News / News analysis: Situation: urgent?

The language used around the NHS is often infused with polemic, but rarely is it apocalyptic.

Yet in the past few weeks, the service in England has been told that it must act quickly to avoid ‘disaster’ in A&E; that there is a ‘crisis’ in emergency medicine staff numbers; and that the whole service is in ‘meltdown’. One million more visits were made to A&E over the last year, health secretary Jeremy Hunt confirmed, and he highlighted that more staff and greater co-ordination between different parts of the system were needed.

For several months there have been rumblings about increased pressure on A&E, even accounting for the traditional spike in activity over the winter months (indeed, managers across the UK spoke of ‘still being in winter mode’ in May). This appeared to be confirmed by the Health and Social Care Information Centre (HSCIC), which said there were an additional one million A&E attendances in the period February 2012 to January 2013 compared with the same period 12 months earlier. This represented a 6% increase in A&E activity.

The media and the various interest groups within the NHS seized on the figures. But the HSCIC data may not be telling the definitive story. Other data collections show a rise, but one that is not as steep.

According to the weekly A&E situation reports– or sit reps – published by NHS England (previously by the Department of Health), there were 21.8 million A&E attendances in the 2012 calendar year.

The HSCIC reported that there were 18.3 million attendances, though the measurement period was slightly different (February 2012 to January 2013). The difference can be explained to some extent by different methods of collection – HSCIC data is based on hospital episode statistics; the sit reps are weekly aggregated data based on counts made in local NHS organisations.

While the HSCIC figures point to an increase of one million attendances, the sit reps suggest growth was half that – a rise of about 2.3%. In a further twist, in a footnote to its data the HSCIC admits the sit reps information should be used in preference to its data. A spokesman told Healthcare Finance that its data was not as reliable as the situation reports.

‘Our figures are not based on as good sources as the sit reps,’ he added.

So what’s going on? It is clear that A&Es across the country are under greater pressure. The Department normally likes to downplay figures like these, but this time it was at least acquiescent that they were true. Perhaps in the lead-up to June’s spending review announcement, the health secretary decided to use the situation to put pressure on the Treasury. His initial response – where he blamed the removal of GPs’ out-of-hours responsibility in the contract agreed under the Blair government – scored political points, certainly, but the Department also wants to renegotiate that contract. This looks like a clear attempt to swing public opinion behind government plans to return out-of-hours responsibility to GPs.

The increase in A&E activity may feel worse due to the combination of factors including GP out-of-hours cover, problems with the new NHS 111 service and funding reductions in social care.

Staffing is also an issue. The College of Emergency Medicine said 50% of vacancies for senior emergency medicine trainees have been unfilled for three successive years.

There has also been an increase in hospital admissions from patients attending A&E. The HSCIC noted 3.8 million admissions from A&E, a growth of 4.6%, while NHS England reported a similar figure for 2012/13, but due to a higher baseline growth in admissions was 3% – an additional 118,000 patients. Anecdotally, lengths of stay are reported to be longer.

Patient confusion

Foundation Trust Network chief executive Chris Hopson claimed the problem has its roots in the wider NHS. ‘Patients can’t get the GP appointments they need, many doctors’ out-of-hours services aren’t working in the way they should and patients simply don’t know where they should be going to get the right emergency care. So up to 30% of people in A&E shouldn’t even be there in the first place.’

Mr Hopson added that the pressure on hospitals was not purely down to numbers. ‘The number of people attending A&E is rising in many places and even where the increases are small, the number of frail elderly patients with complex conditions is increasing, so more patients are being admitted,’ he said. ‘Hospitals are already running close to capacity in winter, which means small changes in the number of patients needing to be admitted creates major problems.’

NHS Confederation chief executive Mike Farrar said there was ‘a perfect storm’ of mounting pressures, compounded by three years of major structural reforms, a ‘lack of honesty about the situation we face’ and not responding quickly enough to financial pressures. ‘In the past 10 years, emergency admissions through A&E have increased by 51%. That's an extra 1.25 million more patients going into hospital on an unplanned basis,’ he said.

‘If we continue with this trend, we will see another half a million patients cramming into our A&E departments in the next three years,’ said Mr Farrar. This will be simply impossible for our hospital services to cope with, despite the heroic efforts of staff to date.’

NHS England’s response was to require each health community to put together a recovery and improvement plan and the creation of urgent care boards (where they do not already exist). These will oversee service effectiveness and marshal the 70% funding retained from the marginal emergency care tariff. Spending of these funds should be for specific purposes, including relieving the pressure on A&E, it said.

Clinical commissioning group leaders, provider chief executives, NHS England area directors and local authority chief executives must sign off plans for the use of this money by the end of June. This will ensure services are in place for the winter.

It continued: ‘Commissioners should also ensure that the financial flows and contracts for services support patients moving through the system, and do not create disincentives and gaming.’

The way A&E departments are paid currently was adding to the pressure, according to the FTN. It said some hospitals were losing more than £5m a year, on top of the 5% efficiency savings they are required to make, because of the marginal rate on emergency admissions. And it added that two thirds of hospitals were admitting more patients through A&E than five years ago (the threshold for the marginal rate, above which payments are made at 30% of tariff).

Mr Hopson said NHS England’s action plan was a start, but further action was needed, including identifying the funding in each local area that will be used to support A&E over the winter and abandoning the marginal rate. Earlier in May, Monitor and NHS England launched a review of the marginal tariff. The emerging principles from Sir Bruce Keogh’s review of the structure of emergency care are due soon.

NHS Trust Development Authority chief executive David Flory said there were a number of different reasons causing the pressures on A&E. While he acknowledged 'the time was right' for a review of emergency care payments, he said the problems in A&E suggested that the NHS had more work to do around integration across both organisational and sector boundaries.

A&E attendances appear to be stabilising, but numbers do not tell the whole story – comorbidities, age, staffing levels and time of attendance are all factors that could increase pressure. It is a complex problem and there will be no simple answer.