive to encourage providers to achieve even better performance over the second half of the year, based on improvement in A&E performance and handover delays.

16. Alongside the NHS winter plan, DHSC published their Adult Social Care (ASC) winter letter which set out the steps that local authorities and social care partners need to take to provide people and their carers with the relevant support this winter. Both the NHS and the ASC letters set out expectations for how NHS and ASC organisations will work together to plan for winter and over the winter period.

17. The ASC letter also announced the allocation of £600m of social care funding to local authorities over 2023-2025. £40m of this fund was ringfenced for Local Authorities which fall within the NHS UEC Tier 1 and Tier 2 systems; these local authorities have been asked to submit plans to demonstrate how they could spend their share of this funding to support the NHS through winter.

18. Over winter, NHSE will regularly review and monitor delivery of the headline ambitious set out in the recovery plan in addition to other input metrics to deliver the plan. To manage risks to delivery, NHS England will undertake specific deep dives with systems, including those in the tiering programme, to provide additional support to deliver against plans.

Annex A – 10 high-impact interventions

1. Same Day Emergency Care: Reducing variation in SDEC provision by providing guidance about operating a variety of SDEC services for at least 12 hours per day, 7 days per week.
2. Frailty: Reducing variation in acute frailty service provision. Improving recognition of cases that could benefit from specific frailty services and ensuring referrals to avoid admission.
3. Inpatient flow and length of stay (acute): Reducing variation in inpatient care and length of stay for key iUEC pathways/conditions/cohorts by implementing in-hospital efficiencies and bringing forward discharge processes for pathway 0 patients.
4. Community bed productivity and flow: Reducing variation in inpatient care and length of stay by implementing in-hospital efficiencies and bringing forward discharge processes.
5. Care Transfer Hubs: Implementing a standard operating procedure and minimum standards for care transfer hubs to reduce variation and maximise access to community rehabilitation and prevent re-admission to a hospital bed.
6. Intermediate care demand and capacity: Supporting the operationalisation of ongoing demand and capacity planning, including through improved use of data to improve access to and quality of intermediate care including community rehab.
7. Virtual wards: Standardising and improving care across all virtual ward services to improve the level of care to prevent admission to hospital and improve discharge.
8. Urgent Community Response: Increasing volume and consistency of referrals to improve patient care and ease pressure on ambulance services and avoid unnecessary admission.
9. Single point of access: Driving standardisation of urgent integrated care coordination which will facilitate whole system management of patients into the right care setting, with the right clinician or team, at the right time.
10. Acute Respiratory Infection Hubs: Support consistent roll out of services, prioritising acute respiratory infection, to provide same day urgent assessment with the benefit of releasing capacity in ED and general practice to support system pressures.

Public Board paper (BM/23/33(Pu)