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NHS Funding

The figures given below are from Stats Wales and detail NHS expenditure per head.[9]

Category	2009-10	2010-11	2011-12	2012-13	2013-14	2014-15
Total NHS Funding (£)	1721.31	1755.77	1759.10	1765.57	1803.82	1876.47
Social care needs (£)	15.78	14.45	13.99	14.69	15.93	16.18

Although these numbers are not adjusted for inflation, there are part of this picture that are quite positive. Social care funding has increased by 9.2% since 2013 – something which cannot be said in England – and overall NHS funding has increased by 5.9% or just under 2% per year. This again compares favourably with the situation in England where the rate of increase has been around 0.7% since 2010.[10]

However, considered more closely a different picture emerges. The Nuffield Trust after adjusting for the fact that older populations have higher health needs and associated costs, Wales is now the lowest spending UK nation on its Health Service.[11] Moreover, since its foundation in 1948 the NHS has spending increases of around 3.7% per annum in real terms.[12] This suggests that while recent spending increases are welcome, increases of around 2% before accounting for inflation are unlikely to arrest declines in performance.

A&E Staffing

The figures given below are from Stats Wales and give details about changes to the emergency medicine workforce since 2010.[13]

Staff Category	2010	2011	2012	2013	2014	2015	% Change since 2010	% Change since 2013
	260.19	274.29	263.42	287.28	286.03	288.08	9.68	0.28
Consultant	49.00	53.50	54.60	61.20	66.80	63.20	22.47	3.16
Specialty Doctor	28.30	36.45	43.20	39.30	45.60	47.85	40.86	17.87
Staff Grade	3.10	2.10	1.00	1.00	1.00	1.00	-210.00	0.00
Associate Specialist	20.72	17.52	17.50	15.86	12.50	11.50	-80.18	-37.94
Specialist Registrar	76.20	86.60	67.00	85.80	73.01	93.71	18.68	8.44
Senior House Officer	10.00	13.00	13.00	19.00	16.00	5.00	-100.00	-280.00
Foundation House Officer 2	55.00	51.00	51.00	52.00	58.00	50.00	-10.00	-4.00
Foundation House Officer 1	14.00	12.00	15.00	12.00	12.00	14.00	0.00	14.29

Year	Total attendances	Percentage of patients who spend less than the target time in A&E	Number of Consultants	Consultant Per Attendance
2010-11	769897	85.76	53.50	14390.60
2011-12	788378	87.01	54.60	14439.16
2012-13	786620	85.46	61.20	12853.27
2013-14	773211	87.67	66.80	11575.01
2014-15	772954	81.98	63.20	12230.28

Questions of staffing are complex, but the point to notice is that although there were considerable increases in the A&E workforce between 2010 and 2013 – when as we have seen A&E actually improved – since 2013 that progress has stalled.

Moreover from 2013-14 the number of consultants per attendance has deteriorated. This has gone from one to every 11,575 attendance in 2013-14 to one to every 12,230 in 2014-15. This echoes our wider concerns about on-going difficulty recruiting staff to support the speciality in Wales. These difficulties are aggravated by the placement of major trauma centres throughout the principality and the continued attractions of more lucrative work in other countries such as Australia.

Between 2013 and 2015 the workforce expanded by no more than 0.28%. One could argue that this is a reflection of the fact that from 2013 to 2015 attendances at major A&E’s were broadly stable. However – as we shall see further below – this does not account the increasingly elderly profile of the Welsh population. This means that the casemix in Welsh A&E is becoming more complex, and more demanding, and requires a workforce of sufficient size and with the necessary number of senior decision makers to treat them effectively.

Unfortunately, more current workforce data is not yet available centrally. However, between 2014-15 and 2015-16 attendances at major A&Es in Wales increased by 11,125 or 1.41%.[14] Furthermore, the data so far published for 2016/17 shows that up to this point attendances have been higher than last year.[15] Either for financial reasons or otherwise, if decisions about the recruitment and retention of A&E do not accurately reflect the nature of demand then performance cannot reasonably be expected to improve.
Bed Availability and Occupancy

The figures given below are from Stats Wales and show bed availability and bed occupancy in the Welsh NHS.[16]

Year	Average daily available beds	Average daily occupied beds	Percentage occupancy
2010-11	12149.33	10294.16	84.73
2011-12	11809.69	10062.42	85.21
2012-13	11497.02	9923.24	86.31
2013-14	11241.49	9653.17	85.87
2014-15	11061.52	9588.74	86.69

What these figures show is that there has been a 9.83% decrease in bed availability since 2010 and a 3.93% decrease since 2013. The number of daily occupied beds has decreased by slightly less, at 7.38% and 3.49% respectively.

While this does something to indicate that the available bed stock is being used more efficiently, gains has nonetheless failed to prevent an increase in bed occupancy to levels greater than 2013.

As was the case for staffing data, more contemporaneous bed availability data is not yet available. Although it is not possible to be certain, it seems highly likely that the number of available beds has continued to decline into 2016/17 and that bed occupancy rates have continued to increase. This is because this would represent the continuation of a trend seen in Wales and the wider UK NHS for at least the last 20 years.[17]

This being the case, we have evidence to suggest that there are higher levels of demand, whilst staffing levels that have stagnated, and there continuing declines in hospital bed capacity. Or to put it in more simple terms, the system has more patients to deal with and less facility with which to do so in a timely fashion. In these circumstances it is unrealistic to expect that the percentage of patients is going to get better.

Aging Population and Delayed Transfers

The figures given below are from Stats Wales collated from the Office of National Statistics.[18]

Year	Population
Mid 2013 All ages	3082412
Mid 2013 Aged 65 and over	600630
Mid 2014 All ages	3092036
Mid 2014 Aged 65 and over	614747
Mid 2015 All ages	3099086
Mid 2015 Aged 65 and over	624773

What these figures show is that the population of Wales – which already had considerable needs centred around an aging population – has continued to become more elderly. From mid 2013 to mid 2015 the population of those over 65 year of age increased by 3.86%. In the same time period, the populations as a whole increased by no more than 0.54%.

It is within this context that the Royal College of Emergency Medicine takes the view that ED have struggle in the face of rising demand, not because success is impossible, but because we continue to systematically under-resource emergency departments in the forlorn hope that the next redirection strategy will succeed where all others have demonstrably failed.

Instead A&E should be resourced to practice an advanced model of care where the focus is on safe and effective assessment, treatment and onward care. While it is essential to manage demand on A&Es, this should not detract from building capacity to deal with the demand faced, rather than the demand that is hoped-for.

If this rate of growth has continued, then by mid 2016 we can expect there to have been 632,821. This would represent an increase of 32,190 since 2013. If these figures are reflected in the age and volumes of patients seen in Welsh A&E departments, then the casemix and time and resources necessary to change them can be expected to have increased. Since – as we have seen – the resources necessary to do so have not been supplied then the situation can be expected to become more adverse.

One aspect of an aging population is that more of those patients who enter hospital are more likely to need some kind of care package in place before they can leave. When this cannot be supplied in a timely fashion then those patients are subject to Delayed Transfers of Care.

The chart given below shows the numbers of patients subject to Delayed Transfers of Care in Welsh hospitals since 2013.[19]

What this shows is from at least 2014 the trend is clearly upwards and the existing data for 2016 suggests that this will continue. For example the mean average number of patients delayed per month in 2015 was 484. The average number of delays per month thus far is 490. This would result in 5885 delays for the whole of 2016 rather than 5810 for 2015.

This is important because the more patients are subject to delayed transfers of care – and the data does not specific how long each of these delays lasted – the fewer beds are available within hospitals to treat patients who arrive at A&E requiring treatment. Logically if there are to be more of these delays then timely performance becomes harder to maintain.

Conclusions and Recommendations

The situation laid out above is not a new phenomenon. Difficulties treating patients in a timely fashion because of a lack of available beds, has been a feature of the Welsh and other UK health systems for some time.

31. This is referred to as Exit Block and can be clearly seen in the available statistics. From 2010-11 to 2014-15 the number of people waiting more than four hours in A&E has increased by 29,080 or 26.65%. During the same period the number of people waiting more than eight hours in A&E has increased by 20,785 or 79.72%.[20]

Exit block is proven to be associated with both significant morbidity and mortality. The latter has been estimated at 3000 patients per year in the UK.[21]

Paradoxically exit block is associated with a greater number of patients admitted to ‘any bed’ rather than an ‘appropriate bed’. In turn this leads to greater lengths of stay, reducing the available bed stock and perniciously increasing the frequency and severity of exit block.

Faced with these trends, and the demonstrable inability of redirection or re-education strategies to alleviate these pressures, it is more logical to respond positively to the needs and demands of patients rather than seek to resist them. It is our opinion that the way to do this is to put in place the co-location of key out of hours urgent care services.

This can be achieved both physically and through the greater use of technology such as virtual consultations. This would improve the quality of care for patients would improve the sustainability of emergency medicine in the Welsh NHS by decongesting emergency departments.

Given the prevailing situation in the NHS in Wales it would seem unlikely at this point that performance against the four hour target will improve. For that to be the case Welsh A&E departments – and the wider NHS – would need to be adequately staffed and resourced to meet the demands placed upon it. At present it is not.

There are too few senior medical staff in A&E departments to deliver effective and efficient care. The attrition rate from UK training programmes has wasted our most valuable resource. We must ensure the work environment and shift patterns promote rather than discourage staff retention.

Planning must especially address the need to cope with rising numbers of attendances by the frail elderly – with complex interactions between health and social care and long term co-morbidities.

Provision of co-located services within an A&E hub to decongest emergency departments will deliver a successful strategy that is patient centred, affordable, efficient and effective.

RCEM Wales has been campaigning for some time for the reform of emergency medicine around the elements of our step campaign. If acted upon this would ensure that A&E were properly staffed and resourced and improve services for patients in need. Details of that campaign can be found here: https://portal.rcem.ac.uk/live/RCEM/Shop/Policy/Campaigns/RCEM/Quality-Policy/Policy/Campaigns.aspx

[5] King’s Fund Understanding Pressures in General Practice The data referred to here is from England but is taken as broadly indicative.