Long A&E waits and excess deaths –

Royal College reveals remarkable, unreported differences across UK!

By stewartb

Candidly, this is a highly sensitive subject. In advance of what follows, and for the avoidance of doubt, excessively long waits in A&E in Scotland are unwelcome: they need to be eliminated. And ANY and ALL avoidable ‘excess deaths’ are deeply regrettable: the causes need to be eradicated.

This blog post summarises new analyses from the Royal College of Emergency Medicine

(RCEM) of 12-hour A&E waits in NHS England. It reports the Royal College’s assessment of excess deaths in England that it claims can be attributed to these long waits. Crucially, it has now also compared the impact of long waits on excess deaths in each of the four nations of the UK. The results are startling!

Motivation/justification

The point of amplifying the RCEM’s comparative analysis is political: once more we find evidence that flies in the face of the negative narrative concerning NHS Scotland and associated Scottish Government oversight. An unqualified negativity – context and perspective-free – is sustained relentlessly by the corporate media, the BBC and opposition politicians in Holyrood. And, arguably, it is a negativity reinforced recently by an SNP leadership contender (albeit a position which seems to be getting rolled back by the individual responsible).

Undermining a reputation for competent government – including over the NHS – is one important plank of efforts to end SNP government in Scotland.

The RCEM’s campaign on 12-hour waits

The RCEM has long been pressing for a change in the way NHS England and the Westminster Government report on long waits in England’s A&E departments.

In evidence to a House of Lords committee, the current practice of measuring 12-hour waits from the time of a ‘decision to admit’ (DTA) rather than from ‘time of arrival’ (TOA – as in Scotland) was described by Dr Adrian Boyle, President of the RCEM as “a fundamentally dishonest way of reporting data. It is hiding and doing our patients a disservice by minimising a very serious problem”.

Source: Public Services Committee, House of Lords (19 January, 2023) Emergency healthcare: a national emergency (https://publications.parliament.uk/pa/ld5803/ldselect/pubserv/130/130.pdf  )

The RCEM returned to the issue of 12-hour waits in a statement issued on 3 March 2023: ‘RCEM Explains long waits and excess mortality’.

Source: https://rcem.ac.uk/wp-content/uploads/2023/02/RCEM_Explains_long_waits_and_excess_mortality.pdf

The RCEMreports a success: ’As a result of our campaigning, from April 2023, NHS England will publish data on 12-hour patient waits from Time of Arrival (TOA). The Royal College of Emergency Medicine (RCEM) welcomes this first step, the Government and NHS England must ensure that this data is published on a monthly basis and broken down by type of ED and at an individual ED level, so that hospitals can use this information to reduce long waiting times.’

‘Honest’ 12-hour waits data for England

The RCEM’s 3 March document also uses NHS England’s long wait statistics to estimate the scale of their adverse impact in terms of excess deaths. 

Firstly, it reports aggregated data on 12-hour waits in England from ‘time of arrival’ (TOA) for the whole of 2022. (These are data held by NHS England but which have not to date been published monthly.)

Here are RCEM’s findings (with my emphasis):

• ‘In 2022, NHS England reported that 347,703 patients waited 12 hours from DTA, 2.1% of Type 1 attendances. We have calculated that in 2022, 1,656,206 people waited 12 hours or more from their TOA at an ED, 10.2% of all Type 1 attendances.’ (ED = Emergency Department)

12-hour wait statistic for Scotland

According to NHS Performs (https://www.nhsperforms.scot/), during 2022 the number of patients attending the main A&E departments in Scotland (equivalent to England’s Type 1 departments) was c. 1,318,100. (Derived by calculation, based on summing weekly data from w/e 9 January 2022 to w/e 1 January 2023.)

The number in this period waiting 12-hours or more in these departments from arrival to admission, discharge or transfer (TOA waits) was 53,163.

So c.4.0% of attendances experienced a 12 hour or longer TOA wait in NHS Scotland in 2022. To recap, the RCEM reports the equivalent statistic for NHS England for 2022 to be 10.2%, a substantial 6.2 percentage point difference!

Adverse impact of long waits on excess deaths

For some time now, media sources and opposition politicians have made much of the RCEM’s claims of excess deaths in Scotland due to long waits at A&E. The RCEM’s claims are not without controversy but unlike with BBC coverage, TuS provides a link (below) to the basis of the methodology: interested readers can check this for themselves.

The RCEM’s estimates of excess deaths due to long waits in A&E are made ‘Using the Standard Mortality Ratio (SMR) and the 12-hour TOA figure’. This approach is founded on the following academic research, conducted initially using an NHS England dataset:

Source: Jones S, Moulton C, Swift S, et al (2022) Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emergency Medicine Journal 39:168-173. (http://press.psprings.co.uk/emj/january/emj211572.pdf)

In its 3 March 2023 statement on 12-hour waits in England, the RCEM reports:

• ‘… we estimate that 23,003 patients potentially died in 2022, equalling 446 patients a week. What’s more, as there is no backstop to the 12-hour TOA data, this figure is likely an underestimate.’

Using the same SMR methodology, the RCEM has calculated for 2022 an ‘excess deaths’ estimate due to 12-hour waits in each of the four UK nations. The results are shown in the chart below published by the RCEM.

Taking the RCEM’s approach at face value:

• the total 2022 figure for Scotland is by far the lowest in absolute terms. Indeed, it is an order of magnitude lower than that for Wales and NI, despite Scotland’s substantially higher population. Scotland’s total for 2022 is just 44.5% of the equivalent figure for Wales and 53.3% of NI’s, despite its bigger population. The implication is clear: over 12-hour TOA waits in Scotland have been substantially lower in 2022 not only in absolute but also in proportional terms compared to NI and Wales.

• the figure for Scotland is just 3.3% of that for England – using a rough and ready extrapolation, based on population size one would expect the figure for Scotland to be close to 9.2%  (and recall, Scotland’s population health is commonly claimed to be worse that in the rUK!)

• the figure for Scotland is just 2.8% of that for the whole UK – based on population size one would expect this to be close to 8.2%.

These RCEM findings appear remarkable, pointing up substantial differences! And they are broadly consistent with the earlier evidence on the percentage of A&E attendances experiencing 12-hour waits in 2022 – 10.2% in England compared to 4.0% in Scotland!

End note

I think its worth noting that in its 3 March report on this topic, the RCEM makes NO COMMENT on the substantial variations between the UK nations in its estimates of excess deaths linked to long A&E waits! Surprising? Why are the marked differences and an understanding of possible reasons not worthy of the RCEM’s attention? Did its representatives in Scotland see no merit in alerting BBC Scotland to these remarkable findings?

Despite frequent use of the RCEM as the goto source of critical comment on NHS Scotland and the Scottish Government, I think we can be confident that the BBC will NOT pick up on the Royal College’s latest analysis!

If only the majority of people in Scotland knew more of what is really being achieved by our NHS and our Scottish Government in the most challenging circumstances!