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%. In March 2018 A&E departments recorded the worst performances since records began in 2010. Just 76.4% of patients needing urgent care being treated within four hours at hospital A&E units in England. 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.
In 2019, the records were broken again. In Winter 2018/19, it was found that only 76.1% of patients were seen within the 4 hour target. A record 320,990 patients were left waiting for treatment as hospitals struggled to cope with the number of arrivals to A&E centres.
Dr Taj Hassan, the president of the Royal College of Emergency Medicine, said:
"Sadly the situation afflicting our emergency departments has become seemingly normalised with a ‘chronic crisis mode’ that does not allow staff to deliver the quality of care they would wish and patients should rightly expect...”
Source: The Health Foundation and Nuffield Trust 2018, based on NHS Digital Data.
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. This goes some way to explaining why only 10 trusts met their targets in 2017/18.
One reason for these worsening waiting times is undoubtedly the increasing number of attendances in A&E units. There is an extra 5,100 attendances a year today compared to 2010/11. 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 below shows that occupancy rates have got consistently worse year on year since 2013, remaining above the 85% suggestion.
Source: The King's Fund, based on NHS Digital Data.
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 September 2017, there were 110,000 reported delays of transfers. 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.
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 there 2.3 million delayed transfer days in England, an average of roughly 6,200 a day. This was 25% higher than the previous year. It is estimated that delayed transfers cost NHS providers £173 million for the previous year.
Source: The King's Fund, based on NHS Digital Data.
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. A GMC survey revealed that staff in emergency medicine noted the highest level of workload pressures of any medical specialty.
This issue of staff shortages is prevalent throughout NHS services. For example, some parts of England are only filling 1 in 400 nursing vacancies. 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. Analysis of ambulance trusts’ performance in 2017 revealed that the three main targets had only been met in 6 out of the previous 49 months. No targets have been met since May 2015, including response times to time critical cases.
In the winter of 2016/17, Nuffield Trust analysis shows that 478 diverts from hospitals were instigated. This is when A&E departments close their doors to ambulances in exceptional circumstances where they cannot cope with any extra patients. This reduces quality of care of patients, increases the time taken for them to be cared for and makes it difficult for ambulances to meet their targets and complete their job properly.
So where does this all leave us now?
Winter 2017/18 has been described as the worst crisis for the NHS. Planned non-urgent operations were cancelled, waiting times in A&Es, ambulances and 'trolley waits' increased hugely to absorb the increased demands coupled with shortage of staff.
Dr Chaand Nagpaul, BMA council chairman, said: “The winter crisis has truly been replaced by a year-round crisis. Doctors and patients have just endured one of the worst winters on record ... we cannot accept that this is the new normal for the NHS.”
The extent of the 2018/19 winter crisis is yet to be fully evaluated. However, at the end of 2018 hospitals up and down the country were putting in an array of emergency measures to combat what was expected to be the worst winter crisis yet.