There is a perception that pressure on accident and emergency departments has grown to unprecedented levels. Recent events at Colchester University Hospital NHS Foundation Trust, where patients have been asked not to attend A&E except for serious and life-threatening conditions, have brought this issue into focus. Additionally, there are reports that all three major hospitals in Cambridgeshire were recently put on ‘black alert’, representing a hospital’s highest possible level of alert. Meanwhile, the government has released £700m in funds to alleviate a potential ‘winter crisis’ in the NHS. This post examines claims about increasing pressures on A&E in England as a whole in the light of published data.

Data for individual NHS providers going back to 2010 is available in our downloadable Excel tool.

PressuresBlog1

A&E departments in England are experiencing their busiest year on record in terms of attendance. This is recorded in the NHS England Weekly A&E Sitreps, which are the source for all data in this post. In the first 33 weeks of the current financial year (up to 16 November), the number of people attending major (type 1) A&E departments was 3.5% higher than the same period last year and 5.3% higher than three years ago. This three-year difference is equivalent to an average of over 2,000 more people going to major A&E departments every day, or an average of around 100 extra patients per week per NHS provider. As the following chart shows, this year has been consistently higher than previous years for almost the entire period since April.

Number of patients attending major A&E departments, 2010 to 2014
England, four-week moving average

Attendance

The number of emergency admissions is rising faster than the number of A&E attendances. Emergency admissions via major A&E departments have risen by 5.6% since last year and by 12.7% since 2011/12, with an average of almost 1,200 more emergency admissions every day in England. This is an average of around 60 more emergency admissions per week per NHS provider. Some departments are experiencing an even greater rise; for instance, the year-on-year increase in emergency admissions at Colchester’s A&E department is almost 15%. Several other providers have experienced increases of a similar proportion.

Number of emergency admissions via A&E departments, 2010 to 2014
England, Four-week moving average

Admissions

So not only are more people going to A&E, but a greater percentage of those attending are eventually admitted to hospital. Given that admitted cases tend to be more serious, the implication is that a greater proportion of A&E patients are presenting with more serious injuries and conditions. Despite this, however, a recent QualityWatch report on A&E did not find evidence that the cases being seen in A&E were becoming more complex.

There is considerable regional variation in these increases. Numbers attending major A&E departments have risen by around 7% in both Bristol, Somerset & South Gloucestershire and Cumbria, Northumberland & Tyne and Wear NHS area teams in Apr-Nov 2014 compared with 2013. In Greater Manchester, Cheshire Warrington & Wirral and London, on the other hand, the increase was below 1% – and major attendances have fallen by 1% in Leicestershire and Lincolnshire. Emergency admissions show even more variation: they have risen by 19% in Essex and 13% in Cumbria, Northumberland & Tyne and Wear, but by less than 3% in seven of the 25 area teams.

Long waits in A&E departments have risen at a higher rate than attendances or admissions. The percentage of patients spending over 4 hours in major A&E departments has risen to around 10%. In recent weeks, a number of providers have seen over a quarter of their patients waiting for four hours or more. Meanwhile, around 7% of emergency admissions involve a wait of over 4 hours between the decision to admit and the eventual admission to hospital. The increase in 4-hour stays in A&E is likely to be related to the increase in admissions, because data shows that patients admitted to hospital typically wait much longer in A&E than patients who are discharged.

Percentage of patients spending over 4 hours in major A&E departments, 2010 to 2014
England, four-week moving average

4hrwaits

Percentage of admitted patients waiting over 4 hours between decision to admit and admission, 2010 to 2014
England, four-week moving average

Admissionwaits

There are other measures of waiting times in A&E, such as median time waited for treatment and median total time in A&E, which are not included in the weekly A&E data releases. A full description of these measures, along with an analysis of the trends can be found in our standard note Accident and Emergency Care in the UK.

The National Audit Office published a report on emergency admissions last year, exploring how well emergency admissions are managed and how they can be reduced. Some of their findings include:

  • Almost all of the increase in emergency admissions over the past 15 years was accounted for by patients who go on to have very short stays in hospital.
  • A&E sometimes is seen as a ‘default’ route for urgent care. The NHS has attempted to address through campaigns such as ‘Think ABC before A&E’, which urge people to explore alternative routes of care before presenting at accident & emergency departments.
  • The four-hour waiting time standard provides an incentive for hospitals not to keep a patient in A&E for observation, but instead to admit the patient to hospital in order to avoid a breach of the four-hour target – potentially leading to short stays in hospital.
  • At times of increased pressure there is evidence of an increased tendency to admit patients to hospital from A&E.
  • There is limited evidence on what works in reducing avoidable emergency admissions.
  • The lack of seven-day working in community and social services compromises efforts to avoid out-of-hours hospital admissions.

Given the trends shown above, there is understandable concern about what the coming winter holds for A&E departments. We are only at the beginning of what is traditionally the period of the year with the greatest A&E pressures. Those interested may wish to monitor the NHS’s Winter Pressure Situation Reports. These were due to be released from mid-November onwards but have been postponed to mid-December. In the past they have recorded daily data on A&E closures and diverts, trolley waits over 12 hours, cancelled operations, ambulances queuing, and a range of other measures – but it is not yet clear what form this winter’s data releases will take.

Two previous Commons Library blog posts also discuss Winter Pressures:

Carl Baker

Raw Data:

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