What is Going on in A&E? NHS Fails to Meet Target Waiting Times
Throughout 2014/15, performance against the target (that 95% of patients should spend no longer than four hours in A&E) was poor (The King's Fund, 2015). The NHS failed to meet the target for the year, with waiting times reaching their highest point in a decade. Many hospitals are predicting high over-spends on their budgets, high levels of bed occupancy and delayed discharges.
The King's Fund reports that the causes of the problems in A&E are complex and reflect wider pressures on the NHS and social care. The urgent/emergency care system is fragmented and confusing for patients and NHS England has been undertaking a review of these services (NHS England, 2014).
Since 2010, when the coalition government
relaxed the target to 95%, the proportion of patients waiting longer than four hours in A&E has increased to the point where, in 2014/15, the 95% performance standard was missed (in aggregate) for the year – the first time this has happened since it was introduced. Waiting times reached their worst levels in a decade, with increased numbers of hospital trusts declaring 'major incidents', higher reports of non-urgent cases being sent elsewhere and operations postponed. Major A&E units are performing particularly badly, with only 3 out of 10 trusts (with major units) hitting the target in the first quarter of 2015/16.
The Number of People Going to A&E has Increased
For many years, the number of people attending A&E remained essentially unchanged (around 14 million a year). In 2003/4, the number of attendances jumped – by 18% – to 16.5 million. This reflects the decision around this time to incorporate data relating to attendances at walk-in centres and minor injuries units (type 3 units). These aimed to divert less serious cases away from major A&E units (type 1 units) and to provide easier access to urgent care.
Since then, the overall number of attendances has increased to 22.3 million in 2014/15. All types of department have seen the number of attendances increase at a similar rate: between 2013/14 and 2014/15 there were increases of 3% in attendances at type 1 and 3 units and 1 per cent at type 2 units.
In 2013, the Secretary of State for Health, Jeremy Hunt, suggested that changes to the GP contract in 2004 led to increases in A&E attendance by removing responsibility for out-of-hours care from GPs. The King’s Fund (2015) argues that there is no evidence that such changes have led to an increase in A&E attendances. In any event, most people go to A&E during working hours. However, access to other types of care out of hours (for example, district nursing care) is important in keeping people out of hospital. Yet the number of district nurses employed by the NHS has decreased by about 30% in the past five years.
More Patients Need to be Admitted to a Hospital Bed from A&E
Compared to 2011/12, in 2014/15 there were an additional 356,000 admissions to hospital from A&E departments, which increased further the waiting times in A&E. This is because many people waiting in A&E are actually waiting for a hospital bed. In the first quarter of 2015/16, 71,380 patients waited more than four hours after the decision to admit them had been made.
Delays in discharging patients prevent beds being freed up for those who need to be admitted, adding to pressures on emergency departments. Since the start of 2014/15 the total number of delayed days has increased by 26%. While a large proportion of delayed transfers can be attributed to the NHS (e.g. as a result of a lack of community services), the proportion attributable to social care has risen recently. This may reflect the pressures faced by local councils who have seen significant cuts to their budgets in recent years and are struggling to maintain social care services.
A&E Tensions and Staff Shortages
A&E departments have faced difficulties in recruiting and retaining staff. In 2012, the Emergency Medicine Taskforce (established by the Department of Health and the Royal College of Emergency Medicine) suggested that fewer higher specialty trainees were opting for emergency medicine due to the 'intensity of work, unsociable hours and working conditions'. Staff shortages add to the pressures on those in post, damaging morale, increasing the use of agency staff, and exacerbating recruitment difficulties.
Mann (2015) argues that patients need the right response – departments need to decongest and retain high-quality staff. Large numbers have already left as a consequence of the demoralisation endemic in A&E departments, arising from poor staffing and poor patient flow. The combination of work intensity, staff shortages and poor work-life balance create a vicious circle in which retention of staff is the greatest resource challenge facing every UK emergency department. In the last three years a third of the workforce (650 doctors) have resigned from their consultant posts or training programmes. This is a waste of expertise and it is ruinously expensive in its consequences. In 2014-15 £700m was allocated to winter pressures funding, yet despite the current situation the figure allocated for 2015-16 is far less - £390m (Mann, 2015).
Mann, C. (2015). A&E is broken - but it can be fixed. The Guardian. 22 September.
NHS England. (2014). Transforming urgent and emergency care services in England Safer, faster, better: good practice in delivering urgent and emergency care.
The King’s Fund. (2015). What’s going on in Accident and Emergency? The key questions answered. October 8th.