A&E performance: a winter’s tale

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With many of us just having enjoyed the warmest weekend in 2014, this may be a good point to take stock on how A&E performed over the winter and what, if anything, it tells us about the state of the NHS and its prospects.

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

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

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

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.


Jeremy Griffith

Director of Innovation,
Comment date
17 March 2014
From working with many NHS organisations this 'winter' the key observations are that the whole health and social care economy needs to understand their and each others part in numbers. They then need to communicate this daily so that operationally there is an empathy for each others role and a transparency which is objective of what 'fitness' the system is currently in. Managing the system this way allows for a targeted approach on both the preventative (pre -hospital) actions as well as the patient flow (community response). Actions are generated daily which have real benefit for that day and going forward
A key output from doing this has been a cultural change in that the whole system knows 'What good looks like' through data and predict where they need to be against those metrics. To balance this it is important to apply a similar approach to clinical quality measures. You then have a view that the system is 'pushing' the right parts operationally to deliver quality of care for its patients.

Happy to share further detail on our experience, please contact via jlg@alamac-ltd.co.uk


Hilton nursing partners
Comment date
15 March 2014
I agree with David's comment on the growth in A&E is linked to the service from GP surgeries.
To prove it ,what are the statistics for hour by hour attendance? Why is anyone attending, without GP support, during 8.30am -6.00pm? And from which surgeries?
Having established any trends , then triage every walk in attendee (not patient !) using a GP in the A&E ( from 6pm-11pm in alignment with an OOH GP surgery plus during the day on Saturday and Sundays) , for true prioritisation . Then treat the" patient "within 1 hour!

Mick Smith

Partner Governor,
West Suffolk NHS FT
Comment date
14 March 2014
I suggest that we stop avoiding the crazy funding of A&E services where hospitals are fined for having too many patients coming into A&E as though it is our fault!
I wonder whether these sorts of reduced funding incentives would be given to the private sector if they had our problems?
If we are running at a deficit, albeit a minor one, then cutting what we get paid for over a capped number of visits is simply going to make matter worse.
Yes we have all done valiant work trying to reduce waiting times et al but there comes a time when we can do no more without adequate funding and a much better system of getting our ambulances in and out quickly and efficiently. Where is the funding for that?
We have improved things by the actions our dedicated staff have carried out; actions that they were involved in designing. This has had a positive impact of services but without being paid what it costs us to perform we physically cannot improve.

David Dundas

Hospital Public Governor,
Burton Hospitals NHS Foundation Trust
Comment date
14 March 2014
One of the pressures on A & E may come from people's wish to be treated promptly rather than wait for their GP to open, a sign of our attitudes these days towards services in general; this probably arises from more and more people working around the clock. What to do about this? I feel that the Minor Injuries departments that stay open 24/7 could help reduce the pressure on A & E as well as GP surgeries opening for longer hours.

Harry Longman

Chief Executive,
Patient Access Ltd
Comment date
14 March 2014
Why are you basing your assessment of performance on the 4 hour target? This is merely the zeitgeist. It doesn't measure flow and it doesn't measure what matters to patients. It's use is for punishment of failure, and trading statistics across the House of Commons. We should talk about different, better measures which do help understand performance. I have the data.

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