NHS England published a new plan in May, aimed at speeding up the response of A&E services and reducing waiting times, setting a new target of 78% of A&E patients to be seen within four hours – way short of the 95% target that was being regularly achieved prior to 2010.
On the same day the Health Service Journal revealed that 40% of the £150m that NHS England had promised to use as an incentive to improve performance last year had not been distributed – with many of the trusts who applied being ruled out because they “did not meet the criteria” – the key one of which was to hit a higher 80% target to treat A&E patients within four hours.
In other words the “incentive” was only available to the trusts which were already best placed and performing above average, and did nothing to help those struggling to cope.
The NHSE plan came hot on the heels of NHS monthly figures showing April 2024 to have been the worst April ever for numbers waiting over 4 hours to be seen (134,344).
Worse still, more than one in ten emergency admissions through A&E (42,078/403,934) were left waiting over 12 hours on trolleys for beds – the worst April figures since records began in 2010.
Most worrying is that the performance is worst for the ‘Type 1’ patients with most serious clinical needs. They are most likely to need admission and a bed.
Only 60.4% of Type 1 patients were seen within 4 hours, compared with the overall figure of 74.4%, (which is skewed by large numbers of minor Type 3 patients who are easily treated and sent home.) The April 2024 performance for Type 1 patients is worse than the 60.9% figure for April 2023, and dramatically worse than the 77.1% in April 2019.
Many of the patients caught up in this are elderly. According to research just published by the Liberal Democrats, two-thirds of the 145,800 patients who faced 12-hour plus trolley waits last year were aged 65 or more, with the longest delay a staggering five days.
University Hospitals Birmingham alone had 11,539 elderly patients facing 12-hour or more trolley waits in 2023, more than anywhere else in the country, and up from just 491 in 2019.
This worsening performance is partly a reflection of demand for A&E services, averaging 45,000 attendances a day, running 16% higher than ten years ago.
But they are also a result of the increased provision of acute hospital beds falling well short of the numbers of patients needing them. Hospitals were 93.7% full in April, far higher than the 85% level considered to be safe: to achieve that level of occupancy another 10,372 beds would have been needed.
However even these figures may understate the scale of the problem, since at least 36 hospitals in England as well as two Scottish Health Boards have adopted a new “continuous flow” system in the hope of speeding patients through A&E and reducing the lengths of time ambulances are stuck waiting to hand over seriously ill patients.
This system means patients can be admitted, and pass through the Emergency Department, but may not immediately be supplied with a bed on a ward. So at peak times in the busiest hospitals there can be more patients than beds. And this raises serious questions for patients and staff over the safety and quality of patient care.
The system is explained well by Helen McArdle of the Herald newspaper in Scotland, reporting on the ‘GlasFlow’ model, introduced by NHS Greater Glasgow and Clyde in December 2022 at the Queen Elizabeth University Hospital.
“The basic idea – now in place across all its adult hospitals – is that a fixed number of patients requiring admission are continuously transferred at certain times each day from A&E onto wards, regardless of whether a bed is available. This can mean that patients lie on a trolley in a side room or get ‘doubled up’, with two beds in a single-person bay.”
She notes “Obviously it also means that the nurses and doctors in that unit – which may already be short-staffed – might end up caring for 50 patients in a department supposed to accommodate a maximum of 40.”
In England the patients moved on from A&E can’t flow very far, because of continued delays in discharging patients ready to leave hospital – for lack of community services and social care. According to NHS data, across England, numbers of patients fit for discharge but unable to leave have ranged between 12-14,000 for the past two years, and were on average 59% higher in April than three years ago when the figures first began to be published.
In the absence of efficient discharge ensuring a supply of free beds, the “continuous flow” system means patients are being wheeled out of A&E on trolleys and parked for hours – or days on end – in corridors, or in empty spaces on otherwise full wards.
The “flow” is sufficient to take them out of A&E, but insufficient to carry them to a satisfactory place for monitoring and treatment. This makes it difficult for patients and their worried relatives to tell if they are in the midst of a new continuous flow system, or an old-fashioned overcrowded hospital.
One Trust that claims to be implementing continuous flow, but doing so in a way that seems indistinguishable from previous bed shortages, is Norfolk & Norwich Hospital. A recent BBC Newsnight report gave shocking details of a 68-year old patient who was moved at 4am from his bed on a ward … and wheeled out to reception, lining the corridor along with another 13 patients. He remained there for three days, with no privacy, having to ask for water and for his meals, until there was room to put him back on a ward.
In typical BBC form, despite the evidence of the case they describe, the report argues that continuous flow “often means hospitals will have to put patients on beds in corridors, albeit in a planned and risk-assessed manner.”
Newsnight explains that in the UK, the US-inspired continuous flow model started at the North Bristol NHS Trust: but it is implemented quite differently there:
“Newsnight was taken to a complex care ward at Bristol’s Southmead Hospital. In the corridor was a bed on stand-by, but the trust ensures nobody spends the night there, with just one such patient per ward. Screens are available to protect patient privacy.”
It’s almost inevitable that whatever the guidance may say, as the pressure mounts on trusts to reduce the delays in ambulance handovers, more will look to the “continuous flow” method – but with more carried out on the lines of the Norfolk & Norwich chaos than the limited measures in Southmead.
Management in Bristol and Norwich argue that the advantage of more speedy treatment of ambulance patients outweighs the much worse care suffered by patients dumped into corridors, but others disagree.
The policy is opposed by the Society for Acute Medicine, whose immediate past president Dr Tim Cooksley said:
“Degrading corridor care and prolonged waits causing significant harm is tragically and increasingly the expected state in urgent and emergency care. [ …] The fact remains there is simply insufficient workforce and capacity to meet the demands of an increasingly ageing population with multiple health issues and simply no resilience to cope with any excess strain.
“While the small increase in four-hour A&E performance is welcome, it is divorced from every day experience on the ground. For patients experiencing appalling conditions and staff working in persistently overcrowded areas, the suggestion things are improving will be bewildering.”
A blog on the Health Foundation website is also highly critical, urging health staff not to get too comfortable with corridor care – because we can be sure patients won’t. The blog explains:
“The increasing frequency of corridor care is alarming – both for patient safety and staff morale, and because it risks normalising substandard care delivery. […]
“For staff, there is consistent evidence that this practice leads to lower morale and poorer mental health outcomes in the workplace. It also impacts their ability to care for patients, as staff working in corridors don’t have direct access to – or room to use – routine equipment such as observation machines and patient hoists. […]
“For patients and their families, the experience can be traumatising. Patients can feel invisible out of the sight of staff. The physical environment is distressing, with harsh lighting, little to no privacy and difficulty accessing basic needs such as water or even a toilet. As such spaces are not designed to accommodate people for long periods of time, families are left standing for hours, unable to leave their relative due to fears they will be alone or forgotten.”
The Royal College of Emergency Medicine has recently calculated that the avoidable deaths arising from overcrowding and delays in A&E are running at more than 268 per week.
The RCEM reaches this figure by using the Standard Mortality Ratio – which calculates there will be one additional death for every 72 patients that experience an 8–12-hour wait prior to their admission – RCEM estimates that there were almost 14,000 associated excess deaths related to waits of 12 hours or longer in 2023 – more than 268 a week.
It is with this in mind, and in the hope of reducing risk to patients and reaching the most pressing cases sooner that the RCEM has also given very cautious support to:
“the practice of boarding [sending patients to wards to wait for vacant beds], and of Full Capacity Protocols, as “least-worst” options, […] as part of a suite of measures to tackle ED (and hospital) crowding. They may represent part of a more honest appraisal of, and response to, the mismatch of capacity and demand in the acute and emergency care system.”
So continuous flow in its too-common form of corridor care is nobody’s preferred option: at best it is a lesser evil, as too many patients need care from too few staff in too few beds.
But at worst it can be a danger and a misery for patients, a constant worry for nursing and medical staff who could easily be scapegoated for any harm suffered by patients, and an embarrassment to management, who can wind up effectively admitting that this “full capacity protocol,” designed for exceptional moments, is being used most of the time.
The pressures that have led to corridor care show no signs of abating. The Health Foundation blog points to the root cause of the rising demand for NHS care:
“There is a dual challenge whereby population health is worsening alongside an erosion of health and social care services. Meanwhile, we have an ageing population, with more people living longer in ill health, causing demand for services to rise. The health and social care system, particularly primary care, has not seen the required investment to ensure this demand can be met.”
It is remarkable that despite the obvious problems posed by corridor care, and the reservations of staff in the front line of implementing it, as Helen McArdle says “there has been no formal independent evaluation anywhere in the UK to assess the safety of flow models”.
Nor has NHS England made any moves to assess the model: they told the BBC in May there are “no plans to conduct a national evaluation.”
This must mean that they know the problems, but don’t want to publicise them or face up to them.
Will the next government be any more concerned than the current government to address these problems of resources that flow from 14 years of under-funding?
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