A&E has a mountain to climb - but which one?

All England hospitals FY1213

Why does waiting in A&E look like this?

Jeremy Hunt complains that all the inspectors can do is tell him which hospitals are failing, and are no help in finding the good ones.  Help is at hand Mr Hunt. We have been out climbing mountains, and while some were shrouded in mist and darkness, we have seen from their heights a vision of excellence.  Sadly this is rare and reached only after great suffering and privation.  But the news at least is here when you click on the link, the best ones first:

Click here: what happens when you go to A&E?

The graceful slopes of Goat Fell on Arran

Graceful slopes of Goat Fell on Arran

We don’t like arbitrary classifications but as a shorthand guide we have divided the hospitals into groups based on the slope of their charts.  There are no winners here, but a select group of six has been given the Arran class.  You may be tempted to think of them as outstanding.  They are not, they are simply behaving in the way that any hospital should.  You arrive, and there is a sense of flow as you are seen promptly, an appropriately skilled clinician decides what to do with you, and they get on with it.  They are simply the best of the lot.  They pay practically no attention to the four hour target, though a few tail enders are pushed in under it - no, not one hospital has escaped its tentacles.

Ben More Mull is not all downhill

Ben More Mull is not all downhill

The second class is Ben More Mull.  These hospitals have a system, and it more or less works as above, most of the time they get on with looking after the patients, but they do worry about that target and as four hours approaches, there’s a lot of rushing around ticking boxes to make it look as if everyone is sorted within the time.  Nobody believes they really are, but we kid ourselves.  One thing we notice is that an increasing number of patients are admitted just before four hours.  Why did they wait so long to make a decision?  Was it clinically necessary?

But things worsen gradually, and we have had to create another class, the Paps of Jura.

The Paps of Jura, a few ups and downs

The Paps of Jura, a lot of up

There is such pressure to meet the four hour target that all the numbers are distorted.  While quite a number of patients are dealt with sooner, a large number are surrounded by panic as they approach the dreaded hour.  Of course there is huge management pressure, though this may not be apparent all the time as staff are conditioned to self flagellate if patients finish outside the limits.  There’s a fear of the consequences personally and for the hospital, and although 90 something percent of patients appear to make it, everyone knows the reality is a one big fib.  We’ve awarded the Monitor Medallion to this class, for knowing how to look good when the inspector calls.

It pains me to say this, but some charts don’t look anything like a mountain.  We’ve had to call them “The Boat”.  Life is grim, as it all revolves around hitting that four hour number, keeping the boss off our backs, doing what it takes (we all know the truth).  Morale is at rock bottom, it’s hard to find and keep staff, patients are simply a nuisance and they know it.  In an Arran hospital most of them would be out in a couple of hours, but here they just sit, not knowing what will happen or when - except that all the staff look harrassed and “something must be done” within four hours.  The problem for the staff is, if they have a minute, they must spend it on the patient who is just about to breach that time, not on the patient who has just arrived.  They can wait until they approach their four hour fate.  Everyone knows they are living a lie - but what can they do?

The Boat

Not a mountain at all

It would be tempting to single out the “worst” of this lot, and it would be wrong (do you read me, Daily Mail?).  They would just argue over an arbitrary measure.  So we have decided to award the whole class the coveted CQC Cover Up Cup, for dedicated service in keeping bad news out of the public domain.  Hearty commiserations.

But something can be done.  Have you spotted a theme?  Have you clicked on the link and looked for your local hospital?   Don’t blame the managers - they are doing exactly what’s expected.   The problem is that the whole system is oriented to hitting that four hour target.  Sure, everyone could try to look like Arran, but they won’t until the rules change.  When you set a target and offer to castrate anyone who can’t hit it, we all look like Olympic archers.  Lansley talked about removing targets, but was outmanoevred by the department.  It was renamed a standard, then a right.  It was relaxed from 98% to 95%.  Nothing changed (in fact, it’s worse).  Lansley didn’t have this data, but as Sir David writes today, evidence is exploding across social media and he asks, “Are we up to it?”. There is just one swift, simple, surefire way to change the system.  The target must be abolished.

Over to you, Jeremy.


2 responses to “A&E has a mountain to climb - but which one?”

  1. simon dodds says:

    This is called a “horned gaussian” and is caused by a target distorting the system. The solution is described in the top ranking essay at https://www.journalofimprovementscience.net

    Simon Dodds
    System Designer

  2. Paula says:

    Its not the target that distorts the system. 4 hours in A&E is long enough to wait. Its the culture and attitudes of the hospital management. Arrans care about looking after their patients. Boats care about looking after their bosses.

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