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A bad winter could be catastrophic for already-stretched accident and emergency departments

By Richard Blogger

Accident and Emergency departments are already failing to meet four-hour targets to see and process patients

A&E is a service that we rely on being there and being functional when we need it.

The four hour target - the target which says people must not wait more than four hours from the time they arrive to the time they depart, or are admitted to hospital or transferred - is a broad measure of not only how well the emergency department is working, but the NHS hospital in general.

NHS England figures for all hospital A&Es in England show that the four hour target has not been met for over a year.

Normally, during summer, A&E figures are expected to recover from the winter pressures, but a recovery has not happened this year.

As far as A&E is concerned, it has been “winter” all year. A&E waiting time figures are getting worse, and if we have a bad winter or an outbreak of flu, the effect on A&Es could be catastrophic

Four Hour A&E waits deteriorating under this government
The health service defines four categories of A&E centres.

Type 1 and type 2 are consultant-led and are generally delivered by an NHS hospital. Type 1 is a full emergency department with resuscitation facilities and type 2 is a specialist service like ophthalmology. Together, there are about 15 million attendances a year at type 1 and 2 A&E units.

Type 3 and type 4 A&E may be doctor-led or nurse-led. Type 3 are Minor Injury Units (MUI) and type 4 are walk-in centres. Type 3 and 4 centres can be based in hospitals, GP practices or may be separate facilities, they do not handle life threatening conditions and are characterised by the fact that patients can access them without an appointment.

In general, type 4 centres are usually delivered by private companies (often, but not limited to companies owned by GPs).

Some type 3 centres are provided by NHS trusts and others provided by private companies like Virgin or Care UK. In total there are about 7 million attendances every year to these units, or about a third of all A&E attendances.

All types of A&E centres are subject to the four hour target. A patient must not wait more than four hours from the time of arrival to the time of departure, admission to hospital or transfer to another hospital. Types 3 and 4 units are usually separate units, insofar as most patients are treated in the unit and do not need to be referred on. In this respect the waiting time in MUI or walk-in centre reflect only the performance of the unit.

Type 1 units handle far sicker people who may need admission to a hospital ward or referred for further diagnostics (like MRI or CT scans) and so the wait in such A&E units will be affected by the availability of those resources. Since type 1 A&E is regarded as the “front door” of an NHS hospital, their waits give a measure of the performance of the hospital, in particular, an indication of the flow of patients within a hospital. If a hospital-based A&E department is failing the four hour target this is often an indication that the hospital has a resource problem elsewhere.

It is important to note that funding of hospital emergency care rarely covers its costs (trusts have to subsidise emergency care by surpluses from elective care) and there is a heinous “30% marginal tariff” where the hospital is paid the costs of emergency patients up until the activity level achieved in 2008/09 and then 30% of the costs for each patient after that.

The hospital cannot control the numbers of patients who turn up at A&E but is penalised if there are more than there were in 2008/09. On top of this, tariff, the main funding of hospital care, has been cut every year since 2010. All of this reduces the funding and makes it much harder for a type 1 unit to achieve the 4 hour target.

The four hour target was introduced in 2004, and set at a level that at least 98% of patients should wait no more than 4 hours (or conversely, that fewer than 2% should wait more than 4 hours). However, almost as soon as they took power, the Coalition government moved the goal posts and changed this threshold to 95%.

Labour focuses on the 4 hour target for just type 1 centres (two thirds of attendances) whereas the government prefers to use figures for all types of A&E which gives a more favourable figure.

NHS England provide weekly “A&E SitReps” (Situation Reports) for all the A&E centres and these list whether the centre met the four hour target.

Sitreps give a week-by-week performance measure, but Clinical Commissioning Groups performance manages providers on the aggregated quarterly figures. At the time of writing, the latest weekly sitrep (19 October) says that for all types of A&E, only 93.0% of patients meet the four hour target, whereas the figure for type 1 waits is 89.3%. The latest quarterly figures (Q2) show that the four hour target was met by 95.0% of all types, but only 92.5% of type 1 centres.

The following chart is taken from NHS England quarterly figures.


In this chart, the lines show the proportion of people waiting 4 hours or less in A&E and so, when the proportion decreases this indicates that more people are waiting longer. The top line is for all types of A&E and the bottom line is for type 1 A&E.

When the Coalition government relaxed the waiting time threshold from 98% to 95% you would expect the proportion of patients waiting to fall to around 95%, and this is what happened over a period of about two years. However, the fall did not stop there and the proportion waiting 4 hours or less at a type 1 unit has continued to fall so that the 95% threshold has not been achieved for at least a year, and the trend appears to be deteriorating.

It is clear that type 1 A&E performance (and by implication, patient flow through hospitals) is declining, but we have not yet hit bad winter weather, nor flu or norovirus outbreaks. This long-term declining trend is worrying hospital managers because it shows there is a long term doubt over the sustainability of hospitals. But more immediately, it shows that the A&E system is not in a fit state to withstand a bad winter this year.


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