Are we missing a trick on A&E?

Card trick

The problem with a relentless focus on something - such as the A&E waiting time target - is that there is a risk the real issue is missed.

Like a magic trick, the eye is diverted elsewhere and fails to spot what has been happening right in front of it.

This may be worth bearing in mind as we follow the story of the NHS in England this winter.

In many respects, the health service has coped well so far.

Yes, the four-hour target was missed at the start of December. But that is not unusual.

During much of the Christmas period it was hit - although this is probably largely down to fewer people attending hospital.

And while the numbers seen within the timescale have again dipped under the 95% target for the first week of 2014, performance on many measures, such as cancelled operations and ambulances queuing, are still up on last year.

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The more emergency cases that are admitted the more challenging it becomes for the rest of the hospital system.”

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And yet, the New Year message from NHS England has been one of caution.

This week Dr Barbara Hakin warned against complacency and said there were tough times ahead.

Why? The main reason is that emergency admissions are up. Before Christmas they were topping 105,000 a week - the highest number since they started being recorded in 2010.

Essentially, these are the serious cases. The majority of people who arrive at A&E are seen and treated without being admitted into the hospital.

But for patients with more complicated or life-threatening conditions admission to hospital is needed.

This matters because the more emergency cases that are admitted the more challenging it becomes for the rest of the hospital system.

In the long-run, the very measures that are holding up so far could start to unravel.

At the moment, it is unclear why this rise in emergency admissions has been seen.

The extra money the NHS was given in the summer, for winter planning, was meant to alleviate just this by helping to provide extra support in the community, such as boosting district nursing and social care, to stop people becoming acutely unwell in the first place.

Possible gaming

It could be that there are more acutely unwell patients this winter?

Or could it be because the NHS is under so much pressure to hit the four-hour waiting time target that when a patient is close to breaching it they are admitted as an emergency to stop the clock ticking?

Data from the Health and Social Care Information Centre, based on previous years, shows that in the final 10 minutes of the four-hour target you are twice as likely to be admitted than in the 10 minutes before that - and three times as likely in the 10 minutes before that again.

Could there be gaming going on? I put that to senior people at the information centre and their response was telling.

Cautious by nature, the statisticians were never going to stick their necks out to suggest it is. But they did concede it needed explaining.

Publicly, hospitals claim it is purely a result of the fact that the most serious cases take a lot more assessment and therefore as time goes on the likelihood of admission increases.

That may be true for some patients. But that doesn't explain why after the four-hour mark the admission rate drops off.

It is left to those on the front-line to explain. "Any A&E doctor would be lying if they said that when it approaches four hours you are not influenced," a member of staff from a busy unit told me recently.

"We have a secretary of state who is ringing hospitals up when they breach the four-hour target. You want to avoid that."

That, of course, doesn't necessarily mean they do not need to be admitted.

As mentioned above the longer waiters tend to be the more complex cases. But it does suggest that the staff treating the patient may not have had the chance to take a fully-informed decision.

Once admitted that information - whether it is test results or specialist opinion - still needs to be gathered. It's just that that wait doesn't show up in the four-hour statistics.

Nick Triggle Article written by Nick Triggle Nick Triggle Health correspondent

Why are hospitals under so much pressure?

The NHS across the UK is already struggling to meet its A&E targets, and winter - the busiest time of year - has only just begun. Nick Triggle looks at why hospitals are under the cosh.

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  • rate this

    Comment number 3.

    A friend of mine is a doctor. She told me that people attend A&E wards regularly for 3 or 4 hours to obtain head ache tablets that cost 99p at Boots. When asked why, the reply is "because they are free here and it's my right."
    With the attitude of entitlement in society the wards are always going to be swamped by takers with no thought of how that impacts those genuinely needing emergency care.

  • rate this

    Comment number 15.

    80% of A&E attendees (apart from the drunks and druggies) are there for a real but not life threatening emergency, so don't need the full crash team. Cuts that need stitching, minor burns that need dressing, all of which could be done by experienced nurses or paramedics. A minor treatment centre next door could process them through quickly, with a triage nurse assessing which way they go.

  • rate this

    Comment number 19.

    Statistics prove nothing and do not solve the fundamental issues.

    The biggest issue facing A&E (it stands for Accident and Emergency not Anything and Everything) is people arriving there who should not be there.

    There should be "walk-in" centres at all A&E hospitals and cases which are not genuine medical emergencies should be triaged to the walk-in centre.

  • rate this

    Comment number 1.

    Just read "Punishment by Rewards" by Alfie Kohn. Setting targets will always lead to "gaming" and focus on hitting targets at the expense of the real outcomes that you want a process to achieve. The more that managers try to influence the hitting of targets the more gaming will go on. A 4 hour minimum wait is not the is the effective and efficient care of the patient that matters.

  • rate this

    Comment number 9.

    Perhaps if some out of hours GP's would see people who really don't need A&E, the department wouldn't be so overstretched.


Comments 5 of 99



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