Accident and Emergency departments in England are managing unprecedented levels of demand. On average, over 40,000 people attended a major, or type 1, accident and emergency department each day across the NHS in 2015–16. Over the same period only 87.9% of patients were admitted, transferred or discharged within four hours—well short of the Government’s target of 95%. The variation in performance between providers was also striking, ranging from 64% to 99% in one survey from July 2016.
Achieving safe and timely performance in urgent and emergency care is an increasing challenge primarily as a result of growing and rapidly evolving demand as patients attend with more complex conditions but also as a result of system-wide pressures affecting the ability of the NHS and social care to cope.
The declining level of performance in A&E is a marker of stress across the whole system of health and social care. But performance standards or targets for A&E should not only be viewed as the ‘canary in the mine’ for system-wide pressures. They matter primarily because long waits in A&E affect patient safety and patients’ experience of care.
Traditionally waiting times in A&E increased in the winter because patients attending A&E tended to be older, more unwell and more likely to require admission than during the summer months. To manage this increase, emergency funding would be provided to open more beds and recruit additional staff. Hospitals then experienced a period of relative respite during the summer when, despite generally higher attendances, A&E patients would be less sick or less likely to be admitted.
That pattern no longer applies. For many hospitals demand pressures are high year round and just reach a more intense peak during the winter. Hospitals no longer have additional bed capacity to flex as occupancy rates are at their highest ever recorded levels. It is notable that England has the lowest number of hospital beds per head in Europe. Measuring occupancy at midnight also overestimates the true levels of spare capacity.
Hospitals are finding it increasingly difficult to maintain the flow of patients out of their emergency departments into wards and on to safe discharge. Reduced bed capacity has contributed to this situation, but simply increasing bed numbers would not solve the problem as so many patients are already experiencing delayed discharge. The response has to focus both on managing the patient’s journey through the hospital and on addressing the increasingly inadequate provision of adult social care services available to enable safe discharge.
We conclude that additional investment in community step-up / step-down beds and adult social care is essential to addressing the widespread pressures on A&E. Emergency departments do not exist in isolation and their performance will be supported by investing in services that can prevent admission via A&E and allow swift and safe discharge from hospital. We call on the Government urgently to address the underfunding of adult social care and to evaluate fully the wider impact of this underfunding on the NHS.
Despite the undoubted challenges there are also steps that hospitals can take to improve their own performance by learning from those which more successfully manage flows in similar situations. We support the measures that NHS England and NHS Improvement are taking to tackle variation but call on them to strengthen their processes for spreading good practice.
We heard many examples of good practice which can prevent unnecessary attendances and admission to hospital. We also heard of measures from the first contact with services through to discharge and beyond which can speed and improve the quality of care through the emergency department.
The current levels of variation in meeting the four-hour performance standard cannot be explained by financial challenge, demographics and demand alone. There are also examples of poor performance which have been made worse as a result of inadequate systems which have been allowed to continue for too long.
We call on the Government to make sure that sufficient funding is available to support the infrastructure investment required to ensure that type 1 emergency departments are fit for purpose, and to review the real terms cuts to NHS capital budgets in the Spending Review. We heard evidence of departments that will struggle to transform performance within existing facilities designed to cope with lower demand.
In the best performing hospitals all staff across health and social care will support efforts to meet the A&E performance target, not as a tick-box exercise but because it underpins patient safety and experience. It is in everyone’s best interests for this to be the culture in every hospital.
31 October 2016