The A&E performance figures published this winter by NHS England were the worst since the four-hour target was introduced in 2004. Here, RCEM vice-president Dr Chris Moulton argues that this is symptomatic of the widespread changes in our society that are overwhelming long-established systems of healthcare provision.
In biology, the state of certain creatures – indicator species – is known to reveal the condition of their environment. They are usually among the most sensitive living things in a region and, as such, often provide an early warning to ecologists. A&E interacts with much of our current society and is affected by almost all socioeconomic changes. The fact that this winter’s performance figures for A&E were the worst ever recorded is common knowledge. All over the country, A&E departments are struggling to cope with their workload and if, as many believe, emergency care is a reliable indicator of general public service functioning, then there may be trouble ahead.
A changing population
The UK population is growing and ageing fast. It has increased by 4% in the last five years and there are 21% more people aged over 65 and 31% more over-85-year-olds than a decade ago. Older people have the highest rates of A&E attendance and the greatest chance of hospital admission when they do attend; two-thirds of hospital emergency bed days are now occupied by patients over 65 years old. The number of people with long-term conditions has also grown sharply; nearly a quarter of the population has one chronic condition, with 20% of these people having three or more. Around 25% of all UK citizens experience a mental health problem at some point in their lives and more than one in 80 people have dementia.
There are 179 type one (major) A&E departments in England. If all were to continue as they were five years ago, then another seven would have had to have been built to account for the population expansion alone! The demographic pressure will only increase as the number of people aged 65 and over is projected to grow by a further 20% in the next ten years and over a million more people will have dementia by 2021.
A different workforce
Work-life balance is a phrase that was unknown to my generation but is often heard in hospital corridors nowadays. Rarely does anybody complain that the ‘life’ part of the balance is too heavy or the ‘work’ part too light! But cynicism aside, modern healthcare professionals do not yearn to spend their youth imprisoned in a hospital for 120 hours a week, and the anachronism of frequent night and weekend working is seen as both undesirable and unsafe. Extended holidays (‘travelling’) and time spent working abroad in Australasia is almost de rigueur. At the same time, we have more women in the medical workforce, which has led to much more than the predictable changes of maternity leave and part-time working for women doctors. The men too have realised the advantages of a less-than-full-time commitment. Where doctors marry, some couples reduce their working hours. In addition, medical students are taught not to do more than they can manage and to work at a rate that they feel is safe for them. These changes may well be improvements, but, nonetheless, they explain some of the shortages in medical manpower.
The paralysing effect of computers, bureaucracy and legal pressures
I spent several tedious hours over the weekend filling in a pharmacy application for my A&E department to stock a new drug. The level of detail required made me feel that I was seeking permission to transplant a monkey’s head onto a human body – not applying for a licensed painkiller that is safely used all over the world. Meanwhile, ward nurses input lengthy electronic care plans to describe care that they will never have time to deliver and medical IT systems require yet another time-consuming layer of data input, usually in addition to handwritten records. Complex computer systems, multiple passwords, emails, checklists, proformas, mandatory training, appraisals and bombardment with information from every possible source are stifling the very people whose job is to care for patients. Many of the changes are the result of safety initiatives that are often driven by legal challenges. Whilst individually well-intentioned, collectively they reduce the only thing that has actually been shown to improve patient survival – doctor and nurse clinical time.
Multiple other medical and social changes
The Ebola epidemic of 2014/15 demonstrated the inability of overcrowded A&E departments to provide adequate space for the cleaning and decontamination of possible carriers. Global pandemics of influenza, SARS, MERS and other easily spread diseases have also put stress on the urgent care system, and travellers to exotic places unsurprisingly return with exotic diseases.
Work-related injuries have largely been replaced with a multiplicity of conditions caused by sport and other leisure activities. Meanwhile, the staple problems of illnesses caused by alcohol and drugs continue to increase. There are many patients now with long-term disabilities that result from the abuse of these substances and they are often surprisingly young. Consanguineous marriages in some communities and better neonatal care are two more factors that have increased the number of people in society with chronic medical problems. People with cancer have a much better chance of survival nowadays but often present to A&E departments with illnesses such as neutropenic sepsis that are a consequence of their treatment. In a 24-hour society, supermarkets are often open around the clock and so people expect that urgent healthcare will be similarly conveniently available and are surprised and angry if it is not.
The canary down the mineshaft
British Rail, the GPO, mining, ship-building and too many other institutions and industries to mention have all been swept away by the tsunami of social change. The NHS alone has continued to be managed and funded in the same way for the 70 years since it began in 1948 – when the life expectancy for men was just 66 years. I believe that the problems that we have witnessed in A&E departments in the last few years are not isolated failures of healthcare delivery but instead undeniable indications of overwhelming social and demographic change in the UK. Like a miner, deep underground with a sick canary, we ignore such warnings at our peril.
Royal College of Emergency Medicine (RCEM)
This article will appear in issue 6 of Health Europa Quarterly, which will be published in August.