A&E must change or face collapse, NHS warned

Patients waiting to see a doctor Pressures have been growing on A&E units for a number of years

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Urgent changes must be made to the way A&E units are run - or the system could collapse, doctors and managers say.

Both the College of Emergency Medicine and Foundation Trust Network have put forward proposals to overhaul the system.

Funding and staffing have been highlighted as key issues.

Health Secretary Jeremy Hunt said it was "very tough out there" and ministers would deal with it by "better joining up" health and social care.

The warnings come as fears grow over whether the NHS can continue to cope with rising demand.

Start Quote

Warnings don't come more serious than this”

End Quote Shadow health secretary Andy Burnham

Last week both ministers and the NHS regulator admitted the problems were a cause for concern.

A&E attendances have risen by 50% in a decade and this winter the NHS in England started missing its four-hour waiting time target.

Pressures have been noted in other parts of the UK too.

The review by the College of Emergency Medicine - based on feedback from more than half the A&E units in the UK - said the scale of the challenge was the biggest for a decade.

It said there were shortages in both middle-grade and senior doctors. As well as highlighting the workforce problem, the college also said more needed to be done to reduce unnecessary attendances.

It believes between 15% and 30% of patients do not need A&E care and instead could be treated in non-emergency settings.

Meanwhile, the Foundation Trust Network (FTN) highlighted the funding system in England which penalises A&E units seeing a rise in patients.

Funding concerns

Under rules designed to encourage the system to reduce A&E admissions, hospitals are only paid 30% of the normal fee for an emergency admission when the numbers rise above the levels that were seen in 2008-9.

But with the NHS failing to curb the rise in patients, that is costing some hospitals millions of pounds a year.

FTN chief executive Chris Hopson said: "Unless we can change the funding structure, the A&E system is going to fall over. We simply cannot carry on."

Why are A&E units getting busier?

Across the NHS more patients are being seen, but the upward trend is perhaps the greatest in A&E.

It is often said that the lack of out-of-hours GP care is the cause of rising demands on A&E.

That is certainly true. Since 2004 GPs have been able to opt out of providing night and weekend cover, leaving it to agencies to provide care.

A lack of confidence in the service has meant patients have to turn to A&E when they have not always needed emergency care.

This has been further compounded in recent months with the roll-out of the new 111 non-emergency phone line. Hospitals have reported rises in patients either because they cannot get through to 111 or have got poor advice and been told to go to their local A&E for trivial reasons.

But this does not tell the full story. The ageing population means there has been a rise in long-term conditions - about £7 in every £10 spent goes on patients with problems such as dementia and heart disease for which there is no cure.

When services are working properly in the community these patients can keep their conditions under control. But when that system fails - as it does too often - they can have crises and inevitably they end up at A&E.

He said the last winter was "very, very difficult" although with the weather now improving there were signs the system was stabilising.

But he added: "Unless we can make some really significant changes over the next six months I think it's pretty clear the system is in danger of falling over next winter."

NHS England has already agreed to plough some of the money it saves through these rules back into the system to support the most troubled A&E units in the short-term.

It has also ordered a review of emergency and urgent care, led by medical director Sir Bruce Keogh. The findings are expected to be published soon.

Shadow health secretary Andy Burnham said: "Warnings don't come any more serious than this.

Jeremy Hunt: "It's too difficult to access out of hours care"

"Too many hospitals around England are sailing dangerously close to the wind, operating way beyond safe bed occupancy levels."

He told BBC Radio 5 live the situation could be improved by "the full integration of health and social care - a national health and care service, if you like".

"As people get older, we've got to support them in their homes so they don't end up in hospital," he added.

"But we've also got to deal with the here and now and we can't have people waiting on trolleys in corridors and being treated in the back of ambulances.

"The government has got to get a grip on the situation and it's got to do it now."

Health Secretary Jeremy Hunt, meanwhile, told 5 live: "I've visited many, many A&E departments and staff are working extremely hard, you can see the lines on their eyes, people are very tired, they're obviously working hard, 24/7, and it's incredibly impressive what they're doing."

He said that, since the government came into power, the number of people using A&E had gone up by a million a year.

"There is that pressure and we have to do something about it," he said.

He admitted there was "a lack of joined-up thinking between health and social care system which we're sorting out".

He cited a care bill, set out in the Queen's Speech, which will introduce a cap on the cost of social care and give carers the legal right to support from their local council.

"That's also a very big problem because what you're finding in a typical hospital is maybe 100 beds are full of people who actually don't need to be in hospital but the doctors aren't able to discharge them into the social care system."

He said the government was putting £7.2bn into the social care system "to protect it against cuts".

A&Es under pressure

Figures for week ending 7 April 2013, to reflect period of higher demand during colder weather.

Trust A&E units % Patients seen in under 4 hours (target: 95%)

Source: Department of Health

University Hospital Southampton

Southampton General Hospital


Weston Area Health

Weston General Hospital


University Hospitals Coventry and Warwickshire

University Hospital Coventry


Queen Elizabeth Hospital King's Lynn


North West London Hospitals

Northwick Park, Harrow

Central Middlesex, London


University Hospitals of Leicester

Leicester Royal Infirmary


Kettering General Hospital


Heatherwood and Wexham Park Hospitals

Wexham Park Hospital, Slough


Royal United Hospital Bath


North Bristol

Frenchay Hospital


Worcestershire Acute Hospitals

Alexandra Hospital, Redditch

Worcestershire Royal Hospital


Milton Keynes Hospital


Oxford University Hospitals

John Radcliffe, Oxford

Horton General, Banbury


University Hospital of North Staffs

City General, Stoke on Trent


County Durham and Darlington

University Hospital, North Durham

Darlington Memorial Hospital


East Lancs Hospitals

Royal Blackburn Hospital


Southport and Ormskirk

Southport Hospital


South London Healthcare

Queen Elizabeth Hospital, Woolwich

Princess Royal University Hospital, Orpington


Great Western Hospitals

Great Western Hospital, Swindon


Burton Hospitals

Queen's Hospital, Burton on Trent


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