Accident and emergency is one of those NHS services that is particularly close to the public’s heart.
Two things I remember from my more formative years are based on A&E, though luckily none of them involves my attendance.
First, I did a large chunk of my growing up in the 80s when the BBC’s Casualty was essential family viewing on a Saturday night – at least it was in our house.
There was the usual guessing game of which actor was going to end up in Holby’s A&E, after falling off the roof or blowing up the shed. But equally memorable was the weekly battle between the doctors and nurses – at the time Charlie, Megan and Duffy – and their manager over cuts to resources.
Secondly, I began my career in health journalism at the turn of the millennium, when the newspapers seemed to be constantly full of stories about patients being left on trollies for excessively long periods.
I thought these anecdotes had become a thing of the past for the NHS. It seems they have not and since last year they have made a depressingly regular return to the news pages.
Those who work in the specialty have been having a particularly hard time of it recently, though other parts of the system are undoubtedly also under great pressure.
Perhaps because of its higher public profile, we have heard about the growing demand faced by A&E departments across the country, especially in winter, which has taken a noticeable step-change recently.
NHS England has described a “general rising tide” in demand, with 5.9% more attendances in 2012-13, than in 2009-10, and 10.6% more emergency admissions in 2012-13 than in 2009-10.
In real terms, according to the Health and Social Care Information Centre, patient attendances at A&E in England have increased by over one million in the past year.
A complex set of factors is driving the problem, but while those in charge often talk about solutions none has so far been forthcoming.
First of all there is the simple fact that the overall age and acuity of the population has increased – in basic terms - more people are more in need of healthcare.
Then there is the behaviour of patients themselves. People are now increasingly used to a 24-hour society where they can do their banking or shopping whenever they want. They view healthcare in the same way and head to A&E knowing they will be seen, rather than wait for a GP appointment.
In urban areas this has led to emergency departments routinely being regarded as a “credible alternative” to primary care, according to the College of Emergency Medicine.
Some commentators have also cited as a factor the government’s decision in 2004 to allow GP practices to give up out of hours provision.
Passing out of hours services from local practices to independent providers and GP collectives covering whole regions has created a psychological barrier for patients in need of help but having to cope with an unfamiliar service – as a result, they go to A&E. Ongoing question marks about the standards of some out of hours providers have not assisted either.
It’s true to say, ministers and managers have been attempting to tackle the problem for some time. Urgent care and walk-in centres and a plethora of advice and information services, such as NHS Choices and the now defunct NHS Direct, were introduced as mid-way alternatives to A&E and primary care.
But, while patients have got to grips with using the bewildering range of options now available, they have continued to use A&E as well – a case of “build it and they will come”, it seems.
As usual there are compounding factors.
NHS leaders have for a long time been talking about the need to shift non-emergency services out of hospitals and into the community, as it’s generally safer and cheaper than acute care.
However, the reality has largely been cuts in the acute sector without the necessary backfill in community services and social care – as a result, more patients are at risk of ending up in A&E.
In addition, there have been claims – so far denied by NHS England – that the chaotic introduction of the new non-emergency phone line, NHS 111, in April may actually have led to greater demand on emergency services.
As working in A&E becomes ever more stressful and demanding, it may also lose the sheen of glamour that it once had – bringing with it recruitment problems.
The A&E problem is viewed serious enough for the government to announce earlier this month that an additional £500m would be spent over the next two years on trying to tackle it. However, this money was described as a “sticking plaster” by the Royal College of GPs.
NHS England medical director Professor Sir Bruce Keogh is also leading a review into the demands on urgent and emergency care and how the NHS should respond. His findings are due in the autumn.
What’s the answer, who can say? But one thing seems obvious for both patient safety and staff wellbeing. A&Es must be adequately resourced and staffed until such time as a solution is found – the patients aren’t going to go away until that happens.
A start would be to use the Royal College of Nursing’s Baseline Emergency Staffing Tool or something similar. BEST tracks the volume and pattern of the nursing workload in an A&E department against its rostered staffing level, which then shows any disparity between the two.
A&E departments always struggle when the flu virus takes hold and the weather worsens but this year they will be approaching the coming winter with even more trepidation than usual.
News Editor, Nursing Times