CQC: Harnessing transformational change in emergency care and across the wider health and care system

Care Quality Commission | June 2020 | Harnessing transformational change in emergency care and across the wider health and care system

Chief Inspector of Hospitals, Professor Ted Baker, discusses how emergency departments have responded to the coronavirus pandemic, highlights some of the challenges they face, and calls for the positive transformational changes to be locked in as we move beyond the peak of the pandemic.

The immediate health and care response to the challenges raised by the coronavirus (COVID-19) outbreak has been phenomenal. We have seen health and care staff go to extraordinary lengths; demonstrating resilience in the face of unprecedented pressure and adapting quickly to work in different ways to keep people safe. The fact that the NHS has not been overwhelmed is a huge achievement, made possible by the rapid transformation in clinical practice, introduction of new and innovative approaches to delivering care and a greater understanding of the skill, value and flexibility of every part of the health and care workforce.

Part of this has involved important changes in the way that emergency care has been delivered. In recent weeks our regular engagement with front line emergency department (ED) clinicians has highlighted a range measures employed to manage patient flow and prioritise safety during the pandemic. Departments have been reconfigured into streams to separate infected and non-infected patients; clinical expertise at the “front door” has increased, with improved access to face-to-face specialists, and closer working with other departments such as radiology. In some cases, we have also heard how greater collaboration between hospitals, primary care and community services has helped to maximise capacity, drive support through NHS 111 and embrace new practices that ensure effective social distancing and infection control.

As we move beyond the peak of the pandemic the number of COVID-19 hospital admissions is in gradual decline, and we are starting to see ED attendances increase. During April attendances fell sharply, allowing departments greater flex to increase staffing numbers and adhere to social distancing. But the expected rise in demand for emergency care coupled with the continued burden brought about by COVID-19 is likely to make maintaining increased staffing levels and bed capacity incredibly difficult and will present wider practical challenges for staff. This is particularly concerning as we head into winter, with the additional risk that subsequent waves of the virus may coincide with seasonal flu, creating further pressures.

The Royal College of Emergency Medicine (RCEM) is absolutely right that we must act now to ensure patient safety is not jeopardised through issues such as poor infection control, physical crowding and corridor care. It is important that we seek to strengthen alternative routes of access for lower acuity patients, whilst maintaining adequate access for those who need to visit an ED. Additionally, efforts to maximise capacity, maintain flow, enable social distancing and ensure robust infection control must continue if we are to safeguard against avoidable risks to patients and staff.

As more and more routine services resume, many of the practical challenges faced by EDs will be replicated across services and systems. While we have seen some examples of good collaboration in response to the crisis, it has not been evident everywhere and barriers to effective system working have been clear. There is an opportunity for providers, regulators and system partners to work together to lock in the positive transformational changes we have seen — many of which have been delivered at pace. We must ensure that the learning from the peak of the crisis is not lost but used to drive a new way of working that is supported at a national, regional and local level by the whole health and care system. The way we plan, commission and deliver health and care must be shaped by the experience of recent weeks which has demonstrated so very clearly how interdependent health and care truly are (Source: CQC)

The Health Foundation: How is COVID-19 changing the use of emergency care by region? #covid19rftlks

The Health Foundation | June 2020 | How is COVID-19 changing the use of emergency care by region?

Key points
  • Recent NHS England data show that A&E visits in April 2020 were 57% lower than in April 2019 and were the lowest monthly number since records began in 2010. This chart explores how COVID-19 is changing use of emergency care on a regional level.
  • Visits to A&E: Falls in visits to A&E in March and April 2020 were very similar across regions. There were bigger falls in April, the first full month of the lockdown, than in March. The fall was also always greater in minor units than major units. Reductions were slightly larger in London than other regions.
  • Emergency admissions: There is more variation in reductions in emergency admissions through major A&E units. In March, there were larger percentage falls in admissions in London (30%) relative to the rest of the country (18-22%). In April, London again saw the largest fall in admissions (45%). Another five regions had falls of between 34% and 40%, with the North West an outlier, seeing a reduction of just 28%.
  • Ambulance incidents: Changes in the overall number of ambulance incidents have been small but there are large changes in how ambulances treat patients, with fewer being taken to A&E and more treated at the scene. The shift has been particularly large in London.
  • Note: The Health Foundation’s webpage was published on 22 May 2020 and updated on 3 June 2020 to include analysis of ambulance incidents.

Full details from The Health Foundation

COVID-19: guidance for first responders

Public Health England | March 2020 |March 2020 | COVID-19: guidance for first responders

Public Health England  have published advice for first responders (as defined by the Civil Contingencies Act) and others who may have close contact with symptomatic people who may have COVID-19.

First responders include those, defined as professionals and members of voluntary organisations, who as part of their normal roles, provide immediate assistance to a symptomatic person until further medical assistance arrives.

Guidance for first responders and others in close contact with symptomatic people with potential COVID-19

Paediatric critical care and surgery in children review: Summary report

NHS England | November  2019 | Paediatric critical care and surgery in children review: Summary report

NHS England has summary report of the national review into paediatric critical care and specialised surgery in children, which took place in October 2016. The aims of the review were to ensure that services are sustainable and fit for the future, and to reduce any variation in the care being provided.



People share what a good A&E experience looks like

Healthwatch | October  2019 | People share what a good A&E experience looks like

New research from Healthwatch  shows that the public value a wide range of factors when it comes to good care in A&E; Healthwatch polled 1700 people in July and October of this year about what they thought about the four-hour A&E waiting time target.

The NHS is currently reviewing this measure as well as other national targets in elective care, cancer, and mental health, to reflect the changing environment so that people receive the best possible care.

The NHS Access Standards Review proposal includes:

  • The introduction of average waiting time measures. This would mark a move away from maximum waiting times, such as the four-hour A&E target and 18-week target for routine operations.
  • New measures to support faster initial assessment and treatment for those with the most urgent needs.

Healthwatch reports that:

  • Awareness of current targets is low
  • People aren’t clear when the clock starts ticking
  • Average waiting times are easier to understand and more helpful
  • Waiting times are less important to people than other aspects of their experience
  • One in ten are happy to wait ‘as long as necessary’ to be treated and discharged for a non-urgent condition
  • Although many people visit A&E without seeking external advice, most are advised to attend by another service
  • Most people are not told how long they should expect to be in A&E when they arrive
  • Time in the department is the not the best indicator of people’s overall experience of A& E.

Healthwatch asked the people they surveyed to rate a series of factors based on what they think should be prioritised in A&E.

1. Prioritise treating patients with the highest level of need (89%)

2. Deliver the right tests and treatment within an hour where people are thought to have a life-threatening condition (88%)

3. Assess patients quickly on arrival so that their level of need can be determined (86%)

4. Offer pain relief while waiting if appropriate (71%)

5. Give people an estimated waiting time on arrival and informing them of any changes (65%)

6. Ensure staff are on hand to provide support while people wait to begin treatment (63%)

7. Admit or discharge all patients as soon as possible (62%)

8. Make information about current waiting times available to people before arriving at A&E and provide information on alternative services (59%)

9. Make sure that people who have been in the A&E department the longest are prioritised (50%)

10. Communicate to patients that a safe number of staff are working (49%)

11. Help people to avoid being admitted to a hospital ward overnight wherever possible, even if that means they spend longer in A&E (48%)

12. Admit or discharge a set proportion (currently 95%) of patients within a set timeframe (currently four hours) (46%)

The percentages reported reflect the proportion of people who gave each factor a high priority rating (4+ on a scale of 1-5).

The four-hour A&E waiting time target was brought in 15 years ago and sets out a national standard that at least 95% of patients attending A&E should be admitted, transferred or discharged within four hours.

The NHS is reviewing this measure as well as other national targets in elective care, cancer, and mental health, to reflect the changing environment so that people receive the best possible care.

The NHS Access Standards Review proposal includes:

  • The introduction of average waiting time measures. This would mark a move away from maximum waiting times, such as the four-hour A&E target and 18-week target for routine operations.
  • New measures to support faster initial assessment and treatment for those with the most urgent needs.

See also:

NHS England Public back NHS plans for new rapid care measures

2018 Urgent And Emergency Care Survey Statistical Release

This survey looked at people’s experiences of using Type 1 (major A&E) and Type 3 (urgent care centres, minor injury units, urgent treatment centres) urgent and emergency care services, from decision to attend to leaving | Care quality Commission

132 trusts took part in the survey, of which 63 trusts had both a Type 1 and a Type 3 department, and 69 trusts had only a Type 1 A&E. The survey only includes Type 3 departments that are run directly by acute trusts, and not those run in collaboration with, or exclusively by others.

Key findings for England

The majority of people were positive about most aspects of the urgent or emergency care they received. Results across both type 1 and type 3 services have remained generally stable and have not significantly changed between 2016 and 2018.


Respondents in both the type 1 and type 3 surveys were very positive when answering questions about their interactions with staff. For example, the majority of respondents ‘definitely’ felt listened to, ‘definitely’ had confidence and trust in the staff examining and treating them and felt they were treated with respect and dignity ‘all of the time’. Staff are also generally providing clear explanations to most people about their treatment.

The survey results suggest there is scope for improvement in a number of areas across both service types, including:

  • waiting times
  • help from staff to control their pain
  • information provision when leaving A&E or the urgent care centre

Certain groups of patients consistently reported poorer experiences of urgent and emergency care services, including:

  • younger type 1 respondents (aged 16 to 35)
  • type 1 respondents who said that they had been to the same A&E about the same condition or something related to it within the past week
  • for both type 1 and type 3 respondents, people whose visit to A&E or the urgent care centre lasts for more than four hours

Further detail at Care Quality Commission

Full report: Urgent and emergency care survey 2018: Statistical release

A&E attendances twice as high for people in the most deprived areas as in the least deprived

NHS Digital | September 2019 | A&E attendances twice as high for people in the most deprived areas as in the least deprived

NHS Digital figures reveal that the most deprived 10% of the population (3.1 million) are more likely to attend A & E when compared with the least deprived tenth of the population (1.5 million).



The report collates newly published data from NHS Digital’s Hospital Episode Statistics (HES) with previously published data from NHS England and NHS Improvement’s A&E Attendances and Emergency.

The HES data shows:

  • Monday is the busiest day of the week and the most popular time of arrival is between 10am and 12pm
  • The number of reattendances to A&E within 7 days was 1.9 million and accounted for 8.7% of all reported attendances
  • Patients arriving from 8am to 10am generally spent the shortest time in A&E with 16% of patients arriving between 8am and 8:59am spending one hour or less; and 90% of arrivals between 9am and 9:59am spending four hours or less
  • Looking at all arrival times, 1.5% (330,000) of all attendances in 2018/19 spent more than 12 hours in A&E, compared with 1.6% (333,000) in 2017/18. This measures the entire duration of stay in A&E.

Further details from NHS Digital

Hospital Accident and Emergency Activity 2018/19

Emergency admissions to hospital from care homes: how often and what for?

The Health Foundation | July 2019| Emergency admissions to hospital from care homes: how often and what for?

In this briefing,  The Health Foundation presents its analysis of a national linked dataset identifying permanent care home residents aged 65 and older and their hospital use in the year 2016/17. In the second part of the briefing it synthesises learning from four evaluations of the impact of initiatives to improve health and care in care homes carried out by the Improvement Analytics Unit (IAU).


The large number of these emergency admissions may be avoidable, with 41% of emergency admissions from care homes being for conditions that are potentially manageable, treatable or preventable outside of a hospital setting, or that could have been caused by poor care or neglect.

This briefing synthesise learnings from The Health Foundation’s evaluations of the initiatives in Rushcliffe, Sutton, Wakefield and Nottingham City to pull out what seem to be key lessons for implementing the framework in care homes. These key lessons are that (i) there is greater potential to reduce emergency admissions and A&E attendance in residential care homes compared with nursing homes, (ii) co-production between health care professionals and care homes is key to developing effective interventions, (iii) access to additional clinical input by named GPs and primary care services and/or multidisciplinary teams (MDTs) may be a key element in reducing emergency hospital use, and finally (iv) our studies show that it is likely to take more than a year for changes to take effect – meaning it is important not to judge success too quickly (Source: The Health Foundation)

Emergency admissions to hospital from care homes: how often and what for?


Report of the 4th Survey of Liaison Psychiatry in England (LPSE-4)

NHS England & Liaison Faculty of the Royal College of
July 2019|Report of the 4th Survey of Liaison Psychiatry in England (LPSE-4)

Liaison Psychiatry is the sub-specialty of psychiatry which addresses the mental health needs of people in general clinical settings.
In England, Liaison Psychiatry is growing as a specialty, in part because of evidence showing that well-resourced services make acute hospitals function more efficiently; shorter admissions, fewer readmissions. 


England issues a survey to the Liaison Psychiatry services in acute hospitals with Emergency Departments in England; the survey tracks Government targets which require half of all these services to be at ‘Core 24’ level by 2021. Data were returned by all 175 of the acute hospitals in England with EDs

NHS England finds that a major potential barrier to continuation of this good rate of growth is workforce; psychiatrists more than other professionals (Source:  NHS England and Liaison Psychiatry in England) (Source: NHS England)

Report of the 4th Survey of Liaison Psychiatry in England (LPSE-4) 

OnMedica Workforce issues threaten continued expansion of liaison psychiatry services


Reducing avoidable emergency admissions

This healthcare insight report details an extensive analysis of avoidable emergency admissions over a five-year period, and in doing so highlights a number of actions that can be taken towards preventing them | Dr Foster

This report looks specifically at ambulatory care sensitive conditions (ACSCs), which can be managed or prevented through effective primary and community care. ACSCs can be chronic conditions where early intervention can help prevent exacerbation; acute conditions where early intervention can prevent progression; or conditions where immunisation can prevent disease.

The report paints a startling picture of avoidable emergency admissions, finding that the admission rate increased by nine per cent over the analysis period, even after adjusting for population growth.

The report reveals which conditions patients are most likely to be admitted for in an emergency, who those patients may be, and the impact of deprivation. It takes an in-depth look at the possible savings to be made across both sustainable transformation partnerships (STPs) and clinical commissioning groups (CCGs) in England, estimating combined potential savings of £125 million.

Full report: Reducing avoidable emergency admissions. Analysis of the impact of ambulatory care sensitive conditions in England.