Waiting times in A&E are never far from the headlines.   It threatens to become the defining healthcare performance issue of our time, much like elective waiting times and hospital acquired infections have been in the past.  Performance has deteriorated over the last few years so that most NHS organisations now miss the target most of the time.  The problem has become so entrenched that it can be difficult to see a way back and the future of the A&E target is now being openly debated.  Within the service, concern extends beyond this narrow performance target, to the capacity and organisation of the urgent care system as a whole.   We need new ways to think about urgent care system dynamics to provide new routes into the problem.

Last year, we published a paper in the Emergency Medicine Journal (https://emj.bmj.com/content/34/12/773) which explored changes in the casemix of patients presenting at A&E and in thresholds for admission.  The paper concluded that low acuity patients present less frequently to A&E than has been the case in the past and that many complex patients are now being treated in A&E without being admitted.  This is great news and shouldn’t come as a surprise.  These have been explicit national policy objectives for many years.  But hitting the 4-hour waiting times target under these new conditions is much more challenging.

The paper generated considerable interest and four follow-up projects, outlined below, are now underway.  These projects have emerged from discussions with clinicians and managers who believe that time worn ways of looking at A&E data have run out of steam.  We’ll post the results of these projects on our website over the next few months, drawing out the practical implications for urgent care systems and staff.

We want to address the issues that are important to those working in health and care services so if you have a novel question about the urgent care system that you think we should look into then please get in touch (strategy.unit@nhs.net or @Strategy_Unit).


The Impact of Bed Occupancy and Overcrowding in A&E on Admission Thresholds

Every winter, considerable efforts are made to alleviate pressures on hospitals by avoiding unnecessary emergency admissions.  Two strategies are commonly adopted; to divert patients away from A&E (reducing A&E overcrowding), and to increase in-patient bed capacity, thereby reducing bed occupancy.  But are these strategies likely to lead to reductions in emergency admissions?  We will explore whether admission thresholds via A&E are influenced by bed occupancy levels or overcrowding in A&E.

Project Sponsor: Prof. Simon Brake, Chief Officer - Walsall Clinical Commissioning Group

Lead Analyst: Steven Wyatt


Recognising the Impact of Casemix and Admission Thresholds on the 4hr Target

All A&Es are expected to hit the 95% 4-hour waiting time target and this target level has stood for 8 years.  But patient casemix varies between providers and has become more complex over time.  We will explore the feasibility and impact of recalibrating the target level (from 95%) to reflect changes in casemix over time and differences in casemix between providers.  The project will also explore the interplay between admission thresholds and timeliness in A&E.  Whilst NHSE / I will ultimately determine how timeliness in A&E is assessed, this project will test whether existing administrative datasets could be used to produce casemix-adjusted target levels and what effect that might have.  Our colleagues in the CSU are interested to identify the subset of patients whose needs cannot be met effectively within a four-hour period in A&E and to develop alternative pathways for these patients.

Project Sponsor: Andy Williams, Accountable Officer, Sandwell & West Birmingham CCG

Lead Analyst: Steven Wyatt


What events might predict pressure in the urgent care system?

Long waits in A&E for patients are associated with poor patient outcomes and creates a stressful working environment for staff.   If we could predict when pressure in A&E will build-up then we may be able to act to prevent long waits.  There are many plausible theories about the events and conditions that precede pressure in A&E, but little work has been done to evidence these theories.  We will explore the association between measures of urgent care activity and indicators of pressure in the urgent care system; and assess the potential of different measures to forecast the build-up of pressure in the system. 

Project Sponsor: Dr Kiran Patel, Medical Director, NHS England (West Midlands)

Lead Analyst: Paul Seamer


Urgent Care System Capacity and its Impact on System Performance

Urgent care systems feel under pressure when demand outstrips capacity.  We are awash with information on demand, but data on urgent care system capacity is not routinely or systematically collected.  We will develop a set of measures relating to the capacity of the urgent care system, collate this data across the West Midlands, and explore the impact of capacity on system performance.

Project Sponsor: Dr Kiran Patel, Medical Director, NHS England (West Midlands)

Lead Analyst: Sarah Jackson