‘THESE changes can not be separated from the problems A&E is facing. Unite believes that at the heart of this issue is a clear structural problem in how people are accessing the NHS.
As a result of failings in primary care, the new 111 service and GP services, particularly out of hours, for many people the only way to adequately access the NHS is via A&E.
The solution to this is to recreate an effective primary care service including out of hours services for patients, based on GPs integrated into the multidisciplinary team alongside other health professionals with local knowledge not only of the patients in their area but also of the wider NHS functions.
The alternative of trying to separate A&E departments from non-emergency care is dangerous as it relies on patients being able to self-diagnose and self-prioritise their own health needs and would make the system more complicated and inaccessible.
Unite is also concerned with the way the NHS pays hospitals for admitted A&E patients. Under current rules, if a hospital admits more A&E patients than it did five years ago, it only gets paid 30% of the cost of treating those patients.
Two thirds of hospitals are admitting more patients than they did five years ago, some as many as 40% more.
This means re-opening wards and employing more staff to cope with this extra demand. Yet hospitals only get paid 30% of these costs.
Some are losing more than £5 million a year as a result, on top of the 5% savings they’re already being required to make.
Other drivers of these problems include the ideological and chaotic way that services are being designed and contracted out, fragmenting services and creating waste.
The failures of GP out of hours services and more recently the shambles of the new 111 phone line show the severe impact that this disruption can have. There is also clearly a breakdown of preventative systems in many other areas of public policy – from cuts to social care to poor housing and increasing poverty and social exclusion – all driven by the government’s ill thought out austerity agenda.
A recent example of this is the abhorrent policy of excluding migrants from the health service, not only a breach of human rights and a public health disaster, but will also mean that many will have no choice but to go to A&E for health treatment.
Unite is therefore not surprised that emergency services are now reaching breaking point.
These pressures on A&E services are reflected in staff morale. The NHS unions commission pay specialists IDS to run a biannual survey of union members in the NHS. The latest of these reports in 2012 has shown that staff are under severe strain.
Looking at ambulance staff, for example, the IDS survey showed that they were one of the groups most likely to be always (33 per cent) or frequently (46 per cent) working in excess of their contractual hours. Similarly 64 per cent of ambulance staff reporting a substantial increase in their workload, with 68 per cent reporting that they were under pressure to meet government targets.
81 per cent of ambulance staff said that workplace morale/motivation has got worse in the previous 12 months, which is up from 71 per cent for this group in 2010. 78 per cent cited increasing workplace stress as a major cause of poor motivation and morale.
These issues are also reflected in the 2012 NHS Staff Survey. Specific issues raised by the inquiry: The role of community and primary care services in the delivery of emergency healthcare, and the appropriate structure for service delivery to meet the demands of different geographic areas particularly sparsely populated rural areas
The challenge posed here is cost of resources against utilisation especially in rural areas where demand is low in terms of numbers and therefore the relative cost for keeping ambulance cover in the area (per patient carried) is high.
Most areas now have community first responders (CFRs) who are trained volunteers responding on behalf of the ambulance service because these are cheaper.
Whilst recognising CFR schemes for the value they bring, there is no point having them if it means that the ambulance is going to be even further away than it would have been if there was no CFR in the area.
They are in the same situation as rapid response paramedics who arrive on the scene quickly but are unable to bring the patient back to a hospital if needed and end up watching patients deteriorating while they wait for a properly staffed and equipped ambulance.
There needs to be a good core ambulance cover that can be supplemented by rapid response vehicles (RRVs) and CFRs in the system rather than replaced by them. Ambulances must be crewed by a paramedic and emergency medical technicians (EMTs) to get to locations within 8 minutes, but these need to be supported by a RRV to get there sooner within 4 minutes, to be of any use in a cardiac arrest.
The biggest flaw to CFR schemes is that they are voluntary and when the volunteers dry up so does the scheme leaving a huge gap in the ambulance coverage.
Primary care has a role in providing pathways for crews who have a patient who does not need to go to hospital and can receive what treatment they need in the community from primary care. This underlines the need for primary care, either through the GP or a new multidisciplinary team to be open and available 24/7 not just 9-5 Monday to Friday and readily accessible to support emergency service needs.
Regarding progress towards moving some minor injury and urgent care services out of A&E and into more accessible community settings
Unite would not oppose this if it was additional services. It is apparent that there are reductions in this cover or that it is being placed where other forms of urgent care should be sought, e.g. in general practice.
The range, severity and incidence of conditions that can be treated
within an accident and emergency unit but not managed at an urgent care centre
As discussed above these decisions should be made by the GP as the first port of call. CCGs now have the money and responsibility to commission services and should therefore take on the responsibility.
Unite members report that in many cases GPs have simply been referring patients to A&E to reduce their own case loads.
The prospects for better integration of ambulance services with primary care under the new
commissioning regime established in April 2013
As above, commissioners and ambulance services need to work together, to look at what can be offered including paramedics working at or out of minor injury units (MIUs) and accepting referrals from emergency crews.
Unite is cynical about the possibility of this joined up and integrated working under the artificial market structures created by the Health and Social Care Act 2012.
Integration has been seriously damaged by the chaos caused by the reorganisations that took place and that is even before the commissioning process has begun.
The ability of ambulance services to continue to meet increased emergency demand whilst contributing to the Nicholson challenge
The ability of ambulance services to continue to meet increased emergency demand is all down to resourcing.
As the Health Committee has correctly recognised, in the past the Nicholson challenge has mostly been met through cuts to staff pay and terms, cuts to the tariff and salami-slicing cuts to services.
These cuts are having a severe impact on ambulance and emergency services across the UK due to the systemic problems caused by cuts in other parts of the NHS and elsewhere.
Either resources are increased and sufficiently trained in emergency services or they should be increased in other parts of the system to alleviate the pressures on ambulance and emergency services.
Unite members have also been in bitter disputes with their employers in various parts of the country as cuts are leading Trusts to send out ambulances and single response cars that are under-staffed or have replaced paramedics with unqualified employees. Crews are facing much greater pressure to respond to calls due to cuts to staff numbers and vacancies going unfilled.
By cutting publicly-funded ambulance services so severely, they have opened the service up to rapidly growing numbers of private firms which is leading to a postcode lottery of service quality.
For example recent figures have shown an increase in spending of £5.4m on private contractors by the South East Coast Ambulance Service, from £1.9m, in 2010/2011, to £7.3m, in 2012/2013; In London, that figure rose by more than £3.8m, from less than £400,000, in 2010/2011, to £4.2m, in 2012/2013 and in Yorkshire the figure rose £1.3m, from £500,000 to £1.8m.
Privatisation of Patient Transport Services will also mean that staff who are no longer able to work on the paramedic crew will not be able to be re-deployed to PTS services, which will bring additional pressures on the NHS.
The Yorkshire Ambulance Service Trust is probably the worst case.
With budgets planned to be cut by £46 million over five years the Trust introduced a new operational model that threatens to downgrade all ambulance staff, removing professionally trained technicians from ambulances altogether and replacing them with untrained driver roles with minimum levels of training.
Posts are not being filled and crews are driving from one 999 call to the next without the time to check or clean the back of their ambulances or have adequate rest breaks.
Unite’s members in Yorkshire raised public safety concerns and have been derecognised as a result.
This took place at the same time that the Francis report was calling for NHS staff to whistleblow on unsafe practices in their workplaces.’