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Nuffield Trust issues stark warning on A&E

With the general election fast approaching the NHS remains at the top of the list of issues of most concern to voters. Now a new policy briefing by the Nuffield Trust has warned that continued financial squeeze on the NHS will accelerate the pace at which the urgent care system reaches breaking point. The report concludes that the most significant issue is not the numbers of people presenting at A&E, but the ability to discharge patients safely and quickly from the hospital
as a whole. That is, it is not A&E as such where the problems lie. A&E is part of an integrated system  and the four-hour target for waiting can distort behaviours inside hospitals and health systems in ways that are not in the interests of patients or staff.

Understanding the real problems through the chain is vital to resolving any issues and they make the key point that

 "the complexity of the system and the highly politicised nature of A&E have impeded progress. Problems will not be solved if policy-makers, political leaders and regulators continue to micro-manage A&E. With changeso urgently needed, it is imperative that there is a cross-party consensus on how to move forward and that action is not postponed or delayed for political reasons."

The report chimes well with the BMA campaign calling for an end to 'political games' with the NHS. The authors point out that problems in A&E are complex and difficult to solve and many of the solutions proposed are 'overly simplistic'.

They make the point that the 4 hour waiting  target has played an important part in improving patients’ experiences of care at A&E. Before the target was introduced, 12-hour waits were
not uncommon. The improved performance was maintained for the best part of a decade.  But performance has slipped since 2012,  and the target has not been met since the summer of 2013.

This increased pressure on A&E is demonstrated by some key fact. There has been a sizeable increase in the number of A&E attendances, from 16.5 million in 2003/04 to 21.8 million in 2013/14; a rise of 32 per cent,  was almost exclusively to do with minor A&Es (for example, urgent care centres, minor injuries units and walk-in centres).

The report puts forward several proposals to deal with the problems.

Focus on getting things right in primary care to enable prevention to work – but be realistic about how much can be achieved. Policy-makers can help to boost primary care through supporting moves to build up the skills and capacity of health care professionals to provide high-quality urgent care services outside hospital.

Remove some of the complexity of different services that has been built into the system, and which confuses the public and NHS staff. Creating a single point of access to community services for patients and GPs would be one way to achieve this.

Focus on the way patients move through hospital – and be realistic about what policy-makers can and can’t do. Policy-makers can help by investing in care outside hospital, but they must let providers find solutions that work for their patients.

Foster a better understanding of the way that local systems work.
Promoting better data outside hospital and encouraging the development of systems modelling in individual trusts would be an important start.

Take a longer-term and broader view of performance in A&E – and consider clustered randomised controlled trials of alternative performance measures. Policy-makers should encourage the adoption of a set of richer performance indicators to sit alongside the four-hour target, which could be trialled in certain areas.

The report concludes with a clear warning that our urgent care system is 'near breaking point'. The continued squeeze on resources will accelerate the pace at which it reaches that point. 'Sticking-plaster solutions will not solve the problem'.


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