Sentry Page Protection
Please Wait...
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.
Example Interview Questions
- 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?
Interview Questions & Example Answers
Why are A&E waiting times increasing?
A&E times are increasing for a variety of reasons. Firstly, A&E attendance has risen substantially over the past few years, on average more than 2% per year since 2011. There are also increased hospital admissions, despite a reduction in beds. With greater pressure on the hospital itself - be it the staff, or the amount of tests the hospital has to process in any given time - comes greater pressure on the A&E as the systems it relies on slow down. Staffing pressures have also contributed, with emergency medicine in particular subject to a rapid churn of its doctors, with most of the experienced doctors choosing to retire early.
Why are A&E waiting times used as a yardstick for NHS performance?
A&E times are used to monitor the performance of a hospital as a whole due to the manner in which the A&E department will interact with almost the entirety of the rest of the hospital. For example, if a particular diagnostic test or investigation is required, then that test must be ready with no delays in the pipeline. If a patient needs to leave A&E and be admitted onto a given ward, then that ward must have bed space and be ready to receive a patient. Thus, we can see how if the hospital is not functioning adequately, then the A&E will bear much of the brunt of it - and in turn this poor performance in the hospital will be reflected as a poor A&E wait time.
How can we make the situation better?
We are perhaps overdue for some form of reform of the A&E system in the UK. As it stands, the triage system is far from perfect, meaning that priorities - whilst normally given correctly - could be improved. However, a concerted effort to make waiting times longer for minor injuries, in order to fast-track anything more major, could lead to hugely long wait times for those with minor injuries - which could lead to them leaving the hospital without treatment. One solution is therefore to encourage those with minor injuries to see their GP for guidance through an emergency appointment, rather than attending A&E. Other services like NHS 111 allow for the public to quickly gain access to medical advice without having to attend A&E. In the future, telemedicine might allow remote A&E consultations to quickly triage those who need to attend and those who are better staying at home or seeing their GP.
Are there multiple types of A&E? If so, what are they?
The UK has three separate types of emergency departments, or accident & emergency departments. Type 1 departments are the major emergency departments, which have 24-hour service, are led by consultants, and have full resuscitation facilities. They take the majority of patients. Type 2 departments are also consultant led, but for particular problems - an example could be a dental A&E. Type 3 departments treat minor illnesses or injuries only and include minor injury units and walk-in centres. There are a total of 180 Type 1 departments across the UK.
Is the government trying to reduce waiting times?
Whilst the government is no-doubt trying to reduce waiting times to some extent, it seems aware of the difficulties of this without significant investment. In fact, the initial target set in 2004 was that 98% of patients would be seen within 4 hours - this was subsequently relaxed to 95% in 2010, although there had been an initial increase in the number of patients who were successfully admitted or discharged within four hours after the target was first introduced. It therefore seems that the government is focused more on streamlining current processes and ensuring that they work efficiently and safely, rather than making waiting times radically shorter.