In its report into why 91% of Trusts failed to meet the A&E four-hour maximum waiting time standard during last winter, health regulator, Monitor, has found the problem was not in A&E departments but at other points in the health and social care system.
Last winter saw the worst performance by A&E departments in 10 years. Monitor’s report examined the 10 leading theories about the cause of those delays in an effort to understand their impact on waiting times for patients across England.
The main cause of longer waiting times across the country was found to be the high levels of bed occupancy across the rest of the hospital. With other departments running at 89.7% capacity this had the biggest impact on A&E waiting times as hospitals struggled to admit patients from A&E within the four hours. Added to this problem, more patients were admitted to hospital from A&E last winter than the winter before. There was also a 7% increase in people coming to A&E via ambulance. As these patients usually need to be seen before those already waiting, this also had an impact on waiting times.
The Monitor research disagreed with many popular theories. It has been suggested that people going to A&E were sicker last winter than in previous years. A number of different proxies were used to test this but Monitor found no real difference from the winter before. It has also been suggested that the pattern of when people came to A&E differed, making it difficult for hospitals to predict demand, but Monitor found the opposite to be true.
There was an increase in the number of people going to A&E, but Monitor found A&E departments coped well with the added demand and it wasn’t until patients needed to be admitted to other departments that the delays occurred because full wards meant patients had to wait in A&E.
There was no evidence to suggest that staffing issues contributed to the delays - if anything, Monitor found that A&E departments had more staff available and the ratio of junior to senior doctors was also stable. Nor was waiting for specialists or diagnostic services from other departments a cause of national delays and the number of beds available to A&E departments nationally was about the same as in the previous year. The challenge was finding an appropriate bed in the rest of the hospital for patients who needed one.
There remains a question mark over the impact of delays in discharging patients to social and/or community care. Many Trusts gave this as a main cause of the delays, with a 27% increase in delayed handover of patients, however, Monitor concluded more evidence than is currently available would be necessary to confidently measure the direct impact of this on A&E waiting times.
