Accident & Emergency: In Crisis?

What Is A&E?

There are three main types of A&E departments in England:

• Type 1 departments are what most people think of as an A&E service: major emergency consultant-led departments providing a 24-hour service. These departments account for most attendances (63% in 2018/19).
• Type 2 departments are dedicated to specific specialities (e.g. treating only eye conditions or dental issues).
• Type 3 departments treat minor injuries and illnesses and include walk-in centres or minor injury units.

The most prominent measure of A&E performance in England is the four-hour standard.

What Has Happened To A&E Waiting Times?

Most A&E departments across England and Wales have struggled to achieve the four-hour standard, as the NHS has experienced a sustained period of financial austerity and staffing pressures.

The NHS has not met the four-hour standard at a national level in any year since 2013/14, and the standard has been missed in every month since July 2015 as of August 2020.

Read more about A&E waiting times here.

Why Are Patients Waiting Longer?

There are a few key reasons why A&E patients are waiting longer:

• Rising A&E attendances. Before the coronavirus pandemic, an increasing number of people were attending A&E. On average in 2018-19, 67,991 people attended A&E each day in England; this was a 17% increase on the 2010-11 numbers. Get key A&E patient statistics.
• Fewer hospital beds. ‘Exit block’ occurs when there is a delay in admitting patients to the ward from A&E due to a lack of beds. The problem of exit blocking leads to delays in diagnosis and treatment, which can in turn cause harm to patients. See the latest analysis on hospital bed numbers.
• Age of patients. An ageing population is likely to also contribute to increased pressure on A&E, as three-quarters of 75-year olds have more than one long term condition, increasing to 82% of 85-year olds. Read the latest annual report from the NHS that breaks down A&E attendance.
• Unnecessary A&E attendances. Another issue is that many people may attend A&E unnecessarily because they don’t know where to go for treatment, or can’t get an appointment with their GP.
• Delayed discharges. Sometimes it can be difficult to discharge patients from hospital as they may need additional home support or a place in a nursing home. A patient who no longer has a medical condition requiring hospital treatment but who cannot be discharged from hospital is described as a delayed discharge or “bed blocking”, which in turn may cause a backlog to A&E due to bed shortages.
• Staffing shortages. Staffing issues in A&E departments often lead to an increased workload for the remaining workers, a greater number of sick days and loss of workers due to transfers or resignations. The burnout rate gets progressively worse for the longest-serving staff, and the cycle can drag down the efficiency of whole departments. Coronavirus made this issue even more acute.

Time To Scrap The Four-Hour Target?

Although the four-hour target is a useful barometer for the overall performance of the NHS and social care system, it’s important not to place too much emphasis on it because it does not provide a full picture of how A&Es are performing. For example, two departments could see the same proportion of patients within four hours with very different average waiting times. Moreover, the safety and quality of care, in addition to patient experience, are just as important as how quickly care is provided.

Some other measures are also used alongside the four-hour target to gauge the quality of service provided in A&E, such as:

• The number of re-attendances within seven days of their first attendance.
• The waiting time to see a clinician.
• The Care Quality Commission (CQC) rating of core hospital services.
• Patient satisfaction surveys, such as the 2018 national survey of patients who have used urgent and emergency care.

In 2018, NHS England began to review the four-hour A&E standard and whether it should be updated. The review was published in March 2019, suggesting the current four-hour A&E target should be replaced with several new measures instead. However, in September 2022 the Health Secretary, Thérèse Coffey, ruled out changes to the four-hour target soon after her appointment.

Other Solutions

Although expensive and time-consuming, one proposed solution to the A&E crisis is to assemble GPs, A&E staff, urgent care teams and pharmacists to create new emergency and urgent care hubs. This could reduce the burden on patients to refer themselves to the most appropriate source of care. These hubs would serve much larger catchment areas, and could draw staff away from more rural surgeries which are often most used by the elderly, vulnerable and less mobile.

In February 2017, it was announced that Peterborough and Cambridgeshire CCG were to run a pilot of Local Urgent Care Services (LUCS) hubs at three hospitals. The aim was to improve access to urgent care by providing a “one-stop service” for patients suffering from minor injuries and illnesses, and to treat a broader range of patients locally. Nearly 13,500 people used the service in the first year, helping to reduce pressure on the local A&E departments. However, setting up such hubs can prove to be difficult because of obstacles such as staffing.

Investing as much money as possible in primary care – such as local GP surgeries and community pharmacies – would also ensure that more patients are treated at a grassroots level and reduce their need to go to A&E.

A&E Interview Questions

Some questions you could be asked during your interview about A&E and hospitals include:

• Why do you think A&E waiting times have increased?
• Can you think of any strategies for reducing the strain on A&E departments?
• What are the implications of setting targets for A&E waiting times?

Check our Interview Question Bank for more questions – and a guide to answering questions just like this.