• Challenged trusts could take 18 months to return 95 per cent four hour benchmark
  • Warning comes amid increasing concern about system-wide A&E performance
  • Emergency Care Improvement Programme chiefs targeting culture and caution against quick fixes

The NHS’s more challenged hospitals could take around 18 months to return to 95 per cent on the four hour accident and emergency standard, improvement leaders have warned.

This comes as NHS Improvement sets out standards to try to avert another winter crisis, amid increasing concern among that A&E performance was “worsening” despite significant efforts to address the issue.

The leaders of the Emergency Care Improvement Programme, the team working with the NHS’s most challenged A&E systems, said there were no “silver bullets” and addressing the significant cultural issues in many areas would take time.

The ECIP team, launched in 2015, is working with 54 trusts. The trusts are all in the lower two groups of NHS Improvement’s single oversight framework (see box below). NHS Improvement declined to release details of the trusts in the ECIP programme, or a breakdown of which trusts are in which group.

Speaking exclusively to HSJ, ECIP director Russell Emeny would not be drawn on whether he thought the system would hit a core target to meet the 95 per cent standard by 2018, or how many of the ECIP trusts would meet the standard.

However, he indicated that many faced a longer journey than might have been hoped with NHS England having pledged the system will hit the four hour target next year. He said: “Improvement takes time. That’s one of our mantras. What we aspire to, is certainly in 18 months there would be a significant improvement in the cohort we are working with.”

He added that he wanted ECIP to work with more areas, because the whole system was in “a difficult place [and] if we all worked together to implement best practice we’d all be much better off”.

ECIP regional director Matthew Cooke stressed the importance of the team’s focus on “attitudes, behaviour and culture, the ABC approach”, and the need for all staff to take “ownership” of new ways of working.

He added: “People have the impression that we go in and say ‘you need this process’ and you drop in a new process… All the evidence is that if you do that, it won’t be sustained.”

Dr Cooke, who is also professor of emergency care and director of the Warwick Clinical Systems Improvement Group, added that “some of the most challenged organisations actually come up with some fantastic solutions. One of our jobs is taking those fantastic solutions to [other trusts].”

Mr Emeny struck a consolatory tone when asked about how the new standards, launched today and developed largely by ECIP with royal colleges, would be enforced. He stressed ECIP’s intention was not to give trusts a “jolly good kicking”. There was an appreciation that organisations could get overwhelmed by too many central demands and he said ECIP did not want to “become part of the problem”.

The former Barnet and Chase Farm Hospitals deputy chief executive also said he expected the programme to expand to work with more systems.

He said: “I personally would like to see us working with more systems so we could help them turn the dial on national performance overall. I am not sure that we want to stay in the space of working with only the very worst challenged because frankly we are all challenged in the NHS. We’re in a difficult place. If we all worked together to implement best practice, we’d all be much better off.”

Emergency Care Improvement Programme

ECIP is the NHS’s main emergency improvement and best practice programme. It developed out of what was the Emergency Care Intensive Support Team, and now has around 65 whole-time equivalent staff from both management and clinical backgrounds.

The programme, far larger than its predecessor, has focused on the most troubled trusts as rated on NHS Improvement’s single oversight framework, though ECIP director Russell Emeny wants to broaden it out to other trusts.

A visiting ECIP team typically carries out an intensive three day visit and a “gap analysis” to assess how far the trust is away from best practice in the core areas set out in guidance today. The team prepares a report that an ECIP support manager then works with the trust, usually one or two days a week, to help implement its recommendations.

The team’s leadership says its approach is largely centred around changing cultures before trying to implement best practice and processes, as well as the need to secure buy in from across organisations to implement significant changes. They also stress the need for organisations to view problems in the broader context of their health economy and system.

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