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STPs must assess cash needed to make outdated A&E departments ‘fit for purpose’

The sustainability and transformation plan (STP) process must include an assessment of the infrastructure investment needed to ensure type 1 emergency departments – or major consultant-led A&E departments open 24 hours a day, seven days a week – are fit for purpose, the Health Select Committee has said in a damning report on NHS winter pressures.

One of the major concerns to emerge out of the committee’s inquiry was the need to expand “outdated” emergency departments that were originally designed to accommodate “far fewer patients” – a point raised by both NHS England CEO Simon Stevens and the Royal College of Emergency Medicine (RCEM).

The RCEM noted that the hike in attendances over the last five years alone is equivalent to the workload of 10 medium-sized emergency departments in England, “none of which have been built”.

Because of this, many A&E departments today are not fit for purpose, with some providers, such as Torbay and South Devon NHS Trust, writing that their “design limits flexibility and does not have sufficient cubicle space to meet demand during busy periods”.

“There are limited facilities for children and for the safe management of people who present with a mental health need,” the trust said in an evidence statement. “There is also limited opportunity to extend ambulatory care pathways for people who are able to be assessed, treated and discharged home on the same day.”

Saffron Cordery, director of policy at NHS Providers, also highlighted the “fundamental mismatch” between the demand for emergency services and the resources available, meaning “even the most efficient hospitals will struggle to cope”.

As identified by Stevens, emergency departments will therefore struggle to manage growing demand unless extra infrastructure cash is made available – perhaps not in time for new builds this year, but to allow the service to improve overall performance and manage “ever increasing background demand” as well as the predictable winter spikes.

The committee added: “It is essential that the government ensures that sufficient capital funding is available for trusts to develop the infrastructure that will enable them to meet performance levels demanded by ministers. The first step will be an assessment of the infrastructure investment required to ensure that type 1 emergency departments are fit for purpose, which should be completed through the STP process.

“Once that assessment is complete, NHS England and NHS Improvement (NHSI) will need to ensure that the available capital funding is directed accordingly – we call on the government to review the real-terms cuts to NHS capital budgets in the Spending Review and to protect the transformation element of the sustainability and transformation fund.”

Expanding on the latter argument, the MPs argued that transformation funding, which should be used to support the ‘T’ in all STPs, will not be available in this Parliament. Instead, this funding is being “used largely to ‘sustain’ in the form of plugging provider deficits rather than in transforming the system at scale and pace”.

Emerging trend of closures

Despite the committee’s calls for greater infrastructure investment, the STP process so far has exposed a trend of closures – in fact, an RCEM survey revealed that almost a third of CCG leaders are considering shutting down emergency departments.

The royal college warned that this would also be matched with a reduction in beds and full-time acute staff over the next 12-18 months, resulting in “potentially catastrophic” plans that will “put lives at risk”.

South West London’s published STP already proposed closing one of the area’s five acute hospitals, while North West London noted that it is considering “challenging” service consolidations. The latest published STP – covering Durham, Darlington, Tees, Hambleton, Richmondshire and Whitby – also mooted plans to reconfigure acute hospital services.

Today’s Health Committee report follows similar concerns from the King’s Fund that STPs are being drawn up without sufficient money to deliver them. The think tank stressed that NHS England and NHSI needed to make “more rapid progress” in developing payment systems designed to support new care models, such as capitated budgets, pooled funds and integrated personal commissioning.

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(Top image c. Rui Vieira, PA Wire)