What's really causing the A&E crisis - and how can we fix it?

Singularly stupid 'marketising' policies have caused our A&E crisis - and none of the main parties have fully grasped what needs doing to fix it.  

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Caroline Molloy
30 January 2015
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Image: Condition critical?

After weeks of headlines about the “crisis in hospitals” over Christmas, last week the government proudly announced that it had only just missed Accident & Emergency target wait times that week.

When you’re chasing headlines saying “we’re still failing, but not as badly as we were before” you know things are bad.

This week it emerged that the government's solution to the spiralling numbers of hospitals declaring ‘major incidents’ was - to make it harder to declare a ‘major incident’.

Even the British Medical Association - a long-time critic of the ‘target driven’ approach to monitoring A&E - said the number of patients waiting over 4 hours showed that ‘services are stretched to the limit’.

Few patients realise that if their local A&E misses its waiting time targets, or receives too big an increase in the number of its A&E patients, it is hit with huge fines. Just one hospital, Royal Stoke, this month revealed it has had to set aside £2million for fines for missing targets (including a £3/4 million fine for long A&E waits). Imposing such fines on already struggling hospitals is a singularly stupid policy, when A&Es are mostly just the frontline to which problems elsewhere in the NHS back up.

Last year nearly 300,000 patients waited more than half an hour in the back of an ambulance before they were even allowed through the door to start the A&E clock. As well as endangering patients, this messes up the ambulance service’s targets - and fines - of course.

Once through the doors and after your 4 hour wait to be seen, that’s not the end of the story. In the fortnight before Christmas, almost 21,000 people who’d been seen and judged to need a bed, waited between 4 and 12 hours on a trolley - four times the level in 2012. Earlier this month some A&Es took the nuclear approach, and simply shut their doors to new patients.

So what’s at the root of all this? And what can we do to fix it?

We’re generally given two answers and sets of ‘solutions’ to the A&E crisis - helping patients access primary, social and preventative care to stop ‘unplanned admissions’ through A&E, and freeing up acute beds for A&E patients who need them.

Both are obviously desirable, and hardly rocket science. To understand why they aren’t happening already, politicians of all colours need to face up to some uncomfortable truths.

Accessing appropriate primary care has been made harder by successive waves of marketisation. GPs were effectively offered hefty incentives to get out of out of hours services, to free them up for the private sector. You can’t really blame overworked GPs for taking the incentives and a chance at a better work/life balance. But the private companies that replaced them often cut corners in the training and numbers of their staff, and are only too quick to offload patients back to the NHS - via A&E. The largely privately run 111 service is a classic example, accused by the Royal College of Emergency Medicine as being largely behind the surge in A&E attendance. And social care - largely privatised in the 80s and 90s - is also keen to offload costlier residents onto the trusty old NHS, as we'll come back to in a minute.

As for beds, in the last year we’ve seen the re-emergence of an old term - ‘bed blockers’ - or less offensively, ‘delayed discharge’. The idea that our hospitals would work just fine and there’d be plenty of beds if they weren’t clogged up by patients who don’t need to be there.

Well, yes - and no.

England has fewer hospital beds than almost anywhere else in Europe, with numbers having halved in the last three decades. There simply aren’t enough acute or non-acute beds. So too many acute beds are indeed taken up by patients who may only need a non-acute bed to recuperate in. But in the NHS non-acute beds are becoming an endangered species, with the closure of cottage hospitals and now the withdrawal of overnight wards from many district hospitals.

Hospitals are taking extreme measures to free up beds - this month a grandfather from Essex told Good Morning Britain he had been moved from his bed and kept in a cupboard for 3 days. Elsewhere they have threatened elderly patients with eviction proceedings.

Get patients out into the community”, politicians of all colours are keen to tell us (“couldn’t this land be sold to developers for housing?” they sometimes add).

But as even its advocates at the Kings Fund admit, ‘care in the community’ isn’t a cheap option - without a hefty injection of funds, ‘care in the community’ will just mean poorer quality (or no) care - as we saw with mental health provision in the 80s.

In fact, it’s already happened. NHS district nurses have been reduced by 40% in the last 10 years.

Medical needs have been redefined as social ones - to be means tested and charged for, and provided by privately employed (or outsourced) social care staff dealing with patients at home, or in privately run, hedge-fund backed care homes. But just like out of hours and 111 services, many private care home operators are not properly equipped to assess or deal with risk, and again offload frail elderly people onto the good old NHS A&E department - admissions from care homes are one of the biggest causes of repeat A&E visits.

We need to tackle the cuts in the creaking adult social care system with both better funding and addressing the massively privatised nature of that system. Labour’s announcements this week suggest they are prepared to set aside some extra cash for more social care workers. But - despite shadow health secretary Andy Burnham's welcome promise to "call time on the market experiment in the NHS" - there are still fears. This week Burnham was pressed - but refused - to put a figure on just how big a "supporting role" Labour would still condede to the private sector. And he has been silent on how far Labour would strip away the even more advanced and failing "market experiment" in social care. Without fully tackling the privatisation in both sectors, money will just continue to drain out of the public purse into investors hands.

Whatever happens in social care, though, people will continue to have emergencies. And emergencies are inherently unpredictable - and therefore not an attractive business model for the private sector. A&E is also disproportionately used by lower income groups, figures show - and who can make a profit out of them?

And this is the biggest - but too often unspoken - reason why A&Es are in crisis. The 2012 Health & Social Care Act accelerated the privatisation of the ‘cheap and easy’ elective procedures - from hip ops to removing skin tags. NHS hospitals are left to pick up the pieces the private sector doesn’t want - and what the private sector really doesn’t want is emergencies. But shorn of the cross-subsidies from elective operations, treated more and more as fallback of last resort by private companies like Circle and BUPA, losing demoralised staff in droves and forced to provide the remainder of services on 'unsustainably' low tariffs, NHS hospitals are struggling to keep their A&Es alive

This article originally appeared on the Centre for Labour and Social Studies website.

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