NHS: Accident and Emergency Services

Lord Bishop of St Albans Excerpts

Thursday 15th January 2015 Lords Chamber

Asked by

[The Lord Bishop of St Albans]

To ask Her Majesty’s Government what is their assessment of the pressures facing accident and emergency services.

[The Lord Bishop of St Albans]

My Lords, I come to this debate not as a doctor with specialist medical knowledge nor with any special insights into the complex processes which hospital managers have to manage. I approach it as someone from an institution, the church, which has been concerned for healing, in its broadest sense, from its very foundation and I live opposite what is left of the great medieval monastery of St Albans, which for centuries was a centre of healing, with its infirmary and herbarium. In my present role, I have regular contact with the hospitals across Hertfordshire, Bedfordshire, Luton and Barnet, which make up the diocese of St Albans.

I also come as someone who has received the benefits of A&E departments in my own family. Not many years ago, my eldest nephew was diagnosed with a brain tumour and had to have serious surgery on several occasions. Sadly, he has since died from the tumour. About five years ago, he and all the extended family were staying with me for Christmas and, in the early hours of Boxing Day, he had a fit. I remember vividly the intense panic as we were all roused out of sleep to find what was going on; as we waited anxiously for the ambulance, willing it to come because we all felt so helpless; as he was rushed into Watford General Hospital A&E department. What a relief it was, in that terrible time, to feel there were people around who knew what they were doing. I am well aware from talking to doctors and nurses and visiting hospitals that the widespread coverage in the media about A&E departments has not only been frustrating for many of those front-line people but profoundly demoralising. I pay tribute to all who work in such departments and thank them for their tireless service, not least those in Watford General Hospital.

The House will be aware that pressures on A&E services have been mounting over a number of years. While the NHS always faces pressures in the winter, these have been compounded by our ageing population. We now have 350,000 more over-75s than four years ago. This rise has occurred simultaneously with a significant increase in A&E attendances and a greater level of sickness among those who arrive, leading to an increase in emergency admissions of nearly 6% on last year. In my own diocese, the A&E departments are facing these challenges with varying degrees of success. For the week of 5 January, Watford General Hospital fell below the Government’s target of 95% of patients seen in four hours, while Luton and Dunstable University Hospital exceeded this target, in line with its track record as one of the top 10 trusts in the country.

What is causing this? Attendances are up, but the problems go much deeper. Reports have emerged of people in some places having difficulty getting appointments with their GPs. There have been discussions about changes in social care leaving some elderly and frail people without the necessary support. There are staff shortages and recruitment difficulties in A&E units. Many in your Lordships’ House will be aware of A&E’s three main areas of activity: triage, treatment and referral. Problems tend to arise in bottlenecks at the triage and referral stages. Effective triage is compromised by the presence of patients whose needs do not fit the current services offered in A&E departments. Until quite recently, these individuals were often referred to as “inappropriate attenders”, but current research suggests that it is not the patients who are inappropriate, but the services that emergency departments provide. Estimates vary that between 15% and 40% of patients require services other than those offered by an emergency department and it is the presence of these patients that creates part of the bottleneck at the triage stage.

At the other end, efficient referral after treatment is compromised by problems in bed allocation in acute medical and surgical wards as well as by accessing appropriate services. In many cases, A&E doctors admit patients for further diagnostic tests or when the additional expertise of medical or surgical staff is required. Around 20% of referrals from A&E to acute wards involve patients whose conditions could be treated appropriately by their GPs or in the community. Up to 40% of patients referred to acute wards are discharged within a few hours of admission. The Department of Health says that the effective management of the flow of patients through the health system is at the heart of reducing unnecessary emergency admissions and managing those patients who are admitted. The problem is how to identify how this can best be done.

Much of the debate in the other place has, not surprisingly, been highly politicised because we are approaching an election. I hope that, in this debate, this House can stand back and take a more dispassionate view, drawing especially on the huge knowledge and experience of some noble Lords who have intimate, personal working experience in the National Health Service. I hope that we can set this debate in a slightly wider and longer term context. Certainly, it needs to be set against the background that A&E services across Europe are facing similar challenges.

Until recently, some emphasis has been placed on attempts to demagnetise emergency departments, even though it has long been established that this tactic meets with little success. Both self-referrals and referrals from GPs willing to short cut protocols have resulted in increased numbers of patients presenting for treatment. Some 20% of A&E patients decide to attend a day in advance, the majority do not consider going first to their GPs, and 80% fail to make use of advice services such as NHS Direct. While there has been a change in people’s expectations and preparedness to wait for an appointment with their GP, we must not overstate the extent to which A&E services are being clogged up by misuse. The vast majority of A&E users are not inappropriate attenders; that is to say, they should be within the health service.

Recently, some pilot projects have begun to change the range of services available in A&E departments. For example, some GPs co-locate in emergency departments as primary care physicians while others locate out-of-hours GP services adjacent to A&E departments. Other GP practices have supplemented NHS Direct with their own telephone consultation services, enabling patients to speak with their own doctors. There is growing evidence over the past decade that these approaches relieve pressure on A&E staff and enable efficient triaging at the front door. Similarly, pilot projects that locate acute medical and surgical staff in or approximate to A&E departments at peak times have enabled improved patient flow as additional diagnostic expertise has resulted in inappropriate admissions to acute wards being minimised. Co-location of acute assessment units has also enabled patients to be monitored and assessed without them either remaining in A&E or by being admitted to acute wards. These approaches require strong leadership, close co-operation among health professionals, focus on patient care and strategic implementation. What more can be done to enable every hospital to have its own 24-hour GP practice?

Ultimately, resolving the current and on-going A&E crisis involves a systematic change to the ways in which health and social care are organised. Access to good social and community care can relieve pressure on GPs, enabling them to play a greater, proactive role in emergency medicine. Allied with a willingness to break down barriers within hospitals between emergency departments and acute wards, strain on A&E staff can be alleviated and patient experience improved. I hope that this debate will play a small part in exploring the complex reasons for the current problems and help us in addressing the challenges facing A&E departments today.