Are we missing a trick on A&E?

Card trick

The problem with a relentless focus on something - such as the A&E waiting time target - is that there is a risk the real issue is missed.

Like a magic trick, the eye is diverted elsewhere and fails to spot what has been happening right in front of it.

This may be worth bearing in mind as we follow the story of the NHS in England this winter.

In many respects, the health service has coped well so far.

Yes, the four-hour target was missed at the start of December. But that is not unusual.

During much of the Christmas period it was hit - although this is probably largely down to fewer people attending hospital.

And while the numbers seen within the timescale have again dipped under the 95% target for the first week of 2014, performance on many measures, such as cancelled operations and ambulances queuing, are still up on last year.

Start Quote

The more emergency cases that are admitted the more challenging it becomes for the rest of the hospital system.”

End Quote

And yet, the New Year message from NHS England has been one of caution.

This week Dr Barbara Hakin warned against complacency and said there were tough times ahead.

Why? The main reason is that emergency admissions are up. Before Christmas they were topping 105,000 a week - the highest number since they started being recorded in 2010.

Essentially, these are the serious cases. The majority of people who arrive at A&E are seen and treated without being admitted into the hospital.

But for patients with more complicated or life-threatening conditions admission to hospital is needed.

This matters because the more emergency cases that are admitted the more challenging it becomes for the rest of the hospital system.

In the long-run, the very measures that are holding up so far could start to unravel.

At the moment, it is unclear why this rise in emergency admissions has been seen.

The extra money the NHS was given in the summer, for winter planning, was meant to alleviate just this by helping to provide extra support in the community, such as boosting district nursing and social care, to stop people becoming acutely unwell in the first place.

Possible gaming

It could be that there are more acutely unwell patients this winter?

Or could it be because the NHS is under so much pressure to hit the four-hour waiting time target that when a patient is close to breaching it they are admitted as an emergency to stop the clock ticking?

Data from the Health and Social Care Information Centre, based on previous years, shows that in the final 10 minutes of the four-hour target you are twice as likely to be admitted than in the 10 minutes before that - and three times as likely in the 10 minutes before that again.

Could there be gaming going on? I put that to senior people at the information centre and their response was telling.

Cautious by nature, the statisticians were never going to stick their necks out to suggest it is. But they did concede it needed explaining.

Publicly, hospitals claim it is purely a result of the fact that the most serious cases take a lot more assessment and therefore as time goes on the likelihood of admission increases.

That may be true for some patients. But that doesn't explain why after the four-hour mark the admission rate drops off.

It is left to those on the front-line to explain. "Any A&E doctor would be lying if they said that when it approaches four hours you are not influenced," a member of staff from a busy unit told me recently.

"We have a secretary of state who is ringing hospitals up when they breach the four-hour target. You want to avoid that."

That, of course, doesn't necessarily mean they do not need to be admitted.

As mentioned above the longer waiters tend to be the more complex cases. But it does suggest that the staff treating the patient may not have had the chance to take a fully-informed decision.

Once admitted that information - whether it is test results or specialist opinion - still needs to be gathered. It's just that that wait doesn't show up in the four-hour statistics.

Nick Triggle Article written by Nick Triggle Nick Triggle Health correspondent

Why are hospitals under so much pressure?

The NHS across the UK is already struggling to meet its A&E targets, and winter - the busiest time of year - has only just begun. Nick Triggle looks at why hospitals are under the cosh.

Read full article

More on This Story

More from Nick


This entry is now closed for comments

Jump to comments pagination
  • rate this

    Comment number 99.

    Beds continue to be cut and departments and wards closed.
    Far too many people using a service that they have never contributed to the cost of or paid for and targets introduced that fit political needs not clinical ones.
    No wonder its in a state. However, don't underestimate just how good the service is despite the above - particularly when it comes to emergency and critical care.

  • rate this

    Comment number 98.

    I am a speciality doctor in surgery who also has a lot of experience working in A&E. 4 hour targets are an overly simplistic political tool for measuring A&E performance. The focus is on moving patients. A significant number of admissions are unnecessary and pressured due to targets because there isn't enough time to wait for a test result. The pressure gets passed on to bed problems instead.

  • rate this

    Comment number 97.

    I work on the front line of NHS healthcare. I don't think the UK public really know about the huge number of bed closures in our hospitals.
    If there are no beds on the wards, people will wait in A&E and breach.

  • rate this

    Comment number 96.

    I have spent a lot of time at my Local hospital, Stoke Mandeville over the past 12 months and can honestly say they are amazing. I have to walk past A&E and all I see are kids with bleeding noses and broken bones from fighting while drunk plus a great number of (dare I say) imigrants who are probably there for some sniffle or cough. So let's start charging for consultation at A&E and surgeries,

  • rate this

    Comment number 95.

    take away the nurses' station - there is more chatting over this than anything else. I said this once and my GP who is now retired said it would, at a stroke, mean better care for patients and shorter waiting times.

  • rate this

    Comment number 94.

    As a GP, I feel we really do need to invest more in community services. A&E by definition are for accidents and emergencies, and its really frustrating to see patients going there thinking they will be "fixed" when actually they need to see a GP; from experience all A&E will do, rightly, as that's their role, is make it's sure not life threatening and tell them to go to the GP.

  • rate this

    Comment number 93.

    As long as we have an establishment and large minority that are adamant that people who don't and choose not to pay in are entitled to use the NHS there will always be a problem,hand wringing and crocodile tears aren't whats needed to sort out this problem,arm bending putting responsibilities as the per requisite for rights is the only way forward,otherwise the system will implode.

  • rate this

    Comment number 92.

    The perception of NHS & state education is one of high professionalism morals & ethics.

    I do not see how this view is valid while whole hospitals & schools commonly cheat the systems introduced to measure standards & productivity standards for purpose of maintaining/improving standards/productivity.

    It is 100% IMPOSSIBLE to measure NHS standards while cheating is so common

  • rate this

    Comment number 91.

    Is the NHS in England coping well this winter?

    It is actually & factually impossible to know the TRUTH, because of endemic standard proceedures accross NHS to circumvent & cheat statistical measuring to show & manipulate better results, same with state education.

    If I regularly cheated/manipulated/circumvented productivity figures at work I would be sacked for gross misconduct

  • rate this

    Comment number 90.

    What about the NHS in the rest of the country why only report on England BBC or should I say EBC.

  • rate this

    Comment number 89.

    Focussing on one statistic is unhelpful.

    We need to know who is attending A&E with what sort of complaints and why A&E instead of their GP.

    Are they there because they are socially inadequate, have nowhere else to go, don't speak English/understand the GP's role here in the UK, out of desperation (GP has failed them); and so on.

    Simplistically banging on about a single number is pointless.

  • rate this

    Comment number 88.

    The NHS struggles because it is woefully inefficient. We have facilities costing a fortune to run that are mainly only available 9-5! Why?

    We are paying SO much for the NHS that the whole of it should be available 24/7.
    It wouldn't bother me to have an appointment at 3am (at least I might be able to park!)

    The exploding population must have something to do with how A&E copes too?

  • rate this

    Comment number 87.

    I work as one of the 20% that do 80% of the physical work & am happy to. What I see every day is that a large unsustainable amount of ppl take the absolute mick out of the service. Like benefits, it is no longer a safety net but some thing that if u shout the loudest / can't be bothered to do a job you don't 'like' you get everything free. It's mad, should all get what 'entitled' to & collapse.

  • rate this

    Comment number 86.

    Time for people to think outside the box on the NHS. It may have been wonderful in 1948 but it's steadily declined and governments of both sides have failed to keep it up to standard.

  • rate this

    Comment number 85.

    Lewisham hospital successful, Queen Elizabeth hospital failing. Minister's solution: close most of Lewisham to force patients to use the failing QE hospital and so increase the QE's turnover. Why? Because the QE was a public/private partnership and the private shareholders didn't like losing money. Thankfully the courts overturned the decision. This farce shows it's "money first, patients last."

  • rate this

    Comment number 84.

    It's been a heavy cold this year not a flu, yet. The winter vomiting bugs have been, but less aggressive so far. Let's see once a proper nasty flu, like last year, kicks off.

  • rate this

    Comment number 83.

    A "free" service is always abused. Always.

    Whilst the service remains "free", the demand will be insatiable. Utterly insatiable. There is NO way of constructing a system that will limit demand by arbitrary rules. You CANNOT rely on 'common sense'. There will always, always be an unstoppable flow of the worried well, neurotic, mildly depressed with physical symptoms and the plain stupid or selfish

  • rate this

    Comment number 82.

    The problem with the statistics for winter so far is that this has been an incredibly mild winter.
    If there's a turn for the worst in the weather we'll then see how the hospitals cope, there is more to the NHS than A&E.

  • rate this

    Comment number 81.

    The country has too many people. It is that simple. Our infrastructures are struggling to cope. End all child benefit and tax credits for having kids and plough the money into the NHS.
    Too bold and radical for most of the country I suspect but rapid action is needed not rhetoric...

  • rate this

    Comment number 80.

    Re. my previous post. COE is dylsexic for CEO. sorry


Page 1 of 5



BBC © 2014 The BBC is not responsible for the content of external sites. Read more.

This page is best viewed in an up-to-date web browser with style sheets (CSS) enabled. While you will be able to view the content of this page in your current browser, you will not be able to get the full visual experience. Please consider upgrading your browser software or enabling style sheets (CSS) if you are able to do so.