Percentage waiting more than four hours in A&E from arrival to admission, transfer or discharge
The relaxation of the government's A&E waiting times target in 2010 partially explains the drop off in performance − although the percentage of patients waiting less than four hours in A&E remains within the current 95 per cent target range. However, this hides considerable variation amongst providers, with more than a quarter reporting breaches of the waiting times target according to our latest quarterly monitoring report. This defies easy categorisation, or explanation.
Performance against the 95 per cent target – despite being an important yardstick of 'managerial grip' and service delivery – is only one measure. Nevertheless we do know that consistently achieving 95 per cent requires sustained effort, focus, clinical engagement and an analytical approach to what amounts to a series of practical issues centring on flow and queuing theory. Delivering care at speed for large numbers of patients is not easy, and unfortunately the processes that support high performance tend not to be self-sustaining. Like plate spinning, things quickly fall out of place if the 'problem' is not actively managed.
The significant and ongoing managerial challenge of meeting demands created by unscheduled care can also be seen outside the UK. Overcrowding in emergency departments, long waits and 'boarding' (the practice of caring for patients in corridors, on trolleys and in the A&E department because there are no available beds) are common problems in the United States. Some of the most informative articles on the problem of 'access block' (problems caused in A&Es due to a lack of beds for patients needing admission) come from Australia. And literature from Canada examines how patients who turn up in A&E departments with non-urgent conditions do − or don't − contribute to increased patient waiting times.
The current performance in England should be considered within the context that the US average bed occupancy in 2008 was 68 per cent. Back in 1999, Bagust, Place and Plosnett demonstrated that acute hospitals can expect regular bed shortages and periodic bed crises if occupancy reaches 90 per cent or more. Such occupancy levels are now regularly occurring case in the UK.
In England most trusts are either reducing their number of beds, or plan to do so as part of their Quality Innovation Productivity and Prevention (QIPP) plans. Despite the fact that reducing A&E attendances has been an NHS priority for some time, attendances continue to rise. Comparing the first three quarters of 2012/13 to the same period in 2009/10 we see that attendances have increased by 353,457 (+3.4 per cent) in major ('type 1') A&E departments and by 829,995 (+5.3 per cent) for all types of A&E departments.
It is unclear how long these trends (rising admissions and reduced bed numbers) are sustainable.
How this translates into pressure at a local level varies, but unfortunately national statistics are only published on trust performance, which leads to a significant gap in our understanding of local demand and supply. Some trusts' average performance reports are masking significant variations between constituent hospitals. There are already 34 trusts in England that run more than one A&E and if trusts continue to get larger (through mergers and acquisitions) the problem of individual hospital variation being masked is likely to get worse. Performance at hospital, as well as trust level, should be published. It would be interesting to see whether the public would change their propensity to attend if they knew quite how badly (or well) their local hospital − as opposed to the trust − was doing.