The NHS faced a perfect storm of gloomy media coverage today, with disappointing new figures on A&E waiting times, and the news that several hospitals had declared “major incidents” due to pressure on emergency departments.
Phrases like “in crisis” and “brink of disaster” are much in evidence today, but what are the hard facts?
Major incidents
A number of NHS hospital trusts have put “major incident” plans into operation, affecting hospitals in Cambridgeshire, the Midlands, Gloucestershire, North Yorkshire, Surrey and Staffordshire.
That sounds bad, but it’s difficult to figure out exactly what it means.
According to NHS guidelines, hospitals can declare a “major incident” in response to “any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties to require special arrangements to be implemented”.
It’s up to hospital trusts to decide how to interpret that and where to set the threshold of seriousness before the big red button is pressed.
Evidently, some trusts today have been so overwhelmed by the numbers of patients turning up that they have decided there is a risk of major disruption to services, and have chosen to implement major incident plans.
Declaring a major incident does not mean, as some cynics have suggested, that trusts get more money from the government.
It means they can bring in extra staff, divert staff from other activities and postpone “some routine procedures”. Patients who had a non-emergency operation planned for today may well have got a late phone call cancelling it.
The move to major incident status has been widely reported today, but we don’t actually know whether there were any more today than last week, as there are no official statistics.
And even if the number of major incidents doubled overnight, it would be difficult to know how bad that meant things had got, since the definition is so vague and different NHS bosses can interpret it in different ways.
There are better indicators of times when A&E departments are really pushed to breaking point, such as “diverts” – when a hospital effectively closes a full A&E department to new patients and redirects ambulances to a different hospital.
This happened 113 times between 3 November and 14 December last year – more than double the 53 incidents in the comparable period the previous year, but almost identical to the 2012 figure.
Waiting times
The big statistic everyone is talking about today is about the four-hour waiting time target for A&E wards.
There is a bit of misunderstanding about this. It doesn’t mean that if they miss the target, you don’t get treated for more than four hours. The target is for patients to be seen, patched up and either sent home or transferred to a different ward within that time.
The government says it wants 95 per cent of people to be treated within four hours and the latest quarterly figure is 92.6 per cent, the worse since records began in 2004.
Obviously that still means that more than nine out of 10 people spend less than four hours in A&E, and other metrics paint a less pessimistic picture. The median average time spent by patients in A&E remains stable at just over two hours.
Experts we have spoken to tend to be cautiously pessimistic about accident and emergency care, avoiding words like “crisis” but leaving little doubt that there is sustained pressure on the system.
Ian Blunt, a senior research analyst from the Nuffield Trust, told us today’s four-hour figures were “both reassuring and concerning” in that they are getting worse steadily, with no sign of sudden meltdown.
His research suggests, not surprisingly, that crowding in emergency wards “has negative impacts for patient experience and patient safety” and points out, ominously, that hospitals have not had to cope with a cold snap, large-scale outbreaks of of illnesses like the norovirus on wards, or a flu epidemic.
Things could be a lot worse.
So what’s the diagnosis?
Some commentators have offered simple answers to the question of why hospitals are in a tight spot, usually with little empirical evidence.
One Conservative backbencher blamed immigrants from eastern Europe, but we found he had misread and misquoted research on the subject.
Health Secretary Jeremy Hunt tried to pin the blame on GPs doing less out-of-hours work. But researchers at the King’s Fund found “no evidence” for this, pointing out that most people go to A&E during working hours.
And the theory that people were staying in hospital too long because of problems with the social care system didn’t really stand up either.
The think-tank was more sympathetic to the idea that staff shortages, in particular a lack of consultant-level emergency doctors, could be a factor.
We know that the numbers of A&E specialists who trained in the UK but preferred to work in Australia went up by 60 per cent between 2008 and 2012.
The College of Emergency Medicine says student doctors are failing to take up specialist emergency medicine training posts.
A Nuffield Trust study found that some of the longest waits in A&E happened when departments were at their least crowded – suggesting that lack of doctors, not lack of beds, was the problem.
The causes of the squeeze are likely to be complex, but the long-term trends are not in dispute: a growing and ageing population has increased pressure on emergency wards and is likely to continue to do so for years to come.
