The public and the media often seem to judge how well the NHS is performing by reference to urgent and emergency care provision. This is the bellwether NHS speciality by which all the others appear to be judged. Long-reported delays and missed targets in accident and emergency (A&E) lead to a public and media clamouring that the NHS is a failing public service.
Emergency and urgent care provision does suffer from the same problems faced by other clinical specialities in the NHS. Services are over-stretched because more patients are using them, which is reflective of a growing elderly population presenting with more complex and multiple conditions. There are also acute staff shortages. When accessing primary care services becomes difficult for patients, they resort to using A&E. If we can sort out better access to primary care, then we will relieve pressure on A&E. There was a 4% increase in attendances at A&E during 2018-19 (24.8 million) compared with 2017-18 (23.8 million), and a 21% increase since 2009-10 (20.5 million) (NHS Digital, 2019). Furthermore, A&E attendances were twice as high for people in the most deprived areas as in the least deprived. Let that sink in: more than twice as many attendances. This raises important issues such as equality of access to primary care services in deprived areas.
The consequences of long waits for patients in A&E and general difficulties in accessing emergency care services can also have major legal and patient safety implications. A rushed, over-stretched A&E may well result in patient safety adverse events occurring and even clinical negligence actions being initiated. Cases have gone to court and damage compensation payments been made as a result of poor care in A&E. NHS Resolution (2019a) makes the point that emergency medicine remains the speciality from where most legal claims originate.
As I have said before, the NHS has an infinite demand for finite resources. The NHS will absorb all the resources given to it and will still require more. Prudent financial management decisions need to be taken to fairly manage NHS budgets across all specialities. However, the savings made can soon be extinguished by litigation, one cancelling the other out. A delicate balance needs to be drawn between prudent financial management and running a service such as A&E at a level that is also seemingly attracting a high level of complaints and litigation.
2018 Urgent and Emergency Care Survey
There seems to be no shortage of reports looking at urgent and emergency care provision and how to make good, how to re-cast service provision in the face of demand on resources. The problems facing this care area are not new and have been a constant presence in the media over many years.
The Care Quality Commission (CQC) recently published findings from a national survey of more than 50 000 people who received urgent and emergency care from 132 NHS trusts across England (CQC, 2019). The survey looked at people's experiences—from decision to attend, to leaving—of using type 1 (major A&E) and type 3 (urgent care centres, minor injury units, urgent treatment centres) urgent and emergency care services. Information regarding patients' experiences is essential in order to develop and plan services. The survey reported both positive and negative findings. Overall most people experience good urgent and emergency care, but an issue that seems to persist, year after year, is lengthy waiting times to receive care. This is seemingly an intractable problem for the NHS.
Waiting times
The reports found that patients are seen quicker, and they have a shorter visit at urgent care centres, whereas 68% of type 1 respondents waited more than 15 minutes before they first spoke to a nurse or doctor. Most type 3 respondents are also waiting longer than recommended. Over half of respondents (57%) who had attended with a pre-booked appointment and 65% of respondents who did not have an appointment were waiting more than 15 minutes before they first spoke to a health professional:
‘The operational standard is that 95% of people should spend 4 hours or less in the urgent and emergency care department. Just over two fifths of type 1 respondents (41% in 2018, an increase from 40% in 2016) said that overall, their visit to A&E lasted for more than four hours. For type 3 departments this is much lower at 12%, improved from 15% in 2016.’
Being informed: communication and interaction
Patients who are visiting an A&E or urgent care centre will want to know how long they will have to wait:
‘Of those respondents who had to wait to be examined, most said that they were not informed how long they would have to wait; 56% of respondents who visited a type 1 department and 52% of respondents who visited a type 3 department said ‘no, I was not informed.’
While waiting to be examined, it is important that patients should be able to get help from a member of staff. Of the type 1 respondents who needed any help, 69% said they were able to get help and 31% that they were not. These findings are disappointing and improvements can be made.
There has been recent litigation on the issue of waiting times in A&E, and the sufficiency of information given to a patient about how long they would have to wait.
Case study: the Darnley case
Darnley is a very important case in the law of tort and spells out key duties when patients present at A&E and in other departments. Mr Darnley, the patient and claimant in the case, sustained a head injury and went to the A&E department of Mayday Hospital, Croydon. The receptionist there told Mr Darnley that he would have to wait up to 4–5 hours before somebody could look at him. The case report states that Mr Darnley told the receptionist that he could not wait that long as he felt as if he was about to collapse. The receptionist replied that if Mr Darnley did collapse he would be treated as an emergency. Mr Darnley, who was with a friend, sat down in the waiting area but then decided to leave for home to take some paracetamol after 19 minutes because he felt so unwell. He went to his sister's house not far away and his condition seriously deteriorated. He returned to the hospital's A&E department later in the evening by ambulance. He was very unwell and later underwent an operation for the evacuation of a haematoma. He suffered permanent brain damage in the form of a severe and very disabling left hemiplegia.
Mr Darnley sued the Trust for negligence and won his case, which was then sent to the Queen's Bench Division Court for an assessment of the damages to be awarded to him. It was found that the hospital had been in breach of its duty of care.
Incomplete and misleading information
The Supreme Court said that the information given to Mr Darnley by the receptionist was incomplete and misleading. The usual practice was that a patient like Mr Darnley would be told that they would be seen by a triage nurse within 30 minutes of arrival. He was not told that, but wrongly told of a 4–5 hour wait. The Supreme Court held that this was negligence. The scope of the legal duty of care extends to a duty to take reasonable care not to provide misleading information that may foreseeably cause physical injury:
‘The pressures on medical staff are enormous, the demand for attention is constantly fluctuating and priorities are likely to change. However, it is not unreasonable to require receptionists to take reasonable care not to provide misleading information as to the likely availability of medical assistance.’
This case from the highest court in the land has major practical implications for all those concerned with meeting patients who are requesting care, such as medical receptionists in primary care as well as receptionists in A&E and other areas.
Applying lessons to other areas
NHS Resolution (2019b: 2) has discussed the case from the perspective of learning lessons in maternity and highlighted some key points:
Other findings from the survey
The CQC (2019) has several other important findings. Pain control is an area that can be improved on: 67% of respondents who attended a type 1 department (65% in 2016) and 64% of those who attended a type 3 department said that they were in pain when they visited the A&E or urgent care centre. Just over half (55% of type 1 respondents and 56% of type 3 respondents) felt that staff ‘definitely’ did everything they could to help control their pain (CQC, 2019: 41).
Food and drink is an important issue for patients who are having to wait a long time in A&E and the report's findings indicate that improvements can also be made here about the information given to patients.
Survey findings overall
The report does share some positive points from the survey. Findings show that most patients who attended a type 1 department said they ‘definitely’ had enough time to discuss their condition with the nurse or doctor. A large proportion of patients in type 1 departments (76%) also said they ‘definitely’ had confidence and trust in the staff examining and treating them. Patients treated at a type 3 service were also positive about interactions between healthcare staff and patients. The report is by no means a catalogue of ‘doom and gloom’ findings. There are many positives, but also some significant negatives, particularly the finding about communication of waiting times to patients, which is an issue that has attracted major litigation and a Supreme Court decision.
Conclusion
NHS Resolution state that emergency medicine remains the speciality from where most legal claims originate. This should put on notice health care resource allocators and budget holders that A& E and emergency services are very exposed areas, legally. Cases are going to court such as Darnley which show how weaknesses in the system can result in tragic patient injury. CQC (2019) lists several positives from the patient survey but there are also some negatives such as information to patients on waiting times, which is an acute cause for concern after the Darnley case.