A&Es under pressure: what the data can tell us

Two weeks ago, new data showed nearly 25 million attendances at A&E departments in England in 2018/19. This is the highest number on record, and a 4.1% increase on A&E attendances in 2017/18.

Performance against the target to treat patients within 4 hours of arrival in A&E also hit a new record in 2018/19, but this was a new low rather than a new high (the last 12 months being the worst performance against the 4-hour target since records began).

Beyond the headlines

Looking beneath the headline numbers reveals a more complex and nuanced picture of demand and performance.

‘A&E’ doesn’t mean the same everywhere. In England, there are three types of emergency department that provide different services and tend to deal with different patients.

• Type 1 departments are major A&Es with full resuscitation facilities and 24/7 consultant-led care, which handle the most serious and complex cases.
• Type 2 departments are the small number of single-speciality A&Es, which offer consultant-led emergency care based around a single specialty (eg eyes or teeth).
• Type 3 departments go by various names – minor injury units, urgent care centres, etc – all treating minor illness or injury and may be led by doctors or nurses.

More people accessing treatment for minor illnesses and injuries

The biggest driver of the growth in A&E attendances was the increase in attendances at type 3 A&Es, with 8.6 million people attending in 2018/19 – an increase of 8.7% from 2017/18. By comparison, attendances at major and single-specialty A&Es grew by just 2.0% and 0.7% respectively.

What has driven this 8.7% increase is not entirely clear. The rate of growth in attendances at type 3 A&Es was the highest since 2010/11, but nowhere near the double-digit growth seen in the mid-2000s. Demographic changes contribute to the long-term growth in A&E demand, but are unlikely to have caused such a dramatic leap in a single year. Possible contributors could include pressures elsewhere in the NHS, such as increasing problems getting convenient appointments at GP practices despite extended opening hours.

Equally, increased supply may also be creating its own demand. Diverting people to type 3 A&E departments, with the aim of relieving pressure on major A&Es, has been a national tactic since winter 2017. Patients can now book appointments at an increasing number of type 3 A&Es via NHS 111. Other measures, such as GPs streaming patients at the front door of every major A&E, may have had an impact too.

Despite the increased attendances at type 3 departments, waiting times have barely changed. 99.1% of people were treated within 4 hours in 2018/19.

What about people attending major A&Es?

The situation in major A&Es is very different. The number of attendances grew more slowly, but in 2018/19 performance was worse than in type 3 A&Es, with only 81.5% of people being treated within 4 hours.

This difference is undoubtedly due to the greater complexity of conditions for those people attending major A&E departments, as shown in our previous analysis of emergency admissions. In 2018/19, 73.6% of all emergency admissions to hospital were via a major A&E department, in comparison to just 0.9% of admissions through type 3 A&Es.

The percentage of people admitted to hospital after attending major A&Es is growing. In 2018/19, nearly one in three (29.9%) major attendances resulted in an admission, and this percentage has grown steadily over time. This is despite evidence that people being admitted now are generally sicker than those admitted a few years ago, with more investigation and treatment happening in A&E than before. This trend is set to continue, especially given the backing for same day emergency care in the NHS Long Term Plan.

In terms of A&E waiting time, the clock doesn’t stop until people are admitted, discharged or transferred. So longer waits in major A&Es – including more people waiting for a bed – are important warning signs of problems with inpatient capacity in hospitals and wider issues with community and social care.

Clinical review of NHS access standards: changes ahead?

Following the recent clinical review of NHS access standards, national reporting of the data telling us what happens in A&Es looks set to undergo major changes – including removal of the 4-hour target.

The wider pros and cons of the proposed changes are a whole other subject, but the increasingly divergent issues faced by the two main types of A&E is important context. Type 3 A&Es have experienced substantial growth in demand, but without a substantial impact on waiting times – so far, at least.

By contrast, major A&Es are experiencing growing difficulties from wider systemic pressures. The new metrics place more emphasis on clinical and operational processes within A&E departments, such as the waiting time to start treatment for some urgent conditions. These processes are important, but will focusing on what happens in A&E come at a cost of fewer measures of patient flow into and out of A&E that help illustrate the wider pressures on hospitals and local systems?

How well these more systemic pressures on major A&Es are highlighted will be an important test of the proposed new metrics. We NHS data lovers wait with bated breath.
 

Tim Gardner (@TimGardnerTHF) is a Senior Policy Fellow at the Health Foundation