Long Waits in Accident & Emergency Departments in England: Some Contributory Cultural Issues Within Hospitals 

Much has been said and written about progressively longer waiting times in emergency departments in England, and will continue to be for the foreseeable future. The NHS emergency access target of 4 hours, during which a patient is either admitted, transferred, or discharged from the emergency department (ED), was first introduced in 2004 by a Labour government. To begin with the bar was set impossibly high, requiring 98 per cent of all ED attenders to be suitably disposed of within 4 hours of registration, before being reduced to a more manageable 95 percent in 2010. Since 2012, performance has steadily dropped, except for two blips during the Covid-19 pandemic, in March/April 2020 and December 2020/January 2021. Not even one of 124 NHS Trusts in England, responsible for around 170 Type 1 major EDs, has met the target in recent years. A new record high of 45.2 percent of patients waiting over 4 hours in hospital EDs was reached in October 2022

When a target is consistently breached and eventually considered unattainable, one option is to abandon it and possibly replace it with another more meaningful performance metric. The Review of NHS Access Standards, published in March 2019, thus proposed replacing the 4-hour target with an alternative set of ED standards, such as average waiting time, time to initial clinical assessment, and time to emergency treatment for critically ill and injured patients. Following a favourable interim report on a trial of these standards in 14 NHS hospital trusts in England, published in October 2019, it is likely that the 4-hour target will be abolished when it seems right. 

Abolition of one target and its substitution with an alternative set of targets will not automatically remove the underlying reasons for long waits, which are multifactorial and demand much time, effort, and money to resolve. Rising demand, brought about by reduced access to general practitioners, increasing ED attendances, older and sicker patients, coupled with a shortage of service providers (doctors, nurses, allied healthcare professionals), both in numbers and skill sets, are commonly cited and will not be dwelt upon further. 

Looking beyond the bare facts and figures, some useful information can be gleaned from Care Quality Commission (CQC) reports, particularly on hospitals deemed to “require improvement” or “inadequate”, and those deserving “special measures”. The CQC evaluates services under the categories of safe, effective, caring, responsive, and well-led. While low staff numbers, inappropriate skillsets, and a lack of physical space are almost universal, some special aspects of how struggling hospitals strive to provide emergency care are worth exploring. 

Emergency doctors usually not have the right to admit patients to inpatient beds and even if they do, bed shortages hold them back. Usually any patient requiring hospital admission has to be first referred to a specialist. But hospital practice has often been described as tribal and territorial, rather than cooperative and collaborative, with specialists frequently working in their own silos and displaying behaviours hallowed by the traditions of their own areas of expertise.  This means that ED specialists may face difficulty in sending their patients to what they consider the most appropriate location.  This is particularly a problem when mental health services are provided by an external provider rather than an in-house “liaison psychiatry” team, and accounts for inappropriately long waits for the mentally unwell in EDs, especially children. Adding to inter-specialty barriers, hierarchical barriers frequently demand that consultants in admitting specialties can only be contacted by ED consultants and not by junior staff in EDs. Specialists covering EDs often demand various scans and other investigations before they will deign to see patients, both prolonging waits and delaying definitive care for patients, while deftly managing their own workloads. Sometimes this may be necessary because of poorly designed rotas, driven by staff shortages, which require their input on wards and even on elective procedural lists while on call for the ED. There are also problems of loss of more generic and holistic skills with the advent of super-specialisation, requiring the development of new specialities of acute medicine and acute general surgery to better cope with the undifferentiated emergency workload. 

A CQC report on urgent and emergency care services at Leicester Royal Infirmary, published on 8 July 2022, notes that “staff working across specialisms in acute services did not always provide sufficient in-reach into the emergency department to improve patient flow and the care received” and that “specialists did not always review their patients in the emergency department within agreed timescales”. The latter reflects a widely-held view that the ED serves as a conventional holding area for patients already referred to specialists. The report also states that “it was difficult to establish who had clinical ownership of patients who were waiting in the emergency department for a hospital admission”, which can contribute to diagnostic and treatment errors.

In the ideal set up, EDs should have senior decision makers at the frontline, who in turn have easy and readily-available access to specialists, also based within the department, who can take timely and appropriate decisions on how to manage patients referred to them, whether by admission to hospital or through outpatient investigation and follow-up. There seems there may be a long way to go before this desirable state is reached in most hospitals. 

There have been considerable advances in medical education in recent, including the recognition of good communication skills and the importance of interdisciplinary and collaborative team working. It would seem, however, that some of this has yet to trickle down into the daily working practices of the NHS. While there is undeniably a shortage of resources, more effective patient-centred working can most certainly be relied upon to improve the current dire situation in which overstretched EDs are reportedly working to the limits of their capacity and beyond. 

Ashis Banerjee