As the year draws to a close, scrutiny of A&E performance will once again become a regular topic of media interest. This attention is as dichotomous as the four hour standard that arbitrates good and poor performance, yet overall both are welcome. A downgrading of the standard would lead to a rapid decline in patient experience and outcomes. Those that doubt that performance is related to scrutiny should review the graphs from 2010 when the standard was “relaxed” from 98% to 95%. [1]
The pressures on A&E departments are greater this year than last. [2] It is extraordinary that this pattern is never accepted. Every year we hear of robust plans to reduce attendances and admissions. Such expectations have a Canute like naivety.
We also need to recognise that A&E departments are often required to see patients who are not best served by them. Usually this occurs because they are, or are perceived to be, the only available service.
A&E has become “Anything and Everything” especially out of hours. Rather than rail against this trend we must recognise it and configure services to meet patients’ needs. A&E should become a hub not a department. Within this hub the emergency department would be just one, albeit key component.
The Sentinel Sites Study published in 2014 demonstrated that at least 2.1 million patients (15%) would be better seen by primary care clinicians. [3] The opportunity to simultaneously provide more appropriate care whilst decongesting A&E departments is compelling.
Key to delivering this model is the provision of co-located urgent primary care outside normal GP opening hours. The hub would benefit further and patients likewise with the inclusion of other services. Pharmacy, liaison psychiatry, community mental health, and urgent dentistry would together mean that patients would find it much simpler to navigate the access routes to services when urgently required. The A&E hub emphasises the specific skill sets of each team whilst providing a cohesive service properly focussed on patients rather than organisations.
Patients find it easy to access “A&E departments” whilst the Patients Association study published earlier this year demonstrated that this was often not the case for other services, even when they existed. [4]
“Ignoring the Prescription” published by the Royal College of Emergency Medicine, highlighted that 60% of emergency departments have no co-located services at all. [5] In consequence the term emergency department and A&E department are often erroneously seen as synonyms. As always when the nomenclature is misleading, expectations are misaligned. The development of A&E hubs will ensure services are aligned with patient needs and expectations. They are in everyone’s best interest.
NHS England has established Vanguard Sites. [6] It is to be hoped these will enable more people to be cared for in the community. Given the demographic trends this is essential if the current bed stock is to be sufficient. Delayed transfers of care from hospital to the community are now the single largest reason for the paucity of available beds. [7]
Much has been made of the “weekend effect” on mortality rates. [8] Rather less attention has been made of the morbidity and mortality associated with exit block. When departments are compromised by lack of beds for patients requiring admission the consequences are predictable, measurable, and unacceptable.
First and foremost the input of specialist teams on appropriate wards is delayed. Often patients are admitted to a ward that is not the most appropriate for their needs—the only bed, rather than the best bed. Perversely this guarantees a longer length of stay and a vicious circle is created.
Secondly, staff are overstretched as they attempt to provide ward based care to patients in cubicles, whilst patients requiring urgent assessment and treatment continue to arrive and are accommodated on ambulance trolleys in corridors. This is hugely stressful to staff who aspire to provide high quality care. Such care is synonymous not only with diagnosis and treatment but compassion and privacy. Without time and space, compassion and privacy are compromised.
Finally let us not assume that the consequences of exit block can always be subsequently mitigated. Data shows that patients admitted during periods of overcrowding have an increased mortality. [9] This effect is not confined to those who are admitted but is manifested in a higher 30 day mortality rate even in those who were discharged.
Eradicating exit block and providing co-located services would decongest A&E departments, improve patient experience and outcomes and simultaneously improve the working lives of frontline staff. Such a virtuous circle cannot be ignored. Successful implementation would improve recruitment and retention into emergency medicine. Failure to do so currently costs the NHS £3 million per week in England alone. Seldom do clinical outcomes, patient experience, affordable staffing, and financial imperatives align so compellingly. [10]
Building on the strengths of the A&E brand, acknowledging the need to provide geographically aligned urgent care whilst promoting accountability and affordability is a real option for the NHS. Some sites already deliver some of these services; it is in everyone’s best interests that the A&E hub becomes a universal feature of all acute hospitals.
Clifford Mann is the President of the Royal College of Emergency Medicine. He is a full time emergency medicine consultant at Taunton & Somerset NHS Foundation Trust.
Competing interests: None declared.
References:
1) Emergency admissions to hospital: managing the demand. National Audit Office HC 739 Oct 2013
2) NHS providers: quarterly performance report (quarter 2, 2015/16)
3) “Better data better planning” British Journal of Hospital Medicine 2014 75:11, 627-630
4) Time to Act—Urgent Care and A&E: the Patient Perspective. RCEM/ Patients Asociation. June 2015
5) “Ignoring the prescription” RCEM. Feb 2015
6) New Care Models—vanguard sites. NHS England
7) NHS England (2015a) Delayed Transfers of Care.
8) Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015;351:h4596
9) “Exit Block in the emergency department: recognition and consequences.” British Journal of Hospital Medicine
10) RCEM and others’ Freedom of Information requests