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Unscheduled Care in Wales – a system under real pressure

21 April 2022
  • What is meant by unscheduled care?

    Unscheduled care is any unplanned, urgent, and emergency care provided by healthcare services. It can cover a myriad of conditions but essentially refers to care which needs to be provided quickly (ie within hours) or in some cases immediately.

    How is the unscheduled care system in Wales currently performing?

    Staff working in the unscheduled care system provide vital treatments and interventions at a time when people need them most. However, countless media articles relaying people’s difficulties when they need urgent, or emergency care tell you that the system these staff work in is really struggling. This is particularly the case when people call for an ambulance or attend an A&E department.

    Whilst A&E departments will prioritise the most seriously ill and injured patients, many people attending these departments can face long waits to be seen. In February 2022, 58% of people attending an A&E department were seen within four hours. The national target is 95%. 75% of patients were seen within eight hours with 84% seen within 12 hours. A&E departments are not designed for such long waits, which means many patients spend hours waiting on chairs or trolleys before being seen or admitted.

    Calls for an ambulance are categorised according to the urgency of a patient’s need. Calls for the most serious and life-threatening conditions are classified as ‘red’ and there is a national target to respond to 65% of these calls within eight minutes. However, the national response time target for red calls has not been met since July 2020. In February 2022, 55% of red calls received an ambulance within eight minutes, with 95% of red call patients receiving a response within 21 minutes.

    Calls for conditions which are not life threatening but still serious are classified as ‘amber 1’ and ‘amber 2’. There is no target response time for these calls and patients in these categories have increasingly faced very long waits for an ambulance. In February 2022, 95% of ‘amber 1’ calls were responded to within five hours and for ‘amber 2’ calls within 12 hours, with 469 people across both categories waiting over 12 hours for a response.

    The availability of ambulances to respond to emergency calls is significantly impacted by delays in handing over patients once they arrive at already crowded A&E departments. In February 2022, the ambulance service lost 23,214 hours to handover delays, the highest number recorded to date. That equates to an average of 827 hours a day. To put these figures in context, some ambulance crews can spend their entire 12-hour shift with a single patient waiting outside an A&E department.

    In addition to handover delays, the volume of 999 calls received and the way in which the ambulance service uses its resources will also have an effect on ambulance response times. During the pandemic, the ambulance service has relied on support from the military to help with its emergency responses. This support ceased at the end of March 2022 with ambulance response times expected to worsen as a result.

    Our new unscheduled care data tool provides further information on how services are performing by pulling together key statistics from different parts of the unscheduled care system.

    What is the impact on patients and staff?

    The unavoidable consequence of the figures reported above is that many patients have an unscheduled care experience that falls below the level of quality they could reasonably expect and which the staff working in those services would wish to provide.

    A recent Healthcare Inspectorate Wales review of ambulance handovers [opens in new window] highlighted that handover delays can hinder the provision of responsive, safe and dignified care. In general, there has been an upward trend in patient safety adverse incidents reported by the ambulance service in Wales during the pandemic. Whilst the majority of these incidents did not result in any harm to patients, there have been cases where minor, moderate or even catastrophic harm has been recorded.

    Is this a new problem?

    Whilst the pandemic has undoubtedly created a new set of pressures on services, managing demand for unscheduled care has been a challenge for many years. The four-hour waiting-time target for A&E departments had not been met for the four years leading up to the pandemic – in fact, performance had been on a steady decline.

    Whilst the ambulance service was largely meeting the eight-minute target for responding to ‘red’ 999 calls in the years preceding the pandemic, response times for ‘amber’ 999 calls had been lengthening since 2017.

    Although delays in ambulance handovers were not as stark as they are now, the sight of ambulances stacked up outside A&E departments particularly during the winter months was common. Between 13,000 and 14,000 lost hours per month were reported in the winter period prior to the pandemic.

    What factors are contributing to the pressure on the system?

    A number of different factors are combining to put pressure on the system:

    • Increasing demand
      The extent to which the 999 service experiences frequent callers has also gradually increased and while the numbers still remain low, the volume of calls generated by frequent callers is increasing at a higher rate.
      Early in the pandemic, attendance in A&E departments dipped sharply as did 999 call volume with resultant improvements in handover delays. A desire to free up bed capacity also meant that delayed discharges were reduced to zero. As the pandemic has progressed, demand has gradually risen to match and then exceed pre-pandemic levels with the added complexity of people presenting with conditions which have worsened.
      Patients accessing the emergency ambulance service are now presenting with increasingly acute needs, as an increasing and more consistent number of patient calls are categorised as red ie life-threatening.
    • Poor ‘flow’ through the system
      The inability to move patients through the hospital system can have major consequences for A&E Departments and ambulance handovers. Difficulties in discharging some patients from hospital once they are medically fit to leave have created an unscheduled care system which is continuously backed-up with A&E Department staff finding it ever-more difficult to admit patients due to the lack of hospital beds to place them in. This in turn results in ambulances being unable to hand over their emergency patients to A&E Departments.
      In November 2021, it was estimated that 1,400 patients who were medically fit were waiting in hospital beds across Wales for their discharge to happen. For a variety of reasons discharge was delayed. The last time the number of delayed discharges reached over 1,000 was back in 2005.
    • People not accessing care appropriate to their needs
      Data collected by NHS bodies shows that a significant proportion of patients (44%) attending A&E Departments are discharged with no further follow-up. A further proportion (16%) are referred to alternative healthcare providers, such as their GP. This data suggests that many people’s unscheduled care needs do not require attendance at an A&E department. The reasons these patients attend A&E are likely to be various and will include perceived or real difficulties in securing a GP appointment, personal choice, and a traditional view that they need to be seen by a doctor, and a lack of awareness to where they can access alternative advice and treatment.
    • Workforce issues
      The pandemic has had a real impact on the workforce. Sickness absence rates within the NHS and social care have been at an all-time high. Alongside this, primary and community-based services have become much more fragile as staff reflect on careers, working conditions and long-term goals (the ‘great resignation [opens in new window]’), and the ability to attract new staff becomes much harder. This had also led to unprecedented staff shortages within the care home and domiciliary care sector – services that many of the patients within the unscheduled care system require to provide ongoing support beyond their hospital stays to keep them well and prevent any future hospital admissions.
    • COVID-19 restrictions
      As well as implications for staff availability, COVID-19 restrictions have also impacted on the capacity available to support people in the unscheduled care system. Increased infection control regimes and social distancing requirements mean that processes can take longer and the physical capacity within A&E departments for example is more restricted. Since the start of the pandemic, temporary reduction in care home capacity to minimise COVID-19 outbreaks has reduced discharge options and hampered the flow of patients out of hospital.

    What is being done in response to these challenges?

    During 2020 and 2021, the Welsh Government has been focusing its attention on transforming access to urgent and emergency care [opens in new window] through the development of the Six Goals for Urgent and Emergency Care’. These will build on the previous unscheduled care policy framework and will be formally launched in April 2022. Implementation will be supported by £25 million of recurring funding alongside £6 million already given to Regional Partnership Boards in 2021-22 to help facilitate hospital discharge for people who need support in their community.

    In addition, at the height of the pandemic, the rollout of the 111 call-handling programme was escalated to all health board areas, providing a single point of access to unscheduled care services. In response to the system being under considerable pressure, a ‘risk summit’ was convened in February 2022 to consider the pressures being faced by unscheduled care services, and a two week ‘system reset’ was attempted in March 2022, with actions aimed at improving management of demand and flow of patients through hospital.

    The extent to which these initiatives and the refreshed policy framework are successful in addressing the challenges which have persisted in unscheduled care remains to be seen.

    During 2022, Audit Wales will be undertaking a programme of work that will assess the extent to which the system and its leadership structures are responding to the pressures in the unscheduled system. Our work will include an examination of the actions being taken by NHS bodies, local government, and Regional Partnership Boards to secure timely and safe discharge of patients from hospital to help improve patient flow. We also plan to review progress being made in managing unscheduled care demand by helping patients access services which are the most appropriate for their unscheduled care needs.

    About the authors

    Anne Beegan is an Audit Manager in the Health Team responsible for a number of all-Wales thematic reviews as well as oversight of the performance audit programme of work in Hywel Dda, Powys, and Swansea Bay Health Boards, and Public Health Wales. Before moving to Audit Wales in 1999, she was a Clinical Governance Manager for an NHS Trust in England.

    Fflur Jones is an Audit Lead in the Health Team responsible for the development of the unscheduled care work as well as day-to-day oversight of the performance audit programme of work in Betsi Cadwaladr University Health Board and the Welsh Ambulance Services NHS Trust. Before joining Audit Wales in 2015, she worked as an Outreach Communications Officer at the Welsh Parliament (then National Assembly for Wales).