A&E Winter Pressures

Winter is a challenging time for health services and particularly for Accident and Emergency departments. Last winter over 350 A&E departments were, at some point, too full to take patients and close to 100,000 ambulances waited over 30 minutes outside A&E hospitals to deliver patients requiring care.

These problems aren’t caused by more people attending A&E departments; the number of A&E attendances actually fall during winter. This raises the question of what is happening, and how is the NHS endeavouring to address the issue and ensure hospitals can cope through the winter.

What is happening?

The cold of winter exacerbates underlying health problems and introduces other health risks. The effects are more likely to impact on the elderly and vulnerable, a fact that contributes to the strain felt by A&E.

One health risk is that during winter months heart attacks are more common and respiratory conditions peak. There is an increased chance of suffering from influenza, the aptly named winter vomiting disease (aka norovirus), and hypothermia. Even those remaining fit as a fiddle face a greater likelihood of a slip or fall in icy conditions, or as a result of enjoying the festivities a bit too much. Of course these events are not mutually exclusive.

Once in A&E, the elderly take longer to assess and treat, and are more likely to require bed or trolley space. They have increased care needs and are more likely to be admitted. Roughly four-fifths of people aged 75+ attending A&E are admitted, in contrast to only one-fifth of under-30s. So even in a period when attendances decrease, pressure on services can increase as patients with greater and more complex needs present at A&E. As beds become full, and patients are not moved on, new patients cannot be accepted from ambulances or examined: a situation known as ‘congestive hospital failure’. As a result patients may be diverted elsewhere and departments may miss their 4 hour waiting time targets.

Addressing the issue and coping this winter

Addressing the issue is focused on two areas: prevention being better than cure, and managing demand by ensuring sufficient capacity and availability of necessary resources.

Encouraging prevention and early treatment of illness helps to reduce the numbers reaching A&E. The public have been urged to seek help before they need hospital care. The message from senior clinicians is to:

Look after yourself this winter. If you know someone who is frail or elderly or has a serious health problem, then help look after them too. Help or encourage them to go to their pharmacy or GP before one problem leads to another and they end up in hospital.

Much of the preventative strategies for health care organisations, professionals and the public are brought together in Public Health England’s Cold Weather Plan. The key messages for the public are to keep homes warm and to ‘get your flu jab’, if you are one of the key risk groups. The flu plan provides vaccinations to care workers, the elderly and vulnerable, including pregnant women and those with a serious medical condition.

Preventative measures will not fully alleviate the pressure, and hospitals have attempted to prepare for the inevitable. Extra beds have been created, more staff hired and doctors are working extra shifts to manage the demand. Some NHS Trusts have been operating their winter plans since September to help them cope better.

The Government has provided additional funding to hospitals that are particularly vulnerable to winter pressures, with a smaller pot of funding to those deemed to be less vulnerable. Hospitals have used funds to recruit more staff, buy extra equipment, build and extend wards and emergency units and improve links and working arrangements with other health care organisations.

Current performance

Whilst major A&E departments continue to miss their 4 hour waiting targets (as they have since the end of July 2013), they appear to be dealing relatively well with winter pressures thus far. Compared with the two previous winters there have been fewer A&E diverts and no A&E closures. So far this winter just over 35,500 ambulances have had to queue at A&E. At the same point last winter this figure was closer to 52,000.

Performance varies across the country however. The BBC has developed a webpage that allows users to see how their local providers are performing; the Library has also produced an interactive visualisation of this year’s winter.

Good preparation will have helped services manage but other factors may have contributed to keeping demand down, in particular the weather and levels of flu. 2013 saw the 33rd warmest December since records began in 1659, and influenza levels have remained at relatively low levels.

So far winter 2013 has not brought the catastrophe that some had predicted. However with half the winter still to go there is time for this to change, particularly if temperatures plummet below the current relatively balmy levels.

Author: Matthew Keep