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A&E delays: Why did patients wait longer last winter?

As Monitor’s senior clinicians, we welcome this thorough report on what made it so hard for England’s hospital trusts to meet the four-hour emergency care standard last winter. The report’s main finding is that trusts’ performance against this important standard fell sharply in the third quarter of 2014/15 because hospitals were too full. Most clinicians knew this already. But what the rigorous number crunching in this report also demonstrates to NHS policy-makers is that accident and emergency (A&E) departments themselves rose to the challenge and coped well with the 6% average rise in A&E attendances last winter.
Departments generally secured the staff and capacity to deal with the greater numbers of attendances and staff worked harder. Levels of sickness among patients appeared to remain relatively stable, and the proportion of patients admitted from A&E to the hospital bedbase remained stable too. The real bottleneck occurred when it came to finding beds for patients being admitted from A&E. Inpatient wards lacked capacity and became blocked up. This had a significant impact on the exit flow from A&E departments themselves, which in turn had an adverse impact on the ability of staff in A&E to care for their patients.

The effect of the bottleneck between emergency departments and inpatient wards on performance against the four-hour standard shows how this standard is actually a quite sophisticated measure of complex interactions within the whole of a local health and care system. What the measure tells us about whole health care systems has never been more important. Staff in all areas on the frontline worked hard to maintain safe effective care last winter but many patients who needed to be admitted to hospital still had to wait for a bed, undoubtedly affecting their experience adversely at times.

The report’s findings suggest that among the best ways to make sure patients receive emergency treatment in a timely fashion this coming winter is to concentrate on smoothing the flow of patients through inpatient wards, to the point of discharge and beyond. That also makes capacity in social and community care important, as the report highlights, and this is beyond the control of hospital trusts. But there are many ways to free up acute capacity that hospital managers can consider, from schemes to provide care to patients closer to home and more standardised management of non-complex elective patients, to smaller-scale but continuous operational improvements across the board.

Any policies and solutions must not, of course, neglect A&E services themselves, which in some areas remain acutely challenged and fragile. Monitor is working closely with our partners to develop a support programme for the most challenged services. The report shows others too will need more help to continue to cope with any increases in attendance.

The key will be to make sure every link in the complex, dynamic matrix measured by the four-hour emergency care standard is as strong as possible. This will lead to safer, more efficient care and, equally important, improved patient experience. We have no doubt there is still much to do but this report and its findings are a valuable contribution that merit attention and action.

While this report has concentrated on the causes of poor four- hour system performance last winter, the next stage is to focus on solutions that can be maintained into the longer term. Monitor and the Nuffield Trust, among others, will shortly publish more on options for improving patient flows.