Overloaded A&Es – Have we got this all wrong? Dr Brad Keogh

Dr Brad Keogh

Accident and Emergency wait times seem to be constantly in the news. Less commonly but equally importantly are headlines that waiting lists for elective operations and procedures are on the rise. Although these topics hit our headlines regularly there is actually very little evidence and understanding behind the reasons for these changes in NHS services, and how the NHS can take positive action to cope with these issues.

From what we understand a lot of the currently held beliefs around the causes for pressure on NHS services come from very basic, non peer-reviewed, and potentially flawed analyses. It does not need too much explaining that making decisions based on these might be a bad idea.

BradPaperIn our recently published study we have begun to build a base on which to investigate if there is truth in the analyses that currently exist, in order to allow an informed debate around the reasons for increases in waiting times, and what might be done about them. This will aid more targeted changes to services to cope with the changes the NHS is seeing, rather than enforcing changes which do not have any benefit to patients. Our findings of this new research were that some of the commonly stated ideas as to the increases in waiting times are not as clear and obvious as some influential blogs, and media, appear to suggest.

Why do we need evidence?

At a time when the NHS has limited resources and increases in demand for its services, it seems prudent to only make changes to the service once you are reasonably certain that what you might do may be in the interest of the patients and staff in the system. By enforcing top-down changes to services with little or no evidence of benefit to patients or staff we are using more of this precious resource for no clear benefit.

As an engineer coming into the healthcare sector several years ago to do data analytics, it has always surprised me how few decisions in the management of NHS services are made with robust quantitative analysis. It is also a contrast to the evidence based decision making and protocols within medicine. My thought for you: “why can’t we have evidence based service management as well as evidence based medicine?“

What are the commonly held assumptions behind the increase in wait times?

There seem to be several reasons currently thought to be responsible:

  • Aging population – the population is older and sicker and need more heathcare treatment
  • Inappropriate use of A&E – patients use A&E when other services may be more appropriate
  • Cuts to social care – reduction to support to people in their own homes/community results in more crises and use of emergency services
  • Rises in delayed transfers of care – patients who are ‘stuck’ in acute hospital beds – taking up beds and resources

You might be thinking: “we already know these are the reasons….”, but do we actually? From what we understand these are often suggested to be the causes, but based on limited evidence.

Just to be clear: none of these factors have been studied robustly in detail, and hence are not yet understood to be clear causes for the waiting time increases. Studying their relative impact in more detail might also allow us to make better decision about how resources are used.

An example: delayed transfers of care (DTOCs)

One example of an idea that is now commonly held and is reported in media and in reports from influential health organisations is that around DTOCs . It is currently a commonly held assumption that increases in A&E waiting times are being caused by larger numbers of Delayed Transfers of Care. The hypothesis here makes sense:

..rising numbers of patients who are ‘stuck’ in acute hospital beds (who are fit and well but waiting to be discharged home) has a knock on effect to A&E departments who are trying to admit emergency patients. Hence the increases in 4 hour A&E waiting times.

However where does this idea come from? To our knowledge the assumption exists only from a blog post, which completed a simple analysis at national level and suggested that the rise in DTOCs is the cause.

What are the aims of our study?

Our recent study aimed to investigate the importance of common explanatory theories of hospital patient flow bottlenecks over 5 years; more specifically to understand the possible patient-flow factors within English hospital trusts which affect the four-hour waiting time and last-minute cancelled elective operation performance.

Our study also makes all the data we collated and the analysis we completed available for anyone. This means that our analysis can be scrutinised and can be developed further by any interested parties.

What did our study find?

The most important factors associated with better acute trust four-hour target performance in England were found to have varied over the period 2012–2016. In 2012 the most important factors in obtaining higher performance were: having a higher proportion of empty inpatient beds, and higher proportion of those attending A&E being admitted. In 2016 we found it was more important that trusts had a higher ratio of day-beds to night-beds. Those that did had a higher performance. One plausible explanation for this is that trusts with higher numbers of day beds can use these as temporary ‘buffer’ capacity to move patients who will be eventually admitted from A&Es.

DTOCs showed limited evidence of being associated with ED performance measures, which is contrary to the current evidence suggesting the association is strong.

Differences in four-hour target performance between English NHS acute trusts can only be partially explained by patient flow, and the ability of patient flow to explain the differences in trust performance has reduced over time.

Differences in the number of cancelled elective operations between trusts has become more explained by hospital patient flow factors between 2012-2016. Trusts that had higher proportions of those attending A&E being admitted, and higher proportion of emergency admissions to elective admissions had greater numbers of cancelled elective operations.

What does this mean?

Some of our common assumptions as to the causes of the pressure NHS acute trusts are facing need to be questioned. By building a robust and (at least more) peer-reviewed debate as to the causes, we can move towards finding realistic and useful action that can be taken.

Read out research paper here.

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