A&E waiting times - what do these say about the state of the NHS?
Accident and Emergency waiting times are often used as an indicator of how well the NHS is performing overall. In March 2018 an 85-year-old man died in a Northampton accident and emergency unit as a result of dangerous overcrowding. Media reports like this from around the country over the last 12 months indicate the extreme pressures faced by the service. This situation is backed up by figures from NHS Digital that show that NHS emergency departments have had the worst performance since the records began.
A&E performance is based on the percentage of patients treated within four hours with the target being 95%. Year on year we see the headline figures revealing once again record worst performances. There have been suggestions since 2019 that the 4-hour waiting time target could be dropped but it remains thus far. In 2019/20, performance dropped to 72% - the lowest levels since the introduction of the target. The term ‘eternal winter’ is being used by experts to describe the crisis, with hospitals remaining under intense pressure following the winter period and struggling to catch up with the backlog of surgeries.
Winter waiting times in 2019/20 also increased. In the winter of 2019, there was a considerable increase in numbers of patients waiting over 4 hours and over 12 hours between decisions to admit and actual admission to general wards. 98,452 patients waited over 4 hours and 2,347 waited over 12 hours. This is substantial compared to 59,805 and 284 respectively in December 2018.
Source: The Nuffield Trust & Health Foundation, based on NHS England data.
This graph evidences the decline in A&E waiting times against targets since 2010 and the beginning of the decade of austerity. (Type 1 refers to traditional A&E departments, Type 2 are consultant-led facilities for single specialties and Type 3 are minor injury units).
So, what are the reasons for these poor performances?
According to The King’s Fund increasing demands, the number of hospital beds available and staff shortages are all playing a role in the extra strain A&E departments are under.
Increasing attendances
One reason for these worsening waiting times is undoubtedly the increasing number of attendances in A&E units. In 2018/19, there was an extra 9,200 attendances each day compared to 2011/12.
However, it is the increasing numbers of emergency admissions to hospital that is causing most of the problems, due to reduced capacity of departments to deal with this increase. Emergency admissions require more specialist care and finding an available bed in an appropriate ward, which is becoming more difficult.
In order to deal with emergency admissions, the Department of Health suggest that bed occupancy rates in hospitals should not exceed 85%. Many hospitals across the country are routinely dealing with occupancy rates well above this figure, particularly in winter months. King's Fund analysis shows that occupancy rates have got consistently worse year on year since 2013, remaining above the 85% suggestion.
Delays in transfer of care
The reason for high bed occupancy rates is delayed transfers of care. This is where medically fit patients continue to occupy beds due to a delay in transferring their care either to other NHS providers or social care services.
In February 2017 the average number of patients delayed per day peaked at 6,660 before reducing slightly. However, in February 2020 this number rose again to 5,370 per day.
Source: Nuffield Trust.
These delays have a knock-on effect on A&E waiting times. It also creates the problem of ‘trolley waits’ with patients stuck waiting to be transferred to hospital following their treatment in A&E, with some patients waiting up to 12 hours. The NHS has been responsible for a majority of the delays in care since 2010, representing 60% in February 2020.
A 2015 government report concluded that delays in transfer of patients to hospitals was the main reason for A&E delays nationally. Hospitals across the country are struggling to accommodate the increasing emergency admissions from A&E. There was also evidence that changes in social and community care capacity can also go someway in explaining poor A&E waiting time performances.
Despite this things continue to get worse. A 2017 Parliamentary briefing paper revealed that in 2016/17 that delayed transfers cost NHS providers £173 million for the previous year. No more recent data on the cost is available yet.
Shortage of staff
The increased demand on the A&E services is coupled with a chronic shortage of staff, due to high job pressures and challenges in recruitment and retention. Emergency medicine continually features on the Government’s occupation shortage list.
Royal College of Emergency Medicine notes that emergency medicine has a high turnover rate of staff in training, early retirement is prevalent and there is a substantial reliance on temporary staff.
This issue of staff shortages is prevalent throughout NHS services. These shortages reduce hospitals' ability to deal with admissions quickly. They also make it harder to provide specialist advice or treatment to patients that could be treated and discharged quickly. All of these factors increase waiting times.
Effect on the ambulance service
The increasing pressures on A&E departments and the growing demands have a negative knock-on effect onto the ambulance service and their ability to meet targets. The average ambulance response time to Category 1 calls worsened to 8 minutes and 7 seconds in March 2020. This is a little way off the 7 minute target.
The situation for the ambulance service has only worsened during the 2020 coronavirus pandemic combined with usual winter pressures. Multiple hospitals across the country have had to divert ambulances away as they declare major incidents and have no room for new patients.
In January 2021, NHS England figures revealed that the number of ambulances waiting over an hour for handover hit a new high. Between 4 and 10 January, 5,513 ambulances were held up over an hour - the highest figure for the last three winters.
King’s Fund chief analyst Siva Anandaciva said the figures released today showed “the NHS is now under the most extreme pressure seen in recent history and is battling on multiple fronts”.
So where does this all leave us now?
The NHS is bearing the brunt of a deadly coronavirus pandemic in the midst of a second wave alongside the typical winter pressures. Elective procedures have been cancelled as hospitalisations rapidly grow. There is now a huge and growing backlog of treatment which will spell long-term future problems for the health service.
Despite demand in emergency departments declining in April and May 2020, there are serious concerns that people who needed emergency care were avoiding A&E services through fear of coronavirus. As lockdowns eased over the summer the demand rose once more which suggests the upward trend of demand will continue once the pandemic is over. Serious planning and funding will be required to help the NHS and emergency departments across the country to recover.