The increasing demands on Accident and Emergency departments: no easy answers

Few health policy issues have received greater attention than how best to meet the demands on hospital A&E departments − and manage the associated unscheduled admissions to hospital. There is now extensive practical advice available on NHS websites, and most trusts have had at least one Emergency Care Intensive Support Team (ECIST) review of their services. Despite this, the reality is that many health economies are struggling to cope with demand.

Percentage waiting more than four hours in A&E from arrival to admission, transfer or discharge

A and E 4 hour waits

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.

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Comments

#40143 Harry Longman
Chief Executive
Patient Access

I started researching this question some three years ago. The problem is demand, much of it inappropriate, ie driven by patients' fear and insecurity. To overcome this they need confidence in primary care, which is driven by the accessibility of their GP. And we know how change that.
The four hour target has simply diverted attention from the true problem, creating its own industry of cheats and inspectors. a culture of compliance not of curiosity and improvement.

#40524 Kadiyali M Srivatsa
Doctor
Private

I have worked on my own for almost ten years to find out why and what makes a person consult doctors. This was not because I was planning to reduce demand but to help reduce patients visiting hospitals and surgeries to help reduce spread of hospital acquired infections and antibiotic abuse.

Using the data, I developed a tool that will help patients and make them access the A&E, demand emergency appointment or simply speak to a doctor. This tool is simple, does not cost money nor do we need and validation or prove this is safe.

The colour coding makes it easy to follow and is based on the criteria I used for almost 30 years to decide to admit a child brought to hospital.
This I am sure will help reduce demand, cost and also reduce wasted consultations, delay in diagnosis and complications.

I have named this as Medical Advice You Access, MAYA in short. I sincerely hope GPs will use the tool and make sure they reduce patients access hospital by passing them making it harder for hospitals to survive.

#41133 Andrew Colclough
Chairperson
South Derbyshire PPG Network

Hospitals can and do avoid breaching the four hour target by admitting patients until consultants get around to seeing them. We need to monitor data on the number of admissions and on the number of people admitted and discharged same day to make sure hospitals don't do this.

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