An alternative guide to the urgent and emergency care system in England

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Part of Alternative guides to health care

A&E is often seen as a service in crisis and is the focus of much media and political interest. But A&E is just the tip of the iceberg – the whole urgent and emergency care system is complex, and surrounded by myth and confusion.

Our animation gives a whistle-stop tour of how the system fits together and busts some myths about what’s really going on  – explaining that the underlying causes go much deeper than just A&E and demand a joined-up response across all services.

Comments

Geoff Lawson

Position
COnsultant Paediatrician and Clinical Director,
Organisation
City Hospitals Sunderland
Comment date
10 April 2014
Brilliant video but I am afraid too many points either untrue or irrelevant to paediatric emergency care. In Sunderland our peak of PED care is 4 - 10pm and weekends. Senior Paediatric involvement (Consultants in PEMedicine) have successfully reduced hospital admissions and will be further reduced by community nursing support. Ineffective, unavailable primary health care is, in my opinion, a major factor.

Louise Hutchinson

Position
Patient Experience Lead,
Organisation
South East Coast Ambulance Service NHS Foundation Trust
Comment date
10 April 2014
Great animation, but very disappointing that the ambulance service – which has a key role to play in urgent and emergency care – was only mentioned in passing towards the end. Also, in my recent experience of an A&E at night, minors patients did wait longer to be seen, as the same doctors were seeing them as seeing majors patients.

Jon Taylor

Position
Advisor,
Organisation
AgeUKSL
Comment date
13 April 2014
One of the best animations I have seen that seeks to explain health issues. I share the comment above about the near absence of the ambulance service but can see how that has happened. I will use the animation to inform, directly and indirectly, my work with local health services.

giles eagin

Position
Emergency Care Practitioner,
Organisation
Ambulance Service
Comment date
18 November 2014
Response to above comments about the afterthought of the Ambulance Service. It is not uncommon for the Ambulance Service to be almost forgotten about. Advanced Practice is a very new approach in the pre-hospital environment but Paramedics being often the first contact with patients can make a great impact in non conveyance to A&E, treating Minor Injury and Minor Illness at home or in the workplace. The issues around the Ambulance Service are about the sharing of information from other Healthcare providers, eg. A&E discharge letters, ECG's and GP notes, which would better inform the Pre-hospital Specialist Paramedic in making a decision about weather to treat or transport. The gatekeepers to Patient information need to allow others to view this information. I suspect there was nobody from the Ambulance Service in the making of this video.

George Coxon

Position
Various inc care home owner,
Organisation
Various
Comment date
07 January 2015
Always entertaining and useful illustration from KF but must agree with comment on out of hours and ambulance service omission I commissioned ECPs in my commissioner days and supported 'first responder' training and roll out too perhaps using local residential care working with ECPs and village based first responders could be worth exploration. Please get in touch to do some scoping for a pilot scheme perhaps. Eg devon has c 100 admissions each wk from residential care. I'm sure mostly preventable with creative innovative ideas

Ceri Davies

Position
Lead Superintendent Radiographer,
Comment date
08 January 2015
I agree that's its an engaging animation, however the Imaging Services have been overlooked, except as an issue to the prevention of pathways it seems. It's disappointing considering that the majority of patients require some sort of imaging during their visit or stay in hospital that Imaging/Radiology are not included with strategy planning.

Andrew Nwosu

Position
Regional Allied Health Professions Lead,
Organisation
NHS England
Comment date
09 January 2015
The animation is indeed engaging and seeks to clarify some of the reasons for our A&E crises, however Improving A&E is also about changes in behaviour and organisation of people and systems, attempting to reduce the "compartment" mentality that still exists.
Human beings, our clients are diverse and as the animation showed, display complex and sometimes multifactorial reasons for A&E attendance.
This diversity and complexity requires more diverse workforce inclusion not just "Drs and Nurses" , echoing some of the comments above it is interesting to note the lack of acknowledgement of the role the Allied Health Professions can play, in the UK there are over 64000 AHPs who straddle the continuum of care for all ages groups,and a number are independent/ supplementary prescribers.
Working with social care and voluntary sector colleagues AHPs can collaboratively start to change the system response, especially around people who have higher disease burdens and lower levels of activation
which in turn can help "unplug" some of the bottlenecks being currently experienced.

Nick Mann

Position
GP,
Organisation
NHS
Comment date
10 January 2015
Your animation shows how flow and balance may tweak numbers of patients bottlenecking in different parts of the system. Inpatient, A&E, primary care, mental health, social care and community services are all inundated. This is a fact which must implicate a more fundamental cause. I would suggest the fact that UK's beds-per-head of population is half the EU average (3rd lowest of 27 countries; 30% that of Germany) and our doctor:bed ratio is 2nd lowest of 11 OECD countries is that fundamental cause. 150,000 beds cut since 1984, 90% of which under Tory Govts. Please will King's Fund do an impact assessment of the effect of these cuts on the ability of the NHS to manage patient throughput? Simply blaming other parts of the system is not an adequate, true or helpful approach.

Ahmad

Organisation
NHS
Comment date
10 January 2015
As the great man himself, Shakespeare said: “AsThis above all: to thine own self be true,
And it must follow, as the night the day,Thou canst not then be false to any man.”
I applaud the work done in showing where the bottle necks are in the system and also possible solutions. But are we really honestly drilling down to the clear and present harsh reality: we just haven’t got enough resources/beds/staff in the system, etc, as the previous poster has written.
A study done and published in the BMJ in the recent past said of 11 or so high income countries we most cost effective in terms of heath care provision and also patient satisfaction. Imagine, therefore, how much more better we will be if we did put more money into the system?
So yes, we should have more joined up thinking and more inter-department communication and coordination, and yes that will help reduce admissions but i am reasonably and honestly sceptical it will make a significant difference till we bite the bullet and are honest with our self that we simply need more money and resource to cope with the inexorable tide. Yes i admit it may not solve our problem completely but it will go a very long way in that direction. It is from there we can progress to say we are being honest with our patients.

COI: best interests of our patients is my professional Raison d'être

philip croft

Position
retired,
Comment date
16 January 2015
As someone who--unfortunately, has had to make FULL use of the NHS in the last 12 years ( and hardly ever previously ), I can honestly say that I have been very well looked after, at all times and in all the departments where I was treated. Yes, A&E can be traumatic to some degree, especially when mainly occupied by stupid drunks who are responsible for their own condition;(don't get me started). I have watched the video twice, and although I'm not qualified to question any of the statements made, I was at least relieved to hear that we are NOT at crisis point at all, which of course, this political football, known to all as OUR national treasure, has been subjected to abuse and neglect by most political parties, for their own meens, especially as General Elections appear on the horizon. Of course there is always room for improvement, but those in the profession should hold sway on the most important descision making--and political neutrality has to be enforced. I will share this video with all those I know--I hope all viewers/commenter's do the same. Philip Croft.

Dr Kadiyali M …

Position
Retired GP,
Organisation
NHS
Comment date
23 January 2015
Its sad, these people in power are adamant, ignorant and stupid to think they can repair the damage to healthcare in UK. I have done all that I can to help save the NHS. This problem can only be resolved using a simple tool that can help reduce demand. It is very important to save the NHS because the threat of emerging infections and bacteria is real. Please shun the ego and accept you have failed and consult doctors who offer their service with passion and not harass, humiliate and ostracise them. This is not about money, power or ego but a service to help reduce pain and suffering to fellow human in UK

Dr Kadiyali M …

Position
Retred GP,
Organisation
NHS
Comment date
23 January 2015
Please check my tool, www.call111.com. This is FREE and I also have a card that can help reduce wasted consultation by 60%-80%. I developed this tool because I got feud of seeing patients who visit walk-in-clinics, nurse-led emergency OOH service developing complications. Duty of doctors is to help reduce complications, by offering false reassurance, wrong diagnosis and treatment patients are suffering. A simple method can not only reduce demand but also cost and save the NHS

JYG District Nurse

Position
Lecturer and District Nurse,
Organisation
NHS
Comment date
03 February 2015
Interesting. Still wonder why everyone recognises the role of social services / GPs in supporting patients in the community and in their own homes, but very few acknowledge or are aware of the harsh cuts to District Nursing services. There has been a loss of 2000 District Nurses over the past 5 years (HSCIC 2014). Might not sound like many to those who don't work 24 hours a day, 7-days a week, 365 days a year to cover care outside of hospital, but to those quietly be ground down under the pressure, it is significant. Fewer than 5000 District Nurses left in the UK, representing a cut of nearly 40% of this vital workforce. This workforce that props up the NHS, and is THE big difference between costly care in the US / Canada / rest of Europe (who all spend more per GDP on health care), and relatively efficient care here.

JYG

Position
Lecturer - District Nurse,
Organisation
NHS
Comment date
03 February 2015
Apologies, for above calculation error- there has been a loss of 2000 over the past 5 years, but the 40% loss is over 10 years (there were over 10, 000 qualified District Nurses 10 years ago). And for information of anyone who maintains there are more of all types of nurses in the community (eg. Community Matrons, 'specialists' etc), the net difference is -2000 over the past 5 years of ALL types of community practitioners (with the exception of Health Visitors). While this trend is slowly reversing, it will continue to have an impact on:
1. How many patients are sent to A&E
2. The speed of the discharge
3. Readmission rates
4. The number of patients prematurely or needlessly going into residential or nursing care
5. The number of patients who would prefer to die at home, but are unable to

Ewa

Comment date
22 February 2015
Good point about people staying in hospital longer than it's needed. When I gave birth to my last child I was waiting 12 hours before he could be seen by the paediatrician although I felt absolutely fine to go home. And that didn't end then. The junior paediatrician said she wants another opinion and the senior paediatrician should see my son. I'm very thankful for such concerns and careful assessment but we had to wait next 24 hours for the consultant. Finally instead of going home straight after successful birth I've spent two days and nights at the hospital, eating hospital food, using it's facilities, having staff working for me and occupying a bed. What was the cost of that unnecessary waiting?

V Suresh

Position
Consultant Physician,
Organisation
Heart of England NHS FT
Comment date
04 June 2015
Enjoyed the animation. Some of the points described are true, vast majority of facts are author's own views rather than backed up by numbers. I am surprised that King's fund has posted this on their website. At any given time, 30% of hospital beds are occupied by patients who are "medically suitable for discharge" outside of an acute hospital. This backlog puts a whole load of pressure all the way to the front end. Acute trusts are constantly fighting to achieve their 4 hours target, in this process, right patient may not get to the right clinical area at the right time.
In addition, politicians should be open and honest to the public about what they can expect from the current health service rather than promising "the pie in the sky". Now that the elections are over, NHS will face its real biggest challenge and the public are going to face the reality of modern NHS.

James Thompson

Position
Senior Research Analyst,
Organisation
The King's Fund
Comment date
12 June 2015
V Suresh, thanks for commenting. The animation has been put together using our interpretation of publicly available data. They are very much backed up by numbers and we stand by these. Referring to your stat on patient backlogs, we seem to compliment each other on our comments about this (we refer to delayed discharges) though we might be using different numbers. If you have any further questions or comments about this piece please feel free to contact me through the website. Thanks, James

Margaret Hughes

Position
patient,
Organisation
N/A
Comment date
24 February 2016
Interesting video. Like almost every article I have read, every meeting I have attended and every person I have spoken to a tokenistic mention is given to patient involvement. Until some serious money is redirected to train patients in PPI, self care and self management this situation is not going to change. Patients need to be part of the solution instead only seen as the problem. Informed patient representatives need to be at every discussion and treated as equal partners. This cannot happen until the patient has a level of knowledge to add to the experience they have gained as patients which will give them the confidence to lead on a solution.

Lynsey

Position
GP Fellow,
Organisation
NHS fife
Comment date
12 September 2016

Much of the information in this film is similar to my current thoughts with regard to the problems and potential solutions facing unscheduled care in the NHS, but there needs to be more factual evidence and cross referencing with other data sets to clearly substantiate the hypothetical points highlighted. This video aims to create discussion around the current concerns that the NHS is facing crisis, the main symptom of which is the increasing pressure being felt in frontline services, with a particular focus on A&E. It is a subjective text with no clear statistical data and states that it aims to highlight the complexity and myths surrounding urgent care and make suggestions around solutions to improve this. I felt this was more narrative and opinion that definite fact, although I could relate to some of the points detailed, in particular that the current system for urgent care is confusing for both patients and staff and also very disjointed with poor information sharing. I agree with the suggestion that the problem is not due to over admission to hospital but indeed the lack of social care support in the community to aid discharge when patients are medically fit. Additionally, there is a well-documented issue with recruitment and retention into front line medical services, particularly A&E but more recently into General Practice, a fact that is overlooked in this film. There is no clear backing for some of the claims in this, many of which are perhaps more anecdotal although perhaps correct. Patients do often self-present to A&E in crisis, and without a doubt it is entirely unsuitable for mental health patients, however at the present time, there is no real alternative due to underfunded and scanty community mental health services.

Simon Dodds

Position
Health care system engineer,
Organisation
NHS
Comment date
07 November 2016
I commend the King's Fund for presenting a hugely complex system in a visually engaging and informative way. Since this was published, emergency care in England as a whole, as measured by A&E 4-hr performance, has deteriorated dramatically. But there are islands of excellence that disprove the belief that it is impossible. The stories from these sites reveal that system-wide collaborative co-design is a common theme, just as the video suggests is a the path to transformation. The challenge now is for the rest of the system to listen, learn and replicate what these positive deviants have achieved.

Ben lovell

Position
Doctor,
Comment date
26 February 2017
Where are the authors getting the data that A&E attendances have remained static? I quote directly from elsewhere in the KF site:
"Since then, the overall number of attendances has increased significantly to 22.3 million in 2014/15, a rise of more than 35 per cent over the period. Until 2012/13, attendances in type 2 and 3 units accounted for the vast majority of this increase, with attendances in type 1 units increasing at a much lower rate.

Ben lovell

Position
Doctor,
Comment date
26 February 2017
I am also puzzled by the claim that more patients are being seen within the 4-hour standard than 10 years ago. Again, they are contradicted from the data for NHS England, which is quoted elsewhere in the KF website thus:
"From 2005-2010 the proportion of patients spending more than four hours in A&E hovered around 2 per cent – an outcome of the 98 per cent target introduced in 2000 and first met in 2005. However, since 2010, when the coalition government relaxed the target to 95 per cent, the proportion of patients waiting longer than four hours has increased."
These inaccuracies make me hesitant to use this otherwise excellent animation as a learning tool for others.

James Thompson

Position
Senior Research Analyst,
Organisation
The King's Fund
Comment date
27 February 2017
Ben, thanks for your comments and questions. In your first question it's about what year you set the baseline and for your second it's about raw numbers versus percentages.

The number of A&E attendances jump from 2003/04 onwards, when type 2 & 3 units were introduced into the data. Most of the increase in A&E attendances occurred in the first few years after this, when more units were opened and more recording of data to these units happened. Whereas between 2010/11 to 2013/14 (just as example) attendances were 21 million (plus or minus some decimal numbers).

For the second question your quote refers only to performance against the 98 and 95 per cent targets. But in actual numbers, the number of patients seen within 4 hours has been increasing. From 340k patients treated after 4 hours in 2005/06 to over 1.8m in 2015/16.

Hope this helps,
James

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