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Emergency care changes – is there more than one waiting list?

Last month, at what we now fervently hope was the height of the current pandemic, we looked at the impact of Covid-19 on hospital waiting lists. Now, as cases and admissions are thankfully on a downward trend, we can take another look at what the A&E activity figures tell us about changes in emergency care.

We already knew from the first lockdown last year that A&E attendances overall were dramatically reduced in the wake of the pandemic. This of course raised questions about why patients were not seeking medical care:

  • Were patients with long-term conditions or complex needs avoiding hospital for fear of Covid?
  • Would this lead to poorer outcomes in the long-run and a greater number of patients not presenting until they are more acutely unwell?
  • How far does this explain the increase in non-Covid mortality we saw last year?

Then of course there is the old argument about the ‘worried well’ who attend A&E unnecessarily. How much of the activity reduction is due to this group staying away?

The latest activity figures – which you can explore on our A&E dashboard – shed a little more light on these issues.

Back in April last year during the first peak of Covid infections, A&E attendances dropped away to almost half (56%) of what they were in April 2019. Fears were raised then about patients being reluctant to come forward for treatment and attempts were made to get the message out that the NHS was still open for business. Although of course, everyone knows very well what the priority has been.

Attendances in January 2021 are still down by over a third on last year (38% of the January 2020 total). So does this suggest that the message has been getting across and things are returning to normal? A look at the number of patients attending A&E who go on to be admitted provides some insight.

The conversion rate (attendances to admissions) remained broadly stable across the two years immediately preceding the pandemic. In April of both 2018/19 and 2019/20 approximately 19% of A&E attendances led to admission. In January of both those years the figure was 20%.

April last year saw an increase in the proportion of patients admitted to 28% and the figure for January 2021 was 27%.

Clearly, a greater percentage of patients being admitted from A&E, at a time when attendances overall are reduced, suggests that those patients who do attend are more acutely unwell. But how much of this is down to Covid-19 infections and how much to patients staying away from hospital with other conditions until they are more severely ill?

January is always a busy time for the NHS and you would expect A&E admissions to increase. In fact, across the two years prior to the pandemic, the figures were again pretty consistent with a mean figure for January 2019 and 2020 of 422, 803 admissions. The drop therefore in January 2021 to 353, 911 is notable enough in itself. If we consider the number of Covid-19 related admissions at the height of the second peak, it becomes all the more telling.

Government figures tell us that there were 113, 033 admissions related to Covid-19 in January. If we subtract these patients from the total number of admissions via A&E for the month, we are left with a shortfall on the previous year’s figure of 181, 925. Not all Covid-19 patients will be admitted via A&E, but even if we assume only half of them are, which seems unlikely, we are still left with over 125, 000 fewer admissions than we might have expected. 

We are yet to see the excess mortality figures for 2021 of course, but just as the reduction in referrals and treatments for cancer last year was concerning, the rise in acuity of A&E attenders is troubling. The potential for another pool of unmet need among the chronically unwell, is further evidence, if it were needed, that the Covid pandemic will cast a long shadow. 

This article only touches the surface of the enduring impact that Covid-19 will have on how the NHS does business.  There are a huge number of areas where customary business practice will need to rapidly catch up with what’s happened on the ground in the first half of 2020.

We will continue to explore these issues over the coming months.  In the meantime, if you’d like to discuss any of the points touched on in this article please get in touch.

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Are we now moving to Integrated Care Systems by default?

One of the most dramatic things coronavirus has done is force through health and social care transformation much more rapidly than has been possible before.

Covid-19 has highlighted how providers and commissioners can work together at a regional scale.  This is the time to capitalise on the response so far to ensure the health and care system is fit for purpose long term and works for patient populations at a health-economy level.

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