Is there a crisis in A&E?

Accident and Emergency departments are the open door of the NHS, treating patients 24 hours a day, 7 days a week, 365 days a year.

But with reports that A&E departments are on the brink of collapse, the government has commissioned a report into the state of emergency care in England.

So how do we explain the rising tide in A&E admissions? And why aren't hospitals coping? 

More visitors

As the size of the UK population increases, A&E departments are dealing with more visitors. 

Here's what's happened to A&E attendance since the late 1980s:

Source: King's Fund

What's the cause?

The Coalition has blamed GPs (and the Labour party) for the increase in A&E admissions. Back in 2004 Tony Blair's government made GPs an offer: in exchange for £6,000 of their salary, they could reduce their working hours and would no longer need to be on-call during the evenings and at weekends.

Recently Jeremy Hunt has argued that more people are turning up at hospital because they can't get an appointment with their GP:

"The decline in the quality of out of hours care follows the last government's disastrous changes to the GP contract, since when we now have 4 million more people using A&E a year compared to 2004." 

However, the sharpest jump in attendance was recorded before the government offered GPs the new working hours contract. As the graph above shows, it's from 2003 that the data begins to include additional patients who are visiting smaller, specialist A&E departments (so-called 'type 2' units) and minor injury centres ('type 3' units). 

Some of these people might have turned up at major type 1 units if type 2 or 3 units didn't exist. However, what the evidence does suggest is that patients with less severe injuries are mostly responsible for the rise in A&E admissions. In other words, they might be in A&E because they can't go to their GP. 

The social care system has also come in for criticism, with those aged 65-85 now accounting for a larger proportion of emergency admissions than five years ago. It's suggested that many who are old and frail only end up in A&E because the local authority has failed to arrange proper care for them. (The government recently announced that £3 billion of NHS money would be spent on 'integrating' health and social care services, with the idea that this will "help relieve pressures on Accident and Emergency".)

But it might also be that these new type 2 and 3 units have been dealing with patients that previously wouldn't have sought treatment ('unmet demand'), while also encouraging more people to seek hospital treatment ('supply induced demand').

Most likely, the rise in A&E admissions is due to a combination of all the above: fewer GP practices being open at evenings and weekends, an over-burdened social care system, and a surge in demand.

Longer waits

An increase in A&E attendance is not necessarily a problem, provided hospitals can cope with the extra patients. However, there's evidence that many A&E departments are struggling. 

In the last six months, there has been an increase in the number of NHS trusts missing the Department of Health's A&E target - that at least 95% of patients wait no longer than four hours to be admitted, transferred or discharged.

Source: NHS England statistics quoted in answer to a Parliamentary Question 

While there is seasonal variation in waiting times (with winter being a particularly busy time), the performance of A&E departments has caused concern in the highest ranks of government. 

The number of patients waiting more than the four hour limit has increased since the Coalition arrived in office, even though the current government actually reduced the target from 98% (of patients waiting more than four hours) to 95% in June 2010.

What's the cause?

According to the College of Emergency Medicine, there's a shortage of A&E doctors at consultant, middle grade and trainee level. It claims that only one in six departments is sufficiently staffed. And at weekends, when A&E departments are likely to be busier, it's more like one in seven.

Patients will also wait longer in A&E if there are a lack of available beds in other departments. According to Jeremy Hunt, NHS Chief Executives have said that the biggest obstacle to their hitting the 95% target is the problem of 'delayed discharges' - often referred to as 'bed blocking'.

What now? 

The government will await the response of Sir Bruce's report into emergency care. In the meantime, A&E departments up and down the country are preparing for another long, hard winter.