The Royal College of Emergency Medicine recently reported that performance against the four-hour A&E standard was 78.9 per cent for March attendances at type 1 units. Over winter, the College’s figures have, on average, been tracking 2 per cent higher than the published NHS data and on that basis, depending on data for the last week of the month, we could see performance of around 77 per cent for March. This alone should sound alarm bells but there are other worrying signs from other data too.
The recent House of Commons report on NHS winter pressures in England concluded that A&E attendances rose by 1.6 per cent this year compared to 2016/17. This winter 22.9 per cent of patients waited more than four hours in A&E compared to only 6.2 per cent in 2010/11 when flu levels were worse than this year. This winter has been very cold and flu levels have been very high (as expected) but nowhere near as cold or as high as in 2010/11 when four-hour performance dropped to 92 per cent. In 2010/11 performance bounced back to 96.4 per cent for type 1 attendances and 97.6 per cent for all types by the summer – performance shows no sign of recovering this year. In fact, there is little confidence on the front line and little indication from the data that the NHS will achieve the 95 per cent target for four-hour performance by March 2019 – the new date given in recent planning guidance.
One of the reasons for this is that many leaders have switched their focus from achieving the four-hour standard to doing what they can to manage patients safely and with as much dignity as possible. I referenced this in a previous blog and, while I and most of my peers and their clinical and managerial teams support the four-hour standard, the concern is that while the idea of treating patients quickly remains as important as ever, the practical reality is that many frontline staff no longer believe this is a realistic proposition – either in winter or summer.
Indeed the BMA has modelled a number of scenarios for this summer’s four-hour performance and the best case scenario is all-type performance of 89.6 per cent (comparable to the winter of 2015) and in the worst case is 87.5 per cent (comparable to the winter of 2016). As a result, some NHS organisations are extending their winter plans into the spring or summer. The University Hospital of North Midlands, along with many others, is keeping winter capacity open and others, such as Nottingham University Hospital, have continued elective cancellations to free up staff time and beds to manage ongoing emergency demand. While this may have some short-term benefit for A&E performance, the negative consequences – of increasing elective waiting lists and added pressures to the finances of providers and commissioners when waiting list initiatives return – will stay with the NHS for much longer. Leaders know this and there may well be more bad news on elective waits, but they are doing everything they can to manage the front line the best way they can now.
NHS Digital has published an analysis of daily A&E attendances over the past four years and Monday is consistently the busiest day of the week – a fact that will not surprise anyone in an operational role. More interestingly, the busiest single day was 10 July 2017 and while there will be more difficult days in terms of the severity of patients’ conditions, it makes the point that emergency pressures are not merely a winter phenomenon.
Challenges are not limited to four-hour A&E performance: an analysis of the mixed-sex accommodation breaches makes for alarming reading. Mandatory data collection started in 2011 when there were more than 2,000 mixed sex breaches in April. By May 2012 the level had fallen to fewer than 600 a month, where it stayed until January 2016 when breaches began to rise. The combination of the removal of the fines levy and the pressure on emergency departments has led to a steady rise to more than 2,200 breaches in February 2018. The NHS has lost six years of improvement and seen a doubling of the problem over the past year, demonstrating the pressure everyone is managing.
It is easy to see why staff and patients continue to be concerned about the situation and why they fear there is no change in sight; NHS leaders need to give them hope and the focus now has to be on what has been learnt from this winter so we can build a more fit-for-purpose emergency care system. These discussions are under way and need to build in experience from areas that have been able to bend the emergency care demand curve. I was recently in North Cumbria where staff described closer system-working and a focus on both out-of-hospital and in-hospital care as reasons for an improvement in performance this year compared with last year.
Sharing knowledge, introducing innovations in the delivery of emergency services and the investment in both hospital capacity and alternatives to hospital need time and space to be developed. This means starting now, despite the continued pressures staff are under, to build confidence among patients and staff that the NHS is not accepting the current situation as the new normal. The recent case at Northampton General Hospital where a patient died ‘due entirely to the dangerous overcrowding of the department’ should be used as a call to frontline staff, local boards and our political and national NHS leaders to ensure we don’t submit to perpetual winter.