This topic refers to concerns over the volume of people visiting Accident & Emergency (A&E)/ Emergency Departments (EDs) and the subsequent waiting times people then experience as a result of the demand this creates.
Over the years newspaper headlines have drawn attention to A&Es struggling to cope with demand, particularly during ‘winter spikes’, and those failing to meet wait time targets for patients. Concerns about the demands on NHS services have been amplified as a result of the COVID-19 pandemic and the associated pressures facing the NHS.
The following are government policy and guidance, addressing the demands on NHS emergency care services, across the four nations of the UK:
Although this is now outdated, it highlights the challenges facing A&E departments and some key methods used to tackle these, which continue to influence practice.
- There are 22 million visits to A&E each year.
- ‘In many places, A&E is running at full stretch’.
- ‘The NHS responds to more than 100 million urgent calls or visits every year’.
Aims to tackle these:
- ‘Urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services’.
- ‘Helping patients get the right care, at the right time, in the right place’, achieved by: ‘evening and weekend access to GPs’; community nurses ‘equipped to provide a much greater range of tests and treatments’; ‘ambulance services empowered to make more decisions, treating patients and making referrals in a more flexible way; and far greater use of pharmacists’.
- ‘New ways of measuring the quality of urgent and emergency services [and] new funding arrangements’.
This focused on the progress that had been made by 2017 and outlined what further actions were needed. Again, although this is examining the NHS in 2017, it is useful to understand what recent, key changes have been actioned as a result of the ‘Five Year Forward View’, including the following:
- ‘Boosted the capacity and capability of NHS 111, which now takes 15 million calls each year [in 2017], up from 7.5 million three years ago’.
- ‘Expanded “Hear and Treat” and “See and Treat” ambulance services’ to 3.5 million people, saving needless trips to hospital.
- ‘Developed an integrated urgent care model, offering a single point of entry for urgent care via NHS 111, and rolled it out to 20% of the population’.
As well as setting out the aims for the NHS for the next ten years, the NHS Long Term Plan also reflects on what the NHS has achieved in the two years since the ‘Next Steps on the Forward View’ in relation to urgent and emergency care, including the following:
- ‘Rolled out evening and weekend GP appointments nationally, ahead of schedule’.
- ‘Reduced the number of people delayed in hospital – reducing the length of stay of patients who remain in hospital for more than 21 days, and freeing up nearly 2,000 beds’.
- ‘Continued rapid growth in the number of whole time equivalent A&E consultants, which are up by 30% over the past five years – the fastest growth of any consultant speciality in the NHS’.
‘Over the period of this Long Term Plan, by expanding and reforming urgent and emergency care services the practical goal is to ensure patients get the care they need fast, relieve pressure on A&E departments, and better offset winter demand spikes’.
Areas that are being targeted to achieve this include:
- ‘Pre-hospital urgent care’ – ‘integrated NHS 111, ambulance dispatch and GP out of hours services from 2019/20’; ‘Urgent Treatment Centre model by autumn 2020’; changes to ambulance services.
- ‘Reforms to hospital emergency care – Same Day Emergency Care’. ‘Every acute hospital with a type 1 A&E department will move to a comprehensive model of Same Day Emergency Care. This will increase the proportion of acute admissions discharged on the day of attendance from a fifth to a third’.
- ‘Cutting delays in patients being able to go home’ – ‘The NHS and social care will continue to improve performance at getting people home without unnecessary delay when they are ready to leave hospital’.
This provides figures on the annual attendance at A&E departments (23.372m) in 2016/17 in comparison to a decade earlier.
It also provides information on the ‘proportion of patients seen within 4 hours at A&E departments in 2016/17’.
It highlights specifically the issues faced by urgent and emergency care services over winter 2018/19.
It outlines schemes that were used to target unnecessary hospital admissions, meaning that ‘more emergency admissions were prevented, particularly for older people’, including:
- ‘Extending access to GP services into evenings and weekends’.
- ‘Enhancing support to care home patients’ .
- ‘Rolling out falls prevention awareness training; and providing lifting equipment to almost every care home in Wales’.
- It focuses on ‘activity, supply and flow’, outlining the demands on urgent and emergency care services and how the NHS coped with these.
- It examines the ‘winter planning and delivery model’ and the impact these plans had.
- It outlines seven key areas of focus for winter 2019/20.
This is particularly relevant as it relates specifically to winter 2020/21 and the targets for urgent and emergency care during the pandemic.
It outlines the ‘goals’, ‘outcomes’ and ‘proposed key deliverables 2020/21’.
The six goals include:
- ‘Co-ordination, planning and support for high risk groups’ – to prevent the need for urgent care.
- ‘Signposting, information and assistance for all’ – to ensure people seek urgent support or treatment from the ‘right place, first time’.
- ‘Preventing admission of high risk groups’ – including community alternatives.
- ‘Rapid response in crisis’ – ‘the fastest and best response at times of crisis’.
- ‘Great hospital care’.
- ‘Home first when ready’ – ‘a home from hospital when ready approach, with proactive support to reduce chance of readmission’.
It highlights that ‘attendances at Accident and Emergency Departments (A&E) have increased over the past three years’, which is partly ‘due to a lack of understanding of what services are available’ meaning ‘approximately 20% of patients who self-present at A&E could be helped to access more appropriate services for their needs’.
It outlines the new service – The Redesign of Urgent Care – aimed to ‘support the public to access the Right Care in the Right Place at the Right Time’. The redesign includes:
- NHS 24 – 111 as the first point of access for urgent care needs. They will advise ‘what care is required and where is the best place to access this’.
- Flow Navigation Centres (hubs) for each local health board which will ‘directly receive clinical referrals from NHS 24’. ‘They will offer rapid access to a senior clinical decision maker within the multidisciplinary team, optimising digital health through a telephone or video consultation where possible, minimising the need to attend A&E’. Where A&E attendance is needed an appointment may be offered to reduce waiting times for patients.
- It states that: ‘Whilst this immediate service redesign is required to keep people and our NHS safe during winter, this is just the beginning and we will continue to look at the long term redesign of urgent and unscheduled care over the next two years to ensure patients continue to receive the right care, at the right place, by the right healthcare professional’.
This guidance aims to ‘eliminate crowding in emergency departments (EDs) in Scotland’.
It details the challenges facing emergency departments, different types of ‘crowding’ and the issues surrounding these.
It outlines ‘The 6 Essential Actions to Improving Unscheduled Care’, as follows:
- ‘Clinically focused and empowered management.
- ‘Capacity and patient flow’.
- ‘Managing the patient journey rather than bed management’.
- ‘Medical and surgical processes designed to pull patients from ED’.
- ‘Seven-day services’.
- ‘Ensuring patients are cared for in their own homes’.
It also emphasises the need to develop a ‘standardised process for managing ED capacity’ and provides ‘tips for implementation’.
- Although this review focuses on out of hours primary care services ‘the model described here takes account of potential future requirements of 24/7 urgent care in the community [and] includes the roles of NHS 24 and the Scottish Ambulance Service (SAS), and the key interface with emergency departments/A&E services and acute hospitals’.
- It provides figures on A&E attendances and calls to NHS 24, as well as patients’ experiences with waiting times (including waiting for a call back from NHS 24).
- It outlines the role of Urgent Care Centres, which may be ‘adjacent to A&E/acute services.
In 2018 the Department of Health announced a review of urgent and emergency care.
- Its aim was to ‘establish a new regional care model for the province, with particular focus on meeting the needs of the rising proportion of older people in the population’.
- It also addressed the challenges in A&E departments, stating that they ‘have been experiencing intensifying pressures over recent years, with growing numbers of patients facing long waits for admission’.
Subsequently, the Urgent and Emergency Care in Northern Ireland – Population Health Needs Assessment was published.
‘The action plan builds upon the learning from the review of urgent and emergency care’
It focuses on ‘ten key actions that will be rapidly implemented in order to ensure that urgent and emergency care services across primary and secondary care can be maintained and improved in an environment that is safe for patients and staff’.
The ten key actions include the following, among others:
- ‘Introduce urgent care centres’.
- ‘24/7 telephone clinical assessment service – ‘phone first’’. You can find more information about ‘phone first’ here.
- ‘Ambulance arrival and handover zones’.
- ‘Timely discharge from hospital’.
Provides ‘information on attendances at emergency care departments (ED) in Northern Ireland and the time waited in EDs’.
Ethical considerations & wider issues
The pressures on emergency care services within the NHS is an ongoing concern and a topic which tends to be raised each year as the demands grow throughout the winter period. During your interview preparations, consider the following in relation to A&E pressures:
- What issues might arise if A&E departments are too busy, struggling to cope with demand and waiting times are long?
- What impact does it have on people’s health, their treatment and their perception of the NHS?
- What impact does it have on NHS staff?
- Does it impact other services?
Having a good understanding of the impact of A&E pressures on the NHS (it’s staff and services) and on patients will support you to discuss the topic in more depth and with greater consideration. A brief knowledge of the statistics surrounding A&E demands and wait times will also support your discussions; while these only need to be rough figures, an understanding of how these have changed over time will be useful.
An obvious but nonetheless key area to research further is how A&E services have been affected as a result of COVID-19 and how the NHS aims to/has tackled this. The following outline plans for dealing with the extra demands of COVID-19 during the winter 2020/2021 and specifically cover emergency care services: