The chairman of the Care Quality Commission, (CQC), David Prior, has said that the NHS in England has a culture that “doesn’t listen” and that the NHS could go bust without “serious change”. The head of the health watchdog called for more competition to drive up standards, adding that rifts between managers and clinicians were jeopardising patient safety and blocking improvements in care.
Writing in the Sunday Telegraph, Mr Prior said, “Parts of the NHS have developed a culture that doesn’t listen – or worse, that stigmatises and ostracises those who raise concerns or complaints.”
“Too often, it delights in the ritual humiliation of those deemed to fail, tolerates and institutionalises outdated working practices and old-fashioned hierarchies, and can almost encourage managers and clinicians to occupy opposing camps.”
He called for successful hospitals to take over failing hospitals and community services, and for better care outside hospitals, and for larger centres of excellence.
He also called for changes to the way the NHS is held to account – particularly an end to trusts being “blindsided” by waiting time targets “that miss the point, skew priorities and have unintended consequences”.
Katherine Murphy, chief executive of the Patients Association, agreed with Mr Prior, saying,
“There is a culture in the NHS where process comes before humans. For years we’ve tried to highlight concern about poor care. We’re often seen as a nuisance for highlighting these issues. The behaviour and culture that was allowed to grow in Mid Staffordshire is no different from that in many trusts in many parts of the country today.”
The Department of Health said it was “focusing on poor care like never before” and was turning around 14 hospitals that are in special measures. A spokesman said, “We are clear that targets must never come before clinical need – and based on clinical advice, we have scrapped a number of them.”
It is exactly 12 months since the report of the full public inquiry into the failings at the Mid Staffordshire Foundation Trust was published on 6th February 2013. The inquiry, led by Robert Francis QC, looked at the role of commissioning, supervisory and regulatory bodies and why serious problems at the trust were not identified and acted on sooner.
In all, 290 recommendations were made by the Francis inquiry which set out a clear blueprint for the creation of a care system which ensures that the safety, dignity and well-being of patients is paramount. The Patients Association made it very clear at the time that it was vital that the recommendations were implemented swiftly and comprehensively; indeed, we are the only organisation that has been consistent in our arguments that the recommendations made by the Francis Inquiry should be implemented in full.
In response to the Francis inquiry, the Government set about implementing a series of further reviews which covered three key areas of concern: patient safety, patient experience and regulation
Whilst we welcome the findings of the various reviews and reports, it is now time for action. It is becoming increasingly apparent that those who run the NHS are reluctant to take the radical steps demanded by the Francis inquiry. We all know what needs to happen: regulation of healthcare assistants, a reformed complaints system, improved training and a properly funded and structured regulatory system. It is time for the government and NHS England to deliver action. We have been saying for many years now that the need to listen to patients, involve them in their care, value staff and for trusts to work together rather than in isolation are all key elements to ensure that standards improve and unnecessary deaths are avoided.
There is still a lot to change. There is a culture in the NHS where processes precede patient care. For years we have tried to highlight concern about poor care despite often being seen as a nuisance for highlighting these issues. The behaviour and culture that permeated in Mid Staffordshire could well be found in many trusts in many parts of the country today.
Ultimately, we believe that patients who use health and care services have the right to be treated with respect, dignity and compassion by staff who have the skills and time to care for them. We must:
1. Put patients (and their carers) first in decisions about their care
2. Help staff to be competent and provide care with dignity and compassion
3. Keep patients and service users safe; encourage whistle blowing where
unsafe care is being practiced
4. Have easy and accessible mechanisms for ensuring patient feedback
through complaints – lessons to be learnt
5. Create open and transparent cultures which are free of blame
A copy of our full response to the first anniversary of the Francis Report can be found here.
Do patients really have a choice?
The British Medical Association (BMA) held an event this week to celebrate the 10th anniversary of their Patient Liaison Group. The event brought together past and present members of the group, along with BMA committee Chairs, representatives from external patient groups and senior BMA staff.
The meeting aimed to provide the BMA with informed and independent advice on the issue of patient choice in the NHS. Dr Mike Smith of the Patients Association was invited to speak at the event along with a representative from Healthwatch England.
Dr Smith highlighted some of the problems that patients have in making an informed choice about their care, and the barriers to obtaining the health care that they want. Patients today expect, and deserve, a variety of choices when it comes to accessing health care from the NHS, and the “Choose and Book” website was set up to enable patients to make this a reality. However, many patients find that there isn’t actually a great deal of choice available (and sometimes none). Furthermore, even when choices are available, patients are finding it difficult to make an informed decision.
Prof. Keith Willett, who led Sir Bruce Keogh’s review of urgent and emergency care, told a Westminster health forum this week that hospitals are too inflexible to meet patient’s demands and could learn from the way supermarkets cater for changes in demand from customers by paying more attention to variations in what care is needed by patients rather than trying to fit them into a rigid system.
Supermarkets use information like the weather forecast and the till roll at nine o’clock in the morning to predict which items shoppers will want when stocking their shelves, he said, whereas “our idea of season variation or predictive modelling is patients in corridors and outliers”.
Prof. Willett said that greater flexibility throughout the NHS could ease the burden on emergency cuts.
Speaking at the same event, Stephen Dorrell MP, the Chairman of the Health Select Committee, warned that hospitals are in danger of becoming “warehouses” for bed-blocking elderly patients due to poor planning, and questioned recent figures presented to the Select Committee by government ministers claiming that the problem of bed blocking was declining.
Last year The Patients Association ran a survey to gauge the public’s awareness of the NHS constitution and the rights that it contains.
The results showed that awareness was extremely low.
They are running the survey again this year, to assess whether the public are now more aware of the constitution and would be grateful if you could take the time to fill it out. It’s a short questionnaire that shouldn’t take more than thirty minutes to complete.
It will remain open until Friday 6th December 2013.
You can take the survey here.
The Patients Association has this week published its fifth annual Patients Stories report, Time for Change, a series of 13 case studies highlighting shocking examples of poor care in NHS hospitals and care homes across the country. The stories have been contributed by patients, or patients’ families, who have contacted the Patients Associations’ Helpline over the past twelve months.
Several stories included in the report are examples of how an inadequate complaints system, similar to that used by many trusts across the country and highlighted in both the Francis and the Clwyd/Hart review, can impact upon patients and their families who do not feel that they have received the correct level of care in their NHS hospital.
The cases in this year’s report indicate the need to implement the recommendations of the Inquiry into Mid Staffordshire led by Robert Francis QC, the new President of the Patients Association. Cases featured in this report include:
- Eighty four year-old Olive Burns, who was admitted to hospital thinking she had fractured her hip, but whose condition soon deteriorated so dramatically that her family believed she had been placed under the Liverpool Care Pathway, only to discover that nurses had apparently forgotten to treat Olive over a busy bank holiday weekend.
- Averil Hart, a nineteen-year old student, who suffered from anorexia. Upon release from hospital, her care plan stated that she was at high risk and her family assured of close and regular monitoring. Neither of the two NHS teams responsible for her care communicated with each other or performed regular health checks on Averil who died following a severe relapse and without the care she so badly needed.
- Andrew Brown, who was shocked to discover that, after making a formal complaint about the treatment he received at Worcester Hospital, he was labelled a ‘vexatious complainant’. He had been complaining about being discharged from the cardiology team despite needing a follow up appointment for heart palpitations.
- Annie Carroll, whose family remain unhappy with the treatment she received, yet the hospital she stayed at has, at the time this report was published, yet to formally investigate any of the family’s concerns and provide them with a detailed response.
- Elizabeth Flood, who was admitted into Northampton General Hospital with a fractured shoulder and later discovered to have a fractured neck, after a fall at home. When Mrs Flood was transferred to a care home, staff there refused to help her eat or drink and asked her husband to come in to feed her instead. She developed bed sores and was admitted to A&E only after a hospital consultant noticed her frail appearance.
- Stan Norman was refused NHS continuing healthcare services because he “wasn’t terminally ill”, even though he suffered from end stage kidney disease and loss of mobility, which had being brought about by a preventative operation.
- Patient A felt that the information she received about her breast cancer treatment was not open and transparent, which led her to use valuable recovery time to check her medical records because she was “so concerned about the muddled information I had received”. Her fears were then increased when she discovered a tissue sample that had been sent to the lab after her surgery had been handled so poorly that is prevented a proper analysis taking place.
- John Munday moved in with his niece after being diagnosed with advanced lung cancer, thinking he would be able to receive the right ‘out of hours’ care. Unfortunately, in the last few weeks of his life, the OOH care he received “made life extremely difficult, painful and unpleasant”.
- Gloria Mary Butcher’s daughter was told that her mother was being discharged from the hospital she had been treated at 11:10am, but did not return to her care home until 8:10pm, despite the home telling the hospital not to return her after 7pm. Gloria’s daughter feels that trying to track her mother, a dementia patient, during this period was “like trying to track a parcel in transit”.
- Patient B, who has the mind of a child, was admitted to hospital after suffering from four seizures. Her relatives feel hospital staff did not listen to concerns about their sister’s condition and report that she was repeatedly left alone with food and drink despite having problems eating and swallowing. Patient B was discharged but needed to be re-admitted some months later. Her family was concerned to note that the issue of poor communication was not addressed despite making a formal complaint.
- John Moore was diagnosed with an aggressive brain tumour, but experienced a critical delay before he was able to receive urgent surgery, due to a junior doctor failing to make a critical referral. On the night before the surgery was meant to take place, Mr. Moore was wrongly told he had a life expectancy of 1-2 years. He sadly died four months after the operation.
- Doreen Hadfield believes that the hospital her parents Herbert and Irene Boswell were being treated at “failed in its duty of care for elderly patients” after witnessing the treatment her late father and mother received, including not being told her father did not have long to live and her mother, who suffers from dementia, being discharged in only her nightgown, and does not believe that lessons have being learnt, despite making numerous complaints.
- Lynne Hambleton, a qualified nurse, is ashamed of her profession after witnessing the poor care her mother, Edith Jamieson, received which included having to go without food or drink for long periods and not being assisted with toileting because her blindness and confusion prevented her from using the call bell.
Katherine Murphy, Chief Executive of the Patients Association, said:
“This is our fifth annual collection of patient’s stories. The first was written in the fevered atmosphere of the run up to the General Election. The next three were produced against the backdrop of colossal upheaval as the Health and Social Care Act made its way through the parliamentary process and then the year before its implementation.
“But I believe that this fifth report, published in our fiftieth year, comes at the end of one of the most tumultuous periods in the history of the NHS. What a year 2013 has been, with ramifications that will stretch for decades.
“The publication of the recommendations of the public Inquiry into Mid Staffordshire was swiftly followed by the coming into law of the NHS reforms. Then we had reviews by Keogh, Berwick, Cavendish, and Clwyd/Hart. Alongside this came the news that the NHS is facing a potential £50 billion black hole over the next twenty years.
“At the heart of these times of upheaval are patients and relatives. They don’t want to hear about reviews and finances, and they don’t want to know any more about the reforms. What they want more than anything else is an NHS they can trust, and when they or a loved one will need it, they will be treated with compassion and dignity and cared for appropriately. Every NHS manager, decision maker and policy proposer in and around the NHS needs to remember that patients today have the same anxiety and fear they have always had, but that it has been worsened by the failings at Mid Staffordshire and the number of poor performing hospitals that have raised concerns and the Care Quality Commission have had to inspect as a priority.
“This year’s collection of stories is different to those that we have used before. In previous years the focus of these reports, and our CARE campaign, has been on the care of the elderly. This remains a concern, despite the huge amount of hard work that is happening to improve care in this area.
“This year the focus is on what could be the single biggest development in healthcare since the launch of the NHS plan over a decade ago- the publication of recommendations of the Inquiry conducted by
Robert Francis QC into failings of care at Mid Staffordshire. We are delighted Robert Francis is now our President and will help us all as we strive for a more honest, open and transparent NHS.
“It is the opinion of the Patients Association that the recommendations that the Inquiry put forward are a comprehensive blue print for a safer, more caring NHS.
“Each and every case contained in this report should make the Government think again about its position. Each could potentially have been prevented if the Francis recommendations had been enacted in full.
“The Patients Association has had one simple message for the Government since the recommendations were published – don’t let patients down any further, please agree to implement the recommendations in full.
Robert Francis QC, newly-appointed President of the Patients Association, said:
“The experiences of patients and relatives remain the best way to detect care that is being delivered without care and compassion.
“Let us all hope that in the near future we will stop having to listen to disturbing reports of poor and unsafe care in many different places and instead be looking at a service which has learned from the mistakes, and has ensured that the excellent practice we know exists has become the norm. If we are to achieve this, we need to keep listening to experiences such as those contained in this report.”
Introduction to the report:
The aim of this report remains the same as it has always been, to amplify the voices of individual patients to highlight wider trends.
But this year there is a difference. Ordinarily we would publish a collection of stories and then a series of calls to action which we felt would improve the care that patients receive. But this year those calls to action already exist. The recommendations of the Francis Inquiry point the way forward for the NHS, and we call on the Government to commit to adopting them in full, with a timetable for doing so.
For those few readers who won’t already know, the report, which was published in February of this year, identified numerous warning signs which were missed. The Inquiry believed that this was caused by:
• A culture that doesn’t put the patient first
• An institutional culture that gave more weight to positive information about the service than to information that could cause concern
• Failure of communication between agencies to share their knowledge of concerns
• Too great a tolerance of poor standards and of risk to patients
• Assumptions that monitoring, performance management or intervention was someone else’s job
• A failure to appreciate the risk of disruptive loss of corporate memory and focus resulting from repeated reorganisation
With 290 recommendations made by the Inquiry it is just not possible to analyse them all here.
However we would identify the key themes to be:
• Foster a common culture shared by all of putting the patient first
• Develop a set of easily understood fundamental standards that should not be breached.
• Make sure all those that provide care for patients are regulated and properly accountable for what they do
• Ensure openness, transparency and honesty about matters of concern
• Strengthen the regulatory system
• Enhance the recruitment, education, training & support of all key contributors to the provision of healthcare
• Improve the complaints system
At the time of the report’s publication the Patients Association was cautiously optimistic about its findings, with our Chief Executive Katherine Murphy saying “We welcome the report. It’s a comprehensive review of nearly every aspect of the NHS, and when it is such a key part of all of our lives, patients and carers deserved nothing less. This is a watershed moment for our health service.
It will take time to digest all of the findings and 290 recommendations that have been made. But it is clear that he has understood some of the very real failings that patients and their families face day in and day out. He (Francis) has recognised what we hear on our Helpline every day – too many parts of the NHS have lost their way and forgotten that care and compassion should be at the heart of what staff do.
He wants to give nursing a powerful voice. He wants the ward sister back in charge and we welcome that. The concept of a registered older peoples nurse is a great idea and should be wholeheartedly pursued. Whilst he recognises it will take some time to implement, he has seen that there can be no other option but to regulate healthcare assistants. The Government has been wrong to resist this idea.
“We have always believed good complaints handling can do so much to improve our health service.
We need standards, we need more independence and we need to empower and support patients and carers when they highlight poor care. It is clear from the report that there is a lot of blame to go around for what happened in Stafford. Unfortunately too many people have escaped genuine accountability. But it’s important now to focus on ensuring the Government doesn’t play politics with this report-they need to focus on making the most of this unique opportunity to improve the NHS for all our benefit.”
“Since that time it has become clear to us that each of the recommendations has merit and the Government should commit to implementing them in full.
But unfortunately it has not done so. Instead the Government has commissioned a series of further reviews. Some, such as the Keogh review of trusts with higher than expected mortality rates, are vital for patient safety and have a great deal of merit. The Patients Association was proud to have been involved, and fully supports the work that has been done to tackle areas of concern.
“But others seem deliberately designed to water down the recommendations of the Francis Inquiry. The Cavendish review, for example, failed to follow the lead of the Inquiry and propose a proper system for the regulation of Healthcare Assistants. The Complaints Review, whilst painting a positive picture of what can be done to improve the complaints system, stops short of taking on the structural change that it clearly needs.
“Perhaps the biggest disappointment was the Berwick review. At the Patients Association it continues to remain unclear to us exactly why a further review of the Francis Inquiry was needed. The findings and sentiments were hard to disagree with. However the lack of solid proposals and a road map for true change was extremely disappointing. As we said at the time “At the moment nobody knows what will be in the report and as such it is difficult to comment on speculation. However we would be extremely pleased if Professor Berwick agrees with Francis and suggests that Healthcare Assistants should be regulated. Everybody knows that this has to happen as quickly as possible and shouldn’t be delayed because it is considered too costly or difficult to introduce. We would also welcome the introduction of minimum staffing levels on the ward.
“Healthcare professionals, patients and relatives are constantly contacting our Helpline to tell us that they don’t think that the wards at their hospital have sufficient numbers of staff to keep patients safe, and this problem has to be addressed. We would also welcome the rumoured new onus on individual candour. Everybody working in the health service needs to understand the importance of openness and transparency.
“What we need to see from the report is a clear blue print for implementing Francis, not more platitudes and acknowledgement that things went wrong. The goal has to be to move towards an open, honest and transparent NHS where everybody is accountable for their actions. This has to be across the whole system, including primary care and a vital step towards achieving it will be a complete change in the culture of the NHS and the way professionals interact with patients and relatives.
“For an NHS that is truly safe and transparent we also need for patients to be able to access meaningful data about performance and patient safety records, as well as infection rates on individual hospital wards. Above all we need to see a clear distinction between the need to cut costs and manage finances, and the need to ensure that patients remain safe.
“We all know that the future facing the NHS is one of great opportunity which can only be viewed through a prism of financial challenges. The Patients Association acknowledges that implementing the Francis Recommendations will be neither quick nor free of financial difficulty. But once the short term pain has been overcome we are confident that the long term gain of an NHS which has the safety and dignity of its patients at the centre will have made it seem very worthwhile.”
Alarming signs of an NHS winter crisis have emerged as official figures show a 42% increase in cancelled operations and a 23% rise in elderly people stuck in hospital, despite mild weather, little flu and lower than usual amount of patients arriving at Accident and Emergency units.
The NHS statistics show that over a 10 day period ending on Wednesday, more than 2,000 surgical procedures were cancelled with less than 24 hours’ notice – including 122 urgent operations, such as those for patients with cancer.
Senior doctors have expressed their concerns over whether hospitals will be able to cope when the weather turns colder.
Dr Cliff Mann, President of the College of Emergency Medicine, said: “It is really worrying; this is a very significant rise so early in the season, when it is barely winter at all. It is especially concerning that so many urgent operations are being cancelled, because that clearly can put patients at risk.” He admitted that A&E units were now under severe pressure all year round, leaving little slack in the system for a harsh winter, an event that has been forecast.
A new contract has been agreed for GP’s between the Department of Health and the British Medical Association (BMA) will see the return of “proper family doctors”, responsible for round the clock care and with dedicated help for the elderly.
Under the contract, four million elderly patients and those with complex conditions will be given a named GP, who will be personally accountable for their care at all times, with doctors having to trawl through their register to identify the frailest 2% of patients. GP’s will also now be personally responsible for the care of all patients aged 75 and over, around the clock, regardless of who delivers it. The aim is to create a much more proactive service whereby the needs of the patient, from home adaptations to intensive nursing support, are met much more quickly, as well as providing greater continuity of care for those patients who visit GP’s the most.
The system of GP pay being dictated by targets will also be scrapped, with more than one third of the indicators got rid of. The BMA have said this will allow thousands of GP’s to attend to their patients, instead of their computer screens.
Secretary of State for Health Jeremy Hunt has hailed the new contract for bringing back the “old fashioned family doctor” and claimed it will bring to an end the current “box tickling culture”, a move that he claimed was vital in ending the “huge pressure on our A&E departments” caused by Labour’s 2004 GP contract.
The Patients Association welcomes the new GP contract and the step towards putting the patient at the centre. Treating people safely, especially the elderly and vulnerable, is vital.
The Care Quality Commission (CQC) has called for urgent action to stem the rise in avoidable emergency admissions among the elderly, after data collected by the regulator revealed that 530,000 over 65s were admitted to England as an emergency for a preventable cause last year, representing an increase of more than 40% since 2007/8.
The CQC report, its annual State of Care Review, also highlighted common themes found during the 35,000 inspections made in 2012/13. Evidence of poor care was found in one in ten hospitals, with half of cases judged to have had a moderate or major impact on patients, while those suffering from dementia continuing to have among the worst outcomes, with similar problems identified in social care.
The regulator’s inspectors were “alarmed” to see the way patients were being treated and found “unacceptable” failures to protect the most vulnerable, with a deterioration in standards from an already poor position. It concluded that hospitals had made “no improvement” in monitoring the quality of care or in ensuring that patients were safe or treated with dignity and respect, and warned that the NHS has still not learned the lessons from the Mid-Staffs scandal.
However, the findings in this report were based on an inspection regime that has being radically revamped.
Avoidable admissions are caused by conditions such as dehydration or infections which could have been prevented with better care.
Katherine Murphy, Chief Executive of the Patients Association, has said:
“Avoidable admissions drain much needed resources from the NHS, but more importantly, they cause huge amounts of distress and discomfort to those patients who would much prefer to be cared for at home.”
Secretary of State for Health Jeremy Hunt has this week outlined the Government’s response to the Francis Report into the deaths at Stafford Hospital, saying that the NHS needs to undergo a “profound transformation” to create an open, honest and learning culture that will give patients “the best and safest care…in the world”.
The Government has agreed to accept all but nine of the original 290 recommendations made by Robert Francis QC in his report, including
- Getting hospitals to publish details of whether they have enough nurses on wards, with the numbers to be put on a new national safety website
- Hospitals will have to produce quarterly reports on how they are handling complaints and clearly set out how patients can raise them.
- A legal duty of candour on organisations to be open and honest about mistakes.
- A criminal offence of willful neglect to hold staff to account.
- A “fit and proper person’s test” so managers who have failed in past will be barred from taking up posts.
- Care certificates to ensure healthcare assistants and social care workers have the right skills and training.
- Every patient should have the names of a responsible consultant and nurse listed above their bed.
The nine recommendations that the Government have chosen not to take forward include the call for the regulators Monitor and the Care Quality Commission to be merged, although the decision made recently to grant both organisations extra responsibilities made that unlikely.
But of the 281 accepted recommendations, one in four of them has not been met fully, for example the inquiry called for a system of registration for healthcare assistants, but the care certificate falls short of that. The inquiry also originally called for the duty of candour to apply to individuals, not just organisations.
However, Robert Francis QC, the chair of the Inquiry, has said he is happy, describing the Government’s response as a “comprehensible collection of measures”.
The Francis Inquiry, which was published at the start of February, was set up to tackle the wider cultural problems in the NHS after the discovery of widespread abuse and neglect at Stafford Hospital. The inquiry accused the NHS of putting corporate self-interest ahead of patients and concluded that the failings went from the top to the bottom of the system.
The Patients Association welcomes the commitment by the Secretary for State for Health to adopt most of the recommendations of the Francis Report. However, the organisation does warn that some vital recommendations have not being accepted and that patient care should suffer as a result.
In particular, the failure to adopt recommendations around the registration of Healthcare Assistants, has led to concerns that the safety of patients will be compromised. The organisation does believe however that the adoption of most of the recommendations will lead to considerable advances in patient safety. In particular, it strongly supports moves to provide more information on staffing numbers in hospitals, safety information on hospitals and closer monitoring of the complaints system.
Speaking about today’s announcement, Katherine Murphy, Chief Executive of the Patients Association, has said:
“We have said on many occasions in the past that the Francis recommendations represent a blueprint for an NHS that treats people in a safe environment, with dignity and respect.
Whilst we should recognise the considerable step forward taken today, we need to remember that it simply isn’t enough to commit to implementing the reforms. In relation to staffing numbers, for example, it is about getting the right staff as well as simply ensuring that the ratio is correct. There is also real concern about where the nurses need to meet the ratio will be found.
In relation to complaints, we need to see tough action taken against those trusts that are consistently underperforming.
For many years the Patients Association has raised concerns about care in hospital, especially for the elderly, and has published a number of reports on the subject. It is therefore extremely welcome that the Government will make it a criminal offence to willfully neglect patients, all of whom will have had complete faith in those that mistreated them.
We will be monitoring the implementation of these proposals closely, but we really do believe that today is a move towards restoring the faith patients have in the NHS.”
The College of Emergency Medicine has published a ten point action aimed at resolving the crisis in emergency departments. It calls for other NHS services to provide “effective alternatives to A&E for patients without acute severe illness or serious injury seven days a week”.
The College calls for GP services, social care services and NHS walk-in centers to open longer to take the pressure off casualty wards, as well as action to resolve a “massive staffing shortage ”by making work on casualty wards more attractive with increased incentives for doctors working nights and weekends.
The College’s Vice President, Dr Chris Moulton, said that GP out of hour’s services were not always comprehensive and A&E was the only 24 hour service.
But GPC out of hours lead Dr Peter Holden said general practice was, alongside A&E, the only part of the new NHS which runs a 24/7 service.