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Accident and emergency (A&E) departments across England are struggling to provide safe, dignified, and equitable care. In August 2022, only 71.4 per cent of patients were seen and either admitted or discharged within four hours. Ambulance waiting times and handover times are at an all-time high as we move into winter – a season notorious for rising rates of admissions and pressures on emergency health services.
As an emergency medicine doctor, none of this surprises me. I am coming up to 10 years working in the NHS, most of that time within A&E. Five years ago, starting a shift with a seven- or eight-hour wait for a patient to see a doctor/clinician would have been completely out of the ordinary, now it is a daily occurrence.
In my experience, the current situation only serves to exacerbate the health inequalities that we see in A&E. As ambulance waiting times, A&E waiting times and referral times get longer, those who were already struggling to access health care in a timely manner are likely to wait even longer and have worsening outcomes. I am using my time at The King’s Fund as a population health fellow to explore the impact of health inequalities in my clinical work and start to consider how A&E health care workers can address these issues in our day-to-day work.
How do health inequalities affect A&E attendances and outcomes?
Health inequalities contribute to the large disparity in morbidity and mortality between the most and least deprived. In the UK, there is an almost 10-year gap in life expectancy between men in the most and least deprived regions. For the women living in the most deprived areas, life expectancy is starting to fall. Although this is not solely due to the Covid-19 pandemic, Covid-19 has further entrenched and worsened inequalities.
'As ambulance waiting times, A&E waiting times and referral times get longer, those who were already struggling to access health care in a timely manner are likely to wait even longer and have worsening outcomes.'
The backlog of patients waiting for treatments continues to grow, in August 2022 more than 7 million people were waiting for care. This backlog exacerbates pre-existing health inequalities; people from more deprived backgrounds wait longer for specialist referrals and care. People from minority ethnic backgrounds, people with disabilities and people from more deprived backgrounds are more likely to access care late, have worse outcomes and higher mortality in certain conditions such as colorectal cancers. In addition, long-term conditions, many of which have predictable patterns of progression, are more prevalent in people from deprived communities.
Over the course of several shifts in different clinical departments, I have reflected on patients I have seen and how population health factors affected their presentation in A&E and their outcomes. People are coming to A&E with increasingly complex health and care needs. More and more I see patients in A&E who are waiting for specialist care but come to A&E with complications of their underlying conditions. For example, while patients wait for hip replacements, their mobility deteriorates, they lose muscle mass and therefore are less fit and have a higher anaesthetic risk when the time eventually comes for their operation. They may come to A&E with increasing pain that they are struggling to manage at home, reduced mobility and falls. Several patients I have seen recently had already tried to access community support or advice before coming to A&E. However, a lack of resources for community teams meant these patients ended up in A&E when community specialist support may have served them better. Patients who are admitted from A&E face long waits to move to a ward due to lack of bed capacity within the hospital. A recent study suggested people from more deprived backgrounds are also more likely to wait longer in the A&E, receive fewer treatments and be discharged more quickly.
What can be done in A&E to address these inequalities?
Seeing patients in A&E is a unique and unscheduled point of contact with people who may be less likely to have regular contact with primary care or community services. The systemic issues and inequalities that feed into this cannot be solved in A&Es alone, but, as integrated care systems develop, there is a real opportunity for collaborative working across local authorities, primary and secondary care, social care, the voluntary sector and beyond to offer different ways to support people before they need to come to A&E.
What this will look like in an A&E department is likely to vary by region and according to need. In some places, it may be that partnerships with the voluntary sector open up new ways to support people. For example, Red Thread is a charity that run hospital-based Youth Violence Intervention programmes across London and the Midlands. They are based in A&E departments, and any member of staff can refer young people affected by violence to them.
Some of the solutions may sit more with how individual clinicians consider the wider situation of individual patients. For example, when we see children with asthma exacerbations this winter, we should consider what their home environment is like, is there mould, are their guardians struggling to pay for heating – how can we think more holistically about the causes behind their visit to A&E? Can we signpost more patients to appropriate social services, community support groups and charities on discharge?
In A&E, we often see the most deprived and excluded people in society. Staff working in A&E are well placed to advocate for our patients, recognise how they are being disadvantaged by their circumstances and ensure we are moving to a more inclusive and socially just healthcare system. For example, by developing collaborative care plans with both hospital and community teams for people who frequently visit A&E. These people are often some of the most deprived in the community and this is an issue of health inequality. Recent work by the Red Cross highlighted that patients who attend A&E more than 5 times a year represent 16 per cent of attendances, 29 per cent of ambulance journeys and 26 per cent of admissions.
'Staff working in A&E are well placed to advocate for our patients, recognise how they are being disadvantaged by their circumstances and ensure we are moving to a more inclusive and socially just healthcare system.'
As clinicians, we should be considering the population factors at play when we see each individual patient. For example, a patient who attends with recurrent exacerbations of chronic obstructive pulmonary disease who may struggle to quit smoking and partake in pulmonary rehabilitation because they work long hours, live in poverty and suffer with mental illness exacerbated by their circumstances. If we see this patient in their context, we know a stop smoking cessation leaflet alone is unlikely to do much to address their situation.
Finally, as anchor institutions within the local community, A&Es and the wider hospital services should be looking at ways we can improve upon our collaboration with local voluntary care sector organisations, businesses and community services and have a greater impact on the wider population health.