Performance against the four hour accident and emergency target did not improve in 2013-14, despite a huge political focus on the issue, as emergency admissions reached record levels, HSJ analysis has found.

Emergency admissions at major A&Es were at their highest in nearly a decade last year, according to data from NHS England.

Just under 3.8m patients were admitted as an emergency in 2013-14, an increase of 38 per cent since 2004-05 when the data was first collected nationally and a nearly 2 per cent rise on 2012-13.

Overall attendances at type 1 A&Es, which are consultant led and open 24 hours, actually fell by 0.3 per cent in 2013-14 compared with the previous year, possibly suggesting patients with more complex conditions.

The proportion of attendances resulting in an emergency admission has been steadily increasing over the past decade, rising from 21 per cent in 2004-05 to 27 per cent in 2013-14.

Director of policy at the King’s Fund, Richard Murray, said the increase in admissions could be partly due to a failure to move away from the traditional hospital model and deliver more care in people’s homes.

He said: “The way we’d all like [A&E improved performance] to be done is that people are supported better at home, there are more services in the community. The admissions went up by quite a lot so it looks like what happened is some of that extra winter money showed up in extra nurses and extra beds and the way the service managed was to admit a lot of people.”

Winter pressure funding totalling £250m was announced by health secretary Jeremy Hunt last September for the geographical areas which had struggled most with their A&E performance in 2012-13.

In November, a further £150m was announced to be handed out to all areas.

In the same month Mr Hunt called the chief executives of five trusts that missed the four hour target demanding explanations for the poor performance. He has also been holding weekly performance meetings with system leaders including NHS England.

However, despite this political focus, and a considerably milder winter, performance against the four hour target at type 1 A&Es dropped slightly from 93.7 per cent in 2012-13 to 93.5 per cent.

Several trusts told HSJ that their allocation of the funding was not received in time to significantly improve A&E performance, for example by recruiting permanent staff.

Shane DeGaris, chief executive of Hillingdon Hospitals Foundation Trust, which received funding in the second tranche, said: “I would absolutely endorse that the winter money was helpful but it should have come a lot earlier to allow us to plan.”

The NHS Alliance has called for all year round funding rather than a seasonally dependent model. Chief executive Rick Stern said: “It is a statement of the obvious that temperature tends to drop in winter and creates additional hazards for the old and vulnerable. Yet each year the NHS treats this predictable cycle as a surprise, reacting to ‘winter pressures’ rather than planning to ensure services that make a difference are in place.”

An NHS England spokeswoman said: “For both tranches of winter money for 2013-14, NHS England passed money to lead CCGs for local systems as quickly as possible once allocations had been agreed.

“As an organisation, we continue to work together with Monitor, the NHS Trust Development Authority and the Association of Directors of Adult Social Services on operational resilience planning for 2014-15, which includes looking back at 2013-14.”

Winter pressures cash funds more beds

Winter pressures money was spent on additional nurses and consultants in almost two thirds of clinical commissioning group areas, HSJ analysis of how the £400m fund was spent suggests.

HSJ asked every CCG that received winter pressure funding - as well as the trusts that benefited from the increased funds - what the money was spent on and collected responses from 49 out of 140 CCG areas that received funding. In total 65 per cent of respondents said they had invested in extra nurses and consultants in emergency departments, while 47 per cent increased bed capacity.

However, several chief executives of trusts that received funding said that the temporary nature of the funding meant that they had to rely on agency staff.

The safety of escalation wards opened to deal with winter pressures was highlighted as an area of concern by chief inspector of hospitals Sir Mike Richards in a recent interview with HSJ.

One chief executive said: “Of course getting bank and agency people is fraught with risks – both clinically as well as the quality you get… the reality is that lots of these winter schemes are run by temporary staff… it was ever thus.”

Other popular initiatives included increased mental health staffing, which was introduced by 29 per cent of respondents, including in some cases a dedicated team to cope with mental health attendances. Discharge teams were also widely targeted for investment, with 43 per cent introducing or expanding existing teams to encourage quicker discharge.

The issue of increasing numbers of frail elderly patients was addressed by several emergency departments that employed geriatricians and set up dedicated frail elderly units.

A significant proportion of respondents, 33 per cent, invested in out of hours primary care or community teams who made home visits to try and reduce admissions.