Press Release - Department of Health: Improving Emergency Care
in England
13 October 2004
NHS trusts have achieved a large and sustained reduction in the
length of time patients spend in accident and emergency (A&E)
departments, largely through improved working practices. This
reduction has followed a strongly increased focus, since 2002, by
the Department of Health on trusts ensuring that patients spend no
more than four hours in A&E. The environment and facilities in
A&E have also improved, to the benefit of both patients and
staff.
Today's report to Parliament by head of the National Audit
Office Sir John Bourn points out that there is still further room
for improvement in the case of patients with more complex needs
(who may include older people and those with mental health needs)
given that they are more likely than others to stay more than four
hours in A&E. For example, in August nearly a quarter of
patients needing admission to hospital spent more than
four hours in A&E. Time spent by all groups of patients,
though, has reduced in the last two years
Variation in performance between trusts has reduced. But while
some trusts are treating virtually all their A&E patients
within four hours, the worst performing trusts still have some way
to go to reach the level of the best. And maintaining the
improvements long-term will depend on addressing the remaining
bottlenecks and barriers to modernisation, many of which are often
outside the control of A&E.
In 2000, the Department of Health, in response to patients views
that reducing A&E waits was a priority, set a target that, by
December 2004, no patients would spend more than four hours in
A&E. In 2002-03, 23 per cent of A&E patients spent more
than four hours there. By April- June 2004, only just over 5 per
cent of patients spent longer than four hours. This comes against a
background of continuing high levels of demand.
The reduction in the amount of time that patients spend in
A&E has largely come through improvements in working practices
within hospitals and in particular the A&E departments.
Improvements include the introduction of See and Treat (under which
the first practitioner who sees a patient with a minor injury or
illness is given the power to assess, treat and discharge that
patient safely without the need to refer to other clinicians), the
development of new roles such as the Emergency Care Practitioner
and measures to speed access to other services (e.g. diagnostics).
Some changes have been relatively low-cost but there has also been
extra funding in A&E, both centrally and locally.
Many of the bottlenecks the Department has identified as still
contributing to delays are outside the control of the A&E
department and result from constraints in the health and social
care system as a whole. These include the following: avoidable
peaks and troughs in the availability of beds on wards caused by
mismatches between admissions and discharges; barriers to obtaining
a specialist opinion, caused by conflicts with specialists
non-emergency work; and difficulties in obtaining authority to
admit patients to wards. Further reductions in time spent in
A&E will depend on better working between A&E, the rest of
the hospital and other parts of the health and social care system;
and the Department is already providing a programme of guidance and
support to trusts to help them address these issues.
According to the NAO report, more than half of trusts who
responded in April had shortfalls in the numbers of emergency care
medical staff needed to provide a robust and responsive service 24
hours a day, seven days a week. And in some cases the design of
A&E buildings can also be an obstacle. Many are not flexible
enough to fit well with modernised working practices and to promote
a more efficient, patient-orientated environment.
The report points out that A&E departments are not the only
source of emergency care, nor the only option for all patients,
though patients continue to expect their emergency care needs to be
met by A&E departments. There are good examples of all the
emergency care services (not only A&E but also ambulance
trusts, NHS Direct and minor injury services) working more
effectively as one system. The Department in 2001 envisaged that
all these services would be linked through a single point of access
but full integration across England is not expected until December
2006. The revised arrangements for commissioning NHS Direct
services locally, as well as the changes in GP out-of-hours
services, provide an opportunity for primary care trusts to
integrate emergency care services better.
The NAO identifies local emergency care networks
(cross-organisational, multi-disciplinary groups) as a promising
development. Many such networks are in their infancy and lack the
authority and influence over funding to bring about cooperation
between the various providers of emergency care.
Today's report makes made 16 recommendations of which some key
ones are listed below.
- Many patients require much less than four hours in A&E. All
providers should monitor processes and performance and making use
of local benchmarking to ensure no patient spends longer than
clinically necessary in A&E.
- All acute trusts should use simple bed management tools to
identify avoidable peaks and troughs in inpatient flow.
- the emergency care networks should analyse the patient pathways
of vulnerable patients, including frail older people, children and
those with mental health who attend A&E to identify
improvements to their journey through the emergency care
system.
- A set of good practice care pathways for emergency medicine
should be developed to measure and improve quality of care.
Sir John Bourn said today:
"I welcome the fact that patients in accident and
emergency departments are experiencing fewer delays. This is
against a background of a continuing high demand for A&E
services. There is scope, however, in those trusts which are behind
the best for further reductions in the time patients spend in
A&E.
“The Department of Health should continue to pursue more
effective joint working: on the one hand, between A&E
departments and other parts of their hospitals; and, on the other,
between all the providers of emergency care. Emergency care
networks are a promising way of taking this forward.”
Notes for Editors:
- The Department’s target requires all A&E providers to
ensure that at least 98 per cent of patients are spend less than
four hours in A&E from arrival to either discharge, transfer to
another provider or admission to a bed, by the end of December
2004.
- Full data collected by the Department on providers’ performance
against the target is available at:
http://www.performance.doh.gov.uk/hospitalactivity/data_requests/index.htm
- A&E departments are defined as follows: Type 1
A&E department - A consultant led 24 hour service with
full resuscitation facilities and designated accommodation for the
reception of accident and emergency patients; Type 2
A&E department - A consultant led single specialty
accident and emergency service (e.g. ophthalmology, dental) with
designated accommodation for the reception of patients;
Type 3 A&E department - May be doctor led or
nurse led with designated accommodation for the reception of
accident and emergency patients. A defining characteristic of a
service qualifying as a type 3 department is that it treats at
least minor injuries and illnesses (sprains for example) and can be
routinely accessed without appointment. Type 3 services include all
NHS Walk in Centres and other open access treatment services
offering at least minor injury/illness services, whether located
alongside a main A&E department or at another location. A
service mainly or entirely appointment based (for example a GP
practice or outpatient clinic) is not a Type 3 A&E service even
though it may treat a number of patients with minor illness or
injury.
- Press notices and reports are available from the date of
publication on the NAO website at http://www.nao.gov.uk/. Hard
copies can be obtained from The Stationery Office on 0845 702
3474.
- The Comptroller and Auditor General, Sir John Bourn, is the
head of the National Audit Office which employs some 800 staff. He
and the NAO are totally independent of Government. He certifies the
accounts of all Government departments and a wide range of other
public sector bodies; and he has statutory authority to report to
Parliament on the economy, efficiency and effectiveness with which
departments and other bodies have used their resources.
Press Notice 57/04
All enquiries to Barry Lester, NAO Press Office:
Tel: 020 7798 7937
Mobile: 07748 181692