Sunday, 7 June 2015

What's wrong in England's A&E departments?

This was originally written during the winter 2013 A&E performance crisis in England’s A&E departments. Most of it still applies.

A&E departments in England are currently in crisis. Patients are waiting too long and some departments are even claiming they can no longer guarantee safe treatment. There has been an orgy of speculation as to why from journalists, commentators and politicians.  But most are acting like a doctor who neither sees the patient or checks her medical history before recommending major surgery.

Simply put most diagnoses and their proposed treatment are not compatible with the basic facts. Lets look at where the blame has been laid and see what the evidence says. Here are some of the more common proposed causes:
  • Rocketing volume of attendance at major A&E
  • GP OOH contract leading to more attendance at A&E
  • More ill casemix driving more admissions
  • NHS 111 sending more people to A&E

Solutions that have been proposed include:
  • rewriting the GP contract
  • major adjustment to the marginal tariff to reward A&Es with extra volume
  • Rethinking OOH care to direct more away from A&E
  • Lots more staff in A&E

But most of these problems and their supposed remedies assume that volume is the problem. But it clearly isn’t. The performance problem is concentrated in 2013. But that period hasn’t seen particularly high attendance. the year 2012/13 was high, but most of the excess volume was concentrated in the middle of 2012 when performance was OK (a failure to look at the weekly data seems to have misled many commentators). There are a lot more people classed as A&E attends now than when the GP contract was signed, but almost all of the large increase is in minor injury units and walk in centres, not major A&Es (again commentators have confused the two by failing to look at the detail). Major A&Es have not seen notable large increases in attendance over the period and the weekly attendance has no relationship at all to performance.

These facts alone should be enough to absolve the GPs of any blame. And they also suggest that NHS 111 isn’t at fault. More importantly, none of the proposed remedies that are designed to curb volumes or provide extra money for extra volume will have any effect on the crisis.

Far too many experts who should know better have interpreted the key symptom incorrectly. They assume that a busy A&E is a sign of increased volume. It isn’t (at least in this crisis). When A&Es treat patients slowly (for whatever reason) they become busy even if the volume doesn’t change. The naive observations that volume is unsustainable have got cause and effect the wrong way round.

So the big question, and the one that has to be answered correctly to solve the crisis, is why are A&Es so slow?

Here is an idea that has the benefit of being entirely consistent with the known facts and is compatible with many detailed observations and statistics from A&Es (either collected directly or from the HES dataset which, unfortunately, isn’t yet available for the last few months to prove the point definitively). It’s the damn beds.

The evidence that points to the problem being about beds comes from several observations. The patient subgroup that spends the most time in A&E is the group who are eventually admitted. There is also some evidence that the larger the number of admissions the slower the A&E (but there is a problem about whether this is cause or effect as rushed decisions often lead to larger number of unnecessary admissions). We know that far too many decisions about admission are made at the last minute (this manifests as a spike in the waiting time for admissions just before 4 hours). And we know from looking at the waiting times across the day and week that the worst performance usually comes when beds are busiest.

A few commentators have pointed to beds a part of the problem. But too many have naively accepted the plausible excuse that this is caused by bed-blocking chronic patients waiting for social care to sort out their transfer. This may well contribute to the problem, but it can’t explain it all. Most hospitals are not actually full of bed-blockers and still manage to discharge 15-25% of their patients on a normal weekday. These patients will usually be fit to go home at the start of the day but many will occupy a bed until the afternoon bed round. This means that the discharges come at the worst time of day to accommodate the needs of the A&E admissions. Small changes in discharge patterns can often free up more than enough beds to meet the needs of A&E, but few hospitals have made the change.

To summarise: most public discussion and most policy fixes assume the problem is related to volume and assign blame to the GP OOH contract or NHS 111 problems. But the data clearly shows it isn’t their fault. It is also probably not entirely the fault of the A&E departments but of a hospital-wide failure to coordinate discharges with admissions.

We could spend the next six months funding new staff in A&Es, renegotiating the GP contract, redesigning the A&E tariff and fixing NHS 111. And the core problem would still be there.

Or we could pay attention to the data, diagnose the problem correctly and fix it.

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