The true picture of A&E waiting times in Wales has been seriously under-reported for a decade, the BBC can reveal. The Royal College of Emergency Medicine (RCEM) has established thousands of hours are missed from monthly figures. Senior A&E doctors have been raising the issue for months. The Welsh government said it would ask health boards for assurances they were following the guidance “to ensure the data is absolutely transparent”. The RCEM said it could not measure “how bad” things were because thousands of patients subject to so-called “breach exemptions” were not included in the overall A&E waiting times.
The Welsh government initially disputed the RCEM’s claim, but after seeing detailed figures – which were obtained through freedom of information (FOI) requests to health boards – it changed its position. Wales’ health minister has repeatedly claimed A&E waiting times in Wales have “bettered English performance”. But once the missing data is taken into account, it suggests the performance in Wales is worse.
What is a ‘breach exemption?’
Doctors don’t normally want to keep patients in emergency departments any longer than necessary, but they are able to in certain circumstances. These are called “breach exemptions” – as they breach the four, eight and 12-hour waiting targets for A&E.
Exemptions may follow when:
- Patients who are clinically unstable need more input from the emergency team
- Test results are needed before they can be admitted or discharged
- Patients need plaster-casts on broken bones
- Input is needed by occupational therapy or physiotherapy
The patient is unlikely to know if they fall into this category and they might not notice the difference in the care they receive. But the RCEM said they do not therefore count towards the official monthly statistics on how long they wait. It said Wales was the only UK nation to do it this way. Doctors warn it could mask underlying issues and not give the full picture of the pressure A&Es are under.
What is the Royal College’s argument?
“We are not getting a true reflection of what is exactly happening on the shop floor,” said Dr Suresh Pillai, vice president of RCEM for Wales. “This year alone from January to June, they have excluded about 45,000 patients and that’s a huge number. “If you don’t factor those patients in the already overcrowded emergency department, we cannot measure how bad things are. “If you don’t get the true figures, then the perception would be “everything is fine”. In fact, it is not.”
Dr Pillai said the issue had been routinely been raised during meetings with the health minister and officials. FOI responses to the RCEM show that in the first six months of this year, 38.7% of patients in Wales waited longer than four hours in A&E departments. When breach exemptions were included, as they were in other parts of the UK, the figure was 50%. That’s more than 45,000 patients – or 12% – removed from the figures. From January 2012 to June this year, more than 670,000 patients were not included in published figures – 23% of the total.
The chart above shows that when the exempted patient waits are included, the position in Wales is consistently worse than previously published. “I’m really concerned about the winter and that is purely because the figure that is published is misleading,” said Dr Pillai. “We always try to make plans for the winter but if we have already excluded 12% of patients in the first six months are we really factoring that to our winter plans?” The RCEM has been campaigning for transparent data to drive up the quality and safety of care, as long waits in A&E are directly related to worse patient outcomes.
How does Wales compare with England?
Waits for planned care in Wales have compared poorly with England, but published data has so far given the impression Wales is doing far better at reducing A&E waits compared to England. The health minister has previously said waiting times at major emergency departments in Wales have “bettered English performance”. Last week, athe Welsh government claimed again that Wales had outperformed England for nine of the last 12 months. But when data from the RCEM is included, it suggests the performance in Wales is worse.
The RCEM is calling on Welsh government to publish all of the figures. When first contacted for a response by BBC Wales, the Welsh government claimed breach exemptions were included but “handled differently” and that they were broadly equivalent to practice in England. But it later said: “Breach exemptions (or clinical exceptions), should be included in our published emergency department statistics. “Sometimes patients in emergency departments need an extended period of observation or treatment before it is safe to leave. Guidance has been in place since 2011 to help staff avoid inappropriately admitting or discharging these patients, in an attempt to ‘hit the target’. “We have asked health boards for assurances they are following the guidance, to ensure the data is absolutely transparent.”
What does this mean for the Welsh government?
This will be embarrassing. A&E waits were one of the few areas where they appeared to be comparing favourably to England. The health minister has repeatedly pointed to emergency departments “outperforming” hospitals in England, despite repeated concerns from the Royal College that something was awry. Typically, requests for data from health boards will show everyone does things slightly differently and comparisons become tricky. Yet the FOI requests returned to the RCEM show every health board has done the same. For more than a decade, none of them has included these clinical exceptions in their total figures. It raises questions about how clear the guidance was in the first place, and why prompts from the RCEM fell on deaf ears.
