Urgent care system 'near breaking point', think tank claims

A set of “richer performance indicators” could sit alongside the four hour target, the authors suggest.

The What’s behind the A&E crisis? report says the urgent care system is “near breaking point” and the “continued financial squeeze” will “accelerate” the pace at which the system reaches it.

This pressure is caused by high bed occupancy levels, staff under strain and scarce financial resources, according to the authors.

The report also finds that a “significant” amount of managerial time is “wasted” by having to report to multiple bodies such as NHS England, clinical commissioning groups and Monitor.

It says there is too much focus on “providing assurance upwards”, which is “very unhelpful” in its impact on frontline staff.

The report found that the number of patients waiting on trolleys for over four hours before being admitted to hospital had “almost trebled” from 2010-11 to 2013-14. Delayed ambulance handovers at A&E have risen by over 70 per cent over the same period.

The authors say that cross-party consensus is “imperative” to deliver the change “so urgently needed” in emergency departments. It adds that problems will not be solved if policymakers, politicians and regulators “continue to micromanage A&E”.

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Progress against improving A&E performance has been “impeded” because of the “complexity” of the system and the “highly politicised nature of A&E”.  

Despite political and media attention on A&E performance struggles, the report says it is a “huge achievement” that activity increases over 10 years have been “accommodated by increasing efficiency within A&E departments”.

Rising attendances at A&E was not found to be the cause of the current pressures. While A&E attendances have increased by 32 per cent from 2003-04 to 2013-14, the authors say this rise is “almost exclusively to do with minor A&Es - for example, urgent care centres, minor injuries units and walk-in centres”.

There has been a 96 per cent increase in attendances at minor A&E departments over 10 years.

The authors found there has been a long term growth in demand for acute services as patients have aged and are living with more complex conditions.

The number of beds available in acute hospitals has fallen by 32 per cent since 2004, which has made the system “increasingly fragile, reduced the resilience… and made it particularly vulnerable to small shocks, such as relatively small increases in demand”.

Pressure on hospital beds has been “further exacerbated” by staff shortages and a high turnover in doctors dealing with medical and A&E emergencies. This has “further reduced” the ability of the system to “absorb small shocks and increased costs”.

The authors say that “magic bullet” solutions such as employing GPs to work in A&E departments do not address the “underlying” problem of managing frail patients with complex needs.

The report adds: “Similarly, it is not clear that additional A&E consultants would deal with the problem of growing hospital admissions of patients with acute medical conditions.”

The report puts forward a number of solutions including training healthcare professionals to deliver urgent care outside of hospitals and creating a single point of access to community services for patients and GPs to make the system less complex to navigate.

Policymakers are also warned to be realistic about what they can do. Investment in care outside hospital “can help” but policymakers “must let providers find solutions that work for their patients”.