Why has only 1 per cent of £700 million NHS emergency winter ‘bonus’ been spent on A&Es?

Edmund Stubbs, 4 March 2015

In June 2014 the Royal College of Emergency Medicine, the Royal College of Surgeons, the Royal College of Physicians, and the Royal College of Paediatrics and Child Health published a paper listing 13 recommendations that would lead to better, more effective A&E departments. A ‘follow up’ report from the Royal College of Emergency Medicine was published today ascertaining to what extent these recommendations had been implemented.

The report disclosed that although there were some examples of full implementation most of its recommendations had not been, and that only 1% of the £700 million winter NHS ‘bonus’ funding had been allocated to A&E; extra funding intended to help meet the hugely increased demands on our health system, demands that caused hospitals to declare major incidents and A&E departments to miss targets by wide margins. In the light of recent horror stories of ambulances queuing outside emergency departments and patients on trolleys waiting in corridors, it is hard to understand why the recommendations have been ignored and just why such a small proportion of this winter’s extra budget has been spent directly on A&E’s?

All of the June report’s recommendations were good ideas, and many were innovative, such as ensuring co-located primary care facilities within A&E departments and ensuing senior clinical decision makers might meet patients at the ‘front door’, thus saving time in diagnosis and increasing safety. Other recommendations were common sense solutions to well known problems. For example, ensuring ‘an appropriate skill mix’ and the ‘capacity to deploy extra senior staff’. These types of solutions would have been implemented long ago if they were easily possible, thus this may be why many of the reports 13 recommendations have largely been ignored.

Another reason why A&E departments did not implement these changes might be the chronic under funding caused by the ‘marginal rate rule’ introduced in 2011. This rule effectively meant A&Es would only get 30% of the funding they would normally receive for each patient if more patients attended than predicted. In this eventuality 70% of budget for each patient would be used to fund those community services that might be expected to reduce demand for A&E. However, If demand for A& E services is often underestimated, as has been claimed to be the case, then chronic underfunding for the treatment of actual A&E patients is likely. This rule also means that emergency departments often become ‘loss making’ entities for the acute hospitals which fund them.

In the light of this it seems at first glace shocking that only 1% of the £700 million extra winter funds, designed to decrease pressure on the system actually was allocated to crisis hit A&E departments, especially those declaring ‘major incidents ‘.

In fact, the £700 million, distributed around Clinical Commissioning Groups (CCGs) was spent on reducing demand, such as by easing access to GPs and other community facilities, enhancing the capacity of the NHS 111 phone line and keeping pharmacies open 7 days a week.

Another area where money was spent was in trying to reduce back log in the system. Many hospitals have over 10% of their beds filled by patients who were medically fit to leave acute hospital but have nowhere to be discharged to; hence the backlogs of ambulances and patients waiting in corridors. A&Es could not admit patients to hospital wards as there were no beds available. Consequently money was spent on all frontline staff in hospitals and in the community, on overflow wards, and also in financing up to 6 weeks in care homes for discharged patients while long term decisions were made for them.

The follow-up report’s authors emphasised that although such community spending was well intentioned;  it did not succeed in relieving pressure on A&E, ignoring the desperate need to increase staffing and equally desperate need to improve poor facilities found in many emergency departments. As a result the authors call for any extra money to be given directly to hospitals next winter and for A&Es to thereby receive the funding they so sorely need.

Edmund Stubbs, Healthcare Researcher