Newsnight asked the Nuffield Trust to look into the most recent data on A&E performance, and to unpick the reasons behind its current decline. Here we present new data on how the NHS is performing on the day of their release by NHS England.
Performance against the totemic four-hour A&E target is the lowest it has been over the summer since records began. That target, which is currently under review, is for at least 95% of people attending A&E to be admitted, transferred or discharged within four hours. In September this year, the target was met for only 85% of patients, compared to 97% in September 2011.
Indeed, the performance this year in September was as bad as it was in January only three years ago. Only two out of 119 major A&E departments met the four-hour target last month.
What is the reason for such a decline in performance?
The most obvious answer is that there are simply more people attending A&E departments, and services cannot keep up with the number of patients (see chart below). There were 2.1 million attendances in September this year, compared to 1.8 million in September 2010 – a 22% increase.
This is being driven by a number of factors, including population growth and which services are available. There are now more services providing urgent care for minor conditions, for example. These new services can make it easier for patients to attend hospital for treatment, resulting in increasing demand. We also know that demand for hospital services is also influenced by fewer people being able to get a GP appointment when they want.
Not only have A&E attendances gone up, but so have emergency admissions to hospital. In fact, they have increased at a faster rate than attendances, with a 25% increase between 2010 and 2019.
This is being driven by a rise in people living with multiple chronic conditions, coupled with an ageing population. There is evidence that people are surviving for longer following an admission to hospital, but this makes it more likely they will require another admission to hospital in future. This may be leading to a growth in the number of emergency admissions.
The gap between demand and supply
Over the same period that demand for services has grown, the resources available to the NHS and other public services have been constrained. Following the financial crisis of 2008/09, growth in funding for the NHS has slowed to an average of 1.7% a year (from 2010/11 to 2019/20), compared with 5.4% between 2003/04 and 2009/10 (see chart).
Hospitals were initially able to maintain the quality of services, but since 2014/15 there has been a decline in performance – including longer waits in A&E, for admission to hospital and for planned care.
This effect has been compounded by workforce shortages across health and social care. Even though increased funding has now been made available to the NHS, the shortage of staff in hospitals, general practice and community services is expected to continue.
The gap between capacity and demand means that hospitals can find it difficult to admit a patient into a bed because the beds are full. Within A&E departments, the number of people waiting over four hours on a trolley – after a decision has been made to admit them – has skyrocketed (see chart). There were 64,921 trolley waits of over four hours in September 2019, compared to 5,907 in September 2010 – a more than eleven-fold increase.
These problems can be exacerbated by delayed transfers of care – where a patient is ready for discharge from hospital but is still occupying a bed.
There is a silver lining here in that delayed discharges had been on the increase until 2016, but have since gone down. In August this year, there was on average 4,802 people delayed per day, down from 6,060 in August 2016.
The reduction follows concerted effort to reduce the time people are spending in hospital waiting for assessments, although the most common reason for delay is still people awaiting a care package in their own home, such as help for getting in and out of bed, cooking, cleaning or other everyday tasks.
What is the outlook for this winter?
The outlook for winter 2019/20 is concerning.
We know that health services come under increasing strain over winter, as a result of a drop in temperatures and increases in flu and respiratory illnesses. Based just on historic trends, we can expect the performance position to deteriorate further over the winter, from a starting point of the worst September on record in A&E.
This year there are additional pressures to consider, such as worries that senior medical cover will be affected due to consultants reducing their overtime over concerns about tax and pensions. Continued uncertainty about Brexit may also impact on services, with concerns raised about access to medicines and devices.
With the prospect of more funding going into the NHS over the next few years, we hope that hospitals can improve performance, and meet the public’s expectations of a high-quality NHS.
Scobie S (2019) “Is it becoming winter all year round for the NHS?” Nuffield Trust comment.