The official reported A&E figures in 2018 make for depressing reading. As widely reported last month people are waiting longer to be ‘treated’ in A&E units up and down the country than ever before. 85.1% of patients were ‘dealt with’ within four hours. The target is 95%.
These are the worst statistics since an A&E waiting time target was introduced in 2004, when the target was 98%.
I will explain why focusing efforts on achieving arbitrary targets is counter-productive in a future blog. In this blog I want to concentrate on the defensive excuses that are repeatedly rolled-out to explain why hospitals are unable to meet the 4-hour waiting time target. I will use analytics to deconstruct the misguided belief in ‘rising demand’. But before I do, it is worth understanding the context and convention.
Patients are often the scapegoats when individual NHS trusts fail to meet the 4-hour A&E target. By definition, patients are people that attend A&E and require some form of medical assistance or intervention.
Scapegoating can take subtle forms. You will often hear the NHS blame ‘rising demand’. This phrase just means more people are using more NHS services, which causes the NHS to miss targets and costs to increase. Sometimes we hear more sophisticated explanations of the same belief, such as ‘winter pressures’ or ‘delayed discharges’. Both expressions are euphemisms for rising demand, but they are specifically referring to a particular type of patient: frail older people or ‘bed blockers’.
Regarding this year’s results, rising demand is again being used to explain the performance gap. Overall attendances were per cent compared with the same time last year. There was also a sharp rise in emergency admissions and calls to NHS 111. In turn, System Resilience Groups (who are comprised of senior leaders from both local commissioners and acute providers) spend a lot of effort, focus and time pouring over localised statistics and jumping to opinion-based solutions which don’t work.
The Myth of ‘Rising Demand’
Now what if I told you rising demand is really a myth? Rising demand is being confused with rising activity, and I’ve got the evidence to prove this.
NHS commissioners and providers suffer from what I call ‘activity obsession disorder’; they capture activity numbers and mistake this for demand. The current applied logic is that if activity increases, the demand also goes up. Well, this is wrong. Activity is not the same thing as demand, it is a consequential component.
Understanding Patient Demand
In healthcare, demand is best understood in person-terms. Demand is quite simply the number of people using the service. Activity and costs are both lagging gauges – they tell you what has happened but not to whom. For this insight you need to study patient demand as it is leading indicator of performance.
Patient demand is relatively stable and entirely predictable year-on-year. When the NHS blame ‘rising demand’, it is not the number of actual patients that is increasing, but the activity we do on them.
The ‘Vital Few’ Patients
Patient demand is stable and predictable but is unevenly distributed. In other words, some patients consume more than others. In fact, really small numbers of patients consume a lot more activity and financial resource. Adopting the late Joseph Juran’s phraseology, I call these the ‘vital few’. Depending on the size of the hospital, you will find a few thousand patients causing anything between a fifth to a third of all the activity in A&E.
At St George’s Hospital in south London, for example, globally one of the largest acute hospitals, patient demand in A&E is a stable 100,000 people per year, of which around a third of them will be admitted. Last year, the Trust’s annual report stated it saw 143,000 patients in A&E. What it meant to say was that they performed 143,000 activities on these 100,000 patients. Activity (and costs) will always be more than patients. 6,500 people account for 20% of attendances. 1,000 of them use 8%of the total activity and account for 14%of the costs. 195 of these patients account for one-seventh of the total bed capacity of the Trust. In my experience, these ratios will differ according to the size of the hospital but the proportions will be roughly the same.
These ‘vital few’ patients, often just a few thousand individuals, come into A&E a lot – 60 to 80 times a year. Contrary to belief, this type of patient demand is very predictable. The same patterns (and patients) keep repeating year-on-year. In any hospital you will find that those individuals that attend A&E multiple times within the year, will begin this pattern in the first quarter of every financial year and they then keep coming back.
When they arrive at the A&E front-door they typically tend to experience longer waits compared to all other users and therefore are disproportionately associated with up to 50 per cent of all A&E breaches of the 4-hour waiting time target. If you thought this was bad, it gets worse, a lot worse. An obsession on meeting the 4-hour target, process flowing patients (who don’t need to flow at all) and making revenue per patient paradoxically leads us to not achieve any of the above.
These same ‘vital few’ people inexplicably get admitted and then up to half of the admissions will come from these small numbers. When they get admitted, where do they go? They find their way almost always to observations units or ‘holding bays’ behind A&E which have grown in number since 2004 as a wheeze to meet the 4-hour target. Discharge lounges are also used for this purpose too. Moreover, with virtually every hospital now facing financial deficit, these small numbers of people will account for each one’s monetary discrepancy. This is empirically guaranteed.
But the worse bit? That’s the mortality numbers. Such patients will be up to 10 times more likely to die in a hospital ward. In fact, they will make up a significant proportion – up to a third of a hospital’s own mortality rates.
So patient demand is not rising, activity and costs are what’s on the increase due to really small numbers of patients who keep literally ‘boomeranging’ and it is this that gets wrongly reported as ‘rising demand’.
Beyond the Kaizer
But why do they keep coming in? You might think that they need to come to A&E due to their acute medical conditions? Are they not all frail elderly with greater levels of chronic conditions? Does conventional wisdom such as the Kaizer Permente model not tell us that these few patients are the chronic condition types who need case management to manage their acute medical needs?
Well the answer to all of the above questions is, not really. Contrary to the Kaizer Permente triangle, there is a weak association between medical acuity and patient consumption of emergency hospital resources. Yes, that’s not a misprint on my part; you read that last sentence correctly.
Nor are they, as reported frail elderly. Some cohorts will be but this is much overstated. In any acute setting anything from three-fifths and two-thirds of these people will be under the age of 70. In fact, it is not uncommon for those at the apex of the hospital consumption charts to be in their mid-30s to late 50s whose lives have gone ‘off the rails’.
When you study random and representative samples of the ‘vital few’ patients you see is that they have social, psychological and environmental needs which are not being successfully met. Consequentially they ‘tip’ into the only part of the healthcare system that cannot turn them away via eligibility criteria and that’s A&E.
Now we shouldn’t be surprised as the system is currently configured to be dysfunctional and paradoxically not work. We haven’t designed a healthcare system to meet their needs so they are met every time with a medical, transactional response which may patch up the physical symptoms but do nothing to address the root causes. It is literally ground-hog day every time they appear. We do the same thing, triage then identify, assess and refer on to others, when what these people actually need is continuity of customised care around their needs.
To conclude, for some people, no amount of empirical evidence such as I have provided here will cause them to move their mind-set. They will mistakenly persist in searching for non-solutions to the wrong problems. But for those of an enquiring disposition I will finish with this statement. If a person attends A&E 260 times in less than four years and is not an acute medical case, the question to pose is not what is wrong with them but what is wrong with us in our system response to them.
Starting with the ‘vital few’, we need to learn how to humanise healthcare and customise care services around individual patients based upon a clear understanding of what good looks like to them and/or their loved ones. This is what improvement is all about. Getting care right never costs, it always pays.
Hamish Dibley is a Managing Consultant and Healthcare Lead with Capgemini Consulting. An experienced change management and service improvement professional, Hamish has delivered better service outcomes and cost reductions across NHS and adult social care. He has pioneered a new and digital-enabled way to better understand and improve services and systems, from the perspective of the patient. Humanising Healthcare fuses operational research and operational improvement expertise with astute strategic vision to achieve better service at less cost.