Volume 12, Issue 4, Pages 185 – 252 (2013)

Another year has flown past, winter is back and as usual everyone is talking about emergency pressures in the NHS. Recent months have seen a deluge of reports, proposing short and longer term solutions to the challenges we face. The messages will be familiar for those working in acute medicine, who will have seen much of this before. Indeed, the sense of déjà vu, and apparent lack of progress in implementing those same solutions which have been proposed repeatedly over the past decade is often frustrating. But maybe the tide is now turning. There appears to be an increasing recognition that patient flow is the key to easing pressure at the front door – and this requires action at both ends. The biggest cause for crowding in the Emergency Department (ED) is the inability to move patients into the hospital after the decision to admit, due to the lack of an available bed. Attendances in A&E actually drop in January and February: the increased pressure which arises in winter mainly results from increased acuity of the patients attending (leading to a greater proportion requiring admission) and the increased number of patients whose discharge from hospital is delayed. The hospital fills up, bed moves and ‘outlying’ (or ‘boarding’) of patients adds to the inefficiency and further delays ensue. And the result of this is further pressure on the ‘front door’ – ED, and AMU bear the brunt.