How can A&E units improve their performance?

The first point that I must make is that I do not wish to appear unappreciative or condescending. Hospital A&E work is amongst the most important that any person can undertake and many of us would find the strain unbearable. I have nothing but admiration for the doctors and nurses who work unsocial, long shifts, take life and death decisions and have to put up with stressed patients and carers as well as people who should not really be in A&E at all.

I have never worked in A&E or for the NHS and am not medically qualified. My interest derives from having been an investment analyst specialising in healthcare for thirty years and more latterly from my role as an elected Councillor. Opinions in this blog are entirely my own and are intended to stimulate constructive debate and study, not to offer final solutions. I certainly would not to be so arrogant as to think that I know better than medical professionals working at the coal face. Where I am wrong I hope readers will tell me by posting a comment on this blog or tweeting @barbararesearch .

International data on the performance of A&E is difficult to compare because the systems, categories and data collected vary considerably around the world. The UK does, however, rate relatively highly. All counties are experiencing financial pressure over healthcare spending. Life expectancy is rising more rapidly than the typical retirement age. As a result the proportion of elderly people in the population is rising, leading to healthcare costs growing in relation to the economy. Medical advances intensify the pressure since improved healthcare is usually more expensive than what went before and is also an important driving force behind increased longevity.

The financial pressures on A&E departments reflect partly the demographic trends behind healthcare, partly the need to fund medical advances along with R&D and partly the limited alternatives especially out of hours. Pressures on the NHS outside A&E are also a factor and largely result from the same underlying trends.

Improving the performance of A&E units is certainly a major challenge. The issues are complex. Many ideas about the deficiencies of A&E departments are either mistaken or overly simplistic. For example, conventional wisdom is that money would be saved if more people who attend A&E without urgent medical needs went to their GP instead. This belief is based on figures suggesting that an A&E assessment costs around £110, roughly three times higher than the GP equivalent. However, common sense suggests that this analysis is wrong. Why should it cost more for a junior hospital doctor to give an opinion in an A&E unit than for a more highly paid GP to do so instead? The likely explanation is that on average cases in A&E really are more complicated and more urgent, pushing up average costs. Patients who should not really have come to A&E ought not to need to see anyone more senior than a junior hospital doctor.

Another suggestion that does not fully fit the facts is that the main cause of pressure on A&E departments is growing difficulty in seeing a GP at short notice or out of hours. The time for which patients have to wait before an available appointment with a GP has recently been moving roughly in line with the normal seasonal pattern. A&E on the other hand has recently seen demand grow by much more than normal. In addition, the hourly pattern of A&E attendance over the course of a day has not changed significantly. A change in hourly attendances in A&E would be expected if the problem was caused mainly by a reduction in the out-of-hours services of GPs.

Yet another myth is that NHS 111, the official NHS medical telephone helpline, is increasing the workload on A&E departments. In fact, only around 8% of calls handled by NHS 111 result in advice to attend A&E. Moreover, 30% of callers say that they would have gone to A&E if NHS 111 had not existed. The truth is that NHS 111 helps to divert patients from A&E rather than adding to those attending.

What can be done to help A&E?

1. Improve Management. Progress has been made over increased cooperation between hospital staff and teams. However, every A&E unit is different as illustrated by the fact that CQC criticisms of A&E vary considerably between hospitals. Meeting the main Government-imposed targets does not in itself mean that all is well. Every A&E unit would benefit from having one person in overall charge with wide ranging powers, just as a country usually has one prime minister (or equivalent) and a company normally has one chief executive. The person selected should have strong leadership qualities and knowledge of A&E. He or she may have other duties apart from managing A&E and might usually work normal office hours. The person chosen should simply be the best for the job and could be a doctor, professional manager or someone from another medical profession.
2. Eliminate bottle-necks. In my experience the longest wait in A&E is usually before seeing a doctor but after a nurse has obtained brief details. One extra junior doctor on duty at all times would have a significant effect on the performances of some A&E departments. Whilst A&E units vary considerably, on average they see about 270 patients per day. The total running costs of all A&E departments in England add up to around £2.6 bn per annum, which corresponds to the attendance of 21.7 m patients at a total of 218 providers. The average number of doctors employed by an A&E department is around 25, of whom about 10 are on duty at any one time. The 25 doctors would typically include about 5 consultants, although sometimes there may be none present at night or weekends. At least one consultant is always on call.The extra cost of having one more junior doctor on duty at all times in an A&E department would on average add about 1% to the department’s total A&E costs. An extra consultant at all times would increase costs by about 3%. With good management and appropriate recruitment the way forward for A&E departments would look much less problematical. The key hurdle is that recruitment is easier said than done.
3. Recruiting staff. Every A&E unit should carry out a detailed analysis of the movement of patients through the facility in order to determine the optimum staffing level for doctors of different levels of seniority and likewise for nurses. The analysis needs to take into account unexpected peaks in numbers of patients, the fact that patients do not arrive at regular intervals and the unexpected absence of staff (e.g. due to illness). The NHS could have a small central team available to help A&E units on request with their statistical analysis and to provide appropriate software. Any bottlenecks that do not relate to staff numbers should also be studied thoroughly. The biggest obstacle standing in the way of major improvements in A&E departments is not money but rather real difficulty in recruiting and retaining doctors. A&E has amongst the least attractive shift working arrangements, the highest workplace stress levels and the least opportunity for private practice. The NHS has tried various approaches aimed at attempting to overcome the A&E labour shortage. Steps have been taken to recruit foreign doctors. Many GPs in England have accepted positions in A&E units and this trend could be reinforced by allowing GPs to establish surgeries in hospitals close to A&E units and with shared facilities. The problems of some GPs in finding affordable accommodation for their practices could thereby be lessened. A new GP contract could allow the GP practices located in hospitals to take some of the load off A&E departments whilst allowing the GPs to continue their own unrelated practices. The difficulty in recruiting A&E doctors has resulted in total A&E expenditure on locum doctors reaching around £80m per annum in England. Locums cost much more than permanent staff. If the money spent on locums were used instead for permanent staff each A&E department could have both a permanent extra junior doctor and an extra consultant on duty at all times.The official Government target is for 95% of A&E attendees to be admitted to hospital, transferred or discharged within four hours of arrival. The worst A&E waiting times for England as a whole in recent years occurred in the week to 4th January 2015, when only 86.7% of attendees had a wait of less than four hours. This failure is not as bad as it might appear. In a typical A&E department seeing 270 patients per day the Government’s target would have been met even in this very bad week if just 22 more people had experienced a wait of under 4 hours. One extra junior doctor and one extra consultant on duty at all times would have been more than sufficient to enable the unit to achieve the Government target providing that the 22 patients did not arrive too closely together.

4. Size of A&E Departments. There are many powerful arguments for having fewer, larger A&E units and only one against doing so. The case against having fewer units is that on average it will take longer to get to the nearest. However, the time taken to get to hospital is less critical than seems intuitively right. There can be no denying that for some patients every minute counts and delays will be fatal. However, for most critically ill patients quality of care affects the outcome more than speed. Most very urgent treatment can be given in ambulances (e.g. stopping severe haemorrhages, resuscitation). Journey time to hospital is only one factor in determining how quickly treatment can begin. Other factors may include, for example, diagnostic tests, x-rays, getting the opinion of a suitable consultant, getting an operating theatre ready, getting necessary drugs from the hospital pharmacy, securing a hospital bed in an appropriate ward and obtaining a medical history (especially if the patient is unconscious or delirious). Valuable time to offset longer ambulance journeys could be saved partly by educating the Public about when to call for an ambulance. Undesirable delays in summoning an ambulance and requesting one unnecessarily should ideally both be addressed. Ways can be explored to help speed the journeys of patients not arriving by ambulance. For example, special 15-minute parking bays for use by drivers offloading patients could be made available near to A&E units.

The advantages of large A&E facilities are:

• More specialist teams will be possible within A&E or at the same hospital e.g. for strokes, heart attacks, trauma, asthma, diabetes.
• Peaks and troughs in patient attendance and staff availability will be more predictable.
• More flexibility will exist to direct medical attention where it is needed and to call on other hospital departments especially when understaffed.
• A greater range of equipment may be available.A&E closures should be avoided unless it can be clearly demonstrated that the overall effect is to improve medical services and help patients.

5. The Long-term future. The long-term pressures on A&E are inevitable, given the long-term demographic trends and medical advances. The problems are global. All we can do is to strive to become ever more efficient and to allocate adequate resources. Attracting more doctors and nurses into A&E without paying them more is not going to be easy but a review and consultation about improving working conditions could only help.