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High bed occupancy rates to blame for poor A&E performance – Monitor

The worst A&E performance in a decade against the four-hour emergency care standard last winter was driven, mainly, by hospitals struggling with very high bed occupancy rates, according to Monitor. 

In a report released by the regulator today (3 September), it was noted that half of the 4.7 percentage point decline in A&E performance against the four-hour target could be explained by ‘national systemic challenges’. 

The most important national cause was “hospitals’ inability to accommodate the increase in admissions from A&E departments generated by the increase in A&E attendances”. This inability was a result of hospitals running at very high occupancy rates of 90% or above. 

Monitor added that other factors such as “blockages” at other stages in the patient pathway had either a “minor” or an “unquantifiable impact” on A&E delays. 

It was also noted that no evidence had been found to suggest problems with staffing in A&E contributing to the deterioration in waiting times performance at a national level. 

“The increase in number of A&E staff per attendance kept pace with the increases in A&E attendances and admissions,” said the regulator. But it did say that there are signs that A&E departments are at “significant risk” of not being able to sustain their performance in the medium to long term. 

Monitor added that hospitals did encounter more difficulties transferring patients awaiting discharge to other care providers. 

It was noted that delayed transfers of care increased by 27% in Q3 2014-15 compared to the same period the previous year. According to the response to Monitor’s information request, this is “likely to have been the result of reductions in social and/or community care capacity”.

In the report’s foreword, Hugo Mascie-Taylor, medical director and executive director of Patient and Clinical Engagement at Monitor, wrote: “But what the rigorous number crunching in this report also demonstrates to NHS policy-makers is that accident and emergency (A&E) departments themselves rose to the challenge and coped well with the 6% average rise in A&E attendances last winter. 

“The real bottleneck occurred when it came to finding beds for patients being admitted from A&E. Inpatient wards lacked capacity and became blocked up. This had a significant impact on the exit flow from A&E departments themselves, which in turn had an adverse impact on the ability of staff in A&E to care for their patients.”

The report’s findings suggest that among the best ways to make sure patients receive emergency treatment in a timely fashion this coming winter is to concentrate on smoothing the flow of patients through inpatient wards, to the point of discharge and beyond. 

Responding to the report, Siva Anandaciva, head of analysis at NHS Providers, said: “Today’s analysis from Monitor adds to the evidence base on why emergency departments are under such sustained pressure throughout the year. 

“The NHS frontline has risen to the challenges of improving patient flow, handling delayed transfers of care and caring for patients with multiple morbidities and long term conditions. However, a challenging winter with high bed occupancy, a backlog of elective patients, and increasing emergency pressure from norovirus, influenza and respiratory exacerbations can create a tipping point for performance. Reducing A&E waiting times is a shared responsibility of a whole local health and care system. 

He added that sufficient funding and adequate numbers of highly skilled staff are a prerequisite for successfully managing A&E waiting times. “Without these, the best of flow plans are destined to fail”. 

Dr Cliff Mann, president of the Royal College of Emergency Medicine, added that the need to decongest the emergency department by providing co-located urgent out of hours primary care services is essential to ensure emergency departments are not “overwhelmed”. 

An NHE investigation earlier this year revealed the extent of the pressures on A&E departments last winter at scores of hospitals that did not declared formal major incidents.