“We are hitting our national A&E targets.”
Jeremy Hunt, 15 May 2013
The background
The Health Secretary has been obliged to defend the government’s record on accident and emergency services again after another organisation warned of a looming crisis in our hospitals.
On Wednesday it was the turn of the Foundation Trust Network, which represents more than 200 health trusts.
Chief executive Chris Hopson said: “A&E services have been under huge pressure and although performance is now stabilising, there is a danger the system will fall over in six months time unless we plan effectively for next winter.”
The dire prediction comes after warnings from the Royal College of Nursing, the Care Quality Commission and Monitor about pressure on emergency departments.
In a BBC interview Mr Hunt praised hardworking A&E staff and added: “It’s also important to say that they are being very successful. We are hitting our national A&E targets.”
The Labour MP Ben Bradshaw immediately tweeted that he was “not sure how Hunt can claim he’s hitting A&E target”. Is this a crisis or not?
The analysis
The target everyone is talking about is a pledge that the vast majority of patients who arrive at A&E will be seen within four hours. The benchmark used to be 98 per cent under Labour, but the coalition relaxed it to 95 per cent.
In 2011 performance was running at 97 per cent, but then A&E waiting times began to increase.
By December 2013 departments were failing to hit the 95 per cent target. It has only been achieved in eight of the last 26 weeks.
It just so happens that the figure has crept up above 95 per cent in the latest two weeks recorded by NHS statisticians, which enables Mr Hunt to say, truthfully, that the government is hitting its targets. For now.
Clearly, the target is an arbitrary one and patients around the country won’t be able to tell the difference between 94.8 and 95.6 per cent.
At no point have wards failed, on average, to treat fewer than 90 per cent of patients within four hours, so we’re not talking about a sudden catastrophic drop in the service.
On the other hand, there are other statistics which don’t give us cause for optimism.
The regulator Monitor pointed out in its latest report that 32 of 144 partly-independent foundation trusts breached the four-hour target in the third quarter of last year, compared to seven in the previous quarter and 14 in the same period a year ago.
Monitor concluded: “This was due to higher attendances and reflected seasonal pressures across the NHS…in addition to seasonal demand, trusts cited outbreaks of the winter vomiting bug, discharge delays due to problems accessing community care services, and increased attendances among elderly people as the causes of breaching the targets.”
There’s a nasty mix of short-term and long-term problems here. Vomiting bugs come and go, but rising numbers of elderly people isn’t a problem that’s likely to go away.
What’s causing the pressure?
As Mr Hunt has rightly pointed out, more than a million more patients attended A&E between February 2012 to January 2013 than they did in the previous 12 months, according to the latest figures from the Health and Social Care Information Centre.
The reasons for this are complex and there’s little expert concensus on the most important single factor. A&E admissions have been rising for more than 30 years but the sharpest rises came after 2003/04.
Britain’s population is ageing, but that doesn’t explain everything. A 2010 study by the Nuffield Trust found that over-85s were 10 times more likely to end up in A&E than people in their 20s, 30s and 40s.
But only 40 per cent, at most, of extra admissions could be explained by the ageing population.
The same study said the rise was not down to one particular kind of illness, and it did not appear that people were becoming more likely to report ill-health.
Oddly, the researchers thought one of the biggest reasons for the rise in admissions is that “advances in medical care and management have reduced the length of stay that patients have in hospitals, which in turn has freed up more available beds and allows doctors to admit more patients”.
In other words, we are victims of our own success. Patients get discharged more quickly now, so there are more empty beds, so patients who turn up at A&E are more likely to get a bed even if they don’t really need it.
The Health Secretary has blamed Labour for changing GPs’ contracts with the NHS in 2004, which allowed them to opt out of providing out-of-hours care.
The decision to shift the responsibility for organising round-the-clock care from individual doctors to primary care trusts has made it more difficult for patients to see a doctor in the evenings and at weekends, according to Mr Hunt.
He says people have lost trust in primary care and A&E has taken up the slack.
Some members of the medical profession have heaped scorn on Mr Hunt for promoting this argument.
Dr Laurence Buckman of the British Medical Association called it “impressively superficial analysis based on no evidence” and “such fatuous nonsense I question the wisdom of the people briefing the Secretary of State”.
In fairness to Mr Hunt, he’s not alone in making a link between rising A&E admissions and problems with the service traditionally provided by GPs.
An Oxford University study on the numbers of children being taken to emergency departments by their parents identified a 28 per cent rise in ten years, with a persistent year-on-year rise from 2003. Increasing numbers of children were being taken to A&E with minor problems like coughs and colds.
The authors concluded: “The increasing admission of children for very short term care, particularly for acute infections, certainly suggests a reluctance of primary care to observe and manage sick children with self-limiting infections in the community.”
The verdict
Mr Hunt is actually correct to say that, in the last couple of weeks we know about, the A&E target has been met. But let’s not crack open the champagne just yet.
The figures show a strong seasonal variation, with emergency services more stretched in winter, so if the pressure remains high towards the end of the year we may see similar failures to meet the four-hour waiting time target.
The health secretary has promised short-term action and long-term reform, but the complex nature of the problem suggest a strategy based on rewriting the GP contract alone will fail to solve it.
By Patrick Worrall
