Department of Health and Social Care
HSIB recommends that the Department of Health and Social Care leads an immediate strategic national response to address patient safety issues across health and social care arising from flow through and out of hospitals to the right place of care.
The Department accepts the recommendation. The Department is continuing to lead the overall response across the health and care sector to improve patient access to services and address risks to patient safety.
On 12 August, NHS England (NHSE) set out immediate next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter. On 22 September the Government published ‘Our Plan for Patients’. These national responses set out a range of measures to improve the urgent care pathway and help the NHS and social care perform at their best for patients.
This includes actions to increase hospital capacity by the equivalent of at least 7,000 general and acute beds, through a mix of new physical beds, virtual wards, and improvements elsewhere in the pathway. Additional bed capacity will help reduce waits for admission from A&E, reducing crowding and improving patient flow along the pathway.
The NHS is also supporting patient access and flow by increasing the provision of same day emergency care and acute frailty services. The NHS winter resilience plan also makes clear that the Directory of Services should be used by staff to direct patients to the most appropriate place, and commits to increasing the number and breadth of services profiled on the Directory of Services to ensure only patients with an emergency need are directed to A&E.
To improve timely discharge across acute, mental health, and community settings, NHSE is working with social care partners and implementing 10 best practice interventions through the ‘100 day challenge.’ A National Discharge Taskforce with membership from local government, the NHS and national government has been established. The department is examining further options to minimise delays to hospital discharge, including identifying capacity to accommodate people who no longer need acute hospital care while continuing to need other forms of support. The Taskforce has provided intensive support to the most challenged areas on discharge, with 14 NHS pilot sites and 12 social care sites so far. This work has identified key and replicable interventions that demonstrably improve flow. These interventions include setting an expected date of discharge and discharge within 48 hours of admission and treating delayed discharge as a potential harm event. The taskforce is in the process of establishing frontrunner sites to test new approaches to discharge, from which it will be possible to identify further replicable interventions to impact delayed discharge nationally, as well as learning further valuable lessons on system working.
Our Plan for Patients sets out further urgent action including £500 million for an Adult Social Care Discharge Fund. This fund can be used flexibly by local health and care systems, targeting the areas facing the greatest challenges and strengthening the sector’s ability to recruit and retain staff. This will help reduce the number of people staying in hospital longer than needed, ensure they get the right care and support in place, and help ensure beds are available for those who need them.
To increase the social care workforce, the Department delivered a National Recruitment Campaign for Adult Social Care last winter, with plans for the next campaign underway. This is alongside working with the Department of Work and Pensions to promote careers in adult social care to jobseekers. To further support local authorities and providers address workforce pressures, care workers have been made eligible for the Health and Care Visa and have been added to the Shortage Occupation List, and we announced on 22 September that we will also invest £15 million this year to boost international recruitment of care workers. Longer term, we announced in our recent People at the Heart of Care White Paper that we would invest in training to boost career opportunities, which we believe will boost the sector’s ability to recruit and retain staff, as well as improve the recognition of our vital Adult Social Care workforce. Building social care workforce capacity will mean patients can be treated in settings that are right for their needs, reducing delayed discharge into social care and creating capacity for those that require hospital treatment, reducing patient safety risks.
To help keep more people out of hospital, everyone aged 50 and over and those most at risk are being offered a COVID-19 booster and a flu jab this autumn under plans to increase protection against respiratory viruses this winter. The flu vaccination programme will also be extended to secondary school children in years 7, 8 and 9. This broad offer will provide necessary protection to those at higher risk of severe illness and will reduce hospitalisations over the winter period, helping ensure sufficient capacity to maintain patient flow along the pathway and ensure patient safety.
We continue to act to increase and support existing NHS workforce capacity, and in the past year we have seen record numbers of staff, including record numbers of doctors and nurses working in the NHS Workforce. The monthly workforce statistics for June 2022 show over 1.2 million Full-Time Equivalent (FTE) staff (which is over 1.3 million in headcount) working in the NHS. In total there are over 29,500 (2.5%) more Hospital and Community Health Services staff compared to June 2021. To help ensure the NHS has the workforce it needs for the future the Department has commissioned NHS England to develop a long-term workforce plan.
There is also action to improve access to out-of-hours GP services, helping to avoid demand on urgent and emergency care services out-of-hours, leaving capacity to treat the patients in emergency departments that really need it. Evening and weekend appointments have been provided by local Primary Care Networks (PCNs) and Clinical Commissioning Groups (CCGs) for several years. From October 2022, these current extended access services are being brought together under one single funding stream through PCNs. This will help to reduce variation across the country and provide a more consistent offer for patients.
To improve general practice capacity more generally, the Government and NHSE made £520 million available to improve access and expand general practice capacity during the pandemic. This was in addition to at least £1.5 billion announced in 2020 to create an additional 50 million general practice appointments by 2024 by increasing and diversifying the workforce. Increasing overall general practice capacity helps reduce demand on Urgent and Emergency Care Services, which in turn improves patient flow through hospital ensuring patient safety.
To further reduce pressures on emergency departments a 2-hour Urgent Community Response (UCR) Service national standard has been established. This sets requirements for systems to respond to adults (over the age of 18) who are experiencing a sudden deterioration in their health and wellbeing, who without urgent response are likely to result in a hospital admission within the next two to 24 hours. The service should be available to all people within their homes or usual place of residence, including care homes. The target is to achieve the minimum threshold of 70% of 2-hour crisis response demand within 2 hours from the end of Q3 2022. In July 2022, 80% of urgent community response referrals were managed by community health services within 2 hours, providing urgent care to people in their homes if their health or wellbeing suddenly deteriorated. UCR prevents hospital admissions and A&E attendances, meaning there is capacity for those that really need to be treated in hospital. This provides better outcomes for patients by ensuring patients receive the right care at the right time.
NHS England (NHSE) and the Department continue to collect comprehensive data across sectors to understand patient flow along NHS care pathways and into social care settings, highlighting bottlenecks in the system and informing a range of work to reduce long waits for care.
Ministers are working closely with the NHS and the social care sector and regularly meet to review progress on improving performance.
Actions planned to deliver safety recommendation:
- Increased capacity and resilience, including timely discharge, greater workforce and increased funding made available, implemented from now. Resources in place to deliver action: Increased funding and operational capacity.
Response received on 24 October 2022.
Department of Health and Social Care
HSIB recommends that the Department of Health and Social Care conduct an integrated review of the health and social care system to identify risks to patient safety spanning the system arising from challenges in constraints, demand, capacity and flow of patients in and out of hospital and implement any changes as necessary.
The Department accepts the recommendation. The Department keeps health and social care performance under continuous review, informing a wide range of interventions to improve patient flow and help support waiting time performance, as set out in the response to recommendation R/2022/196 (above).
This work continues to consider longer term constraints, demand, capacity in relation to the flow of patients in and out of hospital.
The Department recognises the important of an integrated approach across the health and social care system. The Health and Care Act 2022, which received Royal Assent on 28 April, was a milestone in the recovery and reform of how health and care services work together, supporting a more joined up system. The Act ensures that every part of England is covered by an Integrated Care System (ICS), which brings together the NHS, Local Government and wider system partners to empower them to put collaboration and partnership at the heart of planning. The Act put a framework in place to improve integration and collaboration across the healthcare system and to help remove barriers in the discharge process from hospital, reducing unnecessary delays throughout the patient pathway.
Through this Act, two statutory bodies were created within each ICS – an Integrated Care Board and an Integrated Care Partnership. These new arrangements put shared leadership and collaboration between the NHS, local government, and other partners at the heart of strategic planning.
An integrated approach to person-centred care will bring together local actors in health and social care, alongside local and voluntary partners. Potential significant health benefits to patients include increased independence, improved quality of care, reduced preventable (re)admissions into hospitals and higher patient satisfaction.
Actions planned to deliver safety recommendation:
- ICS setup as set out in the H&C Act 2022 and ICS setup already being implemented.
Response received on 24 October 2022.
NHS England
HSIB recommends that NHS England includes staff health and wellbeing as a critical component of patient safety in the NHS Patient Safety Strategy.
We know that staff are critical to the safety of healthcare.
The People Promise describes what good staff experience should look like, including ‘we are safe and healthy’. Looking after and growing our workforce where needed – through successful recruitment and retention of staff – and supporting positive approaches to patient safety are aligned with the potential to establish a virtuous cycle. During 2022/23, we coordinated patient safety and staff health and wellbeing strategies and included a patient safety section within the health and wellbeing practitioner support training package.
Further to this, within the NHS patient safety strategy refresh (2023) we are exploring how a focus on staff safety can support patient safety. This means both psychological safety and physical safety, including considering staff engagement, fatigue, burnout, presenteeism, and the impact these can have on risks to patients and staff alike. The annual staff survey gives us valuable data and insights on these topics, including a new and well evidenced set of questions on burnout.
Actions planned to deliver safety recommendation:
- We will create opportunities to link trust patient safety specialists with their health and wellbeing champions and others, such as professional nurse advocates and professional midwifery advocates, by Q2 2023/24. Resources in place to deliver action: 800+ Patient safety specialists in place across trusts in England.
- We are co-creating a joint patient and staff safety plan, including metric(s) of success to support staff with their wellbeing in delivering quality care, by Q2 2023/24. Resources in place to deliver safety action: We are co-creating a joint patient and staff safety plan, including metric(s) of success to support staff with their wellbeing in delivering quality care.
Response received on 12 April 2023.
Department of Health and Social Care
In interim report 2 a safety observation was made, following the collection of further evidence this has now been escalated to a safety recommendation.
HSIB recommends that the Department of Health and Social Care develops and implements a patient safety accountability framework that spans the health and social care system. This is to help address the lack of accountability relating to patient safety risks spanning health and social care.