By Gordon Miles, Chief Executive The Royal College of Emergency Medicine
This isn’t a story from the popular Game of Thrones series but one about the crisis in our Accident and Emergency Departments (A&Es). In England during 2016 we have seen a steadily worsening performance at our A&Es when measured by their ability to see, treat, admit or discharge patients in under four hours. This is not just something that happens during the winter season. The latest data available to me regarding my context, Emergency Medicine, as I write this was June 2016 where the following key points emerged:
• Attendances up by 2.1% on June 2015 to 1,951,000
• Type 11 A&E department attendances were at 1,282,499 – up 2.7% on the same month last year
• There were 480,000 emergency admissions in the month, 4.7% higher than the same month last year. Emergency admissions via Type 1 A&E departments increased by 5.3% over the same period. Emergency admissions over the last twelve months are up 3.7% on the preceding twelve month period.
• 90.5% of patients seen within 4 hours – up from the previous month, but down from 94.8% in June 2015
• 85.8% of patients were seen within 4 hours in Type 1 A&E departments, compared to 92.3% for the same month last year. The Times2 reported this as the worst ever performance recorded.
• There were 35,300 four-hour delays from decision to admit to admission this month, which compares to 19,100 in the same month last year.
• There were 171,300 total delayed days in June 2016, of which 115,400 were in acute care. This is an increase from June 2015, where there were 139,500 total delayed days, of which 91,100 were in acute care.
• The main reason for NHS delays in June 2016 was “patients awaiting further non-acute NHS care”. This accounted for 29,500 delayed days (28.8% of all NHS delays). The number of delays attributable to this reason showed a general increase between June 2015 and March 2016, but since then appears to be showing a gradual downward trend.
• The main reason for Social Care delays in June 2016 was “patients awaiting care package in their own home”. This accounted for 19,700 delayed days (35.7% of all Social Care delays), compared to 15,000 in June 2015.
• 1,124,990 calls offered to the NHS 111 service in England in June 2016, a 14.0% increase on the 987,107 in June 2015. Of calls triaged in June 2016, 13% had ambulances dispatched, 9% were recommended to A&E, 60% were recommended to primary care, 4% were recommended to another service, and 15% were not recommended to attend any other service3.
The wider NHS system is under pressure and we are often asked: why does winter last all year?
Why does winter in A&E last all year?
The Royal College of Emergency Medicine has been campaigning since June 2013 to improve emergency care in the A&E departments of the UK. Key to this has been our STEP Campaign: where we focus ondemand, capacity and flow of patients through the system, as described by the four elements of our campaign:
1. Staffing: matching the people resources to the volume of patients, and so expanding the workforce, reducing emigration and improving retention of emergency physicians.
2. Tariffs & Terms: getting the systems that pay hospitals for A&E work to fairly cover the costs involved whilst also getting the rights terms and conditions for the workforce in place to stop the leaching of talent
3. Exit Block: tackling the exit blocks to A&E departments that stop patients flowing on to hospital wards
4. Primary Services: co-locating primary care services with A&Es, into an A&E hub, where the emergency department is part of the ‘hub’ not the sole provider
In Scotland where pressures were first experienced at an acute level over four years ago, on our recommendation the government boosted recruitment and worked closely with our College try and tackle the challenge. The results there are now showing an improvement and in recent data Scotland’s performance is the best of the UK nations. That is not to say that the work is done as we are working to make further improvements for patients.
In the other parts of the UK for varying reasons the challenges remain or are worsening, we are working with politicians and NHS management to address the issues but some long term systemic problems remain.
The Urgent and Emergency Care review has been progressing in England since 2013. Much of its attention has been directed at reducing patient demand on A&E Departments. This is commendable, though the College is of the opinion that the gains realisable from such a strategy are limited. In this context it is worth noting that the UK has a relatively low usage of A&E departments when measured as visit per annum per capita. The UK has 27% of its population that used Emergency Departments in the past two years according to a 2013 survey by the Commonwealth Fund International Health Policy Survey as compared with 22 in Austria and Germany and 41 in Canada.
Over the past five years we have experienced a rise in patient attendances: by some 611,250 per annum but importantly admissions have disproportionately risen by 443,059. Three out of every four additional attendances above the 2011 benchmark have required admission. It is therefore clear that redirection strategies will be of diminished value.
The College is of the view that redirection and re-education strategies have largely failed. This is not to suggest that we do not recognise the need to decongest our departments but it is our opinion that this is best done by co-location of key out of hours urgent care services. It is worthwhile highlighting that 84% of A&E attendances are by people who live within 7.5 miles of a major A&E department.
A co-located model is partially implemented in some sites already and has huge potential for collaborative working with better patient focused service provision. We call this model an A&E hub, in which key components of urgent health care are physically and functionally co-located to allow the alignment of behaviours with resources.
This model is endorsed by each of the key stakeholders; the Royal College of General Practitioners, the Royal College of Psychiatrists, the Patients Association, the Royal Pharmaceutical Society and the British Geriatric Society.
The College believes that providing such a hub of services within easy travelling distance of 80% of the population is both effective and efficient. For those not within easy travelling distances non-urban urgent care centres could provide all but hospital based services.
Under shared locally agreed governance, the co-location of the Out of Hours Primary Care Team, Community Pharmacy, Out of Hours Mental Health Team, Frailty Team and the Emergency Department will provide patient services more appropriate to case-mix and skill mix than the current arrangements. This is not to argue for new services but for the co-location of existing services around the point the patients attend: the A&E department.
This endorsement of the British Geriatric Society is particularly important given the rapid changes in the elderly demographic within the UK. The trend data demonstrate that the number of people over 85 years of age will grow by almost 90k per year for the next 20 years. Compared to 2011 there are an additional 500,000 people aged over 85 alive today.
In-reach frailty services based upon a Comprehensive Geriatric Assessment are proven to reduce admissions and length of stay and must be regarded as an essential component of 21st century acute services. The care of this section of our population more than any other will determine the success or otherwise of the acute care system.
Currently the probability of admission is directly correlated with age. It is imperative that this default option is challenged. However it is vital to recognise that meeting this challenge will require a multi-disciplinary approach with skilled and expert teams working together, as the burden of illness carried by this elderly cohort is substantial.
Non-Emergency Medicine Attenders
The College recognises that a significant proportion of patients attending an A&E department can be managed at least as well if not better by other services/ staff. Data from the Royal College of Emergency Medicine Sentinel Sites study published in 2014 shows that more than a third of attendances could be managed without input from an EM doctor.
Moreover A&E has become ‘Anything and Everything’ in the out of hours period, a function it is not resourced to deliver. The lack of other services for urgent care needs leads to clinically improbable spikes in attendances at weekends and bank holidays.
The following graphic highlights this phenomenon and the consequent increase in A&E dispositions by NHS 111 to A&E at weekends.
Establishing an A&E hub model of service provision would ensure that many of the additional weekend attenders were seen by more appropriate services further decongesting the emergency department.
The increase in attendances in the last 5 years is equivalent to the workload of 10 medium sized departments in England alone. Unfortunately the mismatch between patient volumes/casemix and senior medical staff has been exacerbated by the problem of retaining emergency medicine registrars and, to a lesser extent, consultants.
450 registrars were lost to the system as they chose other specialties or emigrated. Although recruitment and retention in 2015 reached a five year high the permanent loss of these senior trainees will be felt for many years.
Workload has therefore increased by a volume equivalent to 10 A&E departments yet the senior workforce has seen an attrition rate equivalent to 15 A&E departments. The cumulative shortfall is the resource equivalent of 25 A&E departments.
These staff shortages are accentuated by the variability in patient attendances per hour. Surges in demand can occur rapidly throughout the day or week and effectively exacerbate acute staff shortages. Such surges lead to queue formation and diminished efficiencies. As such even if departments are staffed for average attendance numbers it is frequently the case that they are substantially understaffed for much of the time.
Over the last 5 years the number of beds available for admission of acutely ill and injured patients has fallen.
We now have the lowest number of beds per capita in Europe and England has the lowest number within the UK.
The winter has seen familiar headlines about performance but plotting the data makes a compelling statement.
Not only has the four hour standard performance declined but the rise in 12 hour trolley waits has increased by 200% in the last 3 years.
These trends provide both cause and effect with respect to A&E department capacity. Reduced flow through the emergency department impedes the accommodation of new attendances. In turn there is a consequent deterioration in ambulance off-load times.
Exit block is proven to be associated with both significant morbidity and mortality. The latter has been estimated at 1000 patients per year in the UK.
Paradoxically exit block is associated with a greater number of patients admitted to ‘any bed’ rather than
an ‘appropriate bed’. In turn this leads to greater lengths of stay, reducing the available bed stock and perniciously increasing the frequency and severity of exit block.
The preceding data, analysis and opinion describe the pressures and constraints that are non-seasonal. The winter period is atypical in that although overall ED attendances per day are lower in winter than summer, the reverse is true of admissions. Whilst most diagnostic categories have seen a steady rise in admissions over the past few years there is a very clear seasonal variation in respiratory admissions, which almost double in December and January.
Set in the context of more patients, more admissions, fewer senior medical staff and fewer acute beds it is hardly surprising that performance against the 4 hr standard has fallen. Indeed it is perhaps more surprising it has not fallen further. The seasonal demand of winter merely highlights the lack of surge capacity endemic within understaffed and under-resourced departments. and the aforementioned bed pressures. Delayed transfers of care exacerbate these bed pressures.
Data shows that admissions are likely to continue to rise by more than 50,000 patients per year. It is beyond dispute that our hospitals will need greater acute bed capacity and more senior decision makers within the emergency department and A&E hub. Planning must address the need to cope with rising numbers of attendances by the frail elderly – with complex interactions between health and social care and long term co-morbidities rather than focussing on reducing attendances by other groups – which are already amongst the lowest per capita in Western Europe. Correct funding of emergency care, fairness of contracts to promote a sustainable career in emergency medicine and the creation of A&E hubs to decongest emergency departments will underpin a successful strategy that is patient centred, affordable, efficient and effective.
1, Type 1 – A consultant led, 24-hour service with full resuscitation facilities and designated accommodation for the re caption of emergency department patients.
2, The Times Friday August 12 2016 ‘NHS crisis deepens as bed blocking costs £6bn’
3, A&E performance June: https://www.england.nhs.uk/statistics/statistical-workareas/ae-waiting-times-and-activity/statistical-work-areasae-waiting-times-and-activityae-attendances-and-emer gency-admissions-2016-17/