1. What different types of A&E departments are there?
There are three main types of A&E departments in England.
Type 1 departments are what most people might traditionally think of as an A&E service. They are major emergency departments that provide a consultant-led 24-hour service with full facilities for resuscitating patients, for example patients in cardiac arrest. Some type 1 departments are located with major trauma centres or specialist emergency hospitals and deal with patients who have highly complex or acute conditions. Type 1 departments account for the majority of attendances (68 per cent in 2016/17) and the vast majority of waits over four hours in A&E.
Type 2 departments are consultant-led facilities but for single specialties, for example, dedicated to treating only eye conditions or only dental problems.
Type 3 departments treat minor injuries and illnesses, such as stomach aches, cuts and bruises, some fractures and lacerations, and infections or rashes. Type 3 departments, which can be routinely accessed without an appointment, include minor injury units and walk-in centres.
2. How is A&E performance measured in these departments?
The most high-profile measure of A&E performance in England is the four-hour standard. This refers to the pledge set out in the NHS Mandate that at least 95 per cent of patients attending A&E should be admitted to hospital, transferred to another provider or discharged within four hours.
The four-hour standard is monitored for attendances at all types of A&E departments, including A&E services provided by the independent sector for NHS patients (NHS England).
The four-hour standard measures the total time patients spend in A&E rather than the time patients spend ‘waiting’ for treatment to begin. The waiting time clock ‘starts’ from the time that the patient arrives in A&E and stops when they leave the department to be admitted, transferred to another provider (for example, where more specialist clinical care is needed) or discharged. For patients arriving by ambulance, the clock starts when the patient is handed over from the ambulance staff to hospital staff or 15 minutes after the ambulance arrives at A&E (whichever is earlier).
Figure 1 shows the emphasis placed on the four-hour standard; 8 per cent of patients are admitted, transferred or admitted in the 10 minutes before they would cause a breach of the standard by spending more than four hours in A&E.
Figure 1: Attendances by total time spent in A&E, 2016/17, England
A&E waiting times are often used as a barometer for overall performance of the NHS and social care system. This is because A&E waiting times can be affected by changing activity and pressures in other services such as the ambulance service, primary care, community-based care and social services. For example, patients cannot be admitted quickly from A&E to a hospital ward if hospitals are full due to delays in transferring patients to other NHS services or in arranging social care.
Being treated quickly in A&E is clearly important for both the experience and clinical outcomes of patients. However, measuring the proportion of people seen within four hours does not provide a full picture of how A&Es are performing. For example, two different A&Es could see the same proportion of patients within four hours but have very different average waiting times. In addition to waiting times, the quality of A&E care can also be measured through patient experience surveys and clinical indicators such as the proportion of patients who re-attend A&E within seven days of their first attendance. Other measures, such as the time a patient waits to see a clinician in A&E, are also now recorded.
For these reasons, we should be cautious about placing too much emphasis on the four-hour standard. The safety and quality of care, as well as patient experience, are as important as how rapidly care is provided. In December 2016, NHS Improvement announced that from 2017 hospitals would be rated against a new scorecard for A&Es that would include the four-hour standard and further metrics on clinical standards and patient and staff experience. These plans were later revised, and NHS Improvement is now piloting an online tool to provide a broader range of information on how emergency patients flow through hospital. However, the four-hour standard is likely to remain the focus of attention for the public, politicians, regulators and the media.
3. What has happened to A&E waiting times in recent years?
A&E waiting times have increased substantially over recent years. The NHS has not met the standard at national level in any year since 2013/14, and the standard has been missed in every month since July 2015. In 2016/17, 89.1 per cent of patients spent four hours or less in A&E. Figure 2 shows both the decline in A&E waiting times over time and the – often dramatic – fall over winter months.
Winter is a particular challenge for A&E departments because of increased demands – for example as a result of flu outbreaks, more emergency admissions to hospital, more complex or acute patient needs – and closures of hospital wards to control winter vomiting bugs. Performance may also be affected by reduced availability of staff due to sickness and holidays.
More detailed data1 on waiting times shows that in September 2013, the average (median) waiting time in A&E for all patients was 2 hours and 9 minutes, with 95 per cent of patients leaving A&E within 4 hours and 32 minutes. By September 2017, the median waiting time had increased to 2 hours 28 minutes, and 95 per cent of patients departed A&E within 7 hours of arrival.
Figure 2: Performance against the four-hour standard, all types of A&E, by month, England
In March 2017, Next steps on the NHS five year forward view set three milestones for bringing national A&E performance back to the standard of 95 per cent of patients being seen within four hours:
- milestone 1: in or before September 2017 over 90 per cent of A&E patients are seen within four hours
- milestone 2: the majority of NHS trusts should meet the 95 per cent standard in March 2018
- milestone 3: the 95 per cent standard should be met nationally within the course of 2018.
The first of these milestones was narrowly missed, with 89.7 per cent of people seen within four hours in September 2017 (Figure 2). In our most recent Quarterly Monitoring Report, only 28 per cent of trust finance directors in our survey were very or fairly confident about meeting the second milestone by March 2018.
The four-hour standard is measured across all A&E departments, but performance is poorest in type 1 A&Es. In the latest data for October 2017, 84.9 per cent of patients were seen within four hours in type 1 A&Es, compared to 90.1 per cent across all types of A&E. Only 10 of the 137 NHS provider trusts reporting data for type 1 A&Es saw 95 per cent of people within four hours (Figure 3).
Figure 3: Percentage of patients seen within four hours at type 1 A&E departments, by provider, Quarter 2 (June to September) 2011/12 to 2017/18
Departments are ranked in order of performance, with those meeting the standard highlighted in green
Source: A&E Attendances and Emergency Admissions 2017-18.
Notes: Each cell represents one of the 135 providers of type 1 (major) A&E departments submitting data within each year of the time period. The performance standard is for at least 95 per cent of patients to be admitted, transferred or discharged within four hours of arrival at A&E. Data are rounded to one decimal place, so some trusts may be below the standard even though they report performance of 95.0 per cent.
It is important to note that the vast majority of patients are still seen within four hours of arrival at A&E. The English NHS also compares favourably with other countries on providing rapid access to emergency care. However, A&E performance has fallen compared to recent years and pressures on services continue to increase.
- 1. NHS Digital note that this A&E data is still provisional, and some waiting time information is particularly sensitive to poor data quality, outliers and data definitional issues
4. Are waiting times increasing because more people are going to A&E?
The number of people going to A&E has risen substantially over time. In 2016/17 there were 23.4 million attendances at A&E departments – the equivalent of 63,000 attendances each day on average. Between 2011/12 and 2016/17, A&E attendances grew on average by 1.7 per cent each year, and increased by 1.9 million in total (or 8.8 per cent). This is the equivalent of an extra 5,100 more A&E attendances each day. The growth in attendances has been higher in type 3 A&Es (such as walk-in centres and minor-injury units), compared to type 1 (major) or type 2 (specialist) A&Es.
However, the rising number of attendances at A&E is not the main factor affecting performance. The increased pressure on A&E departments is more closely associated with rising numbers of emergency admissions to hospital and reduced capacity to meet this rising demand.
It is the emergency admissions from A&E rather than attendances themselves that place greater demands on health services, because patients admitted as emergencies usually need more complex care from a wider range of professionals, and an available bed in an appropriate ward must be found for these patients before they can be admitted.
Figure 4 shows that, compared to 2011/12, attendances at type 1 (major) and all A&E departments have increased at a faster rate than growth in the general population. However, emergency admissions via type 1 A&E departments, which account for over 70 per cent of all emergency admissions to hospital, have increased at an even greater rate than attendances.
Figure 4: Change in hospital activity, overnight beds, and the English population, 2011/12 to 2016/17
It has been suggested that one of the causes of increased pressure on A&E departments over the past decade is people attending unnecessarily because, for example, they can’t get an appointment with their GP or are confused about where to go for treatment. In particular, it has been argued that contractual changes in 2004 that removed responsibility for out-of-hours care from GPs led to an increase in attendances. There is limited evidence to support this theory, with little change in the proportion of attendances at type 1 A&E departments outside working hours (Nuffield Trust 2015).
Around 11 per cent of people who attend A&E are discharged without requiring treatment, and a further 39 per cent receive guidance or advice only (NHS Digital 2017). This does not mean that all these people are attending A&E unnecessarily or could be cared for elsewhere. For example, someone who leaves A&E without being admitted to a hospital bed may well have attended appropriately because they required assessment or clinical advice from A&E professionals.
The Keogh review into the urgent and emergency care system suggested that the fragmented and wide range of services offering urgent and emergency care causes confusion for the public. It committed to simplifying the system, with the aim of helping patients to ‘get the right care, at the right time, in the right place’ by making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies. Since 2015, eight vanguard areas of the country have been exploring new approaches to delivering urgent and emergency care services in line with these principles.
Recent analysis has also indicated that waiting times in A&E may be increasing due to advances in medical practice. For example, some patients who would previously have been admitted to hospital can now be fully treated in A&E with more investigations and treatments. Patients with simpler clinical needs who could be treated quickly in A&E may now also be increasingly treated out of hospital, for example being treated by ambulance services at the scene of an injury. While these advances are delivering better care, they mean that patients attending A&E may require more complex and time-consuming treatment than in the past.
So increases in waiting times may be a result of both rising activity and the increasingly complex care that patients require in A&E.
5. Are A&E waiting times increasing because hospitals are full?
Patients admitted to hospital require a bed to be available. Although medical advances have reduced the average length of time people spend in hospital and allow beds to be ‘turned over’ or made available again more quickly, rising emergency admissions are placing increasing pressure on hospital resources. Figure 4, and our more detailed recent analysis, show that the number of hospital beds for overnight stays continues to decrease even as admissions continue to rise.
These pressures are demonstrated by high levels of bed occupancy in NHS hospitals, which are closely associated with longer waiting times in A&E. Figure 5 shows that hospitals are routinely operating with bed-occupancy rates above 85 per cent – the level at which the Department of Health suggests that hospitals will struggle to deal with emergency admissions. Occupancy levels are highest in the winter months, and this is when A&E performance is most challenged.
Figure 5: Occupancy rate for overnight general and acute beds, by quarter
Source: Bed Availability and Occupancy
Delays in discharging patients who are medically fit to leave hospital (known as ‘delayed transfers of care’) are another factor driving up bed-occupancy rates, preventing beds being available for new patients requiring admission from A&E. In September 2017 there were more than 110,000 delayed days2 in acute hospital care. The majority of delayed transfers (57 per cent in September 2017) can be attributed to delays within the NHS, when there is a delay in patients being transferred to receive care from a different NHS provider such as a community hospital. However, the proportion attributable to social care (ie, patients waiting for care to be arranged at a residential or nursing home or for a care package at home to be developed) has increased over recent years. This reflects pressures faced by local councils, which have seen significant cuts to their budgets in recent years.
One of the clearest indications of the link between A&E waiting times and hospital bed occupancy is the number of patients who experience ‘trolley waits’ in A&E departments – ie, a long wait between a decision to admit the patient being made in A&E and the patient actually being admitted to a hospital bed. Figure 6 shows the increase in recent years in the number of trolley waits of more than four hours and 12 hours. In 2016/17 just over 3,500 patients experienced a trolley wait of more than 12 hours. While this is a small proportion of the 23.4 million patients seen in A&E last year, these trolley waits can cause significant distress for patients and are a clear symbol of the pressure A&E departments are under.
Figure 6: Long trolley waits in A&E departments
- 2. A delayed day occurs when a patient has been delayed one day after they were medically fit to be transferred/discharged. The total number of delayed days for a single patient is the number of days from when they were medically ready to be transferred to the date they were transferred or discharged (NHS England).
6. Is a lack of staff increasing waiting times?
A&E departments face longstanding challenges in recruiting and retaining sufficient staff to cope with rising demand. Emergency medicine is regularly included on the government’s shortage occupation list, as there are not enough resident workers in England to fill vacancies.
The Royal College of Emergency Medicine notes that emergency medicine has a high attrition rate from doctors in training, high early retirement rates for experienced clinicians, and significant reliance on temporary locum clinical staff. In the most recent General Medical Council survey, doctors training in emergency medicine reported the highest level of workload pressures of any medical specialty.
A range of national policies have been put in place over recent years to boost the numbers of clinical staff in A&E departments through increased recruitment and improved retention of existing staff. Between 2012 and 2017 the number of emergency medicine consultants increased by 7 per cent each year. Professional roles such as advanced clinical practitioners and physician associates are also being developed to play a greater role in delivering A&E services to relieve pressures on departments.
However, it remains difficult to recruit and retain sufficient staff in emergency care and other key services. The number of nurses employed by the NHS is falling, and shortages of senior staff are reported in mainstream specialties such as acute general medicine. Staffing shortages in these key areas will reduce the ability of hospitals to admit patients quickly from A&E departments or to provide specialist advice to patients within A&E departments who could be treated and discharged, further increasing waiting times.
The workload in A&E departments is very high, and there is a limit to the workload staff can undertake without having negative consequences on morale, recruitment and retention, and waiting times in A&E departments.
A&E waiting times have continued to increase over recent years. More people are attending A&E departments each year, and the complexity of the problems they have may be rising. At the same time, longstanding staffing issues and continued reductions in the number of hospital beds have made it more difficult for A&E departments to admit patients.
A&E departments have constant interactions with other parts of the hospital, for example, to request diagnostic tests and to transfer patients to beds in other parts of the hospital. A&E performance is therefore dependent on processes and capacity in other hospital departments, as well as other parts of the health and care system. High levels of hospital bed occupancy, delays in transferring patients out of hospital, and staff shortages throughout the urgent and emergency care system have all had an impact on A&E waiting times.
The four-hour A&E waiting time standard is one of the most high-profile indicators of how the NHS is performing. The declining performance against this waiting time standard is a clear indication of the pressures the wider health and care system is under.
It saddens me that many of Australian AE training posts are filled by UK graduates. It also saddens me that there are nearly 50% AE middle grades who are non-trainee posts. Traditionally these are filled by non-EU doctors from Indian and African countries. With the immigration changes these doctors have stopped coming to UK.
While we bust the myths let us also see what is the solution for acute shortage of AE doctors, why our trainees are happy to go to Australia but don't want to do their training in UK and let us learn lessons.
We owe it to our patients and also for our staff. If not quality will drop, cost will increase and both patients and staff will suffer.
I am very sad and also somewhat resentful that doctors are going to Australia.
I am visiting my daughter in Melbourne very soon having been their for three and a half months in 2011.
I was surprised to discover how much must be spent on admin in the Australian system.As a patient with Medicare I had to either pay the total amount and then claim a large percentage back via a Medicare office or fill in many forms or or if they bulk billed then I had to pay the percentage required at the surgery.
One young Australian said he would not take his children to A@E in Melbourne as there would be too much blood??
WE do not hear of the problems in otherrcountries. I have a relation in Vancouver and she had to wait for three days on a trolley in a corridor as they did not have a bed to admit her.
I intend doing some research whilst I am in Australia to find out just exactly how it works.
I wish you all the very best.PS I was admitted to hospital as an emergency ,spent four days there and received surgery eight weeks later. Excellent all round
Much of what is described in this paper is common sense when looking at the impact of policy decisions, investment, geographical pressures, training and recruitment issues and inescapable demographic changes and pressures.
My experience of working in primary, acute and ambulance services at a senior level and at a more remote strategic level tells me that the vast majority of all staff go to work and do a great job with what they have and that there are a great many who are innovative and creative.
The simple fact is that this as your paper highlights a complex area with an incredible number of variables.
It is important to be realistic and honest about what is not only affordable but what is achievable taking into account all the available resources.
Well done again. Keep up the great work - busting the myths and highlighting the issues.
The 'front door' issues make the headlines, but there are untold triumphs and issues lurking beneath that do not get the political and press coverage.
We have an opportunity as clinicians to work with all stakeholders at trust and strategic level to address these issues, with the patient at the centre of the whole scenario - the QIPP savings will follow!
I too enjoy reading the Kings Fund's measured take, on what can be at times a visceral discussion about the future of the NHS, inevitably tarnished with whatever political hue one would wish - a nessecary evil in a system borne by politicians.
We have taken the number used in the data sheet that accompanies the HSCIC report that says: 39% of patients were discharged with no follow-up required. So they could have consumed lots of activity before they were discharged, but with no further treatment required.
But the Focus on A&E report says that, for first A&E treatment, 34.4% of patients received guidance/advice only. So perhaps the true number of patients receiving no treatment is somewhere between the two.
I do think however that we need to be careful about how we class 'guidance only'. Though it is likely that this advice could be given in other healthcare settings, we shouldn't discount its value to patients who felt they needed to see a healthcare professional at short notice.
We have private and public ED's however it is common for the more electronically advanced ED's to charge overseas visitors $400 for an attendance and the you would be eligible to get some of that back from Medicare and the rest from a private insurer ( if you have taken out that level of travel insurance before you travel). Those ED's not so well resourced would likely charge the Medicare rebate only. However Australain health care is based on user pays- we pay for scripts, always GP visits, unless you go you a bulk billing clinic. This is the way it works.
There is no NHS philosophy here for those who can pay and if you are fortunate enough to be able to afford to visit Oz -you pay.
If you have a life threatening illness all bets are off and any ED will ignore all of the above and care for you- even top private ED's would not chase the dollar - if you needed heart surgery after a heart attack they would get on with it and suck it up. This is not infrequent.
TAC - transport accident commission would cover all costs if you are injured on our roads
WC - work cover would cover all costs if you got injured at work
DvA - would cover all costs if ever you out your life on the line for fellow countryman
It's different to the UK but it's not a bad system.
Do not travel and expect fish and chips- unfair. We would grill the fish and have salad and you would feel healthier afterwards.
Enjoy Melbourne- my family have enjoyed my deflection to Oz 25 years ago and on their visits to Oz have needed to utilise the services occasionally and loved it -
Advice. IF YOU PICK UP A MEDICARE CARD FROM A MEDICARE OFFICE AS SOON AS YOU ARRIVE IN THE COUNTRY- to which you are entitled - IT IS LIKELY YOU WILL BE CHARGED NOTHING IF YOU ARE SICK ENOUGH TO NEED ED. You will need to pay a copayment at the GP as everyone does. Unless you go to a bulk billing clinic.
As to why the registrars are coming- look at the case mix and skill base they get here. The days of Oz coming to practice on the POHM's is over. POHm's come here because the training model for ACEM is different and the lifestyle and attitude is wonderful for anyone.
Don't moan that they come- find out what we offer and take it back to UK
The reverse is true. A number of representatives from UK hospitals and government agencies have been recruiting here for UK roles. The money is better in the UK and the bureaucracy problem is less.
The issues we have are globally universal:
Trauma doctors and experienced nurses are in short supply.
Growth in aged care health is growing very quickly
Trolley block is being addressed to avoid ambos being stuck at emergency departments waiting for a A&E bed.
Whats new? Every country has these problems. Doctors and nurses in Australia are paid roughly the same as in the UK if you analyse the higher living costs in Australia and purchasing power.
Relieves the burden on NHS Administrators and Nursing staff
Releases them to focus on caring for patients
Pays for itself quickly and then saves money
Patients love it
Directs patients to the most appropriate health provider
Is already being used by an A&E department in England for 2 years
AND YET WHEN THIS IS INTIMATED TO NHS ENGLAND THEY DON'T BELIEVE THE EVIDENCE BASED STATISTIC ABOUT THE BENEFITS - BECAUSE IT IS "TOO GOOD TO BE BELIEVED" !!!!
You write, "Nearly 40 per cent of patients who attend A&E are discharged without requiring treatment. This does not mean that all these patients are attending A&E unnecessarily or could be cared for elsewhere." What does that mean? Is the A&E designed for people to just stroll in and waste queue time and causing nothing to the system? How is healthcare delivered in the UK- what are the processes?
According to the Foundation trust network, there are systemic problems affecting the NHS see for example http://www.nhsconfed.org/news/2015/01/a-e-performance-indicative-of-intense-pressures-across-system
The Foundation Trust Network also presented problems affecting the NHS and the A&E here http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/171/171vw31.htm#footnote_1
Besides there are other studies that have shown that access to GPs reduce the amount of “unwanted” A&E attendance. See for example
• Inappropriate attendance in A&E by Wise (Wise, 1997)
• Inappropriate attendance in A&E (Murphy, 1998)
• An evaluation of the reasons why patients attend a hospital Emergency Department (Land and Meredith, 2013)
• Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study (Cowling et al., 2013)
• And many more studies
Are there problems within the A&E and GPs operations and within the process of healthcare delivery in the UK? Looking at the data and reports, I feel that there is. What do think? If you see only myths, what are the real problems them or is it that they don’t exist?
Cowling, T.E., Cecil, E.V., Soljak, M.A., Lee, J.T., Millett, C., Majeed, A., Wachter, R.M. and Harris, M.J. (2013) Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PloS One, 8 (6), 1-6.
Land, L. and Meredith, N. (2013) An evaluation of the reasons why patients attend a hospital Emergency Department. International Emergency Nursing, 21 (1), 35-41.
Murphy, A.W. (1998) 'Inappropriate'attenders at accident and emergency departments I: definition, incidence and reasons for attendance. Family Practice, 15 (1), 23-32.
Wise, M. (1997) Inappropriate attendance in accident and emergency. Accident and Emergency Nursing, 5 (2), 102-106.
We have a dedicated ward (in a separate building) for physiotherapy but it is nowhere near large enough. If it was larger, or if there were more places like it, then the flow of patients out of acute wards could be increased. The problem all comes down to money. If halfway wards for PT and OT were built than less could be spent elsewhere.
What we really need is more options for patients so they can be discharged from acute wards. More dedicated rehabilitation facilities for medically fit patients, more carers in the community, better integration with nursing homes so it is quick and easy for families to choose a home and for nursing assessments to be made, and a better supply of equipment so patients can receive care at home if they wish.
1. How much has the non-medical advice at 111 contributed?
2. You need to look for better evidence of patients being sicker eg multiple diagnoses etc.
I tried to answer some of the questions some tn years ago and so went through A&E documents, compiled a list of common presenting symptoms in GP surgery, OOH NHS Direct clinic, Private healthcare in Harley Street, RAF and Island (Isle of white) before I developing my tool called MAYA. (Medical Advice You Access). People who are compiling statistics in A&E and clinic know the documents are not clear and so the statistics are often wrong.
When I did this work, I have seen doctors diagnosis documented as snuffles, cold, flu, chesty, vomit, URTI, LRTI, UTI and all sorts of rubbish. I have also identified numerous mistakes that NHS was not happy to hear. I raised concern, informed GMC, BMA, NMC and Royal Colleges but none wanted to hear what I had to say.
The kind of work I did was not retrospective and so is accurate and likely to be helpful to resolve the crisis. Only way you can know what is going on and how to solve this problem is to start similar study and not use old data. If you want to help, why not ask doctors (clinicians) like me, who worked as staff doctors or registrars and not professors or consultants. I think Peter Gill has highlighted the problem well and Colin Powell has also suggested changes (Arch Dis Child 2013).
I am sure you will know hear more about this when I appear in the high court because I have taken legal action against NHS for harassing me for doing my duty to protect fellow human.
The reason I am not releasing in App store is because this tool will make doctors loose control. If I don't succeed in doctors accepting my work and using to help them selves and their patients, then the I am planning to publish a book and sharing my apps.
Please note I have used the same logic approach to differentiate minor from serious illness for 30 years when I worked in major NHS hospitals. Please note I am still register and licensed to work as a doctor and GP in UK but am too scared to return to work in the NHS.
Thank you for sharing the information.
The last thing we need is scaremongering and, in this election year, we'll get enough of that from politicians without think tanks joining in.
Effeciencies are needed in every system but in an emergency pathway they need to be looked at by experts within the field as an entire pathway issue with ideas, suggestions and clear next steps. Am not suggesting papers here - just requesting for clearly thought through suggestions. No am not teaching a 'granny how to suck eggs' but how when a group is battling staffing issues, flow issues resulting in performance issues, change fatigue and simple exhaustion how can they see clearly and those that are not in the system can they really comment on the system??
Elderly leave with no idea on who to contact especially at weekends .
To leave a 77 year old Man to look after his74 year old wife who is in pain and inconinant where he had to nurse her 24 hours day and night so that he was at his wits end to know what to do shows how the systems and billions of pounds given are not reaching the front line.
You haven't burst the singular and most important myth. The mainstream media refers constantly to waiting times being longer and more and more people attending A&E. The government have spent many hundreds of thousands of pounds putting the message across that we require 24/7 care deliverable via A&E implying that Doctors and emergency staff are failing to pull their weight-This is not only wrong, it's an out and out lie. There's only one reason that queues are getting longer and that's because over 70 A&E departments are closing or have been closed exposing many UK residents. It's happening by stealth and as an independent charity you have let down your subscribers by not exposing the truth. A disappointing read that really could have exposed the PFI reality which is breaking the NHS!
Community care and social care is mostly inadequate.
CCG's have very little insight into the services they commission.
The four hour target is widely manipulated and not collated by trusts as per DOH guidance.
NHS 111 is variable in quality, dependent on which company runs the contract for an area.
A&E nursing is a dying skill, now predominately occupied by pole climbing sycophants more worried about targets than emergency presentations.
It only leaves me to think that politicians of all colours are eager to sell as much of the NHS off to their rich chums, using unsustainability as the reason.
Currently working as part of a 'front door' team - I find this a great read. Currently involved with a project looking at integration across primary secondary and tertiary servives as part of Older Persons Fellowship Kings College - this gives great evidence to support this
1. If graphs of the trends in type I attendances were shown separately it would better reflect the detriorating situation.
2. The figures fly in the face of plans to dramatically reduce the level off attendances by the development of out of Hospital services.
3. The proportion of resources spent in A&e remains very small as a proportion of total. The refusal to match demand with resources seems perverse.
4. The shortages in junior and trained medical staff has been a deliberate policy to justify rationalisation.
5. little mention is made of the problems in nursing homes, social care and housing and their contribution to the problem.
The target is completely achievable and when where it is achieved you'll reduced length of stay as patient
While the latest version of this analysis is useful, there are some points where the conclusions are not stated strongly enough and others where useful additional analysis has been missed. Here are a few examples.
The report claims the is only "limited evidence" that changes in the GP contract have led to increased numbers turning up at A&E. And the analysis says the major factor driving performance is admissions not attendances. A better way to describe the evidence would be to say there is no evidence at all that changes in GPs made any difference to A&E. And there is no relationship at all between the number of attendances and A&E performance. This emphasis is important as rather too much policy effort has been devoted to trying to reduce attendance despite there being clear evidence that this will make no difference whatsoever.
When it comes to staffing the report quotes the essential fact (A&E staffing has grown faster than demand for some years) but fails to draw the important conclusion that staff shortages are not the primary problem in A&E, at least nationally. There are other reasons that lead to this conclusion. One is that any analysis of why patients are delayed in A&E would show that the majority of delays are caused by factors outside the A&E (like a lack of free beds). More A&E staff don't help this blockage. Moreover, the workload in A&E (and the apparent need for more staff) is heavily driven by crowding which is, in turn, caused by those factors outside A&E. If the cause of crowding is fixed the A&E workload goes down. If we add more A&E staff and don't fix the blockage, then the workload will still be a problem but we will have wasted resources by applying them to the wrong place. Hospitals need to see emergency flow as a system not as a fragmented bundle of independent hospital departments. And investment needs to be made in the parts of the system that will unblock the flow. Investing in the wrong place will waste money without leading to improvement.
Here is a suggestion for a more insightful analysis of long waits. Don't look at the published 12hr trolley wait numbers: it is a game-able metric and very misleading. Look at the end-to-end 12hr wait (derivable from the A&E HES dataset). This is not gameable and is a far better indicator of how waits have deteriorated. There were (in 2016-17) about 250k 12hr waits (about 100 times more than 12hr trolley waits and pushing 2% of the type 1 attendance. This is a much more sensitive and more useful indicator of how bad things are than the discredited trolley-wait number.
In short: there are a lot of myths around A&E performance that need to be punctured so policy can focus on things that might actually work. Hedging the conclusions with too many caveats when the evidence is clear doesn't help. Be bold or the myths will resist and policy will continue to be ineffective.
The number of patients waiting in any system is the most obvious and sensitive indicator of a System's performance. There are two reasons for an increasing number of patients waiting in the A&E system. 1) the workload (demand x the cycle time ((time from when a resource starts to process a patient to when the same resource is ready to process the next patient)) is greater than the staff time available at each resource or 2) there are policies or local 'rules' that govern the way the patients are processed that deliberately or unwittingly cause delays. While we would all like to believe that 'lack of resources' (staff, beds, machines) is the cause, unfortunately all the research shows that the latter is the most common and more unpalatable reason. Our healthcare managers do not know how to a) retrieve the data correctly to make the diagnosis and b) design healthcare systems to meet demand - as the unfortunate reference to '85% bed occupancy' in the above article reveals. Most beds are storage for patients while they wait for someone to start the next step in their care. So the number of beds in the system depends on the number of patients waiting for the flow resource. To prevent a queue, the flow resources need resilience capacity to cope with the variations in workload. So the rule of thumb of planning capacity at 85% of the variations in demand, applies to flow resource capacity, not storage.
While patient present with a variety of symptoms, the clinical process is very similar for many of them. It involves taking a history, examining the patient, making a clinical differential diagnosis, diagnostic tests (blood and other fluids, imaging) making the definitive diagnosis, prognosis and plan and then implanting the plan, reviewing the patient's progress against the prognosis and then maintenance. So how long does each step take? An experienced A&E consultant can take a quick history and examination within minutes and come up with the plan for diagnosis. This defines the clinical routing the patient requires and this is defined according to the longest step in the diagnostic part of the process - blood tests. If no blood test required, the patient needs the 'quick' stream often referred to as 'minors', and if a blood test is needed - the routing is referred to as 'majors'. So the majority of patients who require the minor process need 5 minutes of a history and examination, possibly an X-ray or Ultra sound (5 minutes) a diagnosis, prognosis and plan, then a prescription or treatment by a competent nurse /physiotherapy. They should be out of A&E in 20 minutes. For those requiring the major stream they will need a longer history and examination (40 minutes) a blood test (cycle time up to 1 hour) +/- imaging (cycle time 5 to 20 minutes) and definitive diagnosis, prognosis and plan (10 minutes). So now we can calculate how many man-hours are required to perform each task. And when we look at the resource available there are more than enough staff. So what's the problem? The policies: the policy of unwittingly designing the system to have a queue so we then have to reserve resource for the 'urgent patients', leaving others to wait, which further compromises the flow (as the chart above suggests). Then there are 'prioritisation' policies at every stage (GP receptionist prioritise patients calls, GPs do their home visits at lunchtime, the ambulance service prioritise, the hospital receptions staff prioritise, the doctors, nursing staff and porters prioritise, the labs prioritise, the imaging departments prioritise, and as a consequence the system is filled with queues at every stage. b) How about the staffing policies? We put the least experienced person on the front desk to define the routing (usually the receptionist), whereas if we put the consultant at this point the % of patients on the correct routing increases to over 95%, the junior doctors and nursing are guided as to what is required and are no longer overwhelmed. Instead of this simple process in which we need 2 consultants, 4 junior doctors 6 nurses and 9 trolleys to perform the majors process in < 2 hours at the periods of peak demand in a typical district general hospital, we have a series of junior doctors seeing the patient in sequence (rather than in parallel) and with all the delays in the system. As a consequence of all the delays and errors, the most senior and experienced staff can't provide the definitive diagnosis prognosis or plan until the next day. Many patients, particularly the elderly are whisked out into the next available bed without a diagnosis, prognosis or plan in order to 'hit the target'. Not only is this unsafe, but it causes massive rework and delays for patients and the staff downstream. So there are further delays the recovery and discharge where again priority occurs at every stage: discharges are done last after the ward rounds (which may only occur 2x week) as junior doctors focus on their sicker patients first, pharmacy batches and prioritises the prescriptions focusing on the inpatients first, as a result nurses can only organise relatives or other transport late in the afternoon or evening and the ambulance service prioritise the sick coming in over those going home. And then there is the extraordinary process for assessing the elderly and infirm for continuing health or social are funding which may only happen once a month.
A system is only as good as it's feedback loop (Gregory Bateson) and the feedback loop in the NHS is absent or at best delayed by months. Firstly the feedback occurs, if we are lucky, in retrospect once a month or quarter. Second the way the data is presented is by comparing one system with another rather than monitoring each system's performance continuously over time (as doctors do for a System in a hospital bed). Thirdly, the executive and senior mangers do not respond to the feedback signal. This is called Hubris and we, the public and press, collude in their Hubris by believing the yarn that the executive spin to hide their ineptitude.
So what do we need to? Train our managers, or better still encourage managers to find and recognise the skills they need. Unfortunately the science of operations management is unheard of in the NHS - we refer to operational research by academic institutions which takes months and is aimed to improve an authors or academic institution's research ranking in the light of their peers, not solving the problem. This is a chart of a System that tipped into 'chaos' in 2010. We need the data and the courage to consider the possibility that it was the interventions we made to the System that caused the problem and not keep 'blaming' those seeking our help and paying 50 % of the salary bill to the 20% of staff responsible for designing the system.
I glanced through your long article, and as a person (diabetic) aged over 80 I wish to point out that you ( and most of the younger (?) contributors, commentators, newspaper journalists, BBC local journalists, have omitted list or mention of the closures/diminishing of the very many excellent large general hospitals. It was via a short term, penny-pinching, cash from house-building greed/land grab frenzy (under both major governing parties) during recent decades. I recall mainly the Herts & Essex Hospital and Rye Street hospitals in Bishop's Stortford, Saffron Walden Hospital, etc. (Strategic also because close to M11, train line, and Stansted airport). Please ask a researcher and/or newspaper journalist to research and delineate which ones and number of beds UK-wide were lost. All A & E's and "cottage hospitals" are vital to local residents) which were lost. During the process of the slow winding down of the H&E hospital there were multiple protests and people declaiming for years "This closure is a crime!" The population of this particular area has massively increased, and thousands more houses are being built. Planning permission in the H&E area gets passed, even when nobody can get an appointment with a GP currently, and the Herts /Essex councils make no public mention of new GPs nor other medical facilities to be built commensurate with population size being included in "planning". Local Councils, Government and the "organisation" of GPs surgeries themselves hence do hold so much of the blame for the current crisis.
this article does not have a date so I can't cite it correctly
This article was published on 11 December 2017.
Who is the author of this article? I can't cite him/her correctly
I would also like to know the author(s) name(s) for a citation please.
Hi Vanessa and Ria,
Thanks for getting in touch. You will just need to put 'The King's Fund' as the author of this piece and include the publication date (2017) in your citation.
I hope that helps! If you have any further questions, please do not hesitate to get in touch.