The A&E crisis in the NHS this year seems significantly different to the “normal” winter crisis that happens each year from changes in seasonal demand. Given that the problem – waiting times, ambulance queueing, cancellation of routine operations – is happening in hospitals, you might think it represents something that hospital managers could and should solve. This is difficult, if not impossible.
I often hear the argument that an ageing population and the pattern of demand for A&E services is something that managers should anticipate and manage. This may be true, since the first is a well-established demographic change and the second a well-established seasonal phenomenon.
But hospitals aren’t like retailers, who in the face of seasonal demand, have a group of “employees” on zero hours contracts who work when demand requires such as during the busy Christmas period. Wriggle room for employing labour in the NHS comes through deployment of agency staff, but budget constraints can prevent this. Plus, agency staff may take time to adjust to the pressures of A&E and particular ways of working in individual hospitals, thus exacerbating problems of patient flow.
In any case, the labour shortage that contributes to slow processing of patients through A&E is that of medical consultants and these can’t be brought in on an agency basis because there is a national shortage of such staff. Given the pressures of working in such an environment it’s no surprise that there is a national shortage.
I also hear the argument that patients and carers end up at A&E because of lack of access or confidence in other parts of the system – often that they can’t get an appointment with their GP so turn to A&E. However, figures suggest that most A&E attendances occur during working hours, so a lack of out-of-hours GP services does not seem to explain this. And if a patient’s condition is an emergency, GPs are likely to fit that patient into their appointment schedule at short notice.
NHS 111 refers 50% more callers to A&E at weekends compared to rest of week. This suggests there may be an access to GP problem, in contrast to our suggestion above about most A&E admissions being working hours, which suggests GP access may be less to blame than assumed. There is a need for deeper interrogation of figures, which seem at odds with each other.
The two Ps
The problem the A&E crisis comes down to is two-fold. The first is policy. The second is public. Taking the first of these, the “front door” problem in A&E departments is symptomatic of a “back door” problem relating to discharge. Older people in particular require complex care packages to support their safe discharge, essentially a social or community care intervention. However, the current government has hollowed out social and community care by slashing local authority budgets. So it is rather disingenuous to then claim that it is up to local authorities to maintain existing services in this area.
Of course adult social care is going to be affected in the face of significant budget reduction. Given this, hospital managers and clinicians may lack confidence in the prospect of a safe discharge. Perhaps the straw that has broken the camel’s back of a system that has been working at full stretch for the last 12 months is the increase in delayed discharge of patients.
Figures show that these delays increased by 15% over the last year, much of it in the last six months. If you can’t get patients out the back door, then those entering A&E and requiring beds, are accommodated temporarily, sometimes in corridors on trolleys. And queues can then sometimes build up in ambulances (a very expensive way to accommodate them).
The solution to the policy problem is to enhance the community and social care budget. Assuming tax increases are unpalatable for the public and politicians, then health and social care budgets require some redistribution to support this. NHS chief executive Simon Stevens has proposed a redistribution of the health and social care budget out of hospitals. Similarly, shadow health secretary Andy Burnham’s suggestion of a joint health and social care budget (who also has made calls for an A&E crisis summit) makes sense.
But much of the cost is tied up in specialist hospital labour, beds, buildings, the budget for which could not be easily redistributed towards community and social care, or the expert labour force re-trained to carry out this type of care. Redistribution of budget, at best, represents a medium-term solution.
The second “p” relates to misuse of A&E departments and other emergency services. This might sound a trite sound bite – “if we abuse it, we lose it” – but it does capture how many members of the public go to A&E as the default option without considering any alternatives, including managing the care of what is often a minor problem. This is in part what NHS 111 was supposed to tackle. Even if we provide the public with better access to health information via the internet, this doesn’t appear to have driven more wisdom in many cases. It is not clear why this is so, and further research into decision-making from patients and carers around potential A&E attendances is necessary.
The role of A&E departments is evident from its name. It might be that there is a confusing array of possible routes for the would-be patient to follow, so there is needs to be more public education on this, including enhancing their understanding of what part of the system does what. This, for me, represents what might be immediately done to address the A&E crisis: an education programme aimed at potential users.
However, the medium-term issue of shifting the balance of resource from hospitals, including A&E departments, to community and social care remains, so the back door problem doesn’t become a front door problem leading to front-page headlines.
To read more in our A&E crisis series: Jonathan Shapiro on whether we all take a free NHS for granted; Anthea Wilson on how monitoring our own conditions could transform NHS care; Ron Glatter on why nothing will be fixed until politicians lose their taste for permanent revolution; and Terry Young on how the NHS could use computer modelling to solve complex problems.