To improve Emergency Medicine in the NHS we need to address reality, not change the metrics
Since 2011-12 the number of elderly and vulnerable patients has increased while the number of beds to put them in has decreased by just over 7000, says Royal College of Emergency Medicine.
The four-hour standard performance recorded by the Winter Flow Project this year is quite remarkable. While there is no getting away from the fact that routinely recording performance of around 80% speaks of patients and staff being placed at the ‘highest level of risk’, given that NHS England have recorded an increase in attendances at major A&Es of 6.42% compared with quarter 4 of the previous year and a 6.95% increase in the number of admissions, this speaks volumes for the dedication of NHS staff.
So why did this happen? Firstly, the number of overnight beds in England has seen its smallest like for like quarterly decrease since 2010 (202 - a 0.16% change). Secondly, the proportion of patients subject to Delayed Transfers of Care (DToC) has continued to decline. Winter Flow reported DToC as a proportion of bed stock as 5.10% from January to March compared with 5.45% in the same quarter of 2017-18. The same figures for NHS England show 4.23% for quarter 201718 and 3.43% for quarter 4 2018-19.
This, alongside the effects of a mild winter, has meant that the incidence of flu has been significantly lower than last year, and we have seen the lowest number of average weekly bed closures due to norovirus since 2014-15. As a consequence, for the first time since 2013-14 the percentage of acute bed occupancy was lower than had been the case at the same point the previous year (91.70% in quarter 4 2018-19 compared with 92.60% 2017-18).
As a result, performance has been remarkably stable and virtually unchanged from 2017-18. From January to March Winter Flow recorded Type 1 four-hour standard performance of 79.09% compared with 79.00% the previous year. In the same period NHS England recorded scores of 77.20% compared with 76.80% in 2017-18.
This illustrates something we have argued consistently throughout the Winter Flow Project; that it is perfectly possible to achieve full compliance with the four-hour standard, given the right physical resources to do the job. If it is possible to achieve stable performance at or below 80% – with all the patients languishing in corridors that this entails – then it is equally possible to achieve the same stability around 95% and eradicate the spectre of corridor medicine.
What this suggests is that our expectations of the NHS England Clinical review of NHS access standards should be limited. However well intentioned, while a change in ED flow metric may succeed in changing behaviour, it will not improve the practical realities of waiting or working in an Emergency Department for most patients or staff.
For example, this chart shows the actual number of patients in England who spent more than 12 hours in an Emergency Department from arrival to departure.
This shows that between 2011-12 and 201718 there was a 477% increase in the number of patients stranded in an ED for more than 12 hours. While some of this might be explained by flow metrics – although in this time the four-hour standard has not changed – it is not plausible to suggest that problems with the standard explain deterioration of this magnitude.
What has changed since 2011-12 is that the number of elderly and vulnerable patients has increased while the number of beds to put them in has decreased by just over 7000. To improve the reality of Emergency Medicine in the NHS we need to address this reality, not just change the way that reality is measured.
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