Accident and Emergency. Performance update

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1 Accident and Emergency Performance update Prepared by Audit Scotland May 2014

2 Auditor General for Scotland The Auditor General s role is to: appoint auditors to Scotland s central government and NHS bodies examine how public bodies spend public money help them to manage their finances to the highest standards check whether they achieve value for money. The Auditor General is independent and reports to the Scottish Parliament on the performance of: directorates of the Scottish Government government agencies, eg the Scottish Prison Service, Historic Scotland NHS bodies further education colleges Scottish Water NDPBs and others, eg Scottish Police Authority, Scottish Fire and Rescue Service. You can find out more about the work of the Auditor General on our website: Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act We help the Auditor General for Scotland and the Accounts Commission check that organisations spending public money use it properly, efficiently and effectively.

3 Accident and Emergency 3 Contents Summary 4 Key messages 7 Part 1. A&E waiting times 9 Part 2. Reasons for delays in A&E 20 Part 3. Action by the Scottish Government 37 Endnotes 41 Appendix 1. NHS Scotland A&E departments and minor injury units 43 Appendix 2. National context for A&E and unscheduled care, 2004 to Exhibit data When viewing this report online, you can access background data by clicking on the graph icon. The data file will open in a new window.

4 4 Summary Key facts Patients were seen within four hours in December 2009 Patients were seen within four hours in December per cent 93.5 per cent 1.57 million 1.62 million Patients attended A&E departments & MIU in 2008/09 Patients attended A&E departments & MIU in 2012/13 Patients waited longer than four hours in December 2009 Patients waited longer than four hours in December ,659 (2.8 per cent) (6.5 per cent) 8, , , per cent 21 per cent Patient delays in A&E were reported as 'wait for a bed' in 2012/13 Patient delays in A&E were reported as 'wait for first full clinical assessment' in 2012/13 Patients were admitted to hospital from A&E in 2008/09 Patients were admitted to hospital from A&E in 2012/13

5 Summary 5 Background 1. Typically, Accident and Emergency (A&E) departments assess and treat patients with serious or life-threatening injuries or illnesses. There are 31 A&E departments in Scotland. Around 1.35 million patients attended these departments in 2012/13, at a cost of around 163 million. 1 To ensure patients are being treated quickly, NHS boards have a standard to treat and discharge or admit 98 per cent of patients within four hours of arriving at A&E. 2 The four-hour standard also applies to minor injury units (MIUs) where patients are treated for less serious, but urgent, injuries. There are 64 MIUs in Scotland that provide treatment to over 260,000 patients a year, at a cost of around 25 million. In April 2014, the Scottish Government announced plans to set up four new trauma units in Scotland. 3 The units, which will be open from 2016, will provide life-saving treatment for patients who suffer a major trauma such as a serious head injury. 2. We published a report, Emergency departments (PDF) (August 2010), which also included an analysis of data from the Scottish Ambulance Service and NHS We looked at: how these emergency care services met the needs of patients if they were making the best use of available resources, such as money and staffing how effectively services were working together to manage demand and deliver coordinated patient care. 3. We reported that NHS boards had improved the way they tackled longer A&E waiting times, but faced challenges in maintaining the four-hour standard. We made a number of recommendations for the Scottish Government. These included setting out a clearer strategic direction for emergency care services in Scotland and improving information to ensure best use is made of existing resources for emergency care. Since then, A&E departments performance against the standard deteriorated and during winter 2012/13 performance fell to the lowest it has been since the standard came into effect. Winter 2012/13 was particularly challenging for A&E departments across the UK. Patients in England, Wales and Northern Ireland also experienced delays in A&E. 4. In April 2013, the Scottish Government introduced a new interim target of 95 per cent of patients being treated within four hours by the year ending September Maintaining good performance on the four-hour A&E wait was one of the Scottish Government s 25 key objectives for 2013/ As highlighted in our recent report, NHS financial performance 2012/13 (PDF) (October 2013), NHS boards are facing a changing and challenging time. As well as increasing financial pressure, with limited funding increases and difficult savings targets, they face growing pressures from Scotland s ageing population and the challenges of having more people with long-term health conditions needing healthcare. NHS boards face staffing challenges from Modernising Medical Careers and the European Working Time Directive, for example difficulties in recruiting suitably qualified staff and maintaining a flexible medical staffing rota. They also have challenging waiting times targets for planned inpatient and outpatient care, and targets for emergency and urgent care. 6 Whilst facing all of these pressures, NHS boards are striving to continually improve the quality and safety of patient care.

6 6 About the audit 6. We focused on reviewing A&E departments performance against the fourhour waiting time standard since our previous audit. We used information that NHS boards routinely submit to Information Statistics Division (ISD) Scotland. 7 The four-hour standard also applies to MIUs so they are included in our analysis of performance against the standard. Most of these units do not report detailed activity to ISD Scotland because they do not have the same data systems in place as A&E departments and therefore they are not included in the more detailed analysis in this report. We compare 2012/13 performance data with data going back to 2008/09, as this is the base year we used in our previous A&E report. 7. Our objectives were to provide an update on: how NHS boards are performing against the A&E waiting times standard and the main reasons for delays in A&E treatment what the Scottish Government has done to help improve the way A&E departments perform.

7 Key messages 7 Key messages The NHS in Scotland s performance against the four-hour A&E waiting time standard has deteriorated since our last report. The percentage of patients seen within four hours fell from 97.2 per cent in December 2009 to 93.5 per cent in December 2013, although there was improvement during Performance varies considerably between A&E departments, and many face challenges in meeting the interim target of 95 per cent by the year ending September A&E departments are part of a complex health and social care system. Problems across the whole system can delay the flow of patients out of A&E. Around a third of patients who are delayed in A&E are waiting because hospital beds are not available at the time they need them. This can be for a variety of reasons, including the time of day that patients are discharged from hospital. Since our last report, more patients are being admitted to hospital from A&E. Challenges around staffing can also affect how long patients wait in A&E. Although A&E consultant numbers have increased, there are still pressures around medical staffing. The Scottish Government launched the National Unscheduled Care Action Plan in February 2013 in response to the deterioration in performance against the four-hour standard. Supported by planned funding of 50 million over three years, the Action Plan aims to address the challenges that NHS boards are facing in delivering emergency and urgent care, including reducing A&E waiting times. It is too early to comment on the impact of the Action Plan as significant changes to services will take time to deliver, but the Scottish Government and NHS boards are taking steps to address some of the causes of delays.

8 8 Recommendations The Scottish Government should share good practice on: GPs referring appropriate patients directly to hospital without first attending the A&E department protocols that allow senior A&E staff to admit patients directly to hospital themselves effective models of A&E services and use of assessment units effective hospital discharge processes which support early planning of patient discharge. The Scottish Government should: ensure that NHS boards have access to benchmarking information on staffing levels and skill-mix in A&E departments.

9 Part 1. A&E waiting times 9 Part 1 A&E waiting times Longer A&E waiting times are often a sign of pressure across the whole system 8. A&E departments are part of a complex healthcare system. Delays are not always the result of inefficiencies within the A&E department, but can be a sign of pressures across the wider health and social care system. Our last audit highlighted that patient satisfaction with A&E services was linked to how long they had to wait. Longer waits can also compromise patient safety and clinical effectiveness. 9. To provide quick and effective care, A&E departments rely on having: enough staff access to diagnostic tests access to advice from other hospital departments, for example orthopaedics access to hospital beds when required. 10. To achieve the four-hour target, A&E departments depend on all parts of the health and social care system working together. Although most patients attending A&E are discharged home, around 27 per cent of patients are admitted to hospital for further care. Patients who need to be admitted to hospital are more likely to wait longer in A&E, often because beds are not available at the time patients need them. This in turn can be linked to the time of day that patients are discharged from hospital and delays while patients wait for appropriate care outside the hospital. 8 Delays in moving patients through the healthcare system are sometimes referred to as problems with patient flow (Exhibit 1, page 10). the number of patients waiting longer than four hours is higher than in 2008/09 but this has improved recently More A&E departments now have more people attending 11. Across Scotland, overall demand for A&E and MIU combined has risen by 3.1 per cent over the past five years, from 1.57 million attendances in 2008/09 to 1.62 million in 2012/13. This is due to increasing attendances at MIUs which have grown by 34 per cent, from 198,991 attendances in 2008/09 to 266,439 in 2012/13 (Exhibit 2, page 11).

10 10 Exhibit 1 A&E departments within the wider healthcare system There are many factors that can delay the flow of patients around an A&E department. GP 999/ambulance Self referral Triage Diagnostics department Clinical assessment Specialist input Treatments 4hrs Medical admissions unit Acute medical unit Surgical admissions unit Medical ward Surgical ward Potential delays that impact on A&E patients Home or transferred to another service Source: Audit Scotland

11 Part 1. A&E waiting times 11 Exhibit 2 Attendances at A&E departments and MIUs, 2008/09 to 2012/13 Overall attendances at A&E departments have fallen slightly while attendances at MIUs have risen. 1,750,000 Number of attendances 1,500,000 1,250,000 1,000, , , , / / / / /13 Accident and emergency Minor injury units departments Note: Appendix 1 lists ISD Scotland's classification of A&E departments and MIUs within each NHS board. Source: ISD Scotland, A&E datamart 12. Attendances at A&E departments overall reduced by 1.4 per cent over the same period, from 1.37 million to 1.35 million. But some A&E departments have seen a significant increase in attendances, while attendances at others have decreased (Exhibit 3, page 12). 13. Attendance rates vary significantly across Scotland. In 2012/13, there were 305 attendances per 1,000 population at A&E departments and MIUs combined. This is a slight increase since we last reported (302 per 1,000 in 2008/09). Attendance rates are around 38 per cent higher for NHS Greater Glasgow and Clyde (375 per 1,000 population) compared with NHS Borders (231 per 1,000 population). 9 As we highlighted in our last report, deprivation and the distance that people live from an A&E department help explain some of the variation in attendance rates. Attendances vary by type of service 14. Attendances vary across NHS boards by the type of service. For example, NHS Highland treats around 45 per cent of all attendances at MIUs and 55 per cent at its four A&E departments. In NHS Lanarkshire, nearly all patients (99 per cent) are seen at the three A&E departments and one per cent at the two MIUs (Exhibit 4, page 13). Most patients refer themselves to A&E departments 15. The overall pattern of referrals to A&E departments is the same as when we last reported. Most people who attend (66 per cent) refer themselves. GP referrals make up around ten per cent of attendances and NHS 24 referrals make up around four per cent. 10 This varies across A&E departments (Exhibit 5, page 14).

12 12 Exhibit 3 Change in attendances at A&E departments, 2008/09 to 2012/13 Overall attendances at A&E departments have decreased slightly. But attendance varies across Scotland, with significant increases in some A&E departments ,979 6,537 Change in attendance (%) ,811 61,979 6,537 46,030 64,114 11,741 60,326 56,865 48,220 34,169 32,016 62,657 25,075 8,988 67,701 30,957 71,361 23,766 6, ,022 44,700 6,407 52,788 18,042 24,657 46,797 71,563 85,727 41, , Gilbert Bain Hospital Victoria Infirmary Ninewells Hospital Western Isles Hospital Wishaw General Hospital Perth Royal Infirmary Aberdeen Royal Infirmary Galloway Community Hospital Western Infirmary Hairmyres Hospital Southern General Hospital Dumfries and Galloway Royal Infirmary Inverclyde Royal Hospital Belford Hospital Raigmore Hospital Monklands Hospital Borders General Hospital Royal Alexandra Hospital Lorn and Islands Hospital University Hospital Ayr Royal Infirmary of Edinburgh Caithness General Hospital St John's Hospital at Howden Royal Aberdeen Children's Hospital Dr Gray's Hospital Royal Hospital for Sick Children, Glasgow University Hospital Crosshouse Glasgow Royal Infirmary Royal Hospital for Sick Children, Edinburgh Number of attendances in 2012/13 Notes: 1. A&E departments in NHS Fife and NHS Forth Valley are not included in this exhibit because of changes to services over this time period. It is therefore not possible to compare demand at these A&E departments. Appendix 1 lists all the changes to services. 2. Stobhill Hospital changed to a minor injury unit in 2011 and this is likely to have affected the number of attendances at the nearby Glasgow Royal Infirmary. From September 2009, Victoria Infirmary started recording A&E and MIU attendances separately. 3. Balfour Hospital in NHS Orkney is not included in this exhibit as ISD Scotland records the service provided as a minor injury unit. Source: ISD Scotland, A&E datamart

13 Part 1. A&E waiting times 13 Exhibit 4 Distribution of activity at A&E departments and MIUs, 2012/13 Across Scotland, most patients are seen in A&E departments. The number of MIUs and the percentage of attendances at MIUs vary across boards. Ayrshire and Arran Borders Dumfries and Galloway x2 x1 x2 x3 x4 x4 Fife x1 x3 Forth Valley x1 x1 Grampian x3 x14 Greater Glasgow and Clyde x7 x3 Highland x4 x15 Lanarkshire x3 x2 Lothian x3 x4 Orkney Shetland no A&E department x1 x1 no MIU Tayside x2 x9 Western Isles x1 x Percentage Attendance at A&E Attendance at MIU Number of A&E departments Number of MIUs Note: The Acute Receiving Unit at the Western General in NHS Lothian is included as one of its four MIUs. Source: ISD Scotland, A&E datamart Performance has deteriorated over the last five years, although it has recently improved 16. NHS boards performance against the four-hour A&E waiting time standard has varied over the last five years and the NHS in Scotland has rarely achieved the 98 per cent standard in that time. The percentage of patients seen in A&E departments and MIUs within four hours fell from 97.2 per cent in December 2009 to 89.7 per cent in January 2013, the lowest it has been since the standard came into effect (Exhibit 6, page 15). Overall, the number of patients who waited longer than four hours almost trebled from around 36,000 in 2008/09 to around 104,000 in 2012/ Performance has improved over the last 12 months, and the latest figures show that 93.5 per cent of patients were seen within four hours in December However, the number of patients who waited more than four hours (8,300) in December 2013 is considerably higher than when we last reported (3,659 patients waited longer than four hours in December 2009).

14 14 Exhibit 5 Attendances at A&E departments by source of referral, 2012/13 Most patients decide to go to an A&E department themselves. The percentage of referrals from other sources, such as GPs, varies across A&E departments. Referral source (percentage) A&E department Self referral 999 services GP 1 GP referral for admission 2 Out of hours 3 NHS 24 MIU Other 4 Belford Hospital Hairmyres Hospital Southern General Hospital Glasgow Royal Infirmary Dr Gray's Hospital Inverclyde Royal Hospital Lorn and Islands Hospital Victoria Infirmary Aberdeen Royal Infirmary Royal Alexandra Hospital Royal Hospital for Sick Children, Glasgow Galloway Community Hospital St John's Hospital at Howden Perth Royal Infirmary Western Isles Hospital Western Infirmary Raigmore Hospital Wishaw General Hospital Royal Aberdeen Children's Hospital Monklands Hospital Royal Hospital for Sick Children, Edinburgh Gilbert Bain Hospital Caithness General Hospital Forth Valley Royal Hospital Victoria Hospital University Hospital Crosshouse University Hospital Ayr Dumfries and Galloway Royal Infirmary Ninewells Hospital Borders General Hospital Royal Infirmary of Edinburgh SCOTLAND Notes: 1. GP: referral to A&E for assessment and treatment. 2. GP referral for admission: GP refers patient to an inpatient bed but local policy means the patient goes through A&E before being admitted. 3. Out of hours: this is a referral from GP out-of-hours services that provide care after 6pm when GP practices are closed. 4. Other: referrals from same hospital; other hospital; community-based healthcare professional such as a pharmacist; social services; a private organisation such as a nursing home. Source: ISD Scotland, A&E datamart

15 Part 1. A&E waiting times 15 Exhibit 6 Monthly attendances at A&E departments and MIUs, and the NHS in Scotland's performance against the standard and the interim target from April 2008 to December 2013 Compliance with the four-hour standard has been poor but there has been improvement since the lowest performance in January , Number of attendances 120,000 90,000 60,000 30,000 0 Apr Percentage of patients seen in four hours Attendance Percentage of patients Standard 98% Interim target 95% seen in four hours Source: ISD Scotland, A&E datamart 17. MIUs generally perform well against the standard. Only six of the 64 MIUs have performed below 95 per cent since the Scottish Government introduced the interim target in If MIUs are removed from the overall figure, the NHS in Scotland s performance against the four-hour standard drops slightly, from 93.5 to 92.7 per cent in December Fourteen A&E departments met the four-hour interim target in December In December 2013, 14 of the 31 A&E departments reached the interim target of 95 per cent. Performance ranged from 99.2 per cent at the Perth Royal Infirmary to 81.5 per cent at the Western Infirmary in Glasgow. Some A&E departments have performed consistently well against the 98 per cent standard over the last five years (Royal Aberdeen Children s Hospital; Gilbert Bain Hospital; Ninewells Hospital; Royal Hospital for Sick Children Edinburgh; and Perth Royal Infirmary). However, other hospitals have continued to perform poorly, even against the interim target (the Royal Infirmary of Edinburgh; Wishaw General Hospital; the Western Infirmary; Royal Alexandra Hospital; and Glasgow Royal Infirmary) (Exhibit 7, page 16). The Scottish Government has indicated it will review the 95 per cent interim target after September 2014.

16 16 Exhibit 7 A&E department performance against the four-hour waiting time standard and interim target, April 2012 to December 2013 Performance against the standard and the interim target varies considerably across A&E departments. Hospital 2012/13 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar A&E and MIU A&E sites only University Hospital Ayr University Hospital Crosshouse Borders General Hospital Dumfries and Galloway Royal Infirmary Galloway Community Hospital Victoria Hospital Forth Valley Royal Hospital Aberdeen Royal Infirmary Dr Gray's Hospital Royal Aberdeen Children's Hospital Glasgow Royal Infirmary Inverclyde Royal Hospital Royal Alexandra Hospital Royal Hospital for Sick Children, Glasgow Southern General Hospital Victoria Infirmary Western Infirmary Belford Hospital Caithness General Hospital Lorn and Islands Hospital Raigmore Hospital Hairmyres Hospital Monklands Hospital Wishaw General Hospital Royal Hospital for Sick Children, Edinburgh Royal Infirmary of Edinburgh St John's Hospital at Howden Gilbert BainHospital NinewellsHospital Perth RoyalInfirmary Western Isles Hospital Performance below 98 per cent standard 0 Performance at or above 98 per cent standard

17 Part 1. A&E waiting times 17 Exhibit 7 (continued) Hospital 2013/14 Apr May Jun Jul Aug Sep Oct Nov Dec A&E and MIU A&E sites only University Hospital Ayr University Hospital Crosshouse Borders General Hospital Dumfries and Galloway Royal Infirmary Galloway Community Hospital Victoria Hospital Forth Valley Royal Hospital Aberdeen Royal Infirmary Dr Gray's Hospital Royal Aberdeen Children's Hospital Glasgow Royal Infirmary Inverclyde Royal Hospital Royal Alexandra Hospital Royal Hospital for Sick Children, Glasgow Southern General Hospital Victoria Infirmary Western Infirmary Belford Hospital Caithness General Hospital Lorn and Islands Hospital Raigmore Hospital Hairmyres Hospital Monklands Hospital Wishaw General Hospital Royal Hospital for Sick Children, Edinburgh Royal Infirmary of Edinburgh St John's Hospital at Howden Gilbert BainHospital NinewellsHospital Perth RoyalInfirmary Western Isles Hospital Performance below 95 per cent interim target (in place from April 2013) Source: ISD Scotland, A&E datamart 0 Performance at or above 98 per cent standard 0 Performance at or above 95 per cent interm target

18 18 A&E departments have made progress over the last year in tackling the longest waits 19. The number of patients who waited longer than 12 hours in A&E departments has increased since we last reported, from 398 patients in 2008/09 to 1,435 patients in 2012/13. But there has been significant improvement over the last 12 months. In December 2013, 42 patients waited longer than 12 hours compared with 297 patients in December Overall, 25 A&E departments had no patients waiting longer than 12 hours in December Small numbers of patients waited 12 hours or more in the following A&E departments: Royal Infirmary of Edinburgh (17 patients) Hairmyres Hospital (11 patients) Victoria Infirmary (7 patients) Wishaw General Hospital (5 patients) Aberdeen Royal Infirmary (1 patient) Caithness General Hospital (1 patient). 12 The median wait for A&E patients has increased 20. The four-hour standard focuses on reducing delays longer than four hours. This can mean that less attention is given to the overall time patients are in the A&E department. There is an underlying trend of patients generally waiting longer in A&E. The median wait across A&E departments has increased from 99 minutes in 2008/09 to 126 minutes in 2012/ In 2012/13, fewer patients were treated within two hours of arriving at A&E than in 2008/ Around 60 per cent (814,528) of patients were treated within 120 minutes of arriving in 2008/09, compared with 48 per cent (645,253) in 2012/ More patients are seen just before the end of the four-hour target period 21. There is a peak across A&E departments in the number of patients who are discharged or admitted just before the four-hour target. In 2012/13, around 70,000 patients (5.3 per cent of all attendances) were dealt with during the last ten minutes of the four-hour period (Exhibit 8, page 19). This figure is up from 45,000 (3.3 per cent) in 2008/09. Of these patients, 38 per cent (27,000) were discharged home and 58 per cent (41,000) were admitted to hospital in 2012/13.

19 Part 1. A&E waiting times 19 Exhibit 8 Distribution of A&E attendances treated and discharged or admitted within four hours, 2008/09 and 2012/13 The number of patients in A&E departments who are discharged or admitted just before the end of the four-hour period has increased since 2008/09. Number of attendances 100,000 1hr 2hr 3hr 4hr 90,000 Median wait 80, minutes 2008/ /13 70,000 in 2012/13 60,000 50,000 40,000 30,000 20,000 10, Duration in A&E department (10 minute intervals) Source: ISD Scotland, A&E datamart

20 20 Part 2 Reasons for delays in A&E Many interrelated factors affect how A&E departments perform against the four-hour waiting time standard 22. As highlighted in our last A&E report, it is difficult to draw clear conclusions about the relative performance of A&E departments because the services provided vary across the country. No single factor explains the deterioration in waiting time performance since 2008/09. Each local unscheduled care system is complex. The following factors can affect how A&E departments perform against the four-hour standard: pressure on the availability of hospital beds from an increasing number of patients being admitted as emergencies and delays in patients being discharged from hospital increasing complexity of care local policies on emergency admissions local policies on informing A&E patients about alternative services the time of day that patients are discharged from wards many factors affect how long patients wait in A&E staffing pressures. 23. We analysed the national data to look for any features shared by the A&E departments that perform better against the four-hour standard, and identified some factors that may be linked to performance. 16 Where we refer to factors than can affect performance against the four-hour standard, this also applies to performance against the interim target. A&E departments that perform better against the 98 per cent standard generally have fewer attendances, but this alone does not explain the variation in performance (Exhibit 9, page 21). Seasonal variation in demand can affect performance 24. Performance against the four-hour standard shows strong seasonal variation. Performance against the standard is poorer in winter months, even though attendances are lower than average. Admissions to hospital from A&E also peak in winter when performance is lowest (Exhibit 10, page 22). During winter 2012/13, performance against the standard dipped to 89.7 per cent. This is likely to be as a result of increased pressure on the healthcare system caused by patients being more ill during winter, and seasonal illness which can lead to more unplanned hospital admissions overall. For example, from 1 November 2012 to 31 January 2013, NHS Greater Glasgow and Clyde had to close 80 wards due

21 Part 2. Reasons for delays in A&E 21 to Norovirus, compared with 23 wards closed in 2011/12. Ward closures result in greater pressure across the whole system as fewer available beds can cause delays for patients in A&E departments who need to be admitted. Exhibit 9 Attendances at A&E departments and performance against the four-hour waiting time standard, 2012/13 A&E departments with fewer attendances generally perform better against the standard. Performance against four-hour standard (%) 100 BB J 98 S EE DD Y CC T R E C U 96 N I L K 94 AA F H D O W B 92 V M 90 X A G Q P 88 Z ,000 40,000 60,000 80, , ,000 Number of attendances A University Hospital Ayr B University Hospital Crosshouse C Borders General Hospital D Dumfries and Galloway Royal Infirmary E Galloway Community Hospital F Victoria Hospital G Forth Valley Royal Hospital H Aberdeen Royal Infirmary I Dr Gray's Hospital J Royal Aberdeen Children's Hospital K Glasgow Royal Infirmary Source: ISD Scotland, A&E datamart L Inverclyde Royal Hospital M Royal Alexandra Hospital N Royal Hospital for Sick Children, Glasgow O Southern General Hospital P Victoria Infirmary Q Western Infirmary R Belford Hospital S Caithness General Hospital T Lorn and Islands Hospital U Raigmore Hospital V Hairmyres Hospital W Monklands Hospital X Wishaw General Hospital Y Royal Hospital for Sick Children, Edinburgh Z Royal Infirmary of Edinburgh AA St John's Hospital at Howden BB Gilbert Bain Hospital CC Ninewells Hospital DD Perth Royal Infirmary EE Western Isles Hospital There is some evidence that A&E patients have more serious conditions than in previous years, and more older people are attending 25. A&E departments attribute a flow category to each patient attending. This indicates the complexity of the case and length of attendance. 17 The percentage of patients classed within each category varies across A&E departments (Exhibit 11, page 23). We highlighted in our previous report that the methodology A&E departments use to define patient flows differs, and that there are limitations around this data. NHS boards may hold better local information than is available at a national level, on the types of medical conditions that A&E patients have. Using the available national data, fewer patients were classed as minor injury or illness, with 50 per cent of patients being classed this way in 2012/13 compared with 55 per cent in 2008/ There is evidence that A&E departments with more patients classed as minor injury or illness perform better against the four-hour standard. 26. Our report on Reshaping care for older people (PDF) (February 2014) highlighted that people in Scotland are living longer. 19 By 2035, a quarter of Scotland s population are expected to be aged 65 or over, up from 17 per cent in

22 Older people are more likely than younger people to have long-term health problems that may need emergency care. This is a significant cause of growing pressure on all healthcare services. The number of older people attending A&E has risen, from 242,677 patients aged over 65 in 2008/09 to 273,192 patients aged over 65 in 2012/ Exhibit 10 Attendances at A&E departments, percentage of patients admitted to hospital from A&E and waiting times performance, April 2008 to December 2013 Waiting times performance is poorer in winter and dipped most significantly in January Admissions to hospital from A&E peak in winter. 140, Number of attendances 120, ,000 80,000 60,000 40,000 20,000 4hr hr Percentage of patients seen within four hours Percentage of A&E patients admitted to hospital 16 Apr 08 Jan 09 Jan 10 Jan 11 Jan 12 Jan 13 Dec 13 Attendance 3 month moving average 4hr Waiting time performance 3 month moving average Admissions 3 month moving average Notes: 1. Admissions data covers patients admitted from A&E to the same hospital only. This figure does not include patients transferred from other A&E departments. 2. The three-month moving average smooths out spikes in the data to allow the seasonal trend to be seen more clearly. Each mark on the chart is the average of the previous two months and the current month. For example, the dark blue attendance line at December 2013 is the average attendance across October, November and December Data on the percentage of patients admitted to hospital from A&E is not available before April Source: ISD Scotland, A&E datamart

23 Part 2. Reasons for delays in A&E 23 Exhibit 11 Flow category by A&E department, 2012/13 Half of A&E patients are classed as flow 1 (minor injury and illness). SCOTLAND Belford Hospital Western Isles Hospital Gilbert Bain Hospital Royal Aberdeen Children's Hospital Raigmore Hospital Perth Royal Infirmary Lorn and Islands Hospital Galloway Community Hospital Caithness General Hospital Forth Valley Royal Hospital Wishaw General Hospital Hairmyres Hospital Ninewells Hospital Royal Hospital for Sick Children, Edinburgh Royal Hospital for Sick Children, Glasgow University Hospital Ayr Borders General Hospital University Hospital Crosshouse Victoria Hospital Monklands Hospital Dumfries and Galloway Royal Infirmary Dr Gray's Hospital Glasgow Royal Infirmary St John's Hospital at Howden Southern General Hospital Aberdeen Royal Infirmary Western Infirmary Inverclyde Royal Hospital Victoria Infirmary Royal Infirmary of Edinburgh Royal Alexandra Hospital Percentage of patients Flow 1 (minor injury and illness) Flow 2 (acute assessment) Flow 3 (medical admissions) Flow 4 (surgical admissions) Flow 5 (out-of-hospital care) Source: ISD Scotland, A&E datamart

24 Patients aged 65 and over have higher rates of attendance at A&E. Patients in this age group are also more likely to be admitted to hospital from A&E (Exhibit 12). In December 2013, 60 per cent of A&E attendances for people aged over 65 resulted in admission to hospital, compared with 23 per cent of patients aged under 65. Exhibit 12 Rates of A&E attendances and admissions per 1,000 population by age and gender, December 2013 Patients aged over 65 are more likely to attend A&E and be admitted to hospital for further care. 30 Rates per 1,000 population Under 65 Male attendance Male admission 65 and over Female attendance Female admission Note: This excludes patients where a valid Community Health Index (CHI) number was not recorded. Source: ISD Scotland, A&E datamart 28. Our report on care for older people highlighted that effective primary care may be able to prevent emergency admissions to hospital for a series of conditions. These are sometimes referred to as potentially preventable hospital admissions, and include influenza and pneumonia. The rate of potentially preventable hospital admissions has remained relatively stable, from 4,552 per 100,000 population aged 65 or over in 2002/03 to 4,550 in 2012/13. The number of patients admitted to hospital from A&E has increased over the last five years 29. The number of patients admitted to hospital from A&E has risen from 334,879 in 2008/09 to 361,121 in 2012/13, an eight per cent increase. 21 Admission to hospital from A&E varies considerably, from 40 per cent of attendances at University Hospital Crosshouse to 13.9 per cent at the Royal Hospital for Sick Children, Glasgow (Exhibit 13, page 25). 22

25 Part 2. Reasons for delays in A&E 25 Exhibit 13 Where patients go from A&E departments, 2012/13 Most patients attending A&E departments are discharged home but around 27 per cent are admitted to hospital. Where patients go (percentage) A&E department Admission to same NHS provider Private residence Transfer to other NHS provider Other University Hospital Crosshouse University Hospital Ayr Borders General Hospital Dumfries and Galloway Royal Infirmary Royal Alexandra Hospital Western Infirmary Royal Infirmary of Edinburgh Victoria Infirmary Monklands Hospital Caithness General Hospital Southern General Hospital Hairmyres Hospital Inverclyde Royal Hospital Aberdeen Royal Infirmary Gilbert Bain Hospital Royal Aberdeen Children's Hospital Forth Valley Royal Hospital Victoria Hospital Glasgow Royal Infirmary St John's Hospital at Howden Wishaw General Hospital Ninewells Hospital Western Isles Hospital Raigmore Hospital Dr Gray's Hospital Lorn and Islands Hospital Belford Hospital Perth Royal Infirmary Royal Hospital for Sick Children, Edinburgh Royal Hospital for Sick Children, Glasgow Galloway Community Hospital SCOTLAND Note: Admission to same NHS provider includes admission to ward and, if available, assessment unit. Others includes deceased; private healthcare provider; residential institution; temporary residence; not known. Source: ISD Scotland, A&E datamart

26 Performance against the waiting time standard tends to be better in A&E departments that have lower admissions from A&E to hospital. Patients who need to be admitted wait longer in A&E than those who are treated and discharged home. In 2012/13, the median wait across A&E departments for admitted patients was minutes, compared with 109 minutes for patients who were discharged home. 23 The number of patients admitted to a hospital includes those admitted to a hospital ward, an A&E short-stay ward, or an assessment unit. It is difficult to identify the impact that assessment units have on A&E waiting times performance 31. Some hospitals have an assessment unit to accommodate patients who need further treatment or observation before they are transferred to a hospital ward or discharged. 24 These units can reduce admissions to hospital wards and limit the waiting time for patients in A&E departments. 25 Our previous audit highlighted that opening hours and levels of staffing vary across the country. Up-to-date national information about how hospitals use these units and how they operate is limited. Across Scotland, admissions from A&E to these units are not recorded consistently. Of the 27 per cent of patients who are admitted to hospital from A&E, we do not have a complete picture of how many were admitted to a ward or to an assessment unit. Only eight A&E departments submit data to ISD Scotland on the number of patients admitted to an assessment unit. This ranged from one patient to 10,750 patients in 2012/13. This makes it difficult to identify the impact these units have on emergency admissions or waiting times in A&E. Eleven per cent of all admissions to hospital from A&E departments took place within the last ten minutes of the four-hour period 32. In 2012/13, around 11 per cent of all admissions to hospital from A&E departments happened within the last ten minutes of the four-hour period. There is significant variation across A&E departments, ranging from 18 per cent at the Royal Infirmary of Edinburgh to 1.1 per cent at Royal Aberdeen Children's Hospital (Exhibit 14, page 27). Patients admitted during the last ten minutes are more likely to stay in hospital longer 33. We cannot tell from national data whether patients are admitted to hospital inappropriately to meet the waiting time standard. If patients were systematically being admitted to avoid the A&E department failing to meet the standard, then those admitted just before the four-hour period ends would be more likely to spend only a short time in hospital. National data shows that patients who are admitted just before the end of the four-hour period are likely to spend longer in hospital. The data shows that 51 per cent of patients admitted in the last ten minutes stay three days or more, compared with 14 per cent of patients admitted in the last ten minutes who stay less than one day (Exhibit 15, page 28). While it may be clinically appropriate for the patients to remain in A&E until this time, higher than average admissions during the last ten minutes could suggest issues in managing the patient flow through the hospital. There is no evidence that A&E departments with higher admissions in the last ten minutes perform better against the standard.

27 Part 2. Reasons for delays in A&E 27 Exhibit 14 Admissions from A&E departments to hospital in the last ten minutes of the four-hour period, 2012/13 The percentage of admissions made during the last ten minutes varies across A&E departments. SCOTLAND Royal Infirmary of Edinburgh Hairmyres Hospital Royal Hospital for Sick Children, Edinburgh Western Infirmary Southern General Hospital St John's Hospital at Howden Aberdeen Royal Infirmary Victoria Infirmary Forth Valley Royal Hospital Monklands Hospital Dr Gray's Hospital Glasgow Royal Infirmary Wishaw General Hospital Victoria Hospital University Hospital Ayr Raigmore Hospital Borders General Hospital Royal Alexandra Hospital Gilbert Bain Hospital Inverclyde Royal Hospital Western Isles Hospital Caithness General Hospital Ninewells Hospital Perth Royal Infirmary Dumfries and Galloway Royal Infirmary Galloway Community Hospital University Hospital Crosshouse Belford Hospital Royal Hospital for Sick Children, Glasgow Lorn and Islands Hospital Royal Aberdeen Children's Hospital Percentage of admissions from A&E in last 10 minutes (as a percentage of all admissions from A&E) Source: ISD Scotland, A&E datamart

28 28 Exhibit 15 Emergency admissions by length of stay for patients admitted from A&E departments, by the time they spend in A&E, 2012/13 Patients who are admitted in the last ten minutes of the four-hour period in A&E departments, or after the four-hour period, are more likely to stay longer in hospital. 100 Percentage of admissions to to to to to to to to to to to to to to to or more 1hr 2hr 3hr 4hr 5hr 6hr Length of time in A&E (minutes) 0 Days 1 Days 2 Days 3+ Days Note: This excludes patients where a valid Community Health Index (CHI) number was not recorded. Source: ISD Scotland, Unscheduled Care datamart The way that patients are admitted to hospital may affect performance against the four-hour standard 34. There is wide variation among NHS boards in the percentage of emergency admissions that go through the A&E department. Overall, around 98 per cent of NHS Ayrshire and Arran s emergency admissions go through an A&E department compared with 34 per cent in NHS Tayside. Admission rates from A&E to hospital also vary considerably by NHS board. Rates are highest in NHS Ayrshire and Arran (120 per 1,000 population) and lowest in NHS Tayside and NHS Highland (both 36 per 1,000 population). 26 Higher admissions from A&E departments are linked to weaker performance against the standard. 35. NHS boards take different approaches to admitting patients who are referred to hospital by their GPs. Some patients are admitted directly to wards or to special admitting units without first attending the A&E department. In some areas or specialties, patients go through A&E before being admitted to a hospital ward. 36. GP referrals to A&E departments fall into two categories: GP referrals for A&E treatment; and GP referrals for admission. In 2012/13, GP referrals for A&E treatment made up almost six per cent (76,869) of A&E attendances and GP referrals for admission made up almost four per cent (52,413). GP referrals for admission vary from around 16.3 per cent (7,305) of attendances at University Hospital Ayr, to 5.6 per cent (3,581) at Wishaw General Hospital (Exhibit 5, page 14). 27 There are some limitations with this data as A&E departments

29 Part 2. Reasons for delays in A&E 29 record these referrals inconsistently. 28 However, there is some evidence that A&E departments with higher GP referrals for admission perform less well against the four-hour standard. This may be because these patients have more serious health conditions. Three reasons account for nearly 70 per cent of delays in A&E 37. The most common reasons that NHS boards report for failing to achieve the A&E four-hour standard are largely the same as those reported in our previous A&E audit: waiting for a bed waiting for first full clinical assessment 29 waiting for a specialist (Exhibit 16). Exhibit 16 Reasons for waiting over four hours in A&E, 2012/13 Waiting for a hospital bed is the most common reason for patients waiting longer than four hours in A&E. About one in five patients who are delayed are waiting for their first full clinical assessment. 4% 1% 4% Wait for a bed 6% Wait for first full clinical assessment 7% 8% +4hr wait 38% Wait for specialist Clinical reason(s) Wait for diagnostic tests(s) Wait for initial A&E treatment 10% 21% Other reason Wait for transport Not known Source: ISD Scotland, A&E datamart 38. Once a decision to admit has been made, the A&E department relies on the efficiency of the rest of the hospital to be able to move patients out of the A&E department and into a more appropriate setting. Some of the bottlenecks are beyond the control of the A&E department itself.

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