There was a flurry of news reports last week about A&E. The Health Select Committee took oral evidence on Tuesday 21 May from three senior doctors: Mike Farrar, from the NHS Confederation; Patrick Cadigan of the Royal College of Physicians; and Mike Clancy of the College of Emergency Medicine (CEM). I have delayed writing about it partly because it took a week for a transcript of the oral evidence to appear on the web.
Various doctors took the opportunity to lobby. A letter from 20 consultants in the West Midlands was leaked to the Independent warning about the pressure on emergency medicine:
… All of our EDs have been under immense pressure for the last few months. This pressure has been unprecedented and relentless, and felt by every ED in the region. All have shown inexorable rises in attendance rates, year on year, coupled with increasing intensity in workload, as we care for a rapidly aging population with complex needs. There is toxic ED overcrowding, the likes of which we have never seen before. Nurses and doctors are forced to deliver care in corridors … Our departments are simply not equipped to safely care for such numbers of patients, an increasing proportion of whom are elderly and frail with complex medical, nursing and social needs. All of the available evidence demonstrates that in-hospital mortality is increased when the ED is overcrowded and patients have to wait excessively for beds. Such overcrowding is now the norm in our EDs. In addition, we are seeing an inevitable and unsurprising increase in serious clinical incidents and complaints, as well as delays and deficiencies in care…The position is such that we can no longer guarantee the provision of safe and high quality medical and nursing care in our EDs.
The CEM took the opportunity to put out a report showing that a survey of 46k patients in Jan-Mar 2012 showed that 33% spent more than 4 hours in A&E, up from 27% in 2008. Peter Carter of the Royal College or Nurses said it showed we needed more beds and nurses.
Jeremy Hunt, who became Health Secretary last September when Andrew Lansley got sacked after the disastrous handling of the Health and Social Care Bill, has been busy blaming Labour for overloading A&E by freeing GPs from the obligation to provide out-of-hours care. Andy Burnham (his shadow) put down an Urgent Question which forced Hunt to turn up to the Commons at 12:35pm on 21 May (Hansard col 1055). He repeated his view:
The changes the Labour Government made to the GP contract took responsibility for out-of-hours care away from GPs. [[Interruption.] Labour Members may not like to hear the facts about the consequences of those changes, but let us go through them—they asked the question. Since those changes, 90% of GPs have opted out of providing out-of-hours care, and they got a pay rise in addition. As a result of those disastrous changes to the GP contract, we have seen a significant rise in attendances at A and E—4 million more people are using A and E every year than when the contract was changed.
It turned into classic political knock-about stuff with little light shed.
The most surprising thing about the oral evidence for me was the serious confusion about the numbers. We started with a statement from Clancy that the number of patients (“attendances”) at “urgent care services” had increased by 50% from 2003 to 2011. Apparently urgent care services = emergency departments + minor injuries units + walk-in centres. But “type 1 emergency departments” had only seen a 17% increase from 2003 to 2011, although the “latest data from the A&E statistics” had shown a change of 250k new attendances between this year and last year.
According to the CEM website (eg Apr 2010 doc CEM5324, appendix, table 1) Type 1 ED = a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of emergency patients. That sounds like what most of us think of as an A&E department.
Stephen Dorrell (chairing the Committee) queried the 250k:
… can I push you on this? Where does the figure come from that suggests there has been a 1.7%—I think it is, but I do not know the absolute number—decline in attendances year on year for the first quarter of this year?
Dr Clancy: It may be a function of when you choose to measure it—if you are combining quarters in a different sequence, for example—but I have taken the four quarters that constitute 2012-13 against 2011-12.
Mike Farrar: Just for clarity, the 1.7% reduction I think is a comparison of the previous full quarter against that same quarter a year earlier. In aggregate, the total number has been increased over the 12 months, but actually a quarter comparison of the last quarter compared with the year before in that quarter shows that 1.7% rise.
Q6 Chair: So the 250,000 is a full-year number.
Dr Clancy: Yes, absolutely.
Q7 Chair: Taking full-year numbers and accepting that there is not a major seasonal variation, it is a rising trend.
Dr Clancy: Yes.
So that is clear as mud. But trying to find these figures on the web is a nightmare. Most of the figures, apart from being “provisional” are also marked as “(Experimental Data)”. The latest data I can find is for the 12 months from Feb 2012 to Jan 2013. “Recorded A&E attendances” were 18.30M versus 17.27M for Feb 2011 to Jan 2012, an increase of 6.0%. The year to date figures are for Apr 2012 to Jan 2013 at 15.31M compared to 14.63M the previous year, an increase of 4.7%.
The public sector generally works on years 1 April to 31 March, so the quarters are Q1 Apr-Jun, Q2 Jul-Sep, Q3 Oct-Dec, Q4 Jan-Mar. Presumably that means the 1.7% figure (rise or fall) is from comparing Oct-Dec 2012 with Oct-Dec 2011. Downloading the spreadsheet and taking the figures from the “Emergency Admissions” column gives a 3.3% increase. But the total for Apr 2012 to Jan 2013 is 4.46M, so that must be the wrong data.
But some data, also marked “Experimental”, seems to lag a year behind. HESonline (Hospital Episode Statistics) provides a report dated 23 Jan 2013 giving a “Summary Report” on “Accident and Emergency Attendances in England 2011-2012″. Presumably that means it cover the 12 months to 31 Mar 2012. Under Key facts we find
Data is incomplete; there are 17.3 million attendances reported in A&E HES (excluding planned follow-up attendances), compared to 21.5 million reported in the Department of Health’s Weekly A&E situation reports (Sit Reps) aggregate data for the equivalent period.
When I worked in the Treasury we got much exercised about a difference of around 1-2% between the figures from two ways of measuring GDP, but apparently A&E find it difficult to count patients to within 25%.
Giving up on figures, I watched a C4 news item. A reporter had gone to the A&E at the Royal Devon & Exeter Hospital to interview Dr Adrian Harris, apparently head of A&E. He had spent two years implementing a plan to improve the situation there. It had become intolerable (for him) when he had patients stacked up in A&E with no understanding of which of them were dying and which were merely the worried well. He had managed to get more resources, but even more important he had managed to reduce the number of patients turning up by an ad campaign aimed at teenagers and those in their 20s, suggesting that they go to their GP for minor ailments.
I am left fairly confused. However, one point seems indisputable. The 70% rule is totally dotty. For those who missed it, the government decided to give A&E departments an incentive not to take too many patients, so they decreed that payments by commissioning bodies for patients above 2009 levels should be paid 30% to the A&E and 70% to NHS England. In other words, A&E got a massive fine (of 70% of their costs) for treating patients above 2009 levels.
The justification was that the funding to NHS England could be used to fund ways of treating these patients outside A&E (eg paramedics on ambulances treating the patient themselves, or GPs providing better out-of-hours care). But it is quite simply bizarre. A&E have no control over who turns up. What are they supposed to do? Turn away car crash victims in February on the basis that they have reached their quota for the year? Surely governments have had time by now to start to grasp the limitations and dangers of ill-thought out targetry.
But worry not, Hunt is on top of the situation:
Last week, NHS England announced that it would change the basis on which tariff money for certain A&E cases is spent. For the first time, hospitals will have say in how money is spent to alleviate demand when that money is withheld for numbers exceeding the 2009 baseline.
Having a say. Well, that solves that one.