Are A&E waiting times bad because too many people are going there who don’t need to?
Overview
If you’re in A&E, it is normally because of a potentially serious and urgent health issue or that you have nowhere else to go for your health concern. A&E represents the front door of the NHS for many people, but recent years have seen worsening waiting times for the service.
This piece explores what is driving these increases in waits. Is it that many more people are turning up at the front door? Is our population facing more urgent health crises? Could it be public attitudes and where people prefer to receive care? Or is it a result of wider system pressures a lack of capacity outside of hospital and in the community?
Exploring the evidence
It is true that A&E waiting times have worsened. The best-known measure in England is the four-hour standard within which time at least 95 per cent of patients attending A&E should be admitted, transferred or discharged. The NHS has not met this target at a national level in any year since 2013/14, with the standard missed in every month since 2015.
It is also true that this is being driven in part by more people arriving at hospital, with attendances to major A&E departments increasing over recent years.
But is this all that is affecting waiting times and do many of the attendees not need to be there?
The simple answer is no, it is more complicated than that. If there were too many patients in A&E who did not need to be there, we would expect the rate of admission, once someone has been initially assessed, not to have increased. However, we are seeing the opposite, with increases in the rate of admission.
Increasing admissions
Multiple health conditions: Admissions have also grown for patients with multiple health conditions, as well as for older patients, with those aged 65+ accounting for a largest number of attendances among adults and children. This increased likelihood of patients requiring admission points to people arriving in A&E being sicker than before, and genuinely needing to be there.
This in turn increases average waiting times. As more patients with increasingly complex conditions arrive at A&E, the more tests and treatments they require places further pressure on already constrained A&E resources. This increases the average time a patient waits for treatment, their length of stay in A&E and without additional capacity, busier A&E departments.
Community and primary care services: The lack of capacity in or awareness about community and primary care health services leaves some patients feeling that A&E departments are the only place they can go to get immediate help. This is despite the recent campaign by the NHS to increase public knowledge of services such as NHS 111.
GP appointments: People are also finding it harder to get GP appointments. Data shows that 2.8 million people each month are unable to contact a GP practice. Waiting for GP appointments has become a source of concern for the public set within a context of falling numbers of permanent qualified GPs. This is despite primary care providing more appointments since before the pandemic including extended access over evenings and weekends.
This has had an impact on the way that people interact with the health and care system.
An important point to note is that waits in A&E are not experienced uniformly: Type 2 and 3 A&E departments (single specialty or minor injury units) routinely meet their target of seeing 95 per cent of patients within 4 hours. Whereas Type 1 A&Es, major A&E centres, perform less well due to them dealing with higher numbers of attendees and more serious cases, bearing the brunt of the issues described above.
The bottom line
A&E departments are under enormous pressure, and with the current backlog in elective care it is likely that patients will continue to gravitate towards A&E departments where they know they will be seen relatively quickly. However, data and evidence show that it is not simply the case that longer waits are a result of increasing attendance with too many patients going to A&E when they do not need to.
A&E waits are a result of several factors; more patients are arriving at A&E sicker than they were before, increasing the length of time they are likely to spend in A&E and stretching constrained resources further. Furthermore, wider system pressures and a lack of capacity in primary and community care has led to patients increasingly turning to A&E to receive care too.
A&E pressures and waits are a system-wide challenge. In order to address these challenges, NHS strategy and policy will need to catch up with the long-standing policy ambition to deliver more services out of hospital and closer to home. Initiatives such as the urgent and emergency care plan are welcome, but greater focus is needed on increasing capacity and availability of high-quality services outside of hospital, alongside an appropriate and resilient workforce – all of which require additional investment.
Read more from our series of explainers, providing facts and figures to challenge common misconceptions in health and care.
