Are the UK’s A&E departments facing a care crisis?9 November 2013
In recent months, as we head towards the cold season, there has been a notable increase in newspaper column-inches devoted to a perceived crisis taking hold in the UK’s A&E departments. KPMG’s Andrew Hine speaks to Andrew Tunnicliffe about the current situation, how to address it, and his thoughts on the future of this troubled NHS division.
The National Health Service (NHS) is seemingly always in the news and, in recent times particularly, this proud UK institution has attracted many a critical tabloid headline.
The tragedies played out at Stafford Hospital in Staffordshire, the so-called crisis that has befallen accident and emergency departments up and down the land, and trust concerns over spending and 'special measures' mean the images of nurses fussing over babies in cots, played to the world during the opening ceremony of London 2012 in a display of pride, seem a very distant memory.
With the winter months upon us, the doom merchants have for some time been sounding the alarms and, in some cases, it could even be argued, peddling fear. But the reality is that NHS accident and emergency (A&E) departments are facing a real challenge. The nurse to patient ratio is weighed heavily in favour of the patient, front-line staff are coming under increasing pressure and the abuse of primary care services - the result of poor education, a lack of consideration or utter desperation - is continuing apace.
Andrew Hine, KPMG's UK head of healthcare, believes the challenges facing A&E departments pose a genuine threat this winter, especially taking into consideration the much publicised scaling back of NHS walk-in services.
Andrew Tunnicliffe: How real is the threat facing A&E departments across the UK as we head in to winter?
Andrew Hine: The threat is substantial. The growth in patient attendances has been inexorable in recent years, and financial pressure on the NHS and other public services has reduced the ability of the service to respond as effectively as it and patients would like. Hospital occupancy levels are high and this, added to A&E attendance rates, leaves many hospitals with little room for manoeuvre. A prolonged period of very cold weather and/or a significant outbreak of flu or other communicable disease over the winter could see A&E departments really struggling to cope with demand.
Will extra funds announced by the government help meet these challenges in the short term?
The funding is undoubtedly a help, it can enable trusts to put in place short-term expansion of capacity or staffing, or work with their partners such as social services to set up fast response services to enable more people to be cared for at home without the need to go to A&E.
In your view, what has led to the 'crisis'?
This is a complex issue and, in part, the NHS is a victim of its own success. In my view there are four inter-related issues.
Firstly, as a population, we have developed more consumerist behaviour patterns. As a result, we seek care more regularly and assertively, and we are less prepared than previous generations to wait to access it.
Secondly, the maximum four-hour A&E wait (a time within which many people are being seen), means that people who are prepared to wait a few hours know that they will be seen if they go to A&E, irrespective of their level of clinical need.
Thirdly, compared with the waits faced by previous generations, access to care via A&E is now easier than it used to be - and that is a great achievement by the NHS. But some people are undoubtedly now using A&E and similar services in preference to going to their GP.
Fourthly, the acuity of inpatients' needs in hospital is higher than it used to be because simpler cases are now discharged much more quickly than they used to be. This leaves hospitals with less flexibility to respond to peaks in demand than previously.
Finally, services outside hospitals, which are crucial to providing care for people discharged from wards or A&E, such as community and social services, have experienced inexorable demand increases due to demographic change. The flexibility to take pressure off A&E in these areas has therefore reduced, due to this and financial pressures.
In summary, there is more demand due to rising need and changing behaviours and reducing flexibility to respond. As a result, services are running at full speed and full capacity more of the time so small increases in demand can have big impacts.
How important is primary care to the mix when addressing the current situation in A&E, and how has access to it changed over the last decade?
Primary care and other out-of-hospital services are crucial to resolving the A&E problem. There is widespread evidence that large numbers of patients attending A&E could be very appropriately and safely treated somewhere else. The most significant solution would be to make a change that enabled and required these cases to be dealt with away from A&E, thereby freeing up resources for those who genuinely require urgent and emergency care.
Walk-in centres are part of the solution but, in my view, have provided convenience for primary care-type cases where the patients really should have booked a routine appointment at their GP. I would rather see investment and redesign of primary care (and the opening of primary care services alongside A&E as happens in some areas) to improve the access to primary care, rather than spending money on creating more and more alternatives.
What changes should be made to the current primary care system to make it more efficient and effective?
A survey of patients across England and Wales, conducted by KPMG, revealed that the majority want to see extended opening hours from their GP. I echo this and believe that extended opening hours so that all practices opened (as a minimum) on one evening and one weekend morning or afternoon every week is essential. In the vast majority of cases where primary care is delivered in group practices of several GPs, I believe this could be achieved by redesigning working patterns and introducing new shift systems without the need to increase staff numbers materially. The vast majority of services we access as consumers (including many publicly funded ones such as libraries and leisure centres) have these features. I see no reason why primary care should not operate similarly.
What are your initial thoughts on the review into emergency care led by Professor Sir Bruce Keogh?
I think this is a thoughtful and cogent piece of work. Sir Bruce and his team are expressing frankly what many people in the NHS already know - that scarce specialist clinical skills are spread too thinly and, as a result, some patients are receiving less than optimal care, particularly at weekends. Redesigning emergency care in the way this report proposes would undoubtedly benefit patients.
Knowing that A&E visitor number have risen by 50% in the last decade but that four-in-ten receive no treatment, what is this telling us about the use of our A&E departments?
While our population has grown and aged over the last decade, I simply don't believe that those factors account in full (or even in the majority) for this. There is, in my view, a significant factor of people choosing to attend A&E because they perceive that primary care alternatives aren't responsive enough to their needs. Meanwhile A&E is, with much higher levels of senior medical cover than historically and a maximum four-hour wait that is shorter than previous maximum waits, a very effective one-stop-shop for any conceivable health need.
How important is better patient understanding of the A&E department and its function in alleviating the current situation, and how can that understanding be improved?
This is crucial - and the NHS is trying hard to better inform the public. I certainly support initiatives in some areas which, while controversial, seek to redirect clinically appropriate non-urgent cases back to their GP rather than allowing them to wait for service at A&E. Steps of this kind would, I think, relatively rapidly change the view that A&E was a source of care irrespective of need.
What role do the new commissioning bodies have to play in addressing these issues?
A substantial role. It is clearly their responsibility to ensure that appropriate alternatives to A&E exist and are developed over time. Part of this solution, however, involves investment in primary care and (for conflict of interest reasons) this is not in the remit of local CCGs.
Based on your survey, access to medical care within the community - GPs and walk-in centres - was essential. However, there has been criticism of the closure of some facilities such as walk-ins in recent months. How can this real concern of patients be addressed, and are the closures in the best interest of patients and the NHS?
It is undoubtedly the case that access to primary and community-based services needs to be improved. The surge in demand for A&E is in part a response to this problem. But walk-in centres are only one of several possible models and much of the evidence about walk in centres is that they have tended to be used highly by the working-age population whose needs are in most cases lower than older and younger population groups. My preference for the use of these resources would be to expand/extend primary care services and/or to establish primary care services alongside and integrated with A&E departments.
What other options are available to the NHS to address patient needs such as technology, community-based services or placing additional responsibility on current service provision such as paramedics?
The biggest challenge and the biggest opportunity for the NHS is to use technology better, and to redesign its workforce so that more care is available away from hospitals in community settings and in patients' homes. To paraphrase a consultant physician I once worked with on thinking about how to respond to growing demand for healthcare, "We have all the beds we need. They are all in our patients' homes". Patients recognise this - with many telling us in KPMG's survey that, with technology dominating our lives as a consumer, there is little reason for it not to help us.
Technology and workforce redesign can and must lead to a major change in how care is delivered over the next decade - and in many other countries it already has. The most seriously ill people will always need admission to hospital. But, for many people, the best solution will be to enable them to stay at home, supported and monitored using relatively simple diagnostic and remote-monitoring technology with staff responding to their needs flexibly across historic professional boundaries. This approach will not mean we need fewer or smaller hospitals, but it can mean that we don't need to build many more much bigger - and very expensive - new ones.