The worst accident and emergency performance against the four hour target in more than 10 years was due to hospitals struggling with very high bed occupancy rates, Monitor has concluded.

Despite only 88.8 per cent of patients being seen within four hours between October and December last year, the regulator’s analysis suggests this poor performance was “not a reflection of the overall operational performance of A&E departments - i.e. they did not perform worse than in previous years”.

The report said that instead, “A&E departments utilised available capacity more effectively to meet the increased emergency care demand”.

However, the report said “continuing increases in demand on A&E staff and capacity” were “unlikely to be sustainable”.

It added: “This may have important consequences for service quality and patient safety.”

The regulator sought to understand the dramatic decline in performance last winter compared to the previous year when 93.5 per cent of patients were seen within four hours. It received 123 responses from trusts, representing 96 per cent of providers with a major A&E department.

From October to December 2014, national A&E performance fell to 88.8 per cent, its lowest level in more than a decade, and a 4.7 per cent drop from the previous winter.

On average, hospitals had bed occupancy rates of 89.7 per cent throughout last winter, with 72 trusts reporting rates above 90 per cent. This was 14 more than in 2013.

If occupancy rates rise above 85 per cent then patients can be exposed to risk and it is harder to adjust to sudden increases in admissions.

The report concluded: “Even marginal increases in occupancy are likely to have had a disproportionate negative impact on A&E performance.”

Attendances and admissions were 5.9 per cent higher compared to the previous year.


A challenging winter can ‘create a tipping point for performance’, Siva Anandaciva said

Delayed transfers of care increased by 27 per cent last winter compared to the previous year. However, report authors said delayed transfers only accounted for 4 per cent of occupied beds, up from 3.1 per cent the year before.

The review found that staffing did not contribute to the decline in performance and there were 4 per cent more A&E staff per attendance in April to October last year compared to the same period in 2013.

However, the number of temporary staff increased.

The authors said the “most important driver of the decline” for most hospitals “was a reduction in their ability to accommodate the increase in admissions from A&E departments”.

It added: “This resulted from hospitals running at very high occupancy rates – 90 per cent or above. Therefore, measures taken by urgent care systems to improve patient flow through hospital departments other than A&E and into the community are likely to be an effective approach to avoiding another sharp decline in A&E performance this winter.”

Siva Anandaciva, head of analysis for NHS Providers, said: “The NHS frontline has risen to the challenges of improving patient flow, handling delayed transfers of care and caring for patients with multiple morbidities and long term conditions. However, a challenging winter with high bed occupancy, a backlog of elective patients, and increasing emergency pressure from norovirus, influenza and respiratory exacerbations can create a tipping point for performance.

“Sufficient funding and adequate numbers of highly skilled staff are a prerequisite for successfully managing A&E waiting times. Without these, the best of flow plans are destined to fail. In addition to sharing good practice on how to improve patient flow, we urgently need a more coherent solution to the staffing and funding pressures emergency departments are experiencing. Otherwise, patients may be waiting even longer this winter.”