A&E horror stories have dominated the headlines in the UK in recent winters. Reports of A&E patients using temporary waiting areas set up in hospital car parks and store rooms, as well as people dying in the hands of paramedics, have fuelled a revolt by NHS chiefs and MPs. NHS Confederation boss Mike Farrar said that “A&E is on a cliff edge” and close to a “meltdown”. This all comes amidst a parliamentary Health Select Committee inquiry, an NHS England review and a demand from the Labour Shadow Health Secretary for urgent questions.
How can the failure in A&E be tackled?
Address front-end demand for A&E services
Secretary of State for Health, Jeremy Hunt, is pinning the blame for A&E failures on changes to the GP contract in 2004. He calls the decision to allow family doctors to opt out of responsibility for after-hours care “disastrous”. The Secretary of State hopes to engage service users so that their actual and perceived need for an A&E service reduces. PA believe there are three approaches to demand management that could be taken to address primary care:
Identify opportunities for early intervention and prevention. For people with long term conditions greater dialogue and time with their GP can be crucial. A tailored and planned care pathway for people with complex needs can mean costs and dependencies do not escalate, and an A&E admission is avoided.
Change expectations so that service users no longer expect the same response from visiting A&E. The public perception of A&E is that they will receive fast, reliable treatment. However what they receive in reality is a short term reaction to pressing symptoms. The public needs to understand that A&E exists to contain emergency situations, not necessarily to resolve them. Therefore, the NHS could remove free prescriptions to A&E patients that last longer than five days, re-direct service users to other sources of care and avoid unnecessary investigations which could be performed as an outpatient or via a GP.
Implement an alternative urgent care option. Although most GP surgeries offer emergency appointments, these are very limited. Commissioners should be mindful of the high costs of a visit to A&E and make greater efforts to take on urgent care. In a distressing situation patients should be able to request, at the very least, a telephone consultation with a health practitioner in their GP surgery who can give immediate advice and arrange longer term care.
Ensure the A&E system has sufficient capacity and capability
The debate on A&E attendances should also be one on the issue of capacity. The College of Emergency Medicine released a report that finds “unmanageable workloads and a lack of middle-grade doctors and emergency medicine consultants” is creating the biggest challenge for the A&E system in more than a decade. Meanwhile clinicians are reporting an increase in acute care length of stay Dr Patrick Cadigan, Royal College of Physicians. The result of this is a backlog of cases and a blockage in the system. Health commissioners and providers need to better understand “process flow” of service users. Jeremy Hunt must also take into account the following demand management approaches to acute care:
Re-direct service provision to most appropriate provider
An example of this approach would be to convert a proportion of community care beds to nursing beds, to be staffed by trained clinicians who can offer continued clinical support locally, rather than in the hospital. This will allow vulnerable, elderly people to leave hospital sooner.
Smoother discharge to other hospital wards to free up acute care beds
Waiting times are rising above four hours, in part because of a management failure to coordinate discharges of people taking up acute care beds with the pattern of A&E arrivals. Discharge lounges, where patients are sent to receive medication or go through a care plan with a social worker, can offer a more efficient and planned route from hospital to home and free up beds earlier in the day2.
Personalisation of A&E services
Providing individuals and their families with more choice and involvement in developing care once they have entered the acute setting. This can be as simple as asking families ‘what would help you?’ and giving them choice of where to receive their care.
While Jeremy Hunt is focusing on primary care to reduce demand, it is not the only solution to the current failure in A&E. The demand management approaches outlined above will help balance the flow of service users both in and out of hospital. However, the Health Secretary may need to be bolder in reorganising the emergency services system. In certain geographical areas there is clear evidence that we have too many A&E departments - in these cases the closure of A&E departments or the transfer to Urgent Care Centres needs to happen to help patients to find the best care setting. This will ensure that those emergency departments/trauma services have sufficient workers to provide a good quality health service and,vitally, safe care: an objective that must be at the forefront of the Secretary of State’s mind.
To find out how PA is helping health organisations address A&E demands, please contact us now.
1Appleby, ‘Are accident and emergency attendances increasing?’, King’s Fund, 29 April 2013,
2Peter Samuel Hall, ‘Discharge Process Focus Group’, Royal Free Hospital, 17 May 2011, available here.