Last week's A&E performance in England was widely reported in the media as heralding the start of a winter crisis. In the first week of December only 87.7% of people attending a major A&E were treated and discharged or admitted within four hours. This is a big drop in performance compared with previous years.
A&E has been described as a barometer of the whole emergency care system. When things are going wrong they show up first in reductions in A&E performance. Why is this happening? Most reports suggest the crisis is due to unprecedented numbers attending A&E. BBC health correspondent Nick Triggle said "The simple answer is that more people are visiting A&E" and Richard Murray of the Kings Fund said "the number of people showing up at A&E is continually bouncing at the highest level the NHS has ever seen."
But is this true? While it is true that there has been a gradual and predictable increase in A&E attendances over the years, in line with population growth, there has not been a sudden increase in attendances to explain the sudden deterioration in A&E performance. Looking at the figures published by NHS England its clear that there were far higher numbers of people attending A&E throughout the months of June and July than in the first week of December and yet the four-hour target was maintained then above 92%.
For example in the week ending 22/6/14 there were 298,955 attendances and a 93.6% four-hour performance and in the week ending 20/7/14 there were 298,711 attendances with 92.2% performance. Compare this with the "crisis" first week of December when attendances were 286,429 yet four-hour performance was only 87.7%. See for yourself at the NHS England A&E performance data site.
If A&Es could handle higher levels of attendances before why are many of them failing now? These figures show that the simple message that there is an A&E crisis because "too many people are attending A&E" is not an adequate explanation. Blaming increased A&E attendance is a convenient way for the Government to avoid responsibility for the more important factors that are contributing to the problem: lack of hospitals' capacity to deal with the increasing numbers of sick people requiring admission.
It's important to make the distinction between A&E attendances and hospital admissions. Admissions to hospital have been rising faster than population growth for years and in the first week of December were 110,000, one of the highest levels ever. Underlying reasons for this are unclear. As admissions increase pressure builds up in A&E and the four-hour performance falls. This is because not only are there sicker patients requiring more clinicians' time, but delays in transferring patients to hospital beds causes back pressure in A&E, taking up space and tying up staff who therefore can't deal so efficiently with other patients. This is evidenced by the dramatic increase in the number of people spending between four and 12 hours on trolleys before a bed is found for them. In the first week of December this was 7760, the highest since weekly figures began.
The trolley wait figure is perhaps the most alarming in terms of human cost. Imagine being ill enough to need hospital admission but being stuck on a trolley for hours waiting for a bed. And this is one of the most unsafe places to be as ability of staff to monitor and treat is limited compared with in a hospital ward.
Dr Cliff Mann, president of the College of Emergency Medicine and an A&E doctor at the Taunton and Somerset Hospital, told BBC Radio 4's World At One:
There's a real pressure on beds
an awful lot of patients are waiting longer than they should be to get into hospital, and backing up in the A&E department means there's a problem off-loading patients from ambulance trolleys
A Quality Watch investigation by the Health Foundation and Nuffield Trust into the 2012/13 winter crisis found evidence that lack of availability of in-patient beds increased waiting times for all patients in the A&E departments.
Lack of beds is due both to overall reductions in bed numbers and delayed discharge from hospital. Current high bed occupancy rates are an indicator of pressure on beds.
Delayed discharge figures for October (latest available) were at their highest since this data collection started in 2010.
This is caused by the drastic cuts to social services budgets leading to delay in arranging packages of care for patients to support them when they come out of hospital.
Pressure on A&Es is also because A&E capacity has not kept up with demand due to population growth. This has led to crowding in A&Es with a direct impact on the quality of care for patients and performance against the four-hour target. The Quality Watch investigation estimated that we would have needed an additional 25 A&Es to meet increased demand just due to population growth since 2003. Instead the number of major A&Es has been cut by 8% since 2003 and A&Es are still scheduled for closure despite the crisis (see North West London A&E delays).
What is the Government's responsibility for this? BBC health correspondent Nick Triggle seems all too ready to let the Government off the hook:
It seems to be the case that despite all the planning, all the money, and all the hard work of NHS staff, this winter will hinge on factors outside everyone's control.
But the crisis was predictable and should have been planned for. The changing demographics and rising admissions have been known about for years. The interaction between social services budgets and delayed discharge is likewise well understood. The solution is proper planning and investment in NHS and social services. The Government should be responsible for this. Instead it has brought in a top-down NHS reorganisation that no-one voted for which has led to disorganisation of healthcare and enforced £20billion "efficiency savings" in the past 5 years with another £30billion to come. Hospital, community, GP, mental health, and social care budgets have all been cut. Despite all the rhetoric there has been no serious investment in community and home based alternatives to hospital care.
The £700million 'winter crisis funding" the Government is throwing at the problem is too little, too late. It is intended to avert political embarrassment in the run up to the election. Sadly it's unlikely to have much impact on the conditions for patients or staff in our A&Es this winter.