HSJ’s Performance Watch expert briefing, James Illman’s fortnightly newsletter on the most pressing performance matters troubling system leaders. Contact me in confidence here.

A major national target set out this year to move the proportion of “same day emergency care” admissions from around a fifth to a third was widely welcomed. But a new audit reveals SDEC units are being converted into bedded space and funding and staffing shortages are forcing weekend and evening closures. James Illman examines how the system can keep the SDEC agenda on track.

The SDEC principle – that many people who might previously have been admitted overnight can be dealt with in an outpatient-based setting – is viewed by clinicians, managers and patients alike as a Good Thing. In old money, it is basically ambulatory care.

No one wants to be admitted to hospital if they can avoid it, and on top of the improved patient experience, it can improve clinical outcomes, and save the bed space for the patients who really need it.

So, when the NHS long term plan published in January set a target to increase the proportion of admissions seen in SDECs from a fifth to a third it was widely welcomed, if viewed as a little ambitious.

The Society of Acute Medicine says there are around 20 conditions, such as life-threatening blood clots (deep vein thrombosis), dislodged blood clots (pulmonary embolism), cellulitis, seizures and anaemia, which are all suitable for SDEC.

And while no-one is having a change of heart about the principle, clinicians and managers are encountering a range of challenges.

As HSJ exclusively revealed in July, some trusts have been trying to use the new SDEC units as a vehicle for gaming their four-hour waiting times rather than to deliver genuine clinical change.

With between 20 and 30 per cent of emergency admissions being triaged into SDEC units, it means any tampering with this data could have a huge impact on a trust’s overall performance figures.

Multiple NHS sources, at local and national level, have raised serious concerns to HSJ about the issue, with trusts moving patients who could be potential four-hour breaches into SDECs to get them off the clock.

Indeed, aligning the financial incentives with the clinical ones has, not for the first time, proved a significant challenge for national leaders developing the tariff payments for this growing stream of activity.

While HSJ exposed the gaming issue in July, the Society of Acute Medicine’s new president, Susan Crossland, told me this week it was still very much a live issue.

Dr Crossland said there were a variety of tricks being used which also included admitting GP admissions via SDEC which makes it look like “you’re admitting a large number of patients through SDEC, but you need to delve deeper into the figures to work out are those patients actually having SDEC care”.

A more pressing concern for SAM and Dr Crossland, who is the first president of SAM to have completed the society’s Acute Internal Medicine training scheme, is trusts “bedding down” SDEC units when they have run out of beds - ie. replacing chairs in SDECs with beds.

She said: “[This] is the worst thing you can do from a bed point of view… It’s not managing your flow, it’s actually adding to the problem, because you’ve got nowhere to do your quick turnarounds.”

Dr Crossland sympathised with the kinds of physical and staffing shortages which were pushing trusts towards bedding down their SDEC units. But she added: “We should be planning better for our winter capacity and winter capacity plans should not include bedding down our ambulatory care.”

Her concerns are supported by an audit carried out by the society which it published this month.

The Society of Acute Medicine Benchmarking Audit of medical units over a 24-hour period in June found 45 per cent of SDEC units had been “functionally impaired” by hospitals converting the space as overflow for admitted patients.

SDECs were, the society said, at risk of becoming “default overflow” space for patients in need of admission, devaluing their purpose, and meaning the units are becoming victims of the very pressure they are designed to alleviate.

The audit was of course only a 24-hour snapshot of the system. But it is particularly worrying that such a picture could emerge in June, with far greater pressure to come over winter.

The SAM audit also revealed that while 96 per cent of trusts had SDEC units in place, nearly the 100 per cent demanded by NHS England by last month in the long-term plan, many of them were closed over weekends and evenings due to funding and staffing shortages.

The society has rightly said both capital funding to ensure units are fully equipped, and revenue funding for more staff is needed to keep the SDEC agenda on track.

But they are also acutely aware of the shortages of both and the need for trusts to cut their cloth accordingly. Dr Crossland cited SAM’s joint guidance with the Royal College of Emergency Medicine (file attached) as a good place to start for trusts looking how to do the best with what they have.

For SDECs to thrive it also requires both clinicians and managers to work across departmental silos within their hospitals and across wider systemic ones.

The prize is of course better managed flow, which will benefit all parts of the system, but this is not to underestimate the scale of the challenge presented by rising demand and often inadequate capacity and staffing resources.