A&E and Emergency Care
Definitions
Bed Blocking: Hospital beds which are occupied by medically fit patients who can’t leave the hospital due to social care reasons (e.g a shortage of community care).
Acute Disease: Diseases that come on rapidly and require urgent or short team care. They improve once treated.
Chronic Diseases: Diseases which develop slowly and worsen over a long period of time. These are usually managed but not cured.
Ambulances
There a 4 categories for ambulance requests:
Category 1: Life threatening (e.g cardiac arrest).
NHS standard: “90% of category 1 calls should be responded within 15 minutes”.
In March 2022, the average was 9.6 minutes.
The 90th percentile response time was 16.8 minutes - 1.8 minutes above the standard.
Category 2: Emergency - require rapid assessment (e.g stroke or sepsis).
NHS standard: “90% of category 2 calls should be responded within 40 minutes”.
In March 2022, the average was 61 minutes.
The 90th percentile response time was 137 minutes - 97 minutes above the standard - the worst on record.
Category 3: Urgent - not immediately life threatening but need management (e.g. pain control).
NHS Standard: “90% of category 3 calls should be responded within 120 minutes”.
In March 2022, the average was 3.5 hours.
The 90th percentile response time was 8.6 hours - 6.6 hours above the standard.
Category 4: Less urgent - non-urgent but need assessment (e.g. stable clinical cases who need transport).
NHS Standard: “90% of category 4 calls should be responded within 180 minutes”.
In March 2022, the average was 4.1 hours.
The 90th percentile response time was 10 hours - 7 hours above the standard.
The main causes of these delays are:
Increasing demand for ambulances: a 18% increase in calls from December 2020 (1.1 million) to December 2022 (1.3 million).
Staffing shortages and burnout. A UNISON Survey found 57% of ambulance staff feel “overwhelmed” and 28% are using medications such as antidepressants.
The government invested £150m into increasing ambulances and staff. However, this is not nearly enough and it has been emphasised by the 2022/2023 ambulance strikes.
Accident and Emergency
There are 3 types of A&E departments:
Type 1: Major A&E - 24 hour consultant-led service.
Type 2: Single speciality A&E service - a consultant-led service for specific conditions (e.g ophthalmology, dental etc.).
Type 3: Minor Injury Unit/Walk-in Centres - for minor breakages and illnesses.
A&E standards
The current A&E standard is the four hour standard:
“95% of patients are expected to be discharged, admitted or transferred within 4 hours”.
However, on average this been missed every month since July 2015. Only 58% of type 1 attendants met this standard at the start of 2023 (96% of type 3).
Why do we need standards?
Helps guide NHS workers on the order to prioritise patients to meet the standard.
Helps inform patients of expected waiting times.
Issues with the four hour standard:
Many patients believe it is a 4 hour wait to be seen, rather than discharged, admitted or transferred, discouraging them from attending A&E.
Doesn’t focus on quality of care or patient experience.
Doesn’t prioritise emergency patients.
Potential future Standards:
A standard should incorporate both clinically important factors (e.g seeing critically ill patients) and important factors for the patients (e.g waiting times). Some alternate standards that have been suggested and trialed at hospitals are:
Time taken to be seen.
Time taken to treat critically injured and ill patients.
However, the issue with standards that focus on a group of patients (e.g critically ill) is that the waiting times for other patients could greatly increase and waiting rooms could become crowded.
Issues facing A&E
Rising A&E attendants.
18% increase in A&E attendants and admissions in last 10 years.
GP appointment delays cause patients to go to A&E.
Too few hospital beds.
England has an average of 2.4 beds per 1000 people. The EU-OECD average is 4.6 beds.
This causes bed blocking where ambulances and A&E departments can’t admit more patients. An ambulance can only leave the hospital when there is a bed free.
Aging population.
The average age of the population is increasing. This leads to more acute and chronic illnesses. (see: aging population)
75% of over 75 year olds have more than one long term condition.
COVID-19
Cancelled elective appointments and a fear of hospitals led to less appointments.
Therefore, more acute illnesses are entering their chronic phase, placing greater pressures on the NHS (specifically secondary care services) to treat these conditions.
Increasing obesity
Obese individuals are more prone to non-communicable diseases such as heart attacks and strokes. These are common reasons to attend A&E.
Pressures on social care
50% of patients who are fit to leave the hospitals don’t due to a shortage of care services (e.g people to adapt homes, carers, care homes etc.).
Understaffing
Emergency medicine has the greatest vacancy rate in the NHS: 15%. This places pressures on the other staff in emergency medicine increasing burnout and causing more people to leave.
Expensive locum staff are required to fill the gaps, removing doctors form other sectors and costing the NHS millions.
Decreased pay: Nuffield Trust estimates that with inflation, over the last ten years, consultant pay and junior doctor pay has fallen (-11% and -8% respectively).
Solutions
Opening (and renaming) more ‘Urgent Treatment Services’: These include Walk in Centres, Urgent Care Centres and Minor Injury Units. By offering an umbrella name for all these services, it decreases confusion. It is estimated that these will reduce A&E attendants by 3 million each year.
Increase the pay of emergency medicine workers: In 2022 doctors received a 4% pay increase
Increase social care to reduce bed blocking.
Increase GP opening times.
Formation of Primary Care Networks (PCNs) and Integrated Care Systems (ICSs): This enables care plans to be created between healthcare and care services, speeding up the transferal of patients out of the hospital and reducing bed blocking (see: structure of the NHS).