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Medicine Interview Hot Topics: A&E Waiting Times
Overview
There are three categories of A&E departments in the UK. Type 1 departments are major emergency departments, with 24 hour service, led by consultants, and full resuscitation facilities. They take the majority of patients. Type 2 departments are also consultant led, but for particular problems - like a dental A&E. Type 3 departments treat minor illnesses or injuries only. They include minor injury units and walk-in centres.
In 2020, there were 132 NHS trusts operating Type 1 departments, with a total of 180 across the country (i.e. some trusts operate multiple departments).
Overview
There are three categories of A&E departments in the UK. Type 1 departments are major emergency departments, with 24 hour service, led by consultants, and full resuscitation facilities. They take the majority of patients. Type 2 departments are also consultant led, but for particular problems - like a dental A&E. Type 3 departments treat minor illnesses or injuries only. They include minor injury units and walk-in centres.
In 2020, there were 132 NHS trusts operating Type 1 departments, with a total of 180 across the country (i.e. some trusts operate multiple departments).
Increased waiting times
Over recent years, A&E waiting times have worsened significantly. The standard which the NHS aims for is called the four-hour standard. It refers to a pledge that at least 95% of patients attending A&E should be either admitted, transferred or discharged, within four hours. The time begins from the moment the patient arrives. It has become used as a barometer for the overall performance of the NHS.
The initial target was set at 95%, in 2004. However, it was relaxed to 95% in 2010, despite an initial increase in the number of patients who were successfully admitted or discharged within four hours after the target had first been introduced.
The NHS has not met this four hour standard for a year since 2013/14, and has missed the standard every month since July 2015. In 2018-2019, only 88% of patients were admitted or discharged within 4 hours. Performance is best in type 3 A&E departments, and much worse in type 1 departments - with only 73% of patients in type 1 departments being seen within four hours.
Why are patients waiting so long?
There are a range of factors at play, which are systemic problems within the NHS. Firstly, the sheer number of people attending A&E has risen substantially over time - there were 24.8 million attendances in 2018-2019, more than one for every three people in the country. From 2011 to 2019, A&E attendances grew by 2.1% per year on average, leading to a 16% increase overall. Interestingly the highest growth was in type 3 departments - despite type 1 being the most inefficient. There are also far more admissions to hospital, despite a reduction in hospital beds.
Over recent years, the NHS has reduced its total number of beds, relying on modern medicine to allow a quicker turnover of patients, as they are healed faster. However, the rising number of emergency admissions has led to immense pressure on this system, with beds consistently decreasing and the total amount of admissions still rising in face of this.
There are also staffing pressures, with emergency medicine facing a rapid churn of doctors, alongside the most experienced doctors frequently choosing to retire early. It is seen as one of the most intense medical specialties, with three quarters of emergency medicine trainees rating their workload as heavy or very heavy - more than any other group of trainees.
Part of the reason that A&E performance can be seen as a barometer for hospital performance as a whole is because of A&E’s interaction with the rest of the hospital. In order to transfer a patient into a ward, there must be space in that ward. If a particular diagnostic test is required, then that test must be ready to go. Therefore, if the hospital as a whole is not functioning to a high level, then this will be reflected in the performance of its A&E department. Thus, we can see that the declining performance in the four hour standard is indicative of broader problems across the NHS.
Why are patients waiting so long?
There are a range of factors at play, which are systemic problems within the NHS. Firstly, the sheer number of people attending A&E has risen substantially over time - there were 24.8 million attendances in 2018-2019, more than one for every three people in the country. From 2011 to 2019, A&E attendances grew by 2.1% per year on average, leading to a 16% increase overall. Interestingly the highest growth was in type 3 departments - despite type 1 being the most inefficient. There are also far more admissions to hospital, despite a reduction in hospital beds.
Over recent years, the NHS has reduced its total number of beds, relying on modern medicine to allow a quicker turnover of patients, as they are healed faster. However, the rising number of emergency admissions has led to immense pressure on this system, with beds consistently decreasing and the total amount of admissions still rising in face of this.
There are also staffing pressures, with emergency medicine facing a rapid churn of doctors, alongside the most experienced doctors frequently choosing to retire early. It is seen as one of the most intense medical specialties, with three quarters of emergency medicine trainees rating their workload as heavy or very heavy - more than any other group of trainees.
Part of the reason that A&E performance can be seen as a barometer for hospital performance as a whole is because of A&E’s interaction with the rest of the hospital. In order to transfer a patient into a ward, there must be space in that ward. If a particular diagnostic test is required, then that test must be ready to go. Therefore, if the hospital as a whole is not functioning to a high level, then this will be reflected in the performance of its A&E department. Thus, we can see that the declining performance in the four hour standard is indicative of broader problems across the NHS.
How can we deal with this problem?
It has recently been suggested that the A&E system is overdue for reform - those with minor injuries should wait longer than they currently do, and those with serious conditions should be given higher priority than they are currently. Through increasing the effectiveness of triage we could increase the survival chances of those at the highest risk of mortality. However, given that this would result in even longer delay for those with ‘minor’ injuries - and that their diagnosis as having a minor injury will be, inevitably, often inaccurate - this overhaul could provoke problems of its own. Current A&E doctors believe that changing the target will cause more problems than it would solve, and create further delays. As it stands, the government is urging those with minor problems to see their GP, not go to A&E. This public health messaging must continue, as it appears to be the only way to keep A&Es functioning effectively without a huge increase of money and staff.
Potential questions which may be asked in your interview
Why are A&E waiting times increasing?
Why are A&E waiting times used as a yardstick for NHS performance?
How can we make the situation better?
Are there multiple types of A&E? If so, what are they?
Is the government trying to reduce waiting times?