A&E units are under the greatest strain in living memory, with growing numbers of patients waiting more than four hours for care or ending up on a trolley awaiting a bed as hospitals struggle to cope. But what lies behind the unprecedented demand for A&E care? Here three experts offer their views.
Prof Keith Williett, NHS England’s director of acute care
We know that the ageing population is increasing demand. But something different seemed to happen over Christmas.
A&E attendances are going up by about 2.7% a year. But comparing this Christmas to Christmas 2013, A&E attendances were up 9% and hospital admissions were up by 6%, while ambulance services reported 9% more 999 calls – the South West ambulance service saw a 25% rise. And while NHS 111 usually receives 230,000 calls a week for advice, in Christmas week it hit 440,000.
It would seem that a likely explanation for the unprecedented demand we’ve seen over this holiday period is a behaviour change in society in the way that people use NHS services. Younger people are using NHS services much more frequently than the older generation. It’s like the younger generation aren’t bothering to try and get a GP appointment.
We now have a “right now” society; that is, a population that expected to have immediate or very rapid solutions to their queries, whether that’s in banking or click-and-collect food shopping. That’s a major problem for the NHS. It impacts on A&E, NHS 111 and ambulance services, all of which they know have guaranteed response times.
We will have to bear that in mind in how we transform services when we starting implementing our review of urgent and emergency care this year.
Dr Peter Carter, chief executive of the Royal College of Nursing
It’s been a folly to let the number of district nurses in England fall from 12,000 in 2003 to 5,500 now. You don’t have to be a genius to see how that ends up increasing pressure on hospitals.
These are the nurses who do things for patients at home, like helping them with their catheter, that means they can stay at home and out of hospital. They include nurses who specialist in certain conditions, such as serious breathing problems known as chronic obstructive pulmonary disorder.
In some places the lack of district nurses means some patients can’t be discharged from hospital because there aren’t enough of them to look after them once they’re home, which means beds in the hospitals can’t be used for other patients.
Dismantling NHS Direct and replacing it in 2013 with NHS 111 was a huge mistake by the government. NHS Direct was highly effective and had become trusted by the public. Many of its staff were clinically trained, especially nurses, and could give patients appropriate advice, such as to go to a local pharmacist instead or to seek a GP’s appointment and not worry that it’ll take a few days to get. They reassured people and helped ease the pressure on A&E.
However, most of the call-handlers at NHS 111 don’t have a clinical background and work off an algorithm to tell what’s wrong with someone. There’s hard evidence that 111 are directing people to A&E that under NHS Direct wouldn’t have been sent.
Claire Murdoch, nurse and chief executive of the Central and North West London NHS foundation trust
One problem is that the growing population means that A&E units in some parts of the country are too small for the sheer number of people now coming to them. They are struggling to cope, and often can’t recruit enough doctors and nurses.
They literally don’t have the capacity – the space, the number of rooms and the workforce – to deal with that. However, just making them bigger isn’t always the answer.
The key is providing more and better services outside of hospitals. In London, Camden clinical commissioning group has worked with us and the Royal Free hospital and University College London hospital to identify the most at-risk patients locally and then develop more integrated and user-friendly services that will keep them healthier at home for as long as possible.
They have set up one-stop shops where the most vulnerable patients can come and access the range of health professionals – GPs, different types of hospital doctors and district nurses – that they would normally need different appointments to see separately. At those meetings the patient’s health is reviewed, to try and identify any warning signs that someone might end up in hospital. Patients are also given mobile phone numbers for a GP or specialist nurse, so they can call them if they have a problem rather than going to A&E. It’s quite pioneering.
Patients like it; it reduces the amount of time they spend in hospital and it’s cheaper than the traditional way of looking after patients. With hospitals at boiling point, there needs to be more care delivered like that around the country.
Unless we get to grips with that, and patients going to A&E inappropriately, and the small size of some A&Es, then the A&E problem will get worse.
