2 A crisis in A&E?|
10. NHS England's improvement plan for A&E acknowledges
the extent to which A&E services have been subject to pressure.
NHS England say:
A&E performance has deteriorated significantly
over the last six months. In the last quarter of 2011/12, 47 out
of 152 providers failed to meet the 95% standard for patients
being seen and discharged within 4 hours. For the last quarter
of 2012/13 this figure had increased to 94 out of 148 providers,
double the previous number.
11. In June, the King's Fund published a monitoring
report examining waiting time data in A&E departments. It
313,000 patients (5.9 per cent) spent four hours
or more in A&E in the period January to March 2013, an increase
of more than a third on the previous three months and nearly 40
per cent on the same quarter in 2011/12. [...]
Data also shows that the proportion of patients
waiting longer than four hours before being admitted from A&E
to hospital - so-called trolley waits - rose to almost 7 per cent,
also the highest level since 2004.
12. NHS England links this deterioration to a number
of factors including:
Increased numbers of patients arriving at A&E.
There is a general rising tide with 5.9% more attendances in 2012/13,
than in 2009/10. However, the total numbers attending in Q4 of
2012-13 (which is when the significant deterioration began) was
1.7% lower than the previous Q4.
13. The evidence presented to the Committee about
trends in A&E attendances is, however, mixed.
14. John Appleby, Chief Economist at the King's Fund,
has argued that the step change in attendances seen in A&E
since 2004 can be explained by changes in the way in which data
is collected. Mr Appleby has said:
Until 2003/4, statistics on A&E attendances
included 'major' A&E units only. But around this time more,
smaller units - including walk-in centres (WiCs) and minor injuries
units (MIUs) - were introduced with the intention of diverting
less serious emergency cases away from the larger, more expensive
A&E departments, and the statistical collection was changed
to record attendances separately for 'type 1, 2 and 3' units.
So, much of the increase in 2003/4 was due to
previously unrecorded attendances now being collected, but also
additional - but less serious - work being carried out in the
From 2003/4 to 2012/13, attendances in type 1
units have remained more or less unchanged.
15. The King's Fund also challenges the notion that
attendances in A&E over the past year are unprecedented. It
notes that the trend increase over the period November 2010 -
April 2013 "is around 3.5 per cent - about 1.3 per cent per
16. In oral evidence to the Committee Dr Clare Gerada,
Chair of the Royal College of General Practitioners (RCGP), also
questioned whether there had been any real terms growth in emergency
department attendances and activity over the last ten years. She
if we take away urgent care and look at the number
of emergenciesthe tariff onethere has been an increase
of about 1.7% per year over the last decade. The population has
risen by just about the same amount; in other words, it has flatlined.
17. The College of Emergency Medicine present a somewhat
different picture. They argue that the emergency care system is
"facing unsustainable workloads".
Their research, based on a survey of emergency departments across
the UK (not just England), found that:
Attendance rates continue to rise particularly
in England. Other work suggests that this is 3-5% year on year
although some systems report much higher increases especially
out of hours.
The claim that a growing number of emergency department
attendances occur out of hours is not, however, reflected in statistics
published by the Health and Social Care Information Centre (HSCIC).
They report that in 2007-08 56.5% of attendances were in hours
but by 2012-13 the figure was 58.5%.
18. In oral evidence Dr Mike Clancy, President of
the College of Emergency Medicine (CEM) quoted statistics broadly
in line with the King's Fund and RCGP. He told the Committee that
type 1 emergency departments attendances had increased by 17%
from 2003 - 2011, but added that in the last twelve months there
had been a year on year increase of 250,000 attendances in type
1 emergency departments which represented growth of approximately
1%. Dr Clancy also
noted that there has been little variation across quarters, arguing
that attendance growth was not simply a reflection of specific
19. The data detailing emergency admissions to hospital
from A&E departments is also important because it illustrates
the changing demands on A&E. In the five years since 2008-09
emergency admissions from type 1 departments have increased by
over 16% and it is this figure which, in part, helps to explain
the pressure under which emergency departments have been operating.
Several witnesses reported that more patients with more complex
conditions now presented at A&E and the Secretary of State
noted that "the kinds of people coming into A and E have
more complex and acute conditions than they have had previously".
NHS England reports an "increased number of acute admissions
putting pressure on beds"
and say that "there is general consensus (though it is hard
to identify the evidence) that patients presenting are more ill
and hence more likely to need admission and have longer stays."
20. The CEM argued in their oral evidence that it
was demand, combined with a more complex case mix, that had resulted
in emergency departments struggling to meet the 4 hour target
and that type 1 emergency departments "have reached the limits
of their compensatory capacity."
Dr Clancy summarised his view by saying that in emergency departments
there are "more people out of hours, more after midnight,
more ambulance and more elderly."
21. The evidential support for this analysis is unclear.
Mark Docherty, Chair of the National Ambulance Commissioners Group,
told the Committee that "increasingly, we are finding that
some younger patients are choosing to access emergency or urgent
services as opposed to primary care."
Dr Gerada, however, said that:
the patients who turn up at the emergency department
are iller and older and tend to be admitted for longerit
is a cohort. If you look at the patients who turn up at walk-in
clinics, they are younger. They are not the sort of patients who
turn up at emergency departments.
22. The BMA presented written evidence in relation
to the age profile of patients attending emergency departments.
In 2011-12, 43.4% (7,651,005) of all A&E
attendances were for patients aged 29 or under and 16.3% (2,875,643)
were for patients aged 20-29. This latter cohort tends to be a
light user of general practice.
Department of Health statistics show that whilst
the total number of emergency admissions for patient aged between
20-29 have increased by 6.5% in the five years from 2007-08 to
2011-12, these admissions as a proportion of total admissions
have, in fact, fallen very slightly by 0.2%.
The number of people aged 65-85+ admitted to hospital as an emergency
rose from 1.8m in 2007-08 to 2.1m in 2011-12. This represents
growth of 13.5% in five years.
Elderly patients now form a larger proportion of emergency admissions
than five years ago. In 2007-08 patients aged 65-85+ made up 38.8%
of emergency admissions; by 2011-12 this group constituted 40.7%
23. The Committee also heard evidence that the demand
pressures experienced in A&E were equally prevalent elsewhere
in the emergency and urgent care system. The RCGP evidence dealt
extensively with the pressure general practitioners now face and
Dr Gerada told us that GPs had experienced "an approximately
100% increase in our work load over the last decade."
Dr Gerada went on to describe the degree of stress the under which
the primary care system is operating:
I am getting e-mails from colleagues across the
country to say that their surgeries are now fully booked by 8.30
in the morning, which is disgraceful. How can we run an NHS where,
unless it is an emergencyand by that I mean a dire emergencyyou
cannot get an appointment with your GP on the day and appointments
are fully booked by 8.30? This is not because GPs are going to
play golf in the afternoon; it is because they are trying to respond
by working 15-hour days.
The King's Fund analysis demonstrates that it is
type 3 urgent care centres and minor injury units that have experienced
the most substantial growth in patient numbers. Similarly ambulance
trusts have experienced significant year on year growth for their
24. The Committee was surprised by the lack of
clear evidence about trends in the level and nature of demand
for urgent and emergency care. There is a pressing need for clearer
information to be produced which can detail where urgent care
cases present across the system and the case mix of urgent patient
presentations; it is also important to monitor waiting times for
urgent and emergency services in order to ensure that services
are accessible to patients in urgent need of care. The Committee
recommends that NHS England should ensure this data is collected
and reported on a consistent basis across the country.
25. The Chief Executive of the NHS Confederation,
Mike Farrar, argued in oral evidence that the problems in emergency
department were the result of hospitals finally failing to accommodate
ever-increasing demand. He said:
At the heart of all this, the NHS has the increasing
demand, but for the vast majority of the first part of that decade
we were able to put resource across the whole of the system. We
were increasing the resource available in line with demand. What
has really happened since then is that demand has continued to
increase but the resource available to increase supply has reduced.
26. Dr Patrick Cadigan, Registrar of the Royal College
of Physicians, argued that there may be a link between reduced
bed numbers and the pressures experienced in emergency departments.
He said that "the more you reduce the number of beds the
more difficult it is to cope with variations and fluctuations."
Professor Keith Willett, National Director for Acute Episodes
of Care to NHS England, argued that a substantial reduction in
bed numbers allied to an increase in emergency admissions was
evidence of a much more efficient system. He observed that acute
bed numbers had been reduced by a third in the last ten years
and that admissions had increased by the same number.
Root cause analysis
27. Attempts to understand why urgent and emergency
care services face such substantial pressure have resulted in
different parts of the health system being identified as the root
cause of the problems. In oral evidence Dr Gerada dismissed the
suggestion that renegotiation of the GP contract which transferred
responsibility for out-of-hours services from GPs to third parties
in 2004 contributed to the downturn in A&E performance. Dr
Gerada noted that it was emergency department admissions, rather
than attendances, that increased most rapidly, which did not indicate
that patients were choosing A&E over out-of-hours services.
In the general discourse around a 'crisis in A&E' it has also
been suggested that ambulance services are conveying too many
patients and that NHS 111 is directing too many patients to A&E.
28. None of the factors outlined above are irrelevant.
The RCGP has itself accepted that the GP contract requires renegotiation;
NHS England accepts that NHS 111 provided a poor service in many
areas when it was launched; the Ambulance Service accepts that
variations in the quality of ambulance response times need to
be addressed. But none of these issues by themselves represent
an explanation of the developing service pressures which are currently
being experienced in urgency and emergency care. The evidence
outlined in the following chapters demonstrates clearly that public
health advice does not sufficiently facilitate self-care and the
NHS 111 service is not yet able to provide timely, effective intervention.
Primary care in its current form is not designed to provide urgent
care. As Dr Gerada explained, "GPs are trained to deliver
care to patients with complex needs and deal with uncertainty
in acute condition". As NHS England has observed, the existing
services are fragmented with poor sign posting, meaning that there
is little in the way of joined-up working. In such circumstances
patients are making the rational choice to go "where the
lights are on",
which invariably is the local emergency department.
29. The emergency and urgent care functions of
the NHS are undoubtedly working under stress and there is insufficient
resilience in the system. Availability of a hospital bed when
required is a fundamental part of an emergency care system. Successful
delivery of this basic requirement is, however, dependent on the
ability of the system to understand the demands made upon it and
to deploy its resources in the most effective way. Rising demand
for hospital admissions may be as much a symptom of system failure
(for example, failure to provide timely care in a patient's home)
as it is of an underlying rise of demand. Until these systems
failures are addressed, hospital managements need to ensure that
there is sufficient bed capacity available to meet current demand.
30. The system cannot accurately analyse the cause
of the problem, still less resolve it, if it continues to "fly
blind". More accurate information about the causes of rising
service pressures is not simply a management convenience; it is
fundamental to the delivery of high quality care.
6 Improving A&E Performance, NHS England, May 2013,
p 1 Back
Q 184 Back
College of Emergency Medicine, press statement, May 2013 Back
College of Emergency Medicine, The drive for quality - how to
achieve safe, sustainable care in our Emergency Departments?,
May 2013, p 10 Back
Health and Social Care Information Centre, Hospital Episode Statistics
(HES), June 2013 Back
Q 2-3 Back
Q 2 Back
HC 119-iii, Q 240 Back
NHS England, May 2013, p 1 Back
Q 2 Back
Q 8 Back
Q 102 Back
Q 183 Back
ES 26, written evidence from the British Medical Association,
para 2 Back
Hansard, June 10, 2013, Col 144W Back
Q 172 Back
Q 175 Back
Q 13 Back
Q 47 Back
Q 278 Back
Q 194 Back
Q 24 Back