23 July 2014

As hospitals throughout the country increasingly fail to hit A&E targets, patients in England were today warned they could expect greater waits in emergency units.

Days after NHS England data revealed major emergency units had missed the target to treat, admit or discharge emergency patients within four hours for an unprecedented 52 weeks in a row, a wide-ranging new analysis from the Nuffield Trust and Health Foundation uncovers the reasons behind these breaches.

The report tracks a number of contributing factors leading to struggles in A&E. It shows that crowding (the number of people in a department at any one time) is closely linked to waiting times. Crowding has risen as the population has grown and aged, while the number of A&E units has been frozen or reduced under successive governments. There was an 8% increase in crowding between 2010/11 and 2012/13 despite only a 3% rise in A&E attendances – a trend which is likely to continue.

"We may have reached the limit of what we can deliver with our current A&E capacity."

The analysis shows that winter pressures were associated with higher rates of people waiting more than four hours, but by less than most people think. Challenging conventional wisdom, it highlights the strain hot weather puts on A&E departments - when average daily temperatures hit 20°C compared with 5°C, trips to A&E rise by nearly 20%. However, very cold weather does also cause longer waits, and raises the chances of patients needing to be admitted to hospital.

Tracking 41 million A&E attendances from 2010 to 2013, the report exposes an age gap where older people wait in A&E longer than children and younger adults. This is due in part to the complexity of conditions which older people suffer, which often require longer periods of care – but older adults have also seen the fastest increase in waits which breach the four hour target. People over 75 spent around three and a half hours in A&E on average, compared with two and a half hours for under-75s.
Patients who suffer from long-term conditions like arthritis also wait longer to be admitted or discharged, and those with more than one condition wait longest of all. However, aging and long term conditions only explained a small amount of the increase in breaches of the four hour target.

The analysis shows that people whose local GP practice had better patient feedback were less likely to attend emergency units. Practices which were rated as easy to reach by telephone also saw fewer patients go to A&E. However, GP satisfaction did not make a difference to breaches of the four hour target.

Underlying this wider picture, links were also found between long A&E waits and the availability of beds on hospital wards.

Report author and Nuffield Trust Senior Research Analyst Ian Blunt said:

“This report shows that many of the external factors suggested to explain the decline in performance on the four-hour target since 2012 only had a small effect. Although many people in the NHS fear a repeat of the difficult 2012/13 winter, we show that the weather was only one part of the problem. We may have reached the limit of what we can deliver with our current A&E capacity.

“Prolonged poor performance on the four-hour target will not be popular with the public or politicians and will mean exposing patients to the worse outcomes that are associated with longer waits. But without either new money to invest in A&E, or new ways to divert people to other parts of the NHS, rising waits may be inevitable. A lot now rides on NHS England’s Urgent and Emergency Care Review.

“The NHS has been criticised for not having the information it needs to fully understand what's going on in A&E. This report provides some of the new evidence we need so that policy-makers are able to target limited resources most effectively. 

“However, there's still a lot we don't know. It is vital that the health service makes better use of linked data to understand how issues like bed availability and staffing levels have an impact on what people experience in A&E.”

Dr Jennifer Dixon, Chief Executive of The Health Foundation, commented:

“As this report shows,  A&E departments are completely stretched, aggravated by increasing demand for emergency care. But the solutions are more complex than simply ‘more investment needed’, even if that were forthcoming. The access and quality of health and social care available to people outside hospital also needs to be very carefully examined – is it good enough to prevent the need for an A&E visit? We also know that hospitals have huge difficulty discharging patients because of a lack of social care. The flow of patients through hospital – to relieve A&E departments and also free up beds – is often disordered and blocked: two projects funded by The Health Foundation in Sheffield and Warwick have shown that improvements can be made within existing budgets. Only careful attention to all these areas is the solution.”

Notes to editors

  • Focus on: A&E Attendances, is part of the Focus On series of reports from the Nuffield Trust and Health Foundation’s QualityWatch programme. It will be available at 00.01am on Thursday 24th July here: http://www.qualitywatch.org.uk/focus-on/ae-activity. To request a copy of the report under embargo, please email mark.dayan@nuffieldtrust.org.uk.
  • The report uses de-identified patient data to track A&E attendances in the years 2010/11, 2011/12 and 2012/13. It looks only at English Type 1 A&E units, the major units which provide 24-hour urgent care for the most serious cases.
  • QualityWatch is a major research programme from the Nuffield Trust and the Health Foundation that is providing independent scrutiny into how the quality of health and social care is changing over time
  • The Nuffield Trust is an authoritative and independent source of evidence-based research and policy analysis for improving health care in the UK. It conducts cutting edge research and influential analysis, informs and generates debate, supports leaders, and examines international best practice.
  • The Health Foundation is an independent charity working to improve the quality of healthcare in the UK. It is here to support people working in healthcare practice and policy to make lasting improvements to health services. The Health Foundation carries out research and in-depth policy analysis, runs improvement programmes to put ideas into practice in the NHS, support and develop leaders and share evidence to encourage wider change. The Health Foundation wants the UK to have a healthcare system of the highest possible quality – safe, effective, person-centred, timely, efficient and equitable.
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