Last week’s HSJ exclusive showed the vast majority of accident and emergency departments have missed recent targets. What does this mean for patients? At its worst, it can mean long waits in corridors, on trollies or in queuing ambulances; emergency departments trying to cope with twice the volume of patients they were built for; ambulances that can’t get back on the road to deal with the next urgent case and routine surgery appointments cancelled as beds get allocated to A&E admissions.

‘Missing the target isn’t dull and managerial – it shows that care quality and patient safety may be at risk’

The four-hour target is a good barometer of the overall health of the A&E system. Missing the target isn’t dull and managerial – it shows that care quality and patient safety may be at risk, despite the best efforts of all concerned. So Jeremy Hunt is right to focus on this data – the worst for 10 years in many trusts – and to describe the pressure on A&E as the biggest operational challenge facing the NHS right now.

The reasons for the current performance issues vary by trust but there are five common themes:

  • increased demand – A&E demand has doubled over eight years for some hospitals;
  • increased acuity – patients are presenting in poorer shape with conditions more likely to result in admission. Small annual rises in acuity can have a major impact on hospitals running close to capacity;
  • changes in primary care, for example to out of hours services, mean fewer patients being treated close to home and more coming to A&E instead;
  • the impact of reduced social care funding means that it’s increasingly difficult for hospitals to quickly discharge patients and free up beds for incoming A&E patients;
  • the funding model for A&E care is under major pressure with many A&E departments running at a significant loss because of the way the tariff operates.

The key overarching message is that this is a system wide problem. While the spotlight is on performance against the four-hour target, this is only a proxy for a broader range of issues.

Imgainative solutions

Acute trusts are working hard to improve performance and, as we come out of winter, performance is now stabilising. Trusts have invested in rapid assessment teams; GP triage; staggered GP urgent referral patterns; geriatrician outreach to nursing homes to prevent attendances as well as integrated management of A&E and inpatient medical assessment wards to expedite admissions. New one-stop urgent and emergency care facilities are being built; wards have been reopened or allocated to A&E admissions and imaginative “in extremis” solutions have been created to maximise quality of care for waiting patients.

However, for many trusts, accident and emergency care is rapidly becoming clinically and financially unsustainable and the whole system is under enormous pressure in the winter months. So what next, both in preparation for next winter and the longer term?

Short term, we need to find ways to help those trusts under greatest pressure this financial year. CCGs should be required to spend the withheld funding from the marginal rate on admissions and readmissions to support urgent and emergency care providers. This money should also be “dual keyed” – trusts should have to agree how it is spent and NHS England should use its commissioning risk pool to ensure that all providers who need support can obtain it, even if their CCG is facing financial problems.

Commissioners; acute, community and ambulance providers; GPs; and social care services need to urgently come together in each local health economy to develop an integrated plan for the coming winter. NHS England, the Trust Development Authority and Monitor need to work together, at both a national and local team level, to support this process. Creating an integrated approach then justifies the use of the 2 per cent CCG risk funding topslice to support each plan since it combines investment in new integrated models of care but targets this money where it is most needed operationally.

A sustainable model

Once we have shored up the system short term, we can then start to create the new long term, sustainable, model that we need. This needs to fit into a broader vision of how we reconfigure the NHS to deal with long term conditions so that many fewer patients reach a crisis point where A&E is the only apparent option.

’ We will need to revolutionise how we help patients enter and navigate the system’

We will need to reconfigure services; solve the current problems in recruiting and retaining emergency department staff and reform the GP contract to change the role of GPs in delivering out of hours care. We will need to revolutionise how we help patients enter and navigate the system. Sir Bruce Keogh’s review is the obvious place to start this work and government needs to be ready to implement its conclusions, however difficult they may be.

We also need to look at how we fund emergency care long term. Most A&E departments have costs that exceed their A&E income. Not paying the full cost of emergency admissions simply doesn’t work anymore. The Foundation Trust Network has secured a review of these policies and this review has to deliver a sustainable solution for 2014-15 and beyond. We also need to work out how we invest in community and ambulance services that prevent admissions and deliver care closer to home. The benefits of rapid response community teams and see and treat ambulance services is impressive.

It is a false choice to suggest we need to either invest in acute or community and primary care services – we need a funding system that, long term, transforms care models but, short term, keeps the system afloat whilst we implement those new models.

No one wants to see a patient sitting in A&E who could be treated in a more appropriate setting. No one wants to see a patient wait a second longer than they have to before receiving the care they need. To achieve this, we need the sticking plaster of a short term solution that starts to lay the ground for a radical long term overhaul.

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