1Winter pressure?
Evolving demand
1.Achieving safe and timely performance in urgent and emergency care is an increasing challenge primarily as a result of growing and rapidly evolving demand but also as a result of system-wide pressures affecting the ability of the NHS and social care to cope. The evidence submitted jointly by the Department of Health, NHS England and NHS Improvement (this will be referred to as ‘the Government’s evidence’) said:
On average each day in 2015–16, the NHS saw nearly 63,000 people through its A&E departments, carried out nearly 9,200 emergency journeys by ambulance; and offered over 38,000 NHS111 calls. Overall, in 2015–16, 91.9% of patients attending A&E were admitted, transferred or discharged within 4 hours–that is over 21 million attendances.1
2.However, this figure of 91.9% applies to all types of urgent and emergency care provision, which can range from major emergency departments to GP-led walk-in centres. A major, consultant led A&E department which is open 24 hours per day, 7 days per week, 365 days per year is normally referred to as a type 1 department. On average 40,900 patients attended major A&E departments in England each day in 2015–16. The average performance figure for the 176 major A&Es in England is worse than for all types of A&E combined.2 In 2015–16 only 87.9% of patients in type 1 departments were admitted, transferred or discharged within four hours—well short of the Government’s target of 95%. During the first quarter of 2016–17 85.4% of patients in type 1 departments were seen within four hours. By comparison, for the same period in 2015–16, the figure was 91.1%. The variation in performance between providers was also striking. The Care Quality Commission’s report on the state of care in 2015–16 noted that “in July 2016, the percentage of patients spending less than four hours in major A&E departments ranged from 64% to 99%”.3
3.Variation in performance also exists across the United Kingdom with the average performance against the four-hour standard of major A&E departments differing in each nation:
Table 1: Percentage of patients spending less than 4 hours in A&E
Type 1/major departments only, 2015–164
|
England |
87.9% |
|
Wales |
77.7% |
|
Scotland |
93.3% |
|
N. Ireland |
71.7% |
Source: Department of Health A&E attendances and waiting times data Stats, Wales A&E performance data, SD Scotland Emergency Department statistics, Department of Health NI Emergency Care waiting time statistics
4.The NHS standard contract outlines the penalties that can be applied to trusts that breach the four-hour waiting time standard in England:
Where the number of Service Users in the month not admitted, transferred or discharged within 4 hours exceeds the tolerance permitted by the threshold, £120 in respect of each such Service User above that threshold. To the extent that the number of such Service Users exceeds 15% of A&E attendances in the relevant month, no further consequence will be applied in respect of the month.5
Although fines are capped when performance drops below 85%, in some cases no financial penalties will be imposed at all. In July 2016 it was announced that the Department of Health, NHS England, NHS Improvement and the Care Quality Commission would replace national fines with individual improvement programmes for trusts. If A&E performance improved then no fines would be imposed, even if trusts continued to miss the 95% four-hour standard.6
Attendances & admissions
5.The increased pressure experienced by emergency departments during the winter months is not directly related to numbers of attendances at those departments, but rather to the complexity of cases and subsequent admissions to hospital. Attendances peak during the summer months but hospitals experience most pressure and struggle hardest to achieve the four-hour waiting time standard (often referred to as the four-hour target) during the winter. The Government’s evidence explained how this affects the provision of care:
The change in demand is not simply about an increase in the numbers of people accessing urgent and emergency care, as the average daily number of attendances at A&E tends to be higher throughout the summer months than during winter. The change in demand is about a greater proportion of people who attend A&E that are sicker and are subsequently admitted as an emergency—27.9% in winter compared with 25.8% in summer. It is this increase in emergency admissions that increases the demand for hospital beds which is evidenced by the increased occupancy rates with highest levels during winter (quarter four) and lowest levels during summer (quarter two) Consequently this affects the performance of A&E departments with the expected dip in performance during winter compared to summer when performance levels are better. […]
These pressures all need to be put within the context of rising demand in the NHS generally: there were over 6,000 more A&E attendances per day in 2015–16 compared to 2009–10 and Ambulances carried out just under 500 more emergency journeys per day in 2015–16 compared to 2014–15.7
Seasonality
6.Our inquiry set out to investigate why winter seems to present such a significant challenge to emergency departments. We wanted to understand why it is that normal seasonal changes seem to precipitate a lengthy period of crisis management within the NHS. In both 2014 and 2015 our predecessor Health Committee took evidence to investigate the performance failings of the urgent and emergency care system during the winter. Winter happens every year, so why do some acute NHS trusts perform so much better than otherwise similar providers in managing this predictable change in demand?
7.We focused the attention of this inquiry on the management, organisation and resourcing of emergency departments. We took this approach as the starting point for the inquiry as we wanted to investigate the issues that hospitals can do for themselves to cope during the winter.8 We also acknowledge that this is a system wide issue and no inquiry into winter pressure can ignore the compelling evidence on the impact of the deteriorating situation in social care upon NHS performance. It would be wrong to assume, however, that the pressures on social care prevent trusts from taking their own steps to improve A&E performance.
8.As part of the process of informing this inquiry we visited Luton and Dunstable University Hospital NHS Foundation Trust, which has the best performing emergency department in England (judged by performance against the four-hour waiting time standard). In Luton we heard that winter does not represent a substantially more challenging period than any other for their emergency department, and this view was echoed in the evidence we received from other organisations.9 The submission from the think-tank the Nuffield Trust argued that increasing pressure means that the problems associated with meeting the four-hour target are no longer confined to the winter months:
Our analysis suggests that it is increasingly no longer the case that these problems are limited or especially intense in winter. […] performance has continued to deteriorate in the winter months–but the traditional respite in summer has not seen recoveries back to earlier performance levels, resulting in an overall downward trend.10
9.The traditional pattern of intense periods of pressure during the winter with some respite over the summer is less likely to apply. During June, July and August 2016 the performance of English emergency departments was worse than every winter since 2004 bar the winter of 2015–16.11 For many departments the pressure feels relentless.
Performance
10.The challenge now facing the urgent and emergency care system has been underlined by performance against the four-hour target since the second quarter of 2015–16:
Source: Nuffield Trust (WIP 33)
Figures published by NHS England in relation to type 1 emergency department performance showed that in July 2016 85.4% of patients were admitted, discharged or transferred within 4 hours.12 That month Jim Mackey, Chief Executive of NHS Improvement, told the Health Service Journal that performance in the 70–80% range [against the four hour waiting time standard] had become “normalised” in some trusts.13
11.Pauline Philip, National Urgent and Emergency Care Director NHS England and Chief Executive, Luton & Dunstable University Hospital NHS Foundation Trust, put existing performance into context by using numbers rather than percentages, noting in oral evidence that more patients are seen within the four hours than ever before. This point was also argued in the Government’s evidence, which said “thousands more people a day are seen within the four-hour A&E target compared to 2010”.14 Whilst this is true, it is also the case that more patients are waiting longer than four hours in English emergency departments than at any period since the four-hour standard was established. In 2011–12, 700,000 patients spent longer than four hours in emergency departments. By 2015–16 this figure had more than doubled, to some 1.8 million patients.15
12.We are very concerned about the decline in performance of major emergency departments in England. We recognise that hospitals are managing ever growing demands, but the performance of emergency departments against the four-hour waiting time standard is a marker of much wider system pressure.
Impact on patients
13.The winter of 2015–16 was mild and the flu vaccine worked.16 We heard of a fear amongst leaders of acute NHS trusts that 2016–17 could be substantially more difficult, something that has also been noted by Professor Chris Ham, Chief Executive of the Kings Fund.17 It is both significant and concerning that compared to previous years hospitals are working from a much lower base in terms of their performance as we enter the winter period. The decline in performance of emergency departments which is usually associated with winter pressures has become the norm for some NHS trusts. In addition, the Care Quality Commission’s State of Care report showed that the majority of A&E services in England have been rated by the regulator as inadequate or requiring improvement.18
14.The impact on patients is the most worrying aspect of this situation. During the seminar we held with leaders of NHS trusts drawn from across England we heard that patients are likely to experience longer waits for emergency care whether they are in the waiting room, a cubicle or ambulance.19 Evidence to our inquiry from Independent Age reported that people aged over 75 will spend significantly longer waiting for treatment than younger patients.20
15.In the written evidence submitted to this inquiry witnesses stressed the relationship that exists between good performance against the four-hour standard and patient safety. The Royal College of Emergency Medicine said in its written evidence that “performance against the 4-hour standard is a useful proxy measure of crowding” in an emergency department and crowding “adversely affects every measure of quality and safety for patients & staff”.21 Commenting on the various challenges a trust may face during the winter which can range from increased demand to high staff absence, University Hospitals of Morecambe Bay NHS Foundation Trust said that in combination these problems can compromise both patient safety and patient experience.22
2 NHS England, Quarterly Attendances & Emergency Admission monthly statistics, NHS and independent sector, August 2016
3 Care Quality Commission, State of Health Care and Adult Social Care in England 2015–16, HC 706, October 2016, p 17
4 National definitions of type 1 / major emergency departments:
England: ‘Type 1’: A consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients
Wales: ‘Major A&E’: those departments providing a consultant led 24-hour service with appropriate resuscitation facilities and designated accommodation for the reception of accident and emergency patients
NI: ‘Type 1’: A consultant-led service with designated accommodation for the reception of emergency care patients, providing both emergency medicine and emergency surgical services 24 hours a day.
Scotland: ‘Emergency Department’: larger A&E services that typically provide a 24-hour consultant led service
5 NHS England, NHS Standard Contract 2016/17 Particulars, April 2016, schedule 4
6 NHS England, NHS action to strengthen trusts’ and CCGs’ financial and operational performance for 2016/17, NHS England, July 2016
8 Health Committee ‘ A&E winter planning inquiry launched’ July 2016
9 Note of Committee visit to Luton and Bedford
10 Nuffield Trust (WIP 33, para 1.2. See also, for example, the submission from Homerton University Hospital NHS Trust (WIP 30, p 3)
11 NHS England, A&E Attendances & Emergency Admission statistics, NHS and independent sector organisations in England
12 NHS England, A&E Attendances & Emergency Admission statistics, NHS and independent sector organisations in England
13 Health Service Journal, ‘Mackey: A&E failure is ‘normalised’ at some trusts’, July 2016
15 CQC, State of Care, figure 2.9
16 Department of Health, NHS England and NHS Improvement (WIP 35) Annex D
18 Care Quality Commission, State of Health Care and Adult Social Care in England 2015–16, HC 706, October 2016, State of Care, Figure 1.8 (57% of A&E services)
19 Note of Committee visit to Luton and Bedford
31 October 2016