A&E waiting time targets are being missed, but does this single measure of quality tell the whole story?
Between October and December 2014, A&E departments recorded their worst performance against the 95% target in 10 years, with only 88.9% of patients treated within four hours from their arrival. Waiting times began to recover in the first two months of 2015, but just 91.8% of patients were seen in time between January and March – still well below the 95% target. Overall, the annual 95% target has been missed for the whole of 2014-15 for the first time in a decade, with 93.6% of patients seen in four hours.
Obviously, longer A&E waiting times are problematic for patients and not in keeping with the principles of patient-centred and high quality care. Indeed, treatment in crowded A&E departments has a detrimental effect on patient experience and safety: more crowded departments are associated with worse outcomes for patients according to several studies.
What accounts for longer waiting times and overcrowded A&E departments? Some commentators have focused on the fall by about 8% in the number of England’s major A&E units since 2003, coupled with fewer trained staff in A&E, a decrease in the numbers of available staff, and the absence of sufficient support facilities for major A&E departments. Others have stressed the changing way in which people access emergency departments, by arguing that difficulties in accessing GP appointments have led to more people attending emergency departments for non-urgent issues. Similarly, the Nuffield Trust and some top-level senior professionals have argued that higher than expected occupancy levels are associated with longer average waiting times: this is the case of the “exit block”, which, along with bed shortages, has arguably led to crowded and ineffective emergency departments. Finally, the ageing population and winter pressures add further complexity to the issue. For example, delays in discharge are most likely to be experienced by older patients, and in winter the cold weather represents a serious issue for the health of the elderly, the very young and the chronically ill, leading to increased pressures on the health service and on A&E units during this season.
This seems to add up to a message of doom and gloom. However, we should still bear in mind that, despite skyrocketing pressures on A&E in the last decade – when the number of attendances has increased dramatically from 16.5 million in 2003/2004 to 21.8 million in 2013/14, marking a rise of 32% – overall public satisfaction with the NHS has not diminished.
It is however, worth noting that the survey of the British Social Attitudes did not investigate the specific experiences of recent users of healthcare services. As highlighted by Chris Graham, Director of Research & Policy at Picker, “the majority of the improvement in results from 2013 to 2014 is attributable to people who have not used services recently”.
Whilst increasing waiting times are a serious concern, and a reflection on the burden being placed on the NHS, this do not necessarily mean the overall quality of care has significantly decreased.
Of course, waiting times are important, but they’re not the most important factors determining service quality for patients. We should be at least equally mindful of other aspects, such as whether patients and service users are experiencing: effective treatment as delivered by trusted professionals, continuity of care and smooth transitions, emotional support, empathy and respect, involvement of family and carers, attention to physical and environmental needs and the receipt of clear, comprehensible information. For many patients these issues are stronger determinants of quality than waiting alone.
 Barnes, S. (2015, January 6). A&E performance at all-time low as emergency admissions peak. Health Service Journal. Retrieved from http://www.hsj.co.uk/news/acute-care/ae-performance-at-all-time-low-as-emergency-admissions-peak/5077973.article#.VOMfH_msWPU
 Triggle, N. (2015, April 7). A&E waiting in England hits new worst level. The Guardian. Retrieved from http://www.bbc.co.uk/news/health-32202587. Clover,B. (2015, April 1). Exclusive: 26 trusts responsible for half of national A&E target breach. Health Service Journal. Retrieved from http://www.hsj.co.uk/acute-care/exclusive-26-trusts-responsible-for-half-of-national-ae-target-breach/5083848.article#.VSUlvfnF-PU
 Blunt, I. (2014, July 1) Focus on: A&E attendances. Why are patients waiting longer? http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/140724_focus_on_ae_attendances.pdf
 The King’s Fund (2015, January 29). Public satisfaction with the NHS in 2014. Retrieved from http://www.kingsfund.org.uk/projects/bsa-survey-2014
 Graham, C. (2015, January 30). Public satisfaction with the NHS is rising, but will care experiences follow suit? Retrieved from https://www.picker.org/news/blog/public-satisfaction-nhs-rising-will-care-experiences-follow-suit/