Author: DR CLIFFORD MANN, President Royal College of Emergency Medicine
It should come as no surprise to anyone in the health sector that searching for good news relating to A&E performance has become ever more difficult. The data presented by QualityWatch shows the number of patients who have breached the four-hour standard has doubled since 2013/14 and trebled this last winter. Even more worrisome is the absence of the usual post-winter A&E performance recovery. This creates the unacceptable ‘Winter all year’ scenario.
In the last 12 months we have witnessed record attendance numbers – almost 15 million patients attended a type 1 A&E department. This demand pressure in the face of fixed capacity has inevitably created significant challenges to the system. Moreover the number of admissions has also risen substantially.
This rise in admissions has exceeded the trend line over the last five years such that the proportion as well as absolute number has risen beyond that predicted by population growth. Overall admission rates are around 27% but this is set to continue to rise as last year A&E attendances rose by 600,000 but acute admissions rose by over 400,000.
The four-hour standard measure of success is dependent upon demand, capacity and flow; the latter substantially dependent upon the availability of acute hospital beds.
Exit block phenomenon
During the last five years we have reduced the available overnight bed stock by almost 10,000 beds. The last two winters have seen a huge rise in patients ‘trapped’ in hospital because of delayed transfers of care. It should therefore come as no surprise that the QualityWatch data show that there has been a marked increase in the time people wait to move to a hospital ward. Unfortunately this ‘exit block phenomenon’ has two adverse effects.
Firstly, research from North America, Australia and the UK demonstrate that attendance to an overcrowded emergency department results in higher 30 day mortality whether the patient is discharged or admitted – a fact accepted by Sir Bruce Keogh’s review of Urgent and Emergency Care.
Secondly when beds are scarce, patients are admitted to the next available bed, not the most appropriate bed. Admission to an outlying ward is associated with longer lengths of stay, which in turn reduces bed availability and exacerbates exit block; a vicious circle is created.
The seasonal variation associated with higher attendances in summer months but higher admission rates in winter months continues but the case mix data that would explain this in detail is unavailable. The current Emergency Care Data Set is woefully incomplete with more than 30% of patients having no coded diagnosis. This led the Commons Health Select Committee last year to describe the system as ‘flying blind’.
It is unacceptable that in the second decade of the 21st century we are unable to easily source data as straightforward as annual admission rates from A&E for pneumonia, fractured femur or meningitis. Current work to create a mandatory data set that is fit for purpose is advancing; it is in everyone’s interests that it is implemented as soon as possible.
The ambulance data demonstrate some very worrying trends with monthly red-two calls rising by 100,000 (50%) over the last five years. This is inexplicable in terms of demographic change dependent upon either population size or age. Little wonder therefore that the ability of ambulance services to respond within eight minutes has been substantially compromised – indeed the data show a direct correlation between call numbers and response time performance.
Given that only a small proportion of such calls will benefit from such a rapid response time it is prudent that further consideration should be given to improving both the sensitivity and specificity of ambulance dispatch criteria.
There is of course some linkage between A&E performance and ambulance performance. Ideally ambulance crews should be able to transfer care of their patient to A&E staff within 15 minutes of arrival at an A&E department. However, when departments are overcrowded due to exit block and ‘downstream pressures’ this may be impossible. Delaying ambulance crews in A&E departments directly diminishes the number of vehicles and crews available to respond to subsequent calls.
Conversely, every patient transported to an A&E department whose problems could have been dealt with as well, if not better, in their own home, place of residence or community health care facility, similarly places avoidable demands on A&E departments.
These consequential phenomena are all too evident to staff working in front-line services yet they are disempowered to address them. Much of urgent care is defined by silo services. Hospitals, urgent primary and mental health care services, ambulance trusts and district nursing have been developed as autonomous organisations.
Accountability occurs within each service not across the system, feedback is at best anecdotal, more usually non-existent. Targets are blind to other metrics of effectiveness or efficiency, commissioning increases transactional costs and penalties penalise the weakest link.
‘Doomed to iterative failure’?
The data clearly show that without major changes the system is doomed to iterative failure. Of course we can improve current systems and NHS England’s report ‘Safer, Faster, Better’ provides the templates to do so. It would however be naively optimistic to assume that these refinements will consign our problems to history.
Changing demographics and case mix will require all urgent care resources to work collaboratively with an alignment of aims and expectations. Central to this is the recognition that an A&E department cannot be an ‘Anything and Everything department’.
To ensure timely and expert care for patients with urgent care needs we must co-locate other experts – Primary Care providers, Crisis Mental Health Teams and Community Pharmacy; all of whom can provide better care to many patients who currently attend A&E departments.
In addition, and in recognition that the UK cohort of people over the age of 85 is rising by 100,000 per year, we must mandate the provision of in-reach frailty services to all A&E departments. Such services reduce admissions and length of stay, thereby promoting the health and independence of this key group of service users.
The development of A&E hubs, in which the emergency department is but one, albeit important, element will allow services to be properly aligned to reasonable patient expectation, allow collaborative and integrated care delivery, reduce duplication, confusion and transactional inefficiencies and deliver a structure that is aligned to function.
Currently less than 50% of A&E departments have any co-located service – a situation that cannot be allowed to continue.