Monday, 10 November 2014

Urgent and emergency care mythbusters

Pressures on urgent and emergency care have been the focus of much media and political debate, but the system is complex and surrounded by myth and confusion. Here we address some of the main claims that have been made during the debate so far.

Myth one: A&E waiting times have risen dramatically

It is true that, in recent years, the proportion of patients waiting longer than four hours to be treated, admitted or discharged has increased.
As Figure 1, below, shows, the proportion of patients waiting longer than four hours in A&E hovered around the old 2 per cent target for a number of years. It then increased, following the coalition government's decision to relax the target to 5 per cent in 2010. With the exception of the final quarter of 2013/14, when the 5 per cent target was breached, performance has generally remained within the target range. However, the proportion of patients waiting longer than four hours has been rising and the target has only just been met in recent quarters.

Figure 1: Percentage of patients waiting more than four hours in A&E from arrival to admission, transfer or discharge

The national figures mask significant variations in performance. Around a quarter of all A&E units have missed the 5 per cent target in recent quarters (see Figure 2, below). Performance tends to be much stronger among walk-in centres and minor injuries units, which brings up the national average. By July 2014, major A&E units had missed the target for 52 consecutive weeks.

Figure 2: Percentage of providers reporting more than 5 per cent of patients waiting longer than four hours in A&E departments from arrival to admission, transfer or discharge

Myth two: The number of people going to A&E is increasing

For many years, the number of people attending A&E remained essentially unchanged at around 14 million a year. In 2003/4, the number of attendances jumped – by nearly 18 per cent – to 16.5 million. This reflects the introduction around this time of walk-in centres and minor injuries units, which aimed to divert less serious cases away from major A&E units.
At the same time, the way the statistics were collected changed to record attendances separately for type 1 (major A&E units), type 2 (single specialty units) and type 3 units (walk-in centres and minor injuries units). So, much of the increase in 2003/4 was due to previously unrecorded attendances being collected and additional – but less serious – work being carried out in new types of units.
Since then, the overall number of attendances has increased significantly to 21.7 million in 2013/14, a rise of more than 30 per cent over the decade. However, most of this growth has been in attendances at type 2 and type 3 units, indicating a degree of supply-induced demand as these new routes into emergency care have opened up.
The number of attendances at type 1 units has increased at a much lower rate, from 12.6 million in 2003/4 to 14.2 million in 2013/14. While this is an increase of only 12 per cent, it is still a significant number of attendances to absorb for a system operating close to capacity. (See Figure 3)

Figure 3: Annual attendances  at English A&E units: 1987/8 to 2013/14

Myth three: Increases in A&E attendances are mainly a result of reduced access to GPs

It has been said that more patients are attending A&E because they are unable to get appointments with their GP, while the Secretary of State for Health, Jeremy Hunt, suggested that changes to the GP contract in 2004 led to increases in A&E attendance by removing responsibility for out-of-hours care from GPs.
Nearly 40 per cent of patients who attend A&E are discharged without requiring treatment. This does not mean that all these patients are attending A&E unnecessarily or could be cared for elsewhere. Estimates vary but a survey of 3,000 patients in 12 A&E units carried out for the College of Emergency Medicine found that 15 per cent could have been treated in the community; again this is not to say that they all went to A&E 'inappropriately'. Research has shown that attendances are linked to the accessibility of, and patient satisfaction with, local GP services. However, it is difficult to accurately pin down how many people go to A&E to because they can't get get an appointment with their GP. Recent research by a team at Imperial College London estimated this to be as many as 5.7 million A&E attendances in 2012/13 (almost a quarter of unplanned attendances), although they described this as a 'snapshot of the situation' and called for further research to improve understanding in this area. There has not been any research suggesting this has changed over time.
There is no evidence that changes to the arrangements for providing out-of-hours services have led to an increase in A&E attendances. As Figure 4 shows, most people go to A&E during working hours and these hourly patterns in attendances have remained largely unchanged in recent years. The difference in attendance levels between type 1 and type 3 units during the night is explained by the latter not generally being open 24 hours a day.

Figure 4: Percentage of  A&E attendances by hour of day and department type, 2012/13

Myth four: A&E pressures are due to an inadequate number/mix of staff

Staffing issues are a significant factor in pressures on A&E departments. However, the real issue is not just the total number of staff, but having the right combination of staff available, particularly consultants. A&E departments are struggling to recruit to these posts and often end up relying on locums and more junior staff to provide cover.
The College of Emergency Medicine reports that, for the past three years, only 50 per cent of higher specialist emergency medicine training posts have been filled, resulting in a 'lost cohort' of more than 200 potential consultants. It argues that trainees are opting out of emergency medicine due to the 'intensity of work, unsociable hours and working conditions'. This adds to the pressures on those in post, creating a vicious circle of overwork and low morale, which exacerbates recruitment difficulties.
The College of Emergency Medicine recommends a minimum number of ten full-time equivalent consultants for every emergency department, to ensure a consultant presence for up to 16 hours a day. Currently, departments are able to cover 12 hours a day for 77 per cent of the time on weekdays, and for 30 per cent of the time at weekends. (See Figure 5)

Figure 5: Current rates of 12-hour consultant presence in emergency departments, by weekday/weekend

Myth five: Delays discharging patients from hospital are increasing because of problems with social care

Delays in discharging patients prevent beds being freed up for patients who need to be admitted to hospital, adding to pressures on emergency departments. It is often said that these delays are increasing as a result of problems in social care – for example, in arranging places in residential care or for services to be provided in people's homes. The statistics do not support this.
The number of delayed discharges had increased by about 3 per cent at the beginning of 2014/15 compared to 2013/14, but has remained relatively stable for a number of years. Closer analysis of the reasons for these delays suggests that the proportion of delayed discharges attributable to the NHS (caused, for example, by delays in accessing community or mental health services) has risen from around 63 per cent in 2010/11 to almost 80 per cent in 2014/15, while the proportion attributable to social care has fallen from 35 per cent to around 28 per cent of the total number of delayed days (see Figure 6).
This suggests that delays in arranging social care services are not a growing problem. However, anecdotal evidence indicates that delayed discharges are a significant concern for many NHS organisations, so it may be that the official statistics do not tell the full story.

Figure 6: Delayed transfers by responsible organisation, September 2010 – March 2014, delayed days


#41938 Umesh Prabhu
Medical Director 
Wrightington, Wigan and Leigh FT
I am very fortunate to have amazing AE staff and a fantastic CD. Got a brilliant CEO and the Board. But AE middle grade doctors shortage and Consultant shortage is killing us and our performance. When there is a shortage quality of doctors drops and cost increases. Neighbouring Trusts are trying to pouch our consultants with more pay!
It saddens me that many of Australian AE training posts are filled by UK graduates. It also saddens me that there are nearly 50% AE middle grades who are non-trainee posts. Traditionally these are filled by non-EU doctors from Indian and African countries. With the immigration changes these doctors have stopped coming to UK.
While we bust the myths let us also see what is the solution for acute shortage of AE doctors, why our trainees are happy to go to Australia but don't want to do their training in UK and let us learn lessons.
We owe it to our patients and also for our staff. If not quality will drop, cost will increase and both patients and staff will suffer.
#41939 Carol Morgan
Working with manufacturing company
Good afternoon
I am very sad and also somewhat resentful that doctors are going to Australia.
I am visiting my daughter in Melbourne very soon having been their for three and a half months in 2011.
I was surprised to discover how much must be spent on admin in the Australian system.As a patient with Medicare I had to either pay the total amount and then claim a large percentage back via a Medicare office or fill in many forms or or if they bulk billed then I had to pay the percentage required at the surgery.
One young Australian said he would not take his children to A@E in Melbourne as there would be too much blood??
WE do not hear of the problems in otherrcountries. I have a relation in Vancouver and she had to wait for three days on a trolley in a corridor as they did not have a bed to admit her.
I intend doing some research whilst I am in Australia to find out just exactly how it works.
I wish you all the very best.PS I was admitted to hospital as an emergency ,spent four days there and received surgery eight weeks later. Excellent all round
#41942 CR
In response to "myth 3", I remember reading this last year:
#41943 Russell B Hamilton
Experienced healthcare professional
This is an excellent paper. It is good to see a thoughtful and well set out analysis of reality addressing the myths that continue to be promoted by people who to be frank are either ill informed or manipulating the facts for political gain.
Much of what is described in this paper is common sense when looking at the impact of policy decisions, investment, geographical pressures, training and recruitment issues and inescapable demographic changes and pressures.
My experience of working in primary, acute and ambulance services at a senior level and at a more remote strategic level tells me that the vast majority of all staff go to work and do a great job with what they have and that there are a great many who are innovative and creative.
The simple fact is that this as your paper highlights a complex area with an incredible number of variables.
It is important to be realistic and honest about what is not only affordable but what is achievable taking into account all the available resources.
Well done again. Keep up the great work - busting the myths and highlighting the issues.
#41963 Will Denby
As a trainee about to embark on a career in the NHS, I am excited. In the coming years we have a fantastic opportunity to make the NHS even better than it already is as a fully-comprehensive health service, free at the point of delivery. We should be bold, and make the NHS as good as it can be, for everyone - it might look very different in years to come.
The 'front door' issues make the headlines, but there are untold triumphs and issues lurking beneath that do not get the political and press coverage.
We have an opportunity as clinicians to work with all stakeholders at trust and strategic level to address these issues, with the patient at the centre of the whole scenario - the QIPP savings will follow!
I too enjoy reading the Kings Fund's measured take, on what can be at times a visceral discussion about the future of the NHS, inevitably tarnished with whatever political hue one would wish - a nessecary evil in a system borne by politicians.
#41988 Keith Hider
Healthcare manager
"nearly 40 per cent of patients who attend A&E are discharged without requiring treatment." I continue to be astounded by this statistic and fail to understand the behaviour of people who have nothing wrong with them wasting their time sitting in a A&E waiting room. What does this statement actually mean - these people needed no treatment, no reassurance, nothing? Or does it mean they were discharged directly from A&E without the need for any follow-up treatment? Please explain.
#41990 James Thompson
Senior Research Analyst 
The King's Fund
Keith, thanks for the comment/question. This stat originates from the A&E Hospital Episode Statistics (HES) data and was part of the Health and Social care Information Centre (HSCIC) report: Focus on A&E.
We have taken the number used in the data sheet that accompanies the HSCIC report that says: 39% of patients were discharged with no follow-up required. So they could have consumed lots of activity before they were discharged, but with no further treatment required.
But the Focus on A&E report says that, for first A&E treatment, 34.4% of patients received guidance/advice only. So perhaps the true number of patients receiving no treatment is somewhere between the two.
I do think however that we need to be careful about how we class 'guidance only'. Though it is likely that this advice could be given in other healthcare settings, we shouldn't discount its value to patients who felt they needed to see a healthcare professional at short notice.
#42142 Diana Badcock
ED Director 
Australian Healthcare Group
UK citizens have reciprocal Medicare rights in Australia
We have private and public ED's however it is common for the more electronically advanced ED's to charge overseas visitors $400 for an attendance and the you would be eligible to get some of that back from Medicare and the rest from a private insurer ( if you have taken out that level of travel insurance before you travel). Those ED's not so well resourced would likely charge the Medicare rebate only. However Australain health care is based on user pays- we pay for scripts, always GP visits, unless you go you a bulk billing clinic. This is the way it works.
There is no NHS philosophy here for those who can pay and if you are fortunate enough to be able to afford to visit Oz -you pay.
If you have a life threatening illness all bets are off and any ED will ignore all of the above and care for you- even top private ED's would not chase the dollar - if you needed heart surgery after a heart attack they would get on with it and suck it up. This is not infrequent.
TAC - transport accident commission would cover all costs if you are injured on our roads
WC - work cover would cover all costs if you got injured at work
DvA - would cover all costs if ever you out your life on the line for fellow countryman
It's different to the UK but it's not a bad system.
Do not travel and expect fish and chips- unfair. We would grill the fish and have salad and you would feel healthier afterwards.
Enjoy Melbourne- my family have enjoyed my deflection to Oz 25 years ago and on their visits to Oz have needed to utilise the services occasionally and loved it -
Advice. IF YOU PICK UP A MEDICARE CARD FROM A MEDICARE OFFICE AS SOON AS YOU ARRIVE IN THE COUNTRY- to which you are entitled - IT IS LIKELY YOU WILL BE CHARGED NOTHING IF YOU ARE SICK ENOUGH TO NEED ED. You will need to pay a copayment at the GP as everyone does. Unless you go to a bulk billing clinic.
As to why the registrars are coming- look at the case mix and skill base they get here. The days of Oz coming to practice on the POHM's is over. POHm's come here because the training model for ACEM is different and the lifestyle and attitude is wonderful for anyone.
Don't moan that they come- find out what we offer and take it back to UK
#107732 Dr E Partington
It's not surprising that newly qualified A and E doctors go abroad- the working conditions here are dreadful. Rotas are very hard, long days , maybe 9 days in a row. It's difficult to choose your area to be near your family. Holidays have to booked a year in advance, with poor HR support. Colleagues tell me how despairing they become.....we have fantastic , enthusiastic graduates then we exhaust them; they deserve better.

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