Efficiency and Waiting Times in the NHS

Alexander Wood's essay researching waiting times in the NHS was nominated for the Ithaka Prize. 

“As a complex system, A&E departments operate at the edge of chaos and are meant to be highly resilient” (J.Banerjee,2014.)

On the 70th anniversary of the National Health Service, it is a good time to evaluate and celebrate the positives and negatives of this groundbreaking organisation. Most people value the phenomenal service the NHS do on a day to day basis, and on a personal level, accept that the NHS does a great job with the funding they receive. But there is a perception, fueled by mainstream and social media, that the NHS is in crisis, due to underfunding,poor management, inefficiency and increasing demands. Amongst many areas under scrutiny and attracting significant criticism, the one area increasingly subject to judgement is the performance of Accident and Emergency wards in hospitals.

A&E waiting times have been, for many years, used as a measure of the NHS’s efficiency. I have decided to delve deeper into this area in particular, and look at three of the major issues currently having an impact on NHS A&E department waiting times, and to make some practical suggestions to help to elevate these problems facing the NHS.

“In 2016 there were 23.57 million attendees in England’s A&E departments. Only 65% of these were major emergencies” (C.Baker,2017). A&E departments came to overloaded and underfunded crisis point in January 2018, which lead to mass cancellations of elective surgeries across the country to free up bed space. What can be changed and how these changes can be made? Are we wasting precious resources on treating common colds and sore throats easily cured by a local pharmacist or GP? Are we just inefficient ? Is it just lack of resources, especially human ?

It is important to understand the way an A&E department works. NHS A&E departments are different to other NHS departments in that they are ‘reactionary’. There is no way of knowing the injuries and illnesses that will be faced on a day to day basis, although predictions can be made based on the day, time of day and season linked to data taken in the past.  Monday mornings are often the busiest time for broken bones, and January for bronchial issues for example. Unlike any other department, they cannot assign staff perfectly as they will never know the amount of people that will require their attention, or the exacting nature of the medical problems. If this key life-saving department is underfunded or mismanaged, then it can have very serious consequences.

 “The NHS Mandate states that the NHS will receive an additional 2.8 billion between 2017 and 2020, taking NHS funding to over half a trillion pounds in 2015” (Department of Health, 2018). The NHS introduced targets to try and improve the use of this funding, and assess performance in this area: This funding comes with the caveat that the NHS must be more efficient. The mandate states, as part of objective 5, that “to maintain and improve performance against core patient access standards by 2020, 95% of people attending NHS A&E Departments must be seen within 4 hours” (Department of Health,2015) . However, the 95% target for A&E patients to be seen within four hours has become unrealistic and unachievable as can be seen in Figure 1 below, with current systems and funding as they currently are. 

Figure 1. Graph from qualitywatch.org.uk

Prior to 2011 the mandate target was set at 98% and the NHS were quite successful in reaching this target in the first quarter of each year- when it is the most difficult to achieve regarding seasonal illnesses and complications. In 2010 the Mandate target was lowered to 95% and up until 2012 the NHS achieved these targets. In 2012/2013 Q4, although the target remained the same, waiting times took a significant increase with only 91% of patients being seen within the four hour window. Since 2013/14 Q2 the NHS has not reached the target, ending 2017 at 76.8%.  A&E attendances have undoubtedly increased as can be seen in Fig. 1. Hospital A&E departments are just not keeping up with the target set. Type 2 and 3 visits, that is minor injury or specialist departments, stay way above target releasing patients before the 4 hour window. It is the Type 1 A&E visits where the problem lies (major hospital A&E units).

There is no doubt that there are seasonal influences which create extra pressure on these departments, winter being the most difficult time. According to qualitywatch.org.uk, performance in A&E departments is better in the summer months. Summer sees more sprains and cuts, most of which are easily treated, whereas in winter, more elderly visitors and those requiring life-saving support, increase. This level of care requires more specialist treatment and delays the waiting times.

When looking at waiting times on trolleys, since April 2013 there has been a significant increase. “In 2016 16.2% of people spent more than 4 hours in the major A&E departments, a rise of 4.8% from 5 years before” (C.Baker,2017) See fig 2 below. It is shocking to note that the incidences of patients having to wait on trolleys for beds on wards, has increased significantly since Dec 2015 and indeed the bed crisis of January 2018 brought this to a head. In the first quarter of 2017 in Fig 2, 21% of people waiting on trolleys, often in corridors, waited longer than 12 hours (extreme waits),

Figure 2: graph source qualitywatch.org.uk 

So, a quick look at the problem, using the NHS sown figures, shows that there is a undoubtedly quantifiable assessed failure of A&E to achieve set targets. So what are the contributing factors leading to the inability to achieve the target and how might they be reduced ?

1.    Increase of people going to major Hospital A&E units unnecessarily.

”in 2016 there was an average of 2,210 more attendances at major A&E’s every day compared with the year before”.(C.Baker,2017) That is a massive 5% increase per day in just a year.  Any increase of attendance in A&E departments requires a very efficient and effective system providing a method of sifting ailments which can be dealt with by pharmacists and GP’s to allow redirection before A&E is involved. This would require a basic level of medical knowledge for the clerical administrator so that they can quickly and effectively deflect minor injuries, viruses and bacterial infections which are not life threatening, and a more robust approach by first aid responders. In addition, the  launching of a national advertising campaign using all forms of media, hitting all age groups. This should highlight the difference between “Anything & Everything” and ‘Accident and Emergency’, in other words, making it clear the type of injuries and illnesses which should be referred to A&E. This could be done with the use of a poster system, TV information programs, or apps simplifying what requires A&E attention.

2.    Productivity and resilience of NHS staff - stress levels.

The government know that one of the major concerns for NHS Trust managers, is the welfare and resilience of their specialist staff, as well as the ability to train and retain such valuable staff. A BBC survey in 2013 revealed that England’s A&E Departments were understaffed by 10%. The problem isn’t just money, but the time taken to train staff up to the required standard is long and stressful, putting strain on staff who are covering other people’s jobs as well as their own. It is also difficult to recruit the right number and calibre of staff in England; many of the NHS specialists have to be recruited from abroad.  2018 saw a determined increase in the number of medic places at British universities to better sustain a home-grown succession of new doctors and nurses. It is important, going forward, that A&E department managers have a team working together with range of specialities, eg, geriatric, paediatric and orthopaedic specialists in A&E departments.  This would allow quicker assessments to be made as the specialists can confer and increase efficiency and productivity. This will be maximised where staff numbers are at full capacity for each shift. By introducing a simple two hour rota system, this would decrease stress levels and increase resilience, as they will feel refreshed and therefore more productive as we all as feeling more valued; two hours on and half an hour off for example. Transition may be an issue, but I would suggest a specialist remains with their patient whilst in A&E to prevent confusion. It is important to stress that A&E departments require the right amount of staff and the right degree of specialism always available. If productivity decreases, it is directly proportional to the increase in waiting times, and also to medical errors made.

       3.   Lack of funding in the A&E department, and the NHS in general.

As the population increases, strain will increase on the NHS resouces. More people are living longer as medicine progresses too. An older or vulnerable population puts a higher strain on the NHS, because of the higher risk to weak bodies and lowered immune systems, particularly A&E departments. In 2016, people aged 80+ have the highest rates of A&E attendance at 62% of people aged 80-89. 86% of people 90+ visiting A&E in the same year. (C.Baker,2017)

On the 21st April 2017 the Department of Health “announced the allocation of funding of £56 million of the £100 million A&E capital funding to ease pressure on emergency departments in time for winter”.(R.Murray,March 2018) This funding was only allocated to 70 NHS hospitals out of a possible 168 hospital trusts. This 60% of the capital budget spent on 42% of the hospitals is potentially short-sighted of the government and indeed, we still suffered an A&E crisis in winter 2018, Was this funding too little, too late or was it inefficiently used? These potential oversights lead to longer waiting times because of the lack of organisation. Mike Farrar (the chief executive of the NHS confederation 2013), during a BBC interview in 2013 stressed the importance of funding local community improvements, which would reduce the pressure on A&E departments. He suggested making more GP appointments available, improving 101 calls and better specialist support for the elderly and those suffering from mental health issues.  This has not happened sufficiently to avoid the extra strain on the A&E departments in 2017 and 2018 which continues to greatly increase waiting times.

Another possible way of increasing the NHS budget is by charging wealthier patients for their treatments, via a ‘private’ NHS sector. Would this mean they jump queues and become prioritised? This is a very controversial idea, as making certain people pay for their medical attention could be seen as defeating the point of the NHS- free healthcare for all. If there was a system in place-much like the tax bracket system- to decide which people can pay for their healthcare. A wealthier payee could get a major health crisis however  e.g cancer, and not be able to afford it. I would therefore suggest a basic payment system, i.e everyone pays a minimum price for their treatment. This would also deter unnecessary use of A&E as people would start to think twice before going, therefore decreasing waiting times.

Conclusion

It is impossible to deal with all the challenges that NHS face in a short paper, and this paper has done little more than highlight the key issues in one specific area. There is also a clear relationship between decreasing social care capacity outside of the NHS, and increased use of A&E and other hospital capacity, which hasn’t been addressed in this paper. Funding clearly needs to be allocated back to communities providing better access to GP’s and specialist units, e.g. mental health and elderly care, instead of these people being forced to attend hospital A&E departments.

Overall, despite the 70 years of steadfast, reliable service provided by the NHS, it is currently in crisis. I feel it is everyone’s responsibility to ensure this precious service remains for future generations. The core focus of this piece was to highlight three specific issues within the A&E Departments. If these problems can be countered, one area of the NHS may well help to enable capacity to be used more effectively elsewhere. My suggested solutions to these problems, in some areas are already in train, and may be hard to achieve at first, but if understood and implemented effectively, they could have a significant impact on waiting times. In summary, my two suggested solutions to reduce the number of “Anything & Everything” A&E attendances, includes a better awareness campaign and a more robust and earlier triage system. This would counter the amount of people going because it would deflect non-emergency patients. My second point regarding staff wellbeing, highlights the importance of a specialist workforce who feel valued and fulfill their potential. This should include: reduced daily working hours; more rest breaks and a specialist team around the patient. It will require more funding, and better use of the money provided.

As I have already mentioned, A&E departments are reactionary in nature, so improvements in the management of situations, and changing the flow into A&E through signposting elsewhere, can only help to reduce pressure. Even the smallest improvement could mean this prestigious organisation remains for generations to come.

Bibliography:

1.    Banerjee,Dr.J,(2014) .Pressures on A&E: a front line perspective. Retrieved from http://www.qualitywatch.org.uk/blog/pressures-on-ae-front-line-perspective#

2.    Baker,Carl.(2017).Accident and Emergency statistics:Demand, performance and pressure,Breifing paper(6964) retrieved from http://researchbriefings.files.parliament.uk/documents/SN06964/SN06964.pdf

3.    U.K Department of Health.(2018) the governments revised mandate to NHS England for 2017/2018,Jeremey Hunt. Retrieved from http://researchbriefings.files.parliament.uk/documents/SN06964/SN06964.pdf

4.    U.K Deparment of Health.(2015) the governments mandate to NHS England for 2016/2017,Jeremy Hunt. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2015/12/05.PB_.17.12.15-Annex-A-Mandate-to-NHS-England.pdf

5.    Murray,Richard, jabbal,Joni, Maguire,David, Ward,Deborah (march 2018) Hiw is the NHS performing? March 2018 quarterly monitoring report. Retrieved from https://www.kingsfund.org.uk/publications/how-nhs-performing-march-2018

Graphs:

Figure 1: Quality Watch. Independent scrutiny into how the quality of health and social care is changing over time. A&E waiting times. Retrieved from http://www.qualitywatch.org.uk/indicator/ae-waiting-times

Figure 2: Quality Watch. Independent scrutiny into how the quality of health and social care is changing over time. A&E waiting times. Retrieved from http://www.qualitywatch.org.uk/indicator/ae-waiting-times