A&E Performance - Everyone owns the problem and the solution
21 February 2019
Like most things, you can interpret the data behind the headlines like ‘A&E waits at worst level for 15 years’ in a variety of ways. Across England there were 2.11 million attendances in January 2019, over 100,000 more than last year. So, despite achieving ‘just’ 84.4% performance, in absolute terms more patients were seen and treated within four hours than they were this time last year. Plus, if you’re a ‘glass half full’ person you could also point to NHSE’s direction last winter to stand down planned activity to create additional capacity - advice that wasn’t forthcoming this year. The workforce issues that have dogged the NHS haven’t gone away either, placing the current performance in a fairer context than the headlines would perhaps suggest.
The fact is that it is all incredibly finely balanced with A&E departments under extraordinary pressure, acting as they do as the ‘canary in the coal mine’ for the wider hospital and health and care system as a whole. Performance could easily, and very rapidly, slide significantly if a late flu season or ‘Beast from the East 2.0' put in an unwanted appearance - and fortunately for all, both weather and viral outbreaks have been relatively kind this season.
A system wide approach
As the Royal College of Emergency Medicine made clear in their open letter to Simon Stevens, defending the relevance of the four hour standard, A&E performance is a hospital wide issue. The Accident & Emergency Department is not a separate institution in and of itself. It should not be treated as one or be allowed to behave in that way. A siege mentality by frontline A&E staff can only help so much as demand continues to pile in to the waiting areas and ambulance bays.
What’s required is a whole site approach to patient flow; proactive management of the A&E department through consistent ‘huddles’ over a 24 hour cycle, with A&E staff coming together with site managers and wider hospital staff to collaborate and make collective decisions, using real time data and analytics to balance risk across the hospital.
Bed availability will always remain a key determinant of A&E performance and therefore any programme to improve four hour performance must balance interventions within A&E with a focus on the systems and behaviours across wards, site management and discharge teams. This means leadership at every level driving patient flow, with social care partners/discharge coordinators forming a highly functioning part of a genuine multi-disciplinary team (MDT).
At the most advanced NHS Trusts, patient flow is hardwired into the infrastructure of the hospital through technology, allowing the entire MDT, site team and ops managers to coordinate tasks through a digital interface which is optimised for mobile. Manual data collection is minimal and ‘touch point’ meetings reduce in frequency and significance. Too many Trusts are still reliant on Post-it notes and too much staff time spent walking up and down corridors to give out of date or incomplete updates.
The NHS long term plan - a long way off
Over the next five years, the practical steps’ set out in NHS Long Term Plan are intended to move us to a service model that places far less reliance on acute hospitals and their heroic emergency pathways. But this will take time (along with cooperation from system partners to develop new care models and funding arrangements that align incentives).
At present, the ambitious timescales set out in the NHS Long Term Plan's milestones for urgent and emergency care will require some Trusts to undertake significant pathway development in relation to ambulatory care, urgent treatment centres and acute frailty. Many are a long way off what is required in the next 18-24 months.
This is a directive that should be welcomed though. Investing in these areas has a significant impact on both four hour performance and the quality of care. Having capacity to divert patients to lower acuity/specialists units and ensuring those at the ‘front door’ are trained and supported to stream to these areas offers a high return on investment - creating and consistently utilising this capacity significantly decongests the main department, allowing staff there to focus their attention on the most complex patients.
Finding a balance
Like interpreting A&E performance statistics, improving the current position is not straightforward. Trusts need to balance their efforts. Improving A&E performance must in part come from transforming how urgent and emergency care is configured and operated, but also from improving how flow works across the site and in the community, and planning upfront capacity across the system even before winter bites. And all this needs to be done whilst treating two million patients every month… It’s not easy. And if it was easy, everyone would be doing it.
To discuss best practice in delivering against the 4 hour standard, the implications of the NHS Long Term Plan or digitally enabled patient flow please get in touch.