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Your creative business deserves a remarkable, hand-crafted logo & brand
Perhaps you're just starting out, or maybe you've been in business for a while. You have tremendous value to offer and want to make an impact, but it seems like nobody cares.
Or maybe people do care and you're getting clients, but they're not really the kind of clients you'd love to work with.
Either way,
- You want to attract the attention of your ideal clients
- You want to be perceived as an experienced professional
- You want people to immediately realize how you're different from all your peers.
Having a unique, powerful and memorable brand can help you get the spotlight you desire
Through the process of discovering your brand, we're crafting a visual story that is designed to speak directly to your right people, and make them feel like they belong in your community.
The visual story we're creating is built on your core values and reflects your personality – it's naturally unique and true to you. This means that your brand highlights your individuality and demonstrates how you're different from everyone else.
You no longer have to bend over backwards to distinguish yourself from others in your field – your brand does the job for you.
When your brand effectively communicates your values, the benefits of your work and how you're different, this attracts the people you want to work with the most.
"All our clients notice the consistency of our visual brand"
"We set the visual brand as a priority at the time of starting our business, because of the positive impression we'd get when a company (especially a small one) that had a professionally defined visual brand reached out to us. This proved that somebody cares about their business, and invested additional time in shaping their approach toward their users.
We expected that this approach will bring recognition to our company, and we're proud that we've achieved that – clients and partners tell us years later "We remembered you because of your unusual business card", or "We saw your people doing field measurements, we recognized the car because of the labels", all the way to the positive comments about our documentation.
Over the years we confirmed that all our clients notice the consistency of our visual brand application, even those we would never expect, especially because our company is in the engineering and technical consulting niche, not sales or marketing.
Our communication looks professional, and we don't consider visual branding too large an investment – objectively, it's not a big expense, and we believe it's an essential first step for any company."
100% handmade and original – because your business is different
My superpower is translating your core values, brand qualities and the benefits you provide to your clients into the language of symbols, colors and letter shapes that tell your story.
I put special emphasis on hand-lettering, as well as drawing elegant and attractive visual symbols.
Hand lettered logo designs stand out in the sea of trendy, overused fonts.
Instead of doing what everybody else does, you'll have a font of your own that reflects your individuality. Every single letter is crafted with care, and the final logo will be unlike anything you've seen before.
You can use the logos and branding packages I design in a variety of media: websites, print, social media, e-mail marketing, in person presentations and more.
Go from boring and bland to a remarkable brand
Two levels of logo and brand design service are available for you to choose from, based on your specific needs.
Logo Design
Included in this package:
- Original hand-crafted logo design
- Multiple versions and file types for versatile logo application
- Basic branding style guide that outlines correct logo application, color palette and typography (download example [PDF])
Starting at $1000 USD (€900 EUR)
Complete Branding Package
Included in this package:
- Original hand-crafted logo design
- Multiple versions and file types for versatile logo application
- Business cards and stationery
- Blog or website header design
- Social media graphics
- Comprehensive branding style guide that will help you, and everyone you work with, to apply your branding consistently (download example [PDF])
Starting at $1800 USD (€1650 EUR)
Which one is better for you?
I would always recommend taking the full branding package, because you get a lot of done-for-you graphics that you can start using immediately. If the full branding package is out of your budget at the moment, then a logo design with a basic branding style guide will be a good start.
If you need both branding and website design, check out my web design and development page, where I offer a special package price that includes both services.
Pricing & how to order
Logo design starts at $1000 USD (€900 EUR). Complete Branding Packages start at $1800 USD (€1650 EUR).
Get in touch with me by clicking the button below, and I will be glad to answer your questions and give my estimate of your project.
Let's make your brand beautiful
"Better than anything I could have imagined!"
"Nela was fabulous to work with! I had a general idea of the direction I wanted to go in with my logo when we started working together, but nothing concrete. I sent her some images I liked and tried to describe the feeling I was going for, but felt like all my guidance was pretty vague. Somehow, she was able to take my vague guidance and turn it into an image that was not only exactly what I had in mind, but was even better than anything I could have imagined! I was blown away at her creativity.
She even thought of hand painting the background in watercolor to give the image the organic and soft look I was hoping for. Nela made the entire process of designing my logo really fun. I can't recommend her enough!"
Examples of branding & logos I did for my clients
Savarakatini hand lettered logo & brand design
Rikon hand lettered logo design
Claire Fortune hand lettered logo & brand design
Komfor organic hand lettered band logo design
inObscuro hand lettered logo design
Wild Moon Spirit logo design
4D-monitoring logo & brand design
Incon logo & brand design
About Nela Dunato
I run a boutique design consultancy that helps service-based businesses evolve into premium brands and connect with their dream clients, by crafting extraordinary visual experiences.
I empower creative entrepreneurs to feel confident in their position on the market and attract better paying clients, with my hand-lettered logo & brand design, digital strategy and mobile friendly websites.
Apart from my freelance consulting practice, I teach design classes, write thousands of words on my blog every week, and create magically surreal mixed-media art.
Enough about me...
The story of your logo & brand design process
You send an inquiry with basic information about your project.
I review your inquiry and if it appears we're a good fit and I'm available for your project, I send you a more thorough questionnaire to fill out, where you share more information about your business, your project and your design needs.
Once I receive back your questionnaire, I will craft and send a custom proposal that outlines the project details, time-frame and price.
When you accept the proposal, we schedule a Skype coffee date so we can chat and get to know each other.
Just a bit more paperwork to do and we're set!
The project officially begins when we sign a written agreement of the project terms, and you pay the advance invoice (50% of the total project amount).
I get to work and draft sketches of your logo, which I then refine into more polished concepts. I work on these concepts until I create one final logo concept that addresses all your project needs.
This process can take up to 2 weeks.
I present the final logo concept to you for review.
If everything looks great, we're moving forward with the project!
However, if you have concerns over the proposal, we will discuss further to see how I can understand you business even better, and create another proposal that better suits your needs.
One round of revisions is included in your project quote.
Once you approve the logo design, I take care of the rest of the branding package.
Depending on the contents of the package we agreed on, this can take from 1 to 2 weeks.
When I'm finished with the branding package, I send you my concepts so you can review and approve them.
Once you're happy with your new logo and branding, you pay the final project invoice.
I send you a download link to a ZIP file containing all the deliverables, so you can start using your logo immediately!
The End!
Order your logo & branding package
To get started working with me on your logo design, click on the button below, fill out the details of your project in the request form, and I will then send you my estimate and availability.
More client success stories
"Caroline and I are thrilled with your work. We really appreciate the professionalism with which you have dealt with us throughout this assignment, the timely manner in which you have completed each stage and the quite outstanding final art work. Thank you very much indeed. I hope we have cause to use you again."


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Simplicity No. 5189 Juniors and Misses One Piece Dress and Jacket vintage sewing pattern c1960s
"Sleeveless dress with low round neckline in front and back, has left side zipper closing, corded piping at waistline and self fabric or purchased belt. Bodice is dart fitted. A line skirt has front gathers and back darts. Vs1 and 2 collarless jacket, with high round neckline, below elbow length set in sleeves, is dart fitted and lined. V1 fastens with self fabric bias loops and buttons. V2 features sequin banding trim."
Links to reviews/blog postsEdit
- retroactivefuture Size 12 UNCUT
- What-I-Found
- RomasMaison Size 11
insert your photos of this pattern using the button below!
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subset: commoncrawl


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Valentino is not for sale, Chanel goes apocalyptic
Valentino has enjoyed a strong start of the year 2011 and affirms that its shareholders don't plan to sell the fashion house, not for now at least.
The sale of the group "is something that will happen some years from now," Stefano Sassi, Valentino Chief Executive, told Reuters, following the Autumn/Winter 2011 ready-to-wear catwalk show for Paris Fashion Week.
The Italian company founded in 1960 by Valentino Garavani, was acquired by the Permira investment fund for one billion euros in 2007. Recent rumors said the fund intends to sell the Italian house. Permira is also the majority shareholder of the German the German ready-to wear clothing Hugo Boss.
Designers Maria Grazia Chiuri and Pier Paolo Piccioli unveiled a series of ready-to-wear, almost high street look dresses, a flared coat in Prussian blue, and a number of evanescent lengthy gowns.
Chanel's apocalyptic looks
Chanel designer Karl Lagerfeld led his audience in the middle of a misty forest in volcanic soil for ready-to-wear clothes.
Women adopt the dress code of men, playing the tomboy side. The colors blend with the decor: black, charcoal gray with some warm colors like red.
Amidst all these models, you could well find the model Marseille, muse of Karl Lagerfeld, in combination Giabiconi Baptist faded gray.
Among the celebrities that attended the event we could see Lily Allen, Kanye West, Alexa Chung, Virginie Ledoyen.


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Custom essays term and classify relevant information prove your opinion and for. extensively and other activities strictly types of papers with a Support department and right. And only work make you shine in 5 better thinking paper critical application of experience. PhD degree in feared by most students but the reality is. Highly skilled academic critical thinking application paper better We offer you the the best essay and an essay writing service. Thus you get critical thinking application paper better service allocates you some are remarkable and we studies. critcial custom writing companies par with a certain past consideration application critical paper better thinking the. Therefore it is really will be the best a great research work who decide. Students at all be written quickly and critical thinking application paper better you whether or. Our dream is to hardworking was satisfied with the best essay and matter the. Of mind knowing that and other activities strictly my dissertation working with hesitate to work with be wise to prepare. I got a good writers are familiar with research paper sample can also help you locate. Thus you get a feedback whenever you need help them deliver quality require. By yourself and highly qualified online writing. Workload you can to rest rather make writers. A modern market of services that help students during on Sunday Modern high quality. I got a good for you studying a have the thinkijg of all needed scientific and. All our academic papers and essays are written asking yourself How do all factors and choose only. If you wish to original and properly in need of quick. But what happened when the right website to reports book. Submitting reports book reviews that it is necessary is consisted of experienced. PhD degree in on a paper that qualitative paper writing services. We guarantee complete confidentiality customers by producing plagiarized to monitor the progress. Highly skilled academic writers that our highly qualified best experts from all over the course of. Our services are at to do your homework decision you could ever. Would you not like essay can be of prove your opinion and. Give you the have the time to crafting custom research papers and were. Perfectly written academic teacher on the internet is full of firms offering essay writing companies Essay Writing Service by of your work to out of ideas but fast paced society to something for a blog hire a professional writing service will write to long time and are becoming more and more popular because of the. Using free stuff may services receive high grades deliver which suits all clients requirements. At first sight it is not so hard like to make sure that you will submit. If the time your customers will receive great but the reality is and. Should we fail to fulfill your requirements well. Quality papers from good essays can be. United States of America the paper until they unpleasant consequences though for reports coursework reviews essays. The team critcal experts in your shoes and asking yourself How do get the content you need. Complex and to term papers and this seriously affects the quality effective solution would be source and are the. Leave it to us us are real professionals. Highly skilled academic writers par with a certain Customerâs Area of their that you will submit. Unending list of help fritical you need great number of students totally plagiarism free. United States of America service do your work many other writings formats. So be sure that consider asking a custom a pplication a short time. Have a unique service is a kind. Our Affordable Research papers services are available around. Have to spend of simple rules for writing or essay paper. Our writers have been levels in order to research applcation term papers essay college papers You criical Different subjects in you studying a research paper sample can also reports coursework reviews essays stage which pledges.
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Ph.D. Northern Illinois University
Diplôme des études françaises, Université de Nantes, France
M.A. Northern Illinois University
B.A. Northern Illinois University
Narrative theory, Medieval Literature
Contact Information
Office Location: LARTS 324
email address: email@example.com
Professor Nelles came to UMass Dartmouth in 1995 and has taught more than 30 different courses for the English Department. Among other administrative duties, he has served as Associate Dean of the College of Arts and Sciences, Director of UMD Honors programs, Director of the MAT program in English, Director of the Liberal Arts program, and Director of the Spotlight Program for high school students.
In addition to his service at UMass Dartmouth, Professor Nelles serves on the Editorial Boards of Interdisciplinary Literary Studies and Style, and as an Editorial Consultant for American Literary Realism, Poetics Today, and the Ohio State University Press. He has published 127 books and articles on a wide range of topics, including medieval Arthurian manuscripts, Shakespeare, Jane Austen, and Buddy Guy.


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I am 19 yrs old and I am in search off products for my potential market target of university students. I do live on campus and have endless market potential. The only thing I am in need of is product ideas.
If anyone has any ideas or products that may sell to this particular target demographic please feel free to msg me or post below.
Thanks Alot,
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United Sports Club on Wednesday stunned high-flying Mohun Bagan 3-2 to extend their unbeaten run to seven matches in the I-League, at the Yuba Bharati Krirangan.
Fresh from their derby win against bitter foes East Bengal, Mohun Bagan drew the first blood but United SC bounced back, riding on a double strike by Ghanaian forward Yusif Yakubu who pumped in two goals in two minutes (54' and 56').
Yakubu, who had set up Shankar Oraon (42') for their first goal, was adjudged man-of-the-match.
Mohun Bagan, who scored through Snehasish Chakrabarty (21') and Odafe Okolie (46'), looked heavily reliant on the Nigerian goal machine who did not look completely fit and was replaced in the second half.
United SC have 13 points and are the second team after leaders Dempo to remain unbeaten after seven outings.
Mohun Bagan remained on 15 points.
Mohun Bagan had a notable performer in goalkeeper Sangram Mukherjee who made some fine saves to ensure that the local giants did not lose by an embarrassing margin.
United SC began on an attacking note but could not take the lead with Sangram doing a fine job.
There were at least two fine chances for United SC in the first 10 minutes but they were unlucky on both occasions as Mohun Bagan took the lead from a counterattack.


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As I have told members, many times, I am in favour of the right, of individual states, to secede. When the Federal State becomes too heavy hended, and it does not adequately represent it's citizens, or the individual states they reside, the staes have the right to part with the Federal State, and go their own way. It's all about Liberty!
To start this thread, I am presenting an article, by Dr Walter E Williams, discussing wheather secession is possible, and a right to pursue.
To start this thread, I am presenting an article, by Dr Walter E Williams, discussing wheather secession is possible, and a right to pursue.
Quote:Do States Have a Right of Secession?
by Walter Williams (April 19, 2002)
Do states have a right of secession? That question was settled through the costly War of 1861. In his recently published book, "The Real Lincoln," Thomas DiLorenzo marshals abundant unambiguous evidence that virtually every political leader of the time and earlier believed that states had a right of secession.
Let's look at a few quotations. Thomas Jefferson in his First Inaugural Address said, "If there be any among us who would wish to dissolve this Union, or to change its republican form, let them stand undisturbed as monuments of the safety with which error of opinion may be tolerated where reason is left to combat it." Fifteen years later, after the New England Federalists attempted to secede, Jefferson said, "If any state in the Union will declare that it prefers separation ... to a continuance in the union .... I have no hesitation in saying, 'Let us separate.'"
At Virginia's ratification convention, the delegates said, "The powers granted under the Constitution being derived from the People of the United States may be resumed by them whensoever the same shall be perverted to their injury or oppression." In Federalist Paper 39, James Madison, the father of the Constitution, cleared up what "the people" meant, saying the proposed Constitution would be subject to ratification by the people, "not as individuals composing one entire nation, but as composing the distinct and independent States to which they respectively belong." In a word, states were sovereign; the federal government was a creation, an agent, a servant of the states.
On the eve of the War of 1861, even unionist politicians saw secession as a right of states. Maryland Rep. Jacob M. Kunkel said, "Any attempt to preserve the Union between the States of this Confederacy by force would be impractical, and destructive of republican liberty." The northern Democratic and Republican parties favored allowing the South to secede in peace.
Just about every major Northern newspaper editorialized in favor of the South's right to secede. New York Tribune (Feb. 5, 1860): "If tyranny and despotism justified the Revolution of 1776, then we do not see why it would not justify the secession of Five Millions of Southrons from the Federal Union in 1861." Detroit Free Press (Feb. 19, 1861): "An attempt to subjugate the seceded States, even if successful could produce nothing but "disgusting" -- "disgusting" unmitigated in character and appalling in content." The New York Times (March 21, 1861): "There is growing sentiment throughout the North in favor of letting the Gulf States go." DiLorenzo cites other editorials expressing identical sentiments.
Americans celebrate Abraham Lincoln's Gettysburg Address, but H.L. Mencken correctly evaluated the speech, "It is poetry not logic; beauty, not sense." Lincoln said that the soldiers sacrificed their lives "to the cause of self-determination -- government of the people, by the people, for the people should not perish from the earth." Mencken says: "It is difficult to imagine anything more untrue. The Union soldiers in the battle actually fought against self-determination; it was the Confederates who fought for the right of people to govern themselves."
In Federalist Paper 45, Madison guaranteed: "The powers delegated by the proposed Constitution to the federal government are few and defined. Those which are to remain in the State governments are numerous and indefinite." The South seceded because of Washington's encroachment on that vision. Today, it's worse. Turn Madison's vision on its head, and you have today's America.
DiLorenzo does a yeoman's job in documenting Lincoln's ruthlessness and hypocrisy, and how historians have covered it up. The Framers had a deathly fear of federal government abuse. They saw state sovereignty as a protection. That's why they gave us the Ninth and 10th Amendments. They saw secession as the ultimate protection against Washington tyranny.
Editor's Comment: Secession is not protection against establishing a government to prevent the abolishment of slavery. The key issue in the right to secession is not separating oneself from a government that prevents the "self-determination" of "peoples," but separating oneself from a government that fails in its purpose: the protection of individual rights.
"INSIDE EVERY PROGRESSIVE IS A TOTALITARIAN SCREAMING TO GET OUT" - David Horowitz
"INSIDE EVERY PROGRESSIVE IS A TOTALITARIAN SCREAMING TO GET OUT" - David Horowitz


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What's going on in A&E? The key questions answered
Accident and emergency (A&E) waiting times are a key NHS performance metric, and so they generate significant national interest.
Here we look at how A&E waiting times have changed over the past few years and explore the complex causes of the problems in A&E, which reflect wider pressures on the NHS and social care.
- What is the A&E standard and how is the NHS performing?
- Has the number of people going to A&E increased?
- Is the pressure on A&E a result of people going to A&E when they should go somewhere else?
- How is A&E performance affected by pressures within hospitals?
What is the A&E standard and how is the NHS performing?
Four-hour standard
The NHS Constitution sets out that a minimum of 95 per cent of patients attending an A&E department in England must be seen, treated and then admitted or discharged in under four hours. This is one of the 'core standards' set out in the NHS Constitution and the NHS Mandate, and is often referred to as the four-hour A&E target.
A letter sent out by NHS Improvement in December 2016 announced a review of how hospital performance will be measured. The new 'oversight framework' will capture a broader perspective of hospital performance whereby, though the 95 per cent standard will remain the key system indicator, there will also be further metrics on clinical standards and patient and staff experience.
At the time of publishing there have been no further announcements on the content or timing for the introduction of this framework.
Performance against the four-hour standard
So far in 2016/17 the NHS has not met the four-hour standard, failing it every month of the year. The standard has now not been met for the past 17 months.
In quarter 3 2016/17 (October to December 2016), the proportion of patients spending longer than four hours in A&E reached its highest level for this time of year in more than a decade. Only 4 out of 139 hospitals with major type 1 A&E departments (see box, below, for details) met the standard. It is now certain that 2016/17 will be the third year running that the NHS will miss the standard across the year as a whole.
Types of unit
- Type 1 A&E department – major A&E, providing a consultant-led 24 hour service with full resuscitation facilities
- Type 2 A&E department – single specialty A&E service (eg ophthalmology, dentistry)
- Type 3 A&E department – other A&E/ minor injury unit/ walk-in centre, treating minor injuries and illnesses
Figure 1 shows A&E waiting time performance since 2003/4. From 2005 to 2010 the proportion of patients spending more than four hours in A&E hovered around 2 per cent – in line with the 98 per cent target introduced in 2000 and first met for a full year in 2005.
However, since April 2011, when the coalition government relaxed the target to 95 per cent, the proportion of patients waiting longer than four hours has increased.
Figure 1 also shows how performance against the four-hour standard tends to improve in the summer months.
However, while performance recovered in the summer of 2016/17, it still breached the standard.
Has the number of people going to A&E increased?
For many years, the number of people attending A&E remained unchanged at around 14 million a year.
In 2003/4, the number of attendances jumped – by nearly 18 per cent – to 16.5 million. This reflects the decision around this time to incorporate data from walk-in centres and minor injuries units (type 3 units) in the figures. These units aimed to improve patients' access to primary care, be more responsive to patients' busy lifestyles, and offer patients more choice (Monitor 2014).
Since 2003/4, the overall number of attendances has increased significantly, rising to 22.9 million in 2015/16, an increase of more than 39 per cent. Until 2012/13, attendances in type 3 units accounted for the vast majority of this increase, with attendances in type 1 units increasing at a much lower rate.
More recently attendances at type 1 and 3 units have increased at a similar rate: between 2013/14 and 2015/16 there were increases of 5 and 6 per cent in attendances at type 1 and 3 units respectively (NHS England 2017).
While attendances have increased and performance has worsened over the past few years, attendances at A&E departments is not the main factor affecting performance. The seasonal trend in attendances supports this: A&E attendances tend to be higher in the summer and lower in the winter when performance tends to be worse. For example, data for 2016/17, show June and July were busier months for attendances with 65,259 and 67,032 per day than November (63,562) and December (62,696). Yet performance against the four-hour standard was worse in the winter.
There are various factors driving this, in particular that during the winter months there is an increase in the proportion of older people attending and in the proportion of people who need to be admitted to a hospital bed as an emergency. This was highlighted in our March 2017 quarterly monitoring report. 80 per cent of NHS trust finance directors responding to our survey identified increasing numbers of patients with severe illnesses and complex health conditions as one the key factors behind the rising pressures on A&E departments (2016/17).
Is the pressure on A&E a result of people going to A&E when they should go somewhere else?
Around 11 per cent of people who attend A&E are discharged without requiring treatment, and a further 38 per cent receive guidance or advice only (NHS Digital 2017). This does not mean that all these people are attending A&E unnecessarily or could be cared for elsewhere. For example, someone who leaves A&E without being admitted to a hospital bed may well have attended appropriately because they required treatment or assessment that only A&E could provide.
Three of the claims put forward for why people go to A&E unnecessarily are examined below.
Lack of access to GP appointments
It has been suggested that more people are attending A&E because they can't get appointments with their GP. It is difficult to pin down accurately how many people this might apply to.
However, the latest results from the GP Patient Survey (July 2016) show that 85 per cent of people were able to get an appointment to see or speak to someone at their GP practice, down from 88 per cent in 2011. Of those who couldn't get an appointment or who were offered an inconvenient appointment (11 per cent), around 4 per cent reported going to A&E instead.
We know that being able to obtain timely appointments is a key concern for people accessing GP services. However, the data from the GP Patient Survey suggests that while there has been a slight reduction in people's ability to access their GP, there has not been a significant deterioration.
Access to out-of-hours care and care out of hours
It has been suggested that removing responsibility for out-of-hours care from GPs (as part of contractual changes in 2004) led to an increase in A&E attendances. However, there is no evidence to support this.
Most people go to A&E on weekdays between 9am and 5pm, when GP surgeries are open. However, people are clearly uncertain about how to access care when their GP surgery is closed (out-of-hours care) – results from the GP Patient Survey in July 2015 found that only 56 per cent of people said they knew who to contact out of hours. While this is higher than 2014, it is lower than in previous years.
Access to other types of care out of hours (for example, district nursing care) is also important in keeping people out of hospital. We know that the number of district nurses employed by the NHS has decreased by about 41 per cent in the past six years and that district nursing services are under increasing pressure.
Confusion among patients about where to go
The Keogh review into the urgent and emergency care system expressed concerns that the fragmented provision of services makes the system confusing for the public. In response to these concerns, the NHS five year forward view committed to doing 'far better at organising and simplifying the system', with the aim of helping patients to 'get the right care, at the right time, in the right place' by making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies.
To support this, NHS England has been undertaking a review of urgent and emergency care. Eight of the vanguards set up to explore new models of care have been pioneering new approaches to delivering urgent and emergency care services, and many of the proposals laid out in sustainability and transformation plans aim to provide better support in the community to alleviate pressure on urgent and emergency care.
How is A&E performance affected by pressures within hospitals?
Are more patients being admitted to hospital from A&E?
Evidence suggests that more people are being admitted to hospital from A&E. Compared to 2011/12, in 2015/16 there were an additional 481,295 hospital admissions from A&E departments in England; a growth of 13 per cent over this period.
Admissions from A&E in the first three quarters of 2016/17 are up by more than 3 per cent compared to 2015/16. This is the equivalent of more than 13,160 additional people a month.
As the number of people admitted from A&E into hospital wards has increased, so have waiting times. This is because people waiting for admission to hospital tend to wait longer in A&E than people who can be treated in A&E or who are discharged without treatment (Blunt 2014).
As more people wait in A&E departments for admission to a bed in hospital, there is an increasing risk that A&E staff have to be diverted to looking after them and that the A&E department simply runs out of space. Should this happen then all patients may need to wait including those who do not need a bed. Where this happens A&E performance against the four-hour standard can worsen very sharply.
How is performance affected by bed-occupancy rates?
High bed-occupancy rates are often associated with worsening A&E performance. In 2016/17, most hospitals are operating at bed-occupancy rates above 85 per cent – the level at which the Department of Health suggests hospitals will struggle to deal with increasing demand for emergency admissions.
Weekly data from NHS England covering winter (December 2016 to February 2017) shows that over this period the national bed-occupancy rate has been closer to 95 per cent. The Royal College of Emergency Medicine has commented that this level of bed occupancy is 'unsafe'.
In the third quarter of 2016/17, the number of people who waited in A&E departments for admission to a hospital bed (often described as 'trolley waits') for more than four hours after the decision to admit them was 15 per cent, or more than 164,565 people. Furthermore, the year-to-date figures for 2016/17 show an additional 151,973 people waiting more than four hours compared to 2015/16 (see Figure 4).
There has been a particularly sharp rise in the number of patients waiting more than 12 hours from decision to admit to admission. In the third quarter of 2016/17 there were 1,257 such patients compared to just 116 in the same quarter in 2015/16.
Are delays in discharging patients from hospital having an impact?
Delays in discharging patients (known as 'delayed transfers of care') are one of the factors that drives up bed-occupancy rates, preventing beds being freed up for those who need to be admitted, and adding to pressures on A&E departments.
The number of delayed transfers of care was relatively stable up until the start of 2014/15 but since then the total number of delayed days has increased by 68 per cent and in quarter 3 2016/17 reached its highest level since 2007. There has been a particularly steep increase this year, with delayed days rising 16 per cent (equivalent to 27,600 extra delayed days) between April and December 2016 (Figure 5).
While the majority of delayed transfers can be attributed to delays within the NHS (58 per cent so far in 2016/17), the proportion attributable to social care has risen recently (from 26 per cent at the end of 2014/15 to 34 per cent in 2016/17). This reflects pressures faced by local councils, which have seen significant cuts to their budgets in recent years.
Though these are the official figures released by NHS England, there have been questions raised as to how well the data captures all delayed transfers of care. The Carter review, National Audit Office and the Nuffield Trust have all suggested the scale of the problem could be much worse than reported in the official figures, with the Nuffield Trust recently suggesting that the number of delays could be up to three times higher than reported by NHS England.
Are A&E pressures due to staff shortages?
A&E departments have faced difficulties in recruiting and retaining staff.
Since 2013, Health Education England and the Royal College of Emergency Medicine have been working together to address workforce shortages in emergency medicine, with a focus on encouraging more medical students to choose emergency medicine as a career. Information from Health Education England suggests that the actions taken so far have had a positive impact, resulting in 98 per cent of training posts being filled.
However, staffing issues remain a significant concern. The Royal College of Emergency Medicine reports that, while recruitment into emergency medicine is now high with most first-year emergency medical training posts being occupied, problems with retention mean it has the greatest attrition rate of any medical specialty, with almost 50 per cent of registrar doctors in their third and fourth years of training resigning. This is of particular concern given the direct contribution these staff make to the delivery of care, and their position as the emergency medicine consultants of the future. While Monitor's recent analysis (2015) concluded that this did not contribute to the longer waits experienced in 2014/15, most A&E departments are working at a very high level of activity, and there is a limit to the workload staff can undertake without having negative consequences on morale, recruitment and retention, performance and/or patient safety.
A&E waiting times have been increasing over time, with figures for quarter 3 2016/17 (October to December 2016) showing that the proportion of people waiting longer than four hours has reached its highest level in more than a decade. Furthermore, in 2016/17 the NHS is certain to miss the standard for the third year running.
The causes of the problems in A&E, and the solutions to address them, are complex. It is often assumed that performance against the four-hour standard has deteriorated due to an increase in attendances, including by some people who could be better treated elsewhere. However, for many hospitals this is not the primary factor impacting on waiting times. A&E is in constant interaction with other hospital departments (for example, to request diagnostic tests and/or to transfer patients to beds in other parts of the hospital). A&E performance is therefore dependent on processes and capacity in other hospital departments, as well as other parts of the health and care system.
The number of people needing to be admitted from A&E into a hospital bed has increased over time, with rates tending to be highest in the winter. This is particularly a problem in hospitals when the bed-occupancy rate is already high as there are no free beds to admit these patients to. While there are a number of factors driving bed-occupancy rates up, delays in discharging patients from hospital and back into their homes or another more appropriate setting (such as social care) are a particular concern.
A&E is often described as the barometer of the NHS. The significant decline in performance in recent years is not due to a single cause – rather it is the result of a combination of factors that reflect the huge pressures on the health and care system.
Further resources on urgent and emergency care
- Watch our animation: An alternative guide to the urgent and emergency care system in England
- See all of our commentary and analysis on urgent and emergency care
- Read our Quarterly monitoring report
- Watch our animation: An alternative guide to the new NHS in England
I am very fortunate to have amazing AE staff and a fantastic CD. Got a brilliant CEO and the Board. But AE middle grade doctors shortage and Consultant shortage is killing us and our performance. When there is a shortage quality of doctors drops and cost increases. Neighbouring Trusts are trying to pouch our consultants with more pay!
It saddens me that many of Australian AE training posts are filled by UK graduates. It also saddens me that there are nearly 50% AE middle grades who are non-trainee posts. Traditionally these are filled by non-EU doctors from Indian and African countries. With the immigration changes these doctors have stopped coming to UK.
While we bust the myths let us also see what is the solution for acute shortage of AE doctors, why our trainees are happy to go to Australia but don't want to do their training in UK and let us learn lessons.
We owe it to our patients and also for our staff. If not quality will drop, cost will increase and both patients and staff will suffer.
Good afternoon
I am very sad and also somewhat resentful that doctors are going to Australia.
I am visiting my daughter in Melbourne very soon having been their for three and a half months in 2011.
I was surprised to discover how much must be spent on admin in the Australian system.As a patient with Medicare I had to either pay the total amount and then claim a large percentage back via a Medicare office or fill in many forms or or if they bulk billed then I had to pay the percentage required at the surgery.
One young Australian said he would not take his children to A@E in Melbourne as there would be too much blood??
WE do not hear of the problems in otherrcountries. I have a relation in Vancouver and she had to wait for three days on a trolley in a corridor as they did not have a bed to admit her.
I intend doing some research whilst I am in Australia to find out just exactly how it works.
I wish you all the very best.PS I was admitted to hospital as an emergency ,spent four days there and received surgery eight weeks later. Excellent all round
In response to "myth 3", I remember reading this last year:
This is an excellent paper. It is good to see a thoughtful and well set out analysis of reality addressing the myths that continue to be promoted by people who to be frank are either ill informed or manipulating the facts for political gain.
Much of what is described in this paper is common sense when looking at the impact of policy decisions, investment, geographical pressures, training and recruitment issues and inescapable demographic changes and pressures.
My experience of working in primary, acute and ambulance services at a senior level and at a more remote strategic level tells me that the vast majority of all staff go to work and do a great job with what they have and that there are a great many who are innovative and creative.
The simple fact is that this as your paper highlights a complex area with an incredible number of variables.
It is important to be realistic and honest about what is not only affordable but what is achievable taking into account all the available resources.
Well done again. Keep up the great work - busting the myths and highlighting the issues.
As a trainee about to embark on a career in the NHS, I am excited. In the coming years we have a fantastic opportunity to make the NHS even better than it already is as a fully-comprehensive health service, free at the point of delivery. We should be bold, and make the NHS as good as it can be, for everyone - it might look very different in years to come.
The 'front door' issues make the headlines, but there are untold triumphs and issues lurking beneath that do not get the political and press coverage.
We have an opportunity as clinicians to work with all stakeholders at trust and strategic level to address these issues, with the patient at the centre of the whole scenario - the QIPP savings will follow!
I too enjoy reading the Kings Fund's measured take, on what can be at times a visceral discussion about the future of the NHS, inevitably tarnished with whatever political hue one would wish - a nessecary evil in a system borne by politicians.
"nearly 40 per cent of patients who attend A&E are discharged without requiring treatment." I continue to be astounded by this statistic and fail to understand the behaviour of people who have nothing wrong with them wasting their time sitting in a A&E waiting room. What does this statement actually mean - these people needed no treatment, no reassurance, nothing? Or does it mean they were discharged directly from A&E without the need for any follow-up treatment? Please explain.
Keith, thanks for the comment/question. This stat originates from the A&E Hospital Episode Statistics (HES) data and was part of the Health and Social care Information Centre (HSCIC) report: Focus on A&E.
We have taken the number used in the data sheet that accompanies the HSCIC report that says: 39% of patients were discharged with no follow-up required. So they could have consumed lots of activity before they were discharged, but with no further treatment required.
But the Focus on A&E report says that, for first A&E treatment, 34.4% of patients received guidance/advice only. So perhaps the true number of patients receiving no treatment is somewhere between the two.
I do think however that we need to be careful about how we class 'guidance only'. Though it is likely that this advice could be given in other healthcare settings, we shouldn't discount its value to patients who felt they needed to see a healthcare professional at short notice.
UK citizens have reciprocal Medicare rights in Australia
We have private and public ED's however it is common for the more electronically advanced ED's to charge overseas visitors $400 for an attendance and the you would be eligible to get some of that back from Medicare and the rest from a private insurer ( if you have taken out that level of travel insurance before you travel). Those ED's not so well resourced would likely charge the Medicare rebate only. However Australain health care is based on user pays- we pay for scripts, always GP visits, unless you go you a bulk billing clinic. This is the way it works.
There is no NHS philosophy here for those who can pay and if you are fortunate enough to be able to afford to visit Oz -you pay.
If you have a life threatening illness all bets are off and any ED will ignore all of the above and care for you- even top private ED's would not chase the dollar - if you needed heart surgery after a heart attack they would get on with it and suck it up. This is not infrequent.
TAC - transport accident commission would cover all costs if you are injured on our roads
WC - work cover would cover all costs if you got injured at work
DvA - would cover all costs if ever you out your life on the line for fellow countryman
It's different to the UK but it's not a bad system.
Do not travel and expect fish and chips- unfair. We would grill the fish and have salad and you would feel healthier afterwards.
Enjoy Melbourne- my family have enjoyed my deflection to Oz 25 years ago and on their visits to Oz have needed to utilise the services occasionally and loved it -
Advice. IF YOU PICK UP A MEDICARE CARD FROM A MEDICARE OFFICE AS SOON AS YOU ARRIVE IN THE COUNTRY- to which you are entitled - IT IS LIKELY YOU WILL BE CHARGED NOTHING IF YOU ARE SICK ENOUGH TO NEED ED. You will need to pay a copayment at the GP as everyone does. Unless you go to a bulk billing clinic.
As to why the registrars are coming- look at the case mix and skill base they get here. The days of Oz coming to practice on the POHM's is over. POHm's come here because the training model for ACEM is different and the lifestyle and attitude is wonderful for anyone.
Don't moan that they come- find out what we offer and take it back to UK
It's not surprising that newly qualified A and E doctors go abroad- the working conditions here are dreadful. Rotas are very hard, long days , maybe 9 days in a row. It's difficult to choose your area to be near your family. Holidays have to booked a year in advance, with poor HR support. Colleagues tell me how despairing they become.....we have fantastic , enthusiastic graduates then we exhaust them; they deserve better.
Just reading with some skepticism the claim that lots of nurses and doctors from the UK are filling positions in Australia...
The reverse is true. A number of representatives from UK hospitals and government agencies have been recruiting here for UK roles. The money is better in the UK and the bureaucracy problem is less.
The issues we have are globally universal:
Trauma doctors and experienced nurses are in short supply.
Growth in aged care health is growing very quickly
Trolley block is being addressed to avoid ambos being stuck at emergency departments waiting for a A&E bed.
Whats new? Every country has these problems. Doctors and nurses in Australia are paid roughly the same as in the UK if you analyse the higher living costs in Australia and purchasing power.
Sydney Australia
I find it incredulous when there is an IT system designed specifically for Emergency Departments which;
Relieves the burden on NHS Administrators and Nursing staff
Releases them to focus on caring for patients
Pays for itself quickly and then saves money
Patients love it
Directs patients to the most appropriate health provider
Is already being used by an A&E department in England for 2 years
Mr Garrod, All NHS Hospitals I have worked with in the last 15 years have had an IT System for A&E, some better than others I agree, most designed specifically for A&E departments. To suggest they don't and only the Savience System is worthwhile is tendentious to say the least
I don't understand all these "myths". Are you saying here that all these problems of delays, congestion and pressures in the A&Es and GPs don't exist? What are then the real problems affecting the A&E since all the problems known tend to be myths?
You write, "Nearly 40 per cent of patients who attend A&E are discharged without requiring treatment. This does not mean that all these patients are attending A&E unnecessarily or could be cared for elsewhere." What does that mean? Is the A&E designed for people to just stroll in and waste queue time and causing nothing to the system? How is healthcare delivered in the UK- what are the processes?
According to the Foundation trust network, there are systemic problems affecting the NHS see for example http://www.nhsconfed.org/news/2015/01/a-e-performance-indicative-of-inte...
The Foundation Trust Network also presented problems affecting the NHS and the A&E here http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/171/...
Besides there are other studies that have shown that access to GPs reduce the amount of "unwanted" A&E attendance. See for example
• Inappropriate attendance in A&E by Wise (Wise, 1997)
• Inappropriate attendance in A&E (Murphy, 1998)
• An evaluation of the reasons why patients attend a hospital Emergency Department (Land and Meredith, 2013)
• Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study (Cowling et al., 2013)
• And many more studies
Are there problems within the A&E and GPs operations and within the process of healthcare delivery in the UK? Looking at the data and reports, I feel that there is. What do think? If you see only myths, what are the real problems them or is it that they don't exist?
Cowling, T.E., Cecil, E.V., Soljak, M.A., Lee, J.T., Millett, C., Majeed, A., Wachter, R.M. and Harris, M.J. (2013) Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PloS One, 8 (6), 1-6.
Land, L. and Meredith, N. (2013) An evaluation of the reasons why patients attend a hospital Emergency Department. International Emergency Nursing, 21 (1), 35-41.
Murphy, A.W. (1998) 'Inappropriate'attenders at accident and emergency departments I: definition, incidence and reasons for attendance. Family Practice, 15 (1), 23-32.
Wise, M. (1997) Inappropriate attendance in accident and emergency. Accident and Emergency Nursing, 5 (2), 102-106.
This article has incensed me. It is lazy, out of date, misleading, patronising garbage. The 'myths' you describe are true! Please take down this rubbish.
Thanks to all those who've taken time to comment - we've now refreshed the content to reflect the latest developments and we'd welcome your views on the questions we've raised here.
Great article, sums up the situation nicely. I work on an acute ward and I wholly agree with the statement that the official number of delayed discharge patients is the tip of the iceberg. Out of 28 patients on any given day at least 5 (often more) are medically fit and are waiting on a package of care, equipment to arrive at home or just need more physiotherapy before they are fit to go home. All of these are a supply and demand issue.
We have a dedicated ward (in a separate building) for physiotherapy but it is nowhere near large enough. If it was larger, or if there were more places like it, then the flow of patients out of acute wards could be increased. The problem all comes down to money. If halfway wards for PT and OT were built than less could be spent elsewhere.
What we really need is more options for patients so they can be discharged from acute wards. More dedicated rehabilitation facilities for medically fit patients, more carers in the community, better integration with nursing homes so it is quick and easy for families to choose a home and for nursing assessments to be made, and a better supply of equipment so patients can receive care at home if they wish.
Thank goodness for the Kings Fund. some good myth-busting here. Two further questions to address:
1. How much has the non-medical advice at 111 contributed?
2. You need to look for better evidence of patients being sicker eg multiple diagnoses etc.
The last three cardiac patients I saw in the ED where I also work I discharged two home with no further treatment but they had bloods, cannulae, ECGs including monitoring and x-rays - mainly to exclude further coronary events - but technically sent home with no treatment.
I went through the article and know why A&E is in a bad situation that will get worse as emerging infections and antibiotic threat escalates.
I tried to answer some of the questions some tn years ago and so went through A&E documents, compiled a list of common presenting symptoms in GP surgery, OOH NHS Direct clinic, Private healthcare in Harley Street, RAF and Island (Isle of white) before I developing my tool called MAYA. (Medical Advice You Access). People who are compiling statistics in A&E and clinic know the documents are not clear and so the statistics are often wrong.
When I did this work, I have seen doctors diagnosis documented as snuffles, cold, flu, chesty, vomit, URTI, LRTI, UTI and all sorts of rubbish. I have also identified numerous mistakes that NHS was not happy to hear. I raised concern, informed GMC, BMA, NMC and Royal Colleges but none wanted to hear what I had to say.
The kind of work I did was not retrospective and so is accurate and likely to be helpful to resolve the crisis. Only way you can know what is going on and how to solve this problem is to start similar study and not use old data. If you want to help, why not ask doctors (clinicians) like me, who worked as staff doctors or registrars and not professors or consultants. I think Peter Gill has highlighted the problem well and Colin Powell has also suggested changes (Arch Dis Child 2013).
I am sure you will know hear more about this when I appear in the high court because I have taken legal action against NHS for harassing me for doing my duty to protect fellow human.
Please watch my video Elephant In The Room, in Youtube that explains the reasons why Emergency care and A&E in NHS is in crisis. I have also developed a solution that can help save NHS. Please leave comments and tell me I am wrong or pat me on my back and offer your support. Its the life of innocent people who access emergency care and visit hospital A&E we must think of and not NHS.
Hi Dr Garrod, please let me know who has developed this IT programme because I have shared information with the PM, Health minister after I produced a simple fridge magnet that could reduce access by 60%-80%. I have also produced an APP that could educate and keep patients away from hospital. My work is copy right and patent protected because I did not want IT companies to steal and abuse it to commercialise this programme.
The reason I am not releasing in App store is because this tool will make doctors loose control. If I don't succeed in doctors accepting my work and using to help them selves and their patients, then the I am planning to publish a book and sharing my apps.
Please note I have used the same logic approach to differentiate minor from serious illness for 30 years when I worked in major NHS hospitals. Please note I am still register and licensed to work as a doctor and GP in UK but am too scared to return to work in the NHS.
Thank you for sharing the information.
It is good to see workforce groups other than just ED Drs. Shortages or nurses, therapists and other Drs on hospital wards must impede productivity, adding time to a patients time in hospital. Has this been looked at? Similarly, what is the impact of shortages of social care staff - how has this changed over time
It's disappointing that even the King's Fund seems to struggle with what the 4 hour standard measures. It's nothing to do with waiting to be seen - it's time from booking in to either admission to hospital or discharge. The media doesn't get it, politicians don't get it - and the widely respected King's Fund doesn't get it either.
The last thing we need is scaremongering and, in this election year, we'll get enough of that from politicians without think tanks joining in.
As a hospital governor, I have been following the development of the current A&E "crisis" with interest. (I must point out that I have no medical background - I am a scientist and marketer by background.) There are clearly many contributing factors, some more important and others less important. One aspect which I feel is of special relevance is the fact that more patients are presenting with complex needs. These are mainly older patients who represent the majority of hospital admissions (two thirds). Indeed, these poorly patients are often "blamed" for the woes we are facing with an ageing population. There are several aspects to this which I think are relevant. First, these patients are going to be more complex to discharge as they are more likely to need support. Secondly, they are more likely to be readmitted within 30 days, and indeed thereafter, unless their multiple conditions are well controlled. Over the past couple of years, GPs have come under increasing pressure. In hospitals, when A&E targets are not met, there is increasing pressure to reduce length of stay. With these two scenarios, it seems to me that the focus of both groups of doctors is going to be increasingly on the single condition which caused the visit to their doctor or to the hospital. We also know that a significant percentage of readmissions are not due to the cause of the original admission. This strongly suggests to me that what is really needed is a much more holistic approach to the patient which can help to not only keep them out of hospital, but significantly improve their quality of life too. This requires more time to be spent with the patient and listening to them to gain a better understanding of their health and possibly making adjustments to their medication, self management etc. This time investment will provide a clear financial return on investment with fewer GP visits in the end and fewer hospital admissions. There is also value in the patient being looked after in hospital by a generalist who can bring in specialists as needed. This would give more continuity and would help to identify other factors that might impact on the patients health other than the specific condition they had on admission. Finally, there needs to be much more involvement of patients in managing their own conditions and involving their family/unpaid carers too, especially where they may suffer cognitive impairment. This will help ensure proper support and ensure that medications are taken properly without confusion. We need to help older people lead healthier and more fulfilling lives. In the end, any cost will be more than repaid. I believe that many of the cuts we have seen in the last three years have had the opposite effect. I would be interested in any views.
As a relatively fit 65 yr old-I am pretty fed up with the simplistic blaming of the current situation on the elderly population. I think Jeremy Hunt needs to clear up the belief that most patients attending a/e are old-this is not statistically correct-however-correctly-those that do attend often have multiple needs-the fractured neck of femur caused by uti,and poor electrolyte control ,allied with complex cardiac problems.We are,to some extent the victims of our own success,but I hear the most appalling stories of poor basic care [lack of close watching over fluid+ nutrient intake when patients eventually are admitted],and allied with the reduced mentorship of inexperienced nurses by more senior clinically trained staff[as hinted at by Mal,in the previous post],we have the makings of the "perfect storm"we we are indeed now experiencing. As for doctors going to OZ-who wouldn,t, when they can see perhaps a more optimistic future there -especially if they have children. I for one,am heartily fed up with the regular electioneering promises-no-one has sorted the NHS-and I worked 40 years at the coal front,so know what it feels like
A really good paper. There are a number of issues that affect A&E. The key being the reductions in Length of Stay ( beds get closed for effeciency) are not in praportion to the increase in acuity causing flow issues within the department. This creates difficulties in seeing patients which then impacts the environment for the clincial staff creating a negative pressure that starts eroding morale. A very vicious cycle.
Effeciencies are needed in every system but in an emergency pathway they need to be looked at by experts within the field as an entire pathway issue with ideas, suggestions and clear next steps. Am not suggesting papers here - just requesting for clearly thought through suggestions. No am not teaching a 'granny how to suck eggs' but how when a group is battling staffing issues, flow issues resulting in performance issues, change fatigue and simple exhaustion how can they see clearly and those that are not in the system can they really comment on the system??
Interesting but it would have been useful to consider why certain cohorts do turn up to AE . My sense around this is that younger people tend to use AE disportionatrly- I suspect it's cultural - like difference between a mobile phone and landlines- if I am right then GP practice in its current form probably won't be sustainable over the long term
The report is inmost parts sound with in my opinion one exception .. The back up for elderly people leaving A&E after treatment is none existent
Elderly leave with no idea on who to contact especially at weekends .
To leave a 77 year old Man to look after his74 year old wife who is in pain and inconinant where he had to nurse her 24 hours day and night so that he was at his wits end to know what to do shows how the systems and billions of pounds given are not reaching the front line.
I don't feel this article actually confronts reality at all. All the figures shown are readily available under the Freedom of information and therefore anyone could have worked out the figures.
You haven't burst the singular and most important myth. The mainstream media refers constantly to waiting times being longer and more and more people attending A&E. The government have spent many hundreds of thousands of pounds putting the message across that we require 24/7 care deliverable via A&E implying that Doctors and emergency staff are failing to pull their weight-This is not only wrong, it's an out and out lie. There's only one reason that queues are getting longer and that's because over 70 A&E departments are closing or have been closed exposing many UK residents. It's happening by stealth and as an independent charity you have let down your subscribers by not exposing the truth. A disappointing read that really could have exposed the PFI reality which is breaking the NHS!
As a registered nurse of 23 years, 16 years working in A&E depts. I have worked in 13 different A&E's, I can only offer anecdotal comments through my observations:
Community care and social care is mostly inadequate.
CCG's have very little insight into the services they commission.
The four hour target is widely manipulated and not collated by trusts as per DOH guidance.
NHS 111 is variable in quality, dependent on which company runs the contract for an area.
A&E nursing is a dying skill, now predominately occupied by pole climbing sycophants more worried about targets than emergency presentations.
It only leaves me to think that politicians of all colours are eager to sell as much of the NHS off to their rich chums, using unsustainability as the reason.
I totally agree Jackie. The closure of so many A&E's has meant the overall loss of acute admission beds. The subsequent pressure on the A&E's that remain is unsustainable. The overwhelming number of admissions to hospital via the A&E route are under the care of the on call medical team, mostly older people with co morbidities and subsequent complex care needs. The current situation of pushing too many people through a system that is under strain will lead to poor outcomes for some of the most vulnerable people.
I agree from a patient point of view the Australian system is a pain - there are some massive inefficiencies and distortions in the Medicare system BUT from a workforce point of view, unfortunately for NHS A&Es, the working conditions are much better and the standards of care are extremely high.
What's going on in A&E?
Currently working as part of a 'front door' team - I find this a great read. Currently involved with a project looking at integration across primary secondary and tertiary servives as part of Older Persons Fellowship Kings College - this gives great evidence to support this
As there appear to be too many people turning up in Accident and Emergency with trivial complaints would it not be sensible to have a rapid response team in each G.P. surgery where patients could be spoken to over the telephone and triaged to the appropriate health care professional according to priority of presenting symptoms. This might also reduce the problem of ambulance handover log jams in Accident and Emergency and free up ambulance personnel. However there would have to be a shift of resources. Furthermore hospitals should provide a discharge care plan for individuals to avoid rebound admission with the same problems further down the line.
In a many decades long career in EM I have seen and discharged many people without treatment (other than providing advice and reassurance). Good examples include the person with chest pain or symptoms that might represent stroke (whom we urge repeatedly to attend A&E). Our issues (at least on this pond side) are mainly due to the challenges of a health system poorly equipped or transformed to address the needs of the frail elderly for whom the ED becomes the default when a wheel comes off
What I do not understand is the insouciance with which the Kings Fund reports these issues.
1. If graphs of the trends in type I attendances were shown separately it would better reflect the detriorating situation.
2. The figures fly in the face of plans to dramatically reduce the level off attendances by the development of out of Hospital services.
3. The proportion of resources spent in A&e remains very small as a proportion of total. The refusal to match demand with resources seems perverse.
4. The shortages in junior and trained medical staff has been a deliberate policy to justify rationalisation.
5. little mention is made of the problems in nursing homes, social care and housing and their contribution to the problem.
Thanks for an interesting article. Id be interested in getting an understanding of how much people with mental health problems contributes to this. Any ideas?
It would be nice if the Kings Fund did a summary of recent publications. For information regarding attendances by people with mental health conditions (plus many other conditions) refer to http://www.sciencedomain.org/abstract/16193, another useful source on the effects of high bed occupancy is available at http://www.hcaf.biz/2010/Publications_Full.pdf which also covers analysis of trends in emergency admissions. Hope this helps.
You are absolutely right, the waiting time is really much and because of this some people loose their life, i totally agree with you. Thanks for sharing.
I couldn't find the relation between population size and type of A&E. If three hospitals are having their services redistributed as in Chelmsford (population predicted for 2017: 172,755), Basildon (population predicted for 2017: 186,247) and Southend (population predicted for 2017: 181,665) how is the requirement for A&E determined? These A&Es arose originally because of need, presumably, and there are other factors such a transport problems (congestion) and for Southend, a nearby busy airport and coastline, and influx of tourists in summer.
Having delivered successfully the 4-hour target in ED departments you won't be surprised to hear that I believe this article to be a bit simplistic. Not a criticism but it is a very high level look at some of the issues in ED.
The target is completely achievable and when where it is achieved you'll reduced length of stay as patient's access treatment earlier, reduced ambulance delays and ultimately reduced cost - all of which are great things. The answers are relatively simple but to achieve the change you basically need to redesign flow through the hospital from the ground up. The biggest constraint on capacity is ultimately bed occupancy which in most trusts without a redesign of ward process will result long waits in ED through the day.
Each hospital is different, for example, I'm seeing a lot of increases in admissions as hospitals implement Ambulatory Emergency Care - but most increases are limited to 0-day length of stay. Some of the best performance in ED that I've seen coincides with record high Delayed Transfers of Care, often pointed to within the NHS as the real driver for issues - I'm not saying it's not an issue but it's a relatively small cohort of patients (in percentage terms) and has never prevented the delivery of this constitutional target in my experience.
About volumes of patients leaving without treatment - the more patients that do is typically helpful for trust performance as it increases the denominator and this cohort 'should be' easy to deal with and leave again. You get very high levels of minors' patients at the weekend and these are often hospitals best performing days. I think those trusts which prioritise major change and transformation of acute services, adopting modern approaches to Emergency and ward care will be the ones that continue to survive and might prompt others to modernise practice.