Rethinking A&E problems to reduce winter pressures

17 January 2019
By Nick Bosanquet
Professor of Health Policy
Imperial College London
Nick Bosanquet

A&E pressure, trolley waits, ambulance delays: these are media nightmares. How can NHS teams manage all this to deliver better care? The first step is to recognise two A&E problems.

The first of these challenges is to provide rapid treatment for patients with minor problems, and on this issue, there has been much progress.  There are a range of actions which can be taken by A&E managers and clinicians which can produce results in months, including triage by nurse practitioners, GP clinics in A&E, and mentoring of frequent attenders, as pioneered in Blackpool. These measures in many departments have met the four-hour target for most minor problems and may well have raised quality of care on which there is a sad lack of evidence. One further step forward here would be to have a single NHS protocol for triage.

More difficult is the second A&E problem: timely and quality care for patients in need of emergency admissions. At present they contribute 67 per cent of long waits with 81,000 patients waiting on trolleys over 12 hours. By any standards this is poor quality and probably contributes to mortality.  Under the present system the sickest in most need are waiting longest.

This problem has got worse in large Type 1 A&E departments and cannot be solved by more limited re-organization within the A& E departments. It requires recognition of three key misconceptions which are deeply embedded in current care.

  • Misconception 1. Elderly patients (who are now getting much more access to high cost diagnostics and treatment than happened in the dark times of age discrimination) can be discharged in 2-3 days without much support and rehab. Many of these patients are going to turn up at A and E as emergency admissions.
  • Misconception 2. The NHS has given due priority to treatment to problems of aging and long-term conditions. In fact, the NHS has used the aging population as a main part of its case for more funding - but it has spent the money on specialist commissioning. The 143 areas of specialist commissioning now take twice the national spend on primary care, and do not treat many over 65s. There was more accent on "geriatrics" in the 1970s than now. There are some promising signs such as the Frailty Units pioneered by the Leicester and Kettering Trusts but much more can be done.
  • Misconception 3. There can be more acute hospital beds any time soon. It takes ten years to produce experienced staff and there are few keen on 24/7 working.

To begin to improve the timeliness and quality of care for patients in need of emergency accommodation, significant changes need to happen. Firstly, The NHS needs to see hospital treatment as the start of a recovery and rehab process. Here primary care can give leadership, working with hospital teams who would redefine their role to bring about recovery and not just discharge. We also need to give special personal support to patients, who are at risk of frequent re-admissions, covering social as well as medical care. Finally, the NHS has to revisit the case for more convalescent beds often in collaboration with nursing homes. For some patients there may even be the opportunity for monitoring though virtual wards as now pioneered in Bradford.

There are very positive opportunities for effective care - in and out of hospital – and this is what integration is all about.

To begin to improve the timeliness and quality of care for patients in need of emergency accommodation, significant changes need to happen.