NHS emergency services are facing a major breakdown this winter due to staffing and funding shortages.

Reviews by the College of Emergency Medicine and the Foundation Trust Network have warned that A&E demand is continuing to outstrip capacity.

Health Secretary Jeremy Hunt responded that better “joined-up thinking” between health and social care was necessary to reduce the demand.

A&E attendance figures have increased by 50% in the last 10 years, due to a number of factors: the ageing population, lack of out-of-hours GP services and, more recently, problems with the new 111 helpline.

The College of Emergency Medicine surveyed more than half of UK’s A&E units and concluded that a shortage of both middle-grade and senior doctors was weakening the service.

In addition, it said, as many as 30% of patients attending A&E could be treated in non-emergency settings, given better access and information.

The Foundation Trust Network (FTN) noted that some hospitals are losing millions of pounds each year due to current rules designed to reduce A&E admissions.

Where A&E admissions rise above the 2008–9 level, the hospital is only paid 30% of the normal fee for each admission.

Fining hospitals for having too many A&E patients was no way to improve services, the FTN said.

Its Chief Executive Chris Hopson argued: “Unless we can change the funding structure, the A&E system is going to fall over. We simply cannot carry on.” This winter was likely to see the collapse of the A&E system, he warned.

Health Secretary Jeremy Hunt commented that the underlying problem was “a lack of joined-up thinking between the health and social care systems which we’re sorting out”.

The NHS has launched a plan to support its overloaded A&E services, with the formation of ‘urgent care boards’ able to invest in emergency care.

NHS England will work with the NHS Trust Development Authority and Monitor to address the problem of increasing A&E waiting times.

One priority is for hospitals to bring forward their planning for next winter to ensure that seasonal urgent care needs are under control.

The growing pressure on A&E services is due to increasing demand – four million more people in England are using these services than in 2004 – combined with the budget cuts of the ‘Nicholson challenge’.

Health Secretary Jeremy Hunt angered the BMA by blaming the increased A&E attendance figures on lack of GP access, but it is beyond doubt that many people use A&E to bypass primary care and referral barriers.

The NHS support plan therefore aims not only to help maintain A&E capacity, but to relieve the pressure on emergency care through GP and outpatient care.

At the same time, the increasing number of people attending A&E who require urgent hospital care points to a need to improve not just access to care, but the quality of care outside hospital.

While 90% of patients in A&E are seen within four hours, the average waiting time is increasing. The support plan notes: “Long waiting times in A&E not only deliver poor quality in terms of patient experience, they also compromise patient safety and reduce clinical effectiveness.”

The urgent care boards will bring together healthcare leaders from across the local NHS. By the end of May, these boards will ensure that local recovery and improvement plans are in place for each A&E department.

NHS England will ensure that extra money is made available: the urgent care boards will oversee the use of the fees paid for emergency admissions, and ensure that expenditure achieves specific improvements.

Professor Keith Willett, NHS England’s National Director for Acute Episodes of Care, commented: “When pressure builds across the health and social care system, the symptoms are usually found in the A&E department.”

The incidence of hospital admissions for acute asthma episodes varies almost 20-fold between areas of the UK.

Data released by Asthma UK for 2010–11 show that variations in access to ambulances and A&E facilities are putting many asthma patients at risk.

The charity has launched an online tool to help patients and their families compare local asthma care with national standards.

The variations cannot be attributed to differences in the incidence of asthma attacks, since some areas – such as Tower Hamlets in east London – where hospital admissions are low have high air pollution rates.

The charity called the inequalities “alarming”, since three in every 200 acute asthma episodes are fatal.

In 2010–11, 39 in every 100,000 children in Tower Hamlets were admitted to hospital as an emergency asthma case, compared to 733 in Liverpool.

Adult asthma care also showed wide variation: 30 in every 100,000 adults in Bromley, Kent underwent emergency admissions, compared to 193 in Newham, east London.

Dr Samantha Walker, Director of Policy and Research at Asthma UK, commented: “Guidelines are in place to give doctors and nurses the information and advice they need to prevent asthma attacks and save lives. But if these are not put into practice, they’re just a piece of paper.”

Asthma UK’s Compare Your Care tool offers comparative information to help local health providers meet national standards in asthma care, and help patients make informed choices about their care.

Emily Humphreys, the charity’s Head of Policy and Public Affairs, said: “We’re alarmed to see that people’s risk of ending up in hospital with an asthma attack depends on where they live. The next step is to build a picture of where care is good and where it may be falling behind.”

The chair of the Royal College of General Practitioners (RCGP) has hit back at claims by Health Secretary Jeremy Hunt that doctors are to blame for the increased pressure put on A&E services.

Dr Clare Gerada (pictured) issued a statement claiming Mr Hunt was wrong to blame GPs for a lack of out-of-hours provision and said doctors were being used as a “scapegoat” by the Health Secretary.

She said it is “not acceptable” to point the finger of blame at GPs for rising levels of A&E use and there is “no evidence” to prove this increase is down to the 2004 GP contract – as some ministers have claimed.

Hunt first made the accusation in the House of Commons when he was discussing the 2004 GP contract introduced under the former Labour government. A DH spokesperson subsequently insisted the Health Secretary was “clearly not blaming GPs.”

However, Hunt reiterated that doctors were to blame during a speech at Age UK where he outlined plans to “rethink the role of primary care” and said that “inaccessible primary care” had resulted in increased pressure on A&E services.

Dr Gerard insists “it is not true that the rise in demand on A&E services is due to a reduction in out-of-hours provision by GPs” and that there are “numerous reasons why our colleagues working in A&E departments are under pressure.”

She highlighted a shortage of consultants and a lack of integration between community and social care which has caused a “myriad of problems, including unnecessary admissions.”

The chair added that assumptions that the NHS “starts and ends with hospitals” should be ended and called upon the Health Secretary to consider the wider picture before pointing the finger of blame. “We are one NHS with patients accessing different services at different times,” she said.

“These are tough times for us all and one of the issues Mr Hunt should be addressing is the shortage of 10,000+ GPs across all services, not just out-of-hours. As a national health service we should all be working together with Government to improve patient care, not blaming GPs for perceived ‘inadequacies’ in patient care.”

Health Secretary Jeremy Hunt has pointed the finger of blame at GPs for rising A&E admissions and the added pressure placed on emergency services.

Speaking to MPs, Hunt said that “poor primary care provision” was behind some four million additional people unnecessarily visiting accident and emergency services.

But the General Practitioners Committee called Hunt’s claims “nonsense”.

A Department of Health spokesperson played down Hunt’s accusations insisting the Health Secretary was “clearly not blaming GPs” and that he was referring to procedures set by the former Labour government.

Hunt was responding to figures published by Labour that showed the NHS had missed its national A&E waiting times each week for the past six months.

He claimed this was down to poor alternatives to primary care which was the result of changes introduced by Labour to the GP contract.

“The reason that there is so much pressure on A&E is because of the disastrous GP contract that was negotiated,” he told the House of Commons. “That is what is causing the huge pressure. That is what we are determined to put right.”

The Health Secretary said the solution to the rising number of A&E admissions was to analyse the GP contract, introduce alternatives to secondary care and integrate health and social care services.

The Mid Staffordshire NHS Foundation Trust has been placed under administration by Monitor, the NHS economic regulator.

A report for Monitor said the Trust was “unsustainable” and recommended closing down its maternity, A&E and intensive care units.

The first Foundation Trust to go into administration, Mid Staffs will be run for the next 145 days by two analysts from Ernst & Young before it is reconfigured.

The report stated that the services it recommended for closure could be provided at hospitals in North Staffordshire, Wolverhampton and Walsall.

While Monitor said the Francis report was not the reason for its decision, it warned that Mid Staffs was “neither clinically nor financially sustainable”.

Mid Staffs received a £20m bailout in 2012, pending the Francis report’s publication. The report, which listed the Trust’s failures during four years in which over 400 patients died through neglect, did not inspire confidence in its future.

The administrators will seek to work with local commissioners and other healthcare organisations to produce a long-term plan for service delivery. Current services will continue during the 145-day administration period.

A local campaign group, Support Stafford, has called the plans for shutting down acute services in Stafford “unacceptable”.

Jeremy Lefroy, Conservative MP for Stafford, commented: “There is a vital need to retain acute services in Stafford and Cannock because the capacity elsewhere is simply not there.

“They also need to consider the huge disadvantage to local people who would have to travel much longer distances for their treatment, but also for hospital visitors who would have to do the same.”

Like a patient in acute care, public satisfaction with the NHS is now in a stable condition after a severe fall.

According to a King’s Fund report based on the annual British Social Attitudes survey, 61% of the public are ‘satisfied’ with NHS services, compared with 58% in 2011.

These figures are statistically equivalent, but follow a steep fall from 70% in 2010 – though 58% represents only a return to the 2008 level.

Satisfaction with social services in 2012 was at a much lower level (30%) than satisfaction with the NHS, suggesting that social care is the ‘poor relation’ in the family of integrated care.

The figures are based on interviews with over 1,000 randomly selected adults, with the data being weighted to match the overall adult population.

Public satisfaction with the NHS rose consistently from 40% in 2003 to 70% in 2010, but dropped by 12% in the first year of ‘austerity’ measures.

The 2012 figures show a 5% improvement in satisfaction with A&E services relative to 2011, and no significant changes in satisfaction with GP, inpatient or outpatient care.

John Appleby, Chief Economist at The King’s Fund, commented: “With no real change in satisfaction with the NHS in 2012, this suggests the record fall in 2011 was not a blip and that the ground lost may take some time to recover.”

However, the King’s Fund report also notes that the 2011 figures may reflect anxiety about NHS reform, while the 2012 may reflect a better experience of consistency in NHS services than many people had feared.

In support of this conclusion, the think tank notes that “key measures of performance likely to have been noticed by the public”, including waiting times and hospital infection levels, did not change between 2011 and 2012.

At a time of year when employees may look for a fresh start, Naysan Firoozmand explains how to keep talented personnel on side.

Pharmaceutical reps can usually spot a medical analogy from a mile away. On a recent online pharma discussion board one contributor reposted an article from the Gallup Business Journal, ‘Turning Around Employee Turnover’ – originally written by Jennifer Robinson in 2008. This article explored the available research into employee retention and how it can be used to identify key warning signs that organisations should look out for. The attention grabbing metaphor?

Sadly, too many managers have tied all the tourniquets around the wrong limbs, yet they’re wondering why their teams keep bleeding.

Or, to move slightly away from the world of triage and A&E, even the most potent remedy will not successfully deal with the patient’s symptoms if the underlying diagnosis is faulty. Nor will the HR equivalent of a ‘cure-all’ be any more effective than a placebo: if the presenting symptom is high turnover or repeated loss of key talents, the task is not to attempt a blanket cure, but to identify which of many potential complaints is triggering the organisational malaise.

Vision and strategy
The qualities that are readily admired in rising talents can often be out-of-step with those that the emerging leader’s followers are looking for. Indeed in its 2010 White Paper, The Leadership Challenge in the Pharmaceutical Sector, the Center for Creative Leadership identified ”having too narrow a functional orientation” as the greatest potential derailment factor for budding pharma executives.

While their own expertise and knowledge provide a shortcut to establishing trust within their organisations, technical knowledge is not all that is required of them. A successful leader needs to provide more: the ability to provide vision and strategy, the emotional intelligence to relate to others interpersonally and show a willingness to engage with them, and a desire to inspire achievement and attainment.

In the context of the pharmaceutical sector, they must also typically be able to communicate effectively and credibly with an audience that comprises highly intelligent and critical individuals working in various scientific, research and academic or supporting roles. Moreover, to do so requires them to effectively deploy emotional intelligence in an arena where intelligence and factual reasoning will often hold greater appeal than self- or social awareness, never mind self- or relationship management.
It’s not you, it’s me

Like any relationship scenario, whether they involve two people or many more, a high turnover rate or the loss of ‘someone special’ probably suggests there’s a problem. Perhaps a key member of staff really has found ‘someone new, someone truly special’ and your previously perfectly adequate contribution to their life and wellbeing simply can’t compare. Naturally, that stings a little at the time, but these things do happen: if you are seeking lifelong dedication and fidelity, swans would be a better proposition – although their sales skills would no doubt be highly questionable!

But, like any frequently dumped or jilted partner, an organisation that keeps finding itself on the receiving end of ‘the big elbow’ should start asking itself why this is a recurring pattern. There comes a point when it’s not them: it probably is you – although former employees might say otherwise during their exit interview. And at that point, the employer becomes both the question and the answer.

If you’ll excuse a further pun, engagement – and the factors that encourage it – provides some potent clues. In another Gallup report from 2002, A Hard Look at Soft Numbers, the article compared responses to Q12 Surveys across 308,987 employees from 10,885 organisations. Apart from, probably unsurprisingly, revealing that business units with high employee engagement have a 44% higher success rate – less turnover – than those with low engagement, its meta-analysis also showed 9 of its 12 factors as having ‘strongest positive correlations’ with retention. One further factor (recognition) has a ‘positive, generalised relationship’ – which it is probably arguable is stronger in the pharma sector, given the role that peer review plays in the development of individuals’ personal ‘portfolios’ and the importance of validation within the industry. Only two factors (having a best friend at work and having opportunities to learn and grow) were not clearly statistically proven.

Looking specifically at companies with sustained profitability and revenue growth, a commitment to quality and a working culture in which respondents strongly agreed that “at work, my opinions seem to count” both showed 20% improvement by comparison to the overall Gallup database.

Different challenges
Statistics, of course, speak in terms of generalisations. Each organisation will face different challenges, driven partly by their internal structure and culture and partly by sector-specific issues and general trading and operational environments. Leaders and managers who can provide clarity and cohesion around vision, mission and strategy have an important role to play: it is hard for anyone to engage with something that is nebulous, unclear or contradictory. Until organisations can answer the theoretical question ‘What do you want?’ it is impossible for companies to provide it no matter how willing, or otherwise, they might be.

Organisations can, to revisit the earlier relationship metaphor, help themselves by thinking of this stage as what might be called the ‘wooing’ period. The more clearly an organisation can explain what it is offering potential recruits and talented individuals – in terms of culture, opportunities and the recognition and reward practices that aren’t measurable in cash terms – the better the chances that it will not endure a series of unfruitful blind dates or tempestuous but short-lived flings. An industry that is built on research and product development processes with long timeframes is more dependent than most on not just the recruitment, but the retention of its key talents: the more honestly and transparently it can set out its stall, the better the prospects of a happier and more enduring outcome. While history may have shown us that successful scientific endeavour can often be a result of serendipity, life science companies should not, indeed cannot, rely on achieving success through mere chance – although they can create opportunities for serendipity amongst and between the individual talents that they procure.

Staying onside
This process – creating a compelling employee value proposition – doesn’t end when the contract is signed, however. Nor is it all about talking: it’s probably more about listening, the traditionally more neglected element of ‘communication’. Compelling is what compelling does, to rework a careworn phrase. And this listening extends to many other elements of broader talent management practice.

The pharmaceutical industry can be partly characterised by two motivational characteristics of those within it. The first, in many cases, is an altruistic wish to serve humanity by helping to eradicate diseases, treat symptoms and reduce distress and suffering. While altruistic tendencies may be out of place in many sectors, or at least poorly aligned with organisational missions, in the case of pharmaceuticals there should, surely, be a close degree of alignment with the organisation’s strategies and vision. As long, of course, as that element of the vision is clearly visible to those helping to work towards it.

The second characteristic – a desire to achieve professional recognition, often from peers in scientific practice who may be external to the organisation – may present a more difficult challenge in relation to talent retention. But an organisation that recognises the possible threat of departures to competitors and the importance of providing opportunities to shine may face fewer problems. And there’s an element to be learned from Cinderella, at least in terms of the role of job design and career progression pathways. Sometimes, no matter how much pressure might be applied to shoehorn one thing into another, it’s the shape of the shoe that needs to be adjusted rather than the foot.

Naysan Firoozmand is a Managing Consultant at ASK Europe plc.

The train ride towards a new commissioning landscape will reach its final destination next April, but is already encountering leaves on the track along the way.

It’s been another eventful few weeks as the commissioning structure continues to take shape. On Monday 1 October, the NHS Commissioning Board (NHS CB) was finally formally established as an independent body with executive powers and exceptional responsibilities. But it will have to wait until April 2013 to take on its full range of responsibilities.

Professor Malcolm Grant, NHS Commissioning Board Chair, said the formal establishment was a “new phase
in the history of the NHS”. Sir David Nicholson, Chief Executive of the Board, called the new responsibilities the Board now holds a “once in a lifetime opportunity to do things differently”.

The transition completes a hectic twelve months for the Board. Having only been established at the end of October last year, it has played a fundamental role in the Government’s vision to modernise the health service as outlined in the Health and Social Care Act. Arguably its main and most important task, before it takes on full statutory responsibilities next April, has been to assist in the development and authorisation of more than 200 evolving clinical commissioning groups.

As you would expect, this has not been an easy process. Alongside the introduction of clinical commissioning, it has also been given the responsibility for authorising Commissioning Support Units
(CSUs), who will assist clinicians in the procurement of certain services. While this may seem a routine task compared with the authorisation of a raft of CCGs, the Board has been criticised for the time it has taken them to appoint managing directors for the CSUs when clinicians are finally in a position to tender services.

The Board has also issued its response to the Government on the draft mandate for its NHS care objectives. Professor Malcolm Grant agrees the mandate is “fundamental” to the Government’s vision of a ‘liberated NHS’. However, he urged David Cameron and Health Secretary Jeremy Hunt to be “ambitious” in searching for new opportunities to focus on the “outcomes that matter to patients and the public.”

Professor Grant said that the “critical tests” of the mandate will be whether newly empowered CCG leaders can address and analyse the mandate and then say ‘‘Yes, this gives me the necessary freedom to address the needs of my local population.” Grant added that the mandate “provides a unique opportunity to make this happen.”

The Commissioning Board has also been informed by the Department of Health of an initial set of specialist
services it will be expected to commission nationally. Although the central powers for commissioning have now been transferred locally, the NHS CB will still retain responsibility for certain services which are defined as treating rare and uncommon conditions and illnesses. The 38 specialist services, which were selected by the Clinical Advisory Group for Prescribed Services, include:

• Specialised Cancer Services (adults)
• Haemophilia and related bleeding disorders (all ages)
• Cystic Fibrosis services (all ages)
• HIV/AIDS treatment and care services (adults)
• Specialised Mental Health Services (all ages)
• Morbid Obesity Services (all ages).

A final set of regulations will be established later in the year on which services will be commissioned nationally – following a consultation between the DH and the NHS CB on the initial recommendations.

Board under fire
But it hasn’t all been clear sailing for the NHS CB. Alongside being accused of delaying the authorisation of certain CCGs because of its stuttering CSU MD recruitment drive, the Board has admitted that it has failed to recruit a significant number of individuals from ethnic minority backgrounds. Jo-Anne Wass, HR Director, admitted the Board’s recruitment data did “not make easy reading”.

Questions have also been raised about the huge variation between clinical commissioning groups’ internal staff levels when compared to support service organisations. Critics have argued that CCGs will be forced to rely heavily on support units after analysis showed huge variations in staffing levels. Recent estimates from the DH show there are 4,200–6,300 staff employed by CCGs. Commissioning support units are expected to employ around 8,000 people.

Dame Barbara Hakin, National Director for Commissioning Development, has also been put under the spotlight by the General Medical Council. The GMC has commenced an investigation after a complaint against the commissioning director, who allegedly placed United Lincolnshire Hospital Trust under unnecessary pressure in 2009 when she was Chief Executive of the now disbanded East Midlands Strategic Health Authority. It’s claimed that waiting times and A&E targets were prioritised ahead of patient safety, despite warnings the trust was over capacity. Depending on the outcome of the investigation, the GMC may decide to take no action, issue a warning, refer Dame Barbara to a fitness to practise panel where she may be ‘struck off’, or decide on undertakings to allow her to keep her registration.

Commissioning Groups
Yet despite the disparity in numbers, evolving CCGs appear to be in good shape. Following the successful scheduling of all of the wave one applications, the NHS CB confirmed that all 67 CCGs in the second authorisation wave had submitted their applications on time. In fact, every proposed CCG is now involved in an aspect of authorisation with the Board – be it a 360° stakeholder survey, a desk-top review, a case study or a site visit.

However, the authorisation process has been delayed. Initially the Board moved the ‘waves’ back by a month each. It subsequently moved the waves back by an additional month, meaning all CCGs will now be authorised by March 2013.

CCGs have also learnt when their final commissioning budgets will be confirmed. Commissioning Groups will have to wait until December to find out how much money they have been allocated to organise local services to meet the needs of their residents. The budgets will be decided using a system called the Fair Shares formula, which analyses the unique circumstances practices face and the health and wellbeing
of local populations.

Commissioners have aired frustration about the amount of ‘red tape’ they face when trying to organise new local health services. NHS Clinical Commissioners, who represent CCGs across the country, say bureaucracy is hindering doctors in their attempts to redesign new services. Dr Charles Alessi, Chair of the National Association of Primary Care, said there was an “overwhelming number of rules and regulations” which were having a significant impact on commissioners.

Supporting units
But it seems the frustration many commissioners have aired at the slow rate at which CSUs are being established may soon be coming to an end. David Stout has left the NHS Confederation to lead CSUs in Essex and Hertfordshire; Tim Andrews has also been given joint responsibilities at Cheshire, Warrington and Wirral CSU and at Merseyside CSU; Derek Kitchen will lead Staffordshire CSU and Lancashire CSU. Dr Leigh Griffin has also been appointed as the MD of Greater Manchester CSU – meaning only two of the 23 CSUs are still awaiting a permanent managing director.

While the NHS Commissioning Board is readily completing the authorisation process for CSUs it has recently been distanced from employing their support staff. The NHS Business Services Authority has agreed to employ some 8,000 staff during the hosting period up to 2016. The move means that although the NHS
CB will provide oversight and direction to CSUs it will not be the legal employer of CSU employees to avoid conflicts of interest. The new distancing arrangements were welcomed by the Board, who said it would help CSUs “develop appropriately as organisations in their own right.”

After confirming four lead CSUs to provide communications and engagement services around the country last month, the Commissioning Board will now focus on assisting support units to provide services and help to CCGs through the authorisation process, to ensure they are as individually autonomous as possible, to
help CSUs develop to become specialist suppliers and to ensure units seize opportunities open to them.

As the NHS reforms continue to evolve it would seem the commissioning landscape is far from being complete. It’s going to be a busy few months.

Too many children are being admitted to hospital with throat infections that could be treated in primary care, according to a new study.

Researchers at Imperial College London found the number of children admitted to hospital with throat infections has increased by 76% over the past decade.

The increase correlates with a 115% increase in children’s short hospital stays (less than two days), and both point to over-reliance on A&E rather than GPs.

Children aged between one and four years showed the highest rates of acute admissions for throat infections.

The researchers did not find any evidence that the infections are more severe and thus demanding of secondary care.

The four-hour waiting time target in A&E is a major reason for the increase in admissions, the report said, with doctors making decisions under time pressure.

Difficulties in GP access were also identified as a factor in driving the use of A&E as a short cut to treatment.

Lead study author Dr Elizabeth Koshy commented: “Our findings relating to short hospital stays suggest that many of the children admitted with acute throat infections could have been effectively managed in the community.

“Our study highlights the need to urgently address the issue of healthcare access, with improved models of integrated care within primary and secondary care, to avoid potentially unnecessary hospital admissions for relatively minor infections.”