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.