‘Pressure Leads to Near Misses’: Why are A&E Services in Crisis?

In the latest in her series on the National Health Crisis, Sian Norris reports on the impact of patients waiting more than four hours to be seen in A&Es across England

Just over a quarter of patients (27.9%) are waiting for more than four hours in Accident and Emergency across NHS England trusts, as services struggle to cope with staff shortages, the ongoing impact of the pandemic, and more than a decade of underfunding. 

Leaked NHS data published in the Independent found that A&E waits are now “apocalyptic” and “worse than ever imagined” – and could be driving 1,000 patient deaths a month.

The news comes after Conservative Party leadership hopeful Liz Truss announced public sector pay cut plans that would see millions of nurses have their pay cut by £1,500 a year. Her proposal to evaluate public sector pay depending on where staff live “is an attack on NHS values and a direct assault on its professionals," according to the Royal College of Nursing, which added that "national salaries are key to a national service”.

Truss has since said her plans have been “willfully misrepresented”.

Those living in deprived areas of the UK are worst affected by the delays – with the rate of A&E attendances nearly twice as high in the poorest areas compared to the least deprived regions of the country. 

The most high-profile measure of A&E performance in England is the four-hour standard – the pledge in the NHS Constitution that at least 95% of patients attending A&E should be admitted to hospital, transferred to another provider, or discharged within four hours.

But, according to data published by The King's Fund think tank, the percentage of patients being seen within four hours in A&E has collapsed since 2010.

Back then, the number of people seen within four hours was above the target – at just under 100%. By February 2022, just over 70% of patients were seen in time.

'The Pressure Leads to Near Misses'

Natalie has worked as an NHS nurse for decades. As a sister in an acute medical unit of a large hospital, her team is under constant pressure to take patients from A&E. Having previously worked in A&E, "I have seen both sides” she told Byline Times.

Up until 2016, hospital trusts were fined for every patient who waited more than four hours in A&E, but financial penalties were scrapped that year.

“As soon as the threshold was close to being reached, you would be surrounded by management wanting to move an A&E patient to my ward,” Natalie said.

Her greatest fear is that the pressures on A&E risks having an impact on patient safety in other areas of the hospital, including her own acute medical unit. 

“I had a patient who was rapidly deteriorating,” she told Byline Times. “Because we were getting close to a target for how long a patient should be on the ward, there was pressure to move him to another section of the hospital for treatment. I was insisting he was too ill to be moved, that if we moved him to another ward he would end up dying on a trolley.

"Thankfully I was listened to, and we eventually moved him to intensive care when a space opened up. But I have no doubt that if I had not stood my ground, he would have died on a trolley in a corridor.” 

On another occasion, Natalie recalled how she was told to put a patient “in a cupboard, because we needed to bring a new ambulance patient in".

"Even a layperson could see how ill this person was," she said. "I told the charging nurse there was no way I was putting him in there.”

Natalie is clear that she does not blame her colleagues or the paramedics who are all working under "unbelievable pressure".

“It’s not their fault,” she said. “It’s the pressure they are under, the horrific working conditions, that risk leading to bad decisions. It’s horrendous when you have ambulances queuing outside, when you have patients waiting for eight hours to be seen. That pressure leads to near misses, unfortunately.”

Pressure Points

There are specific pressure points that are fuelling the issues facing A&E departments and their patients. 

First is the number of hospital beds, which have halved in the past 30 years. There is a good reason for this – medical advances mean more people now receive treatment outside of hospital or only require short hospital stays. However, rising emergency admissions are increasing the pressure on hospital resources, including beds. 

According to The King's Fund, “these pressures are demonstrated by high levels of bed occupancy in NHS hospitals, which are closely associated with longer waiting times in A&E". The think tank has found that this is particularly the case in the winter months, when "hospitals are routinely operating with bed-occupancy rates above 92% – the level at which the Department of Health and Social Care suggests that hospitals will struggle to deal with emergency admissions”.

More people are going to A&E than ever before – despite a drop in numbers during the height of the Coronavirus pandemic.

The increasing numbers are down to numerous factors. But, for those living in the most deprived areas, one of the drivers of increased A&E attendances is that people feel they have no alternatives due to closures of walk-in clinics and pressured GP services. In 2019/20 there were 25 million attendances at A&E, compared to 21.5 million attendances in 2011/12. 

The second pressure point is social care and the challenges of moving vulnerable people out of hospital and into a safe setting where they can be looked after. 

Natalie described a bottleneck that “starts with pressure from the front door, with ambulances arriving". She said "this trickles through the hospital" and "you’ve got these blockages at the ends of the wards where there’s nowhere to send vulnerable patients who can be discharged, but have no safe place to go”.

Successive governments have struggled to grapple with the social care crisis, which the 2019 Conservative Government planned to solve with a rise to national insurance that would be a social care levy – although initial money raised would go to the NHS.

Liz Truss, currently ahead in the Conservative Party leadership contest, has said she would reverse the national insurance rise, and both she and fellow contender Rishi Sunak have said they would provide more funding for councils to deliver social care.  

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