Amber Davenport

The NHS is hitting the headlines daily at the moment. This is not surprising given that we are in the midst of winter, which always seems to bring bad NHS news stories and is a time when photos of patients waiting on trolleys in A&E corridors crop up more frequently in the news and on social media. Even the Red Cross, which seldom speaks up about the NHS, has recently warned of a “humanitarian crisis” following 14 trusts warning of overcrowding in their A&Es.

There is no escaping the fact that the NHS is under immense pressure and this winter feels slightly more wearing than any other. Comments such as “unprecedented” and “record” levels of demand are correct, and reflections from clinicians that pressures in A&E are “the worst I can remember” ring true.

It is therefore right that we acknowledge and raise these concerns, but we should also be wary of frightening patients and undermining public confidence. The four hour A&E waiting time standard is widely known but the reasons behind a breach of this standard are complex and, as our recently published briefing explores, if taken in isolation does not necessarily paint an accurate picture of the standard of care being delivered.

One thing is definitely clear – trusts are treating a record number of patients. More than 60,000 people attended A&E departments on 27 December 2016 – the second highest level for a single day. Some trusts are even reporting increases in A&E attendances of over 20% compared to this time last year.

The reasons for this rise in demand are well reported and widely acknowledged – patients who are often more ill at this time of year, ongoing and worsening pressures in social care, restricted access to GPs and other parts of primary care, insufficient funding, workforce shortages – the list could go on. But how trusts are dealing with this rapid increase in demand is often clouded by official statistics based on the rather simple metrics.

One thing is definitely clear – trusts are treating a record number of patients. Some trusts are even reporting increases in A&E attendances of over 20% compared to this time last year.

While official data does show that as a collective hospitals are not meeting the four hour waiting time standard, if you look beyond these figures and at the actual numbers, trusts are admitting, transferring or discharging more patients under four hours than ever before (5,462,464 patients between July and September 2016 compared to 5,350,952 in the same period in 2015).

We must therefore recognise the outstanding effort being put in by frontline NHS staff and managers, often working beyond the call of duty, to cope with current record levels of demand. We should also celebrate and promote the progress being made by local health and care services across the country to keep patients well, at home and outside of A&E, for example:

• Trusts are implementing new protocols that help improve patient pathways, by placing clinical expertise at the doors of A&E departments.
• Some trusts have successfully implemented new arrangements where specialist clinicians from other hospital departments are based in A&E, so that patients can be treated quickly and discharged, rather than needing to admit them to hospital to receive this care.
• Others have developed ‘discharge to assess’ schemes that allow patients to receive care assessments within their own homes rather than on an acute medicine ward.
• In many areas trusts have developed “trigger tools” that give staff a prediction with several hours notice on whether patients are likely to breach the waiting time standard based on early warning indicators, meaning there is sufficient time to call in additional staff and resources to support patients being admitted in a timely fashion.

Alongside the above interventions, there has been a renewed emphasis on local communication to improve public awareness of the increased pressure at A&E departments and how to proactively self-manage conditions and illnesses. Local urgent and emergency care system boards, often chaired by acute trusts, have also been established to oversee improved system-wide A&E planning and delivery, focussing on ensuring appropriate primary and social care capacity is available for patients who need it.

Demand management however, must be a joint effort and cannot just be addressed at a local level. There is a need for a national debate on what is expected of our A&E departments, as well as the NHS more widely. We welcomed the health secretary’s recent comments about the need for an honest discussion with the public about the purpose of A&E and the need to avoid inappropriate attendances.

There is a need for a national debate on what is expected of our A&E departments, as well as the NHS more widely.

It is right that A&E services should be focused on those with most urgent care needs and the public needs to be cognisant of that, but patients won’t always have a choice. So, there must also be alternatives available to those who are turning to A&E because other local health and social care services are unavailable to them. This will either require national investment or an honest recognition that, despite the commitment and hard work of frontline staff, the NHS will struggle to meet all its existing priorities and performance standards.

In reality, the NHS is neither “breaking down” nor “coping well” – the vast majority of trusts are delivering a good service and high-quality care to patients, despite the pressure they are under.

Some may even say that the NHS is "just getting by". And we shouldn’t underestimate how difficult this level of performance is given the unprecedented pressure the health service is under.

This blog was first published by the Guardian Healthcare Network on 25 January 2017