Urgent and emergency services - Health Committee Contents

2  A crisis in A&E?

Growing demand

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.[6]

11. In June, the King's Fund published a monitoring report examining waiting time data in A&E departments. It found that:

    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.[7]

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.[8]

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 new units.

    From 2003/4 to 2012/13, attendances in type 1 units have remained more or less unchanged.[9]

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 year."[10]

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 said:

    if we take away urgent care and look at the number of emergencies—the tariff one—there 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.[11]

17. The College of Emergency Medicine present a somewhat different picture. They argue that the emergency care system is "facing unsustainable workloads".[12] 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.[13]

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%.[14]

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%.[15] Dr Clancy also noted that there has been little variation across quarters, arguing that attendance growth was not simply a reflection of specific seasonal demands.[16]

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"[17]. NHS England reports an "increased number of acute admissions putting pressure on beds"[18] 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."[19]

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."[20] 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]

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."[22] Dr Gerada, however, said that:

    the patients who turn up at the emergency department are iller and older and tend to be admitted for longer—it 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.[23]

22. The BMA presented written evidence in relation to the age profile of patients attending emergency departments. They reported:

    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.[24]

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%.[25] 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.[26] 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% of admissions.[27]

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."[28] 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 emergency—and by that I mean a dire emergency—you 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.[29]

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 services.

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.

Bed capacity

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.[30]

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."[31] 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.[32]

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.[33] 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",[34] 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

7   http://www.Kingsfund.org.uk/press/press-releases/new-analysis-confirms-government-target-missed-ae-waiting-times-hit-nine-year Back

8   Ibid Back

9   http://www.Kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing Back

10   Ibid Back

11   Q 184 Back

12   College of Emergency Medicine, press statement, May 2013 Back

13   College of Emergency Medicine, The drive for quality - how to achieve safe, sustainable care in our Emergency Departments?, May 2013, p 10 Back

14   Health and Social Care Information Centre, Hospital Episode Statistics (HES), June 2013 Back

15   Q 2-3 Back

16   Q 2 Back

17   HC 119-iii, Q 240 Back

18   NHS England, May 2013, p 1 Back

19   Ibid Back

20   Q 2 Back

21   Q 8 Back

22   Q 102 Back

23   Q 183 Back

24   ES 26, written evidence from the British Medical Association, para 2 Back

25   Hansard, June 10, 2013, Col 144W Back

26   Ibid Back

27   Ibid Back

28   Q 172 Back

29   Q 175 Back

30   Q 13 Back

31   Q 47 Back

32   Q 278 Back

33   Q 194 Back

34   Q 24 Back

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© Parliamentary copyright 2013
Prepared 24 July 2013