First, and critically, despite the many harbingers of doom, winter 2013-14 has been remarkably short on 'A&E in crisis' headlines, at least at a national level (not forgetting that local variation means there are still hospitals operating consistently below the target). With due credit to the hard work of NHS staff and the hours spent on planning, A&E performance this winter is better than it was last year, and unless the weather takes a turn for the worse, March and April are likely to continue this turnaround. This upturn is more impressive given that the performance of major A&Es (which excludes walk-in centres and single specialty units) has declined in every quarter since the first quarter of 2010/11 (which makes 15 consecutive quarters) compared to the same period in the previous year. Until now that is.
Figure 1: Major A&E performance on the 4-hour waiting times target, percentage change compared to same quarter in the previous year, 2010-14
It’s at this point that some nay-sayers point out variously: it’s been a mild winter, in temperature if not rainfall; it’s been an easy season for diarrhoea and vomiting/norovirus; or there was more winter money than in previous years which has enabled the service to bring in staff and open up extra beds at winter to help with increased demand (though with some concerns over the reliance on agency staff that these can entail).
Such a response implies better performance is down to money and luck. But it’s worth remembering that, whilst a lot of noise has been made about winter money this year, it is not a new phenomenon. We shall never know how the NHS could have managed a more trying environment and, good weather or not, reversing the pattern of decline this late into the Nicholson challenge still deserves praise.
However, this improvement in performance doesn’t appear to have been caused by any particular success in stopping patients showing up at A&E.
Figure 2: 2013-14 percentage growth in major A&E attendances over the same quarter in the previous year
This is perhaps unsurprising. For many hospitals, the number of patients who show up at A&E is not the primary problem (as long as the unit is adequately staffed – which last week’s Public Accounts Committee report noted some are struggling with), it’s the number of patients that need to be admitted. Indeed, as we know, performance against the four-hour waiting times target is at its worst in winter and yet this is when A&E attendances tend to be lower. Winter causes stress on the system because a much higher proportion of those that do show up need to be found a bed.
So was the relative success of this winter due to new schemes helping people to manage their care better at home without a hospital admission? Or indeed, once admitted, to be sent home without delay once they are ready? Well, the answer seems to be no to both on the evidence available so far. Although over the whole year to date the growth in emergency admissions has been pretty subdued by historical standards, the bad news is that the rate of growth has been accelerating – particularly sharply at the point performance has improved. Delayed transfers have also risen, but only gently.
Figure 3: 2013-14 percentage growth in all emergency admissions over the same quarter in the previous year
What does this tell us? I think it suggests a couple of things:
- At national level the NHS has handled winter 2013-14 partly by admitting more people to hospital and thereby avoiding them waiting in A&E; for all the hopes of new models of care and keeping people out of hospital, this appears to be the `old model’ at work
- To do this, the NHS must have created more capacity. The winter money may have helped alongside local prioritisation. Over and above that, the post-Francis surge in staff numbers may also be a factor enabling hospitals to admit more patients. The downside may be the deteriorating finances in the acute sector as reported by Monitor and NHS Trust Development Authority – in the current financial context this may not be a sustainable solution.
The planning guidance issued by NHS England and its national partners noted that in 2015/16 the NHS will need to reduce emergency activity by 15 per cent as a consequence of supporting social care and its integration with health through the Better Care Fund. With that in mind, coming through winter 2013-14 with growth rates in emergency admissions of +4 per cent just underlines how much still needs to be done to reduce emergency admissions and to get patients discharged quickly once they have been admitted. Our own work on this has shown the potential for reductions in admissions, but this is no easy ask. So while congratulations are in order for making the 'old model' work rather better than it has done recently, this still leaves next winter looking as hard as ever and the (never great) odds on delivering fundamental change by the following year ever slimmer.
This blog is also featured on the Health Service Journal website