This is the scariest chart in the NHS. It may be the scariest chart in the UK, scarier even than George Osborne’s growth and debt projections. It’s a chart of hospital accident and emergency (A&E) admissions and it shows that in three NHS hospitals studied five per cent of patients consume almost half the resource.
The urgent question is: who are these needy patients? Sufferers from chronic cancer or other serious conditions? Accident or violence victims needing extensive reconstruction? Diabetes or obesity sufferers? Nope. Four out of five of them are people with chaotic lives – homeless, drug or alcohol users, or any combination of the above – who shouldn’t be in A&E at all but constantly re-present for minor ailments because their problem hasn’t been solved elsewhere. The buck stops at the NHS – which picks it up, assesses it and spits it out again and again, learning nothing in the process.
In other words, 40 per cent of the entire A&E resource goes up in failure demand – demand created by a failure to do something or do something properly the first time round; demand that shouldn’t be there.
What we have here therefore is not a health but a management problem.
Scary as it is in its own right, there are several other scary things about this graph. One is that neither the NHS or the government realise that the problem is a management issue, because amazing as it seems, these are not the kind of things that they measure. The data was collected and the graph plotted by the consultancy Vanguard, not the NHS.
If ministers or NHS managers knew what kind of problem they were dealing with they would also understand that the efficiency and productivity measures they have adopted to cope with apparently inexorably rising demand – such as 10-minute limits on GP appointments and the four-hour wait limit in A&E – are actually the cause of it. So they would stop them. But they don’t.
Why does the four-hour A&E target make things worse? Here’s another Vanguard chart. It shows that the nearer patients get to the four-hour limit, the more likely they are to be admitted to hospital, until at the four-hour cut-off point, everyone is. This is not primarily because they need to be admitted, although they might, but so as not to breach the target.
The knock-on effect for the three hospitals is that 50 per cent of all admissions are short stayers dismissed within 72 hours, many of them repeat presenters of the kind described above. Admitting people to hospital is expensive and time-consuming. In 2011 consultants followed the case of a diabetic with alcohol issues who was trying to quit the booze and stabilise his life. Over nine weeks he made seven visits to A&E for cuts and bruises, spent 44 days in hospital involving nine professions, 13 lab tests and 32 assessments – all for a person whose medical and social condition was well known to all the services and whose problems A&E couldn’t solve anyway.
In the same way, limiting GP appointments to 10 minutes, as many practices do, makes it harder to solve complex issues and may be another clue as to rising total demand on both GP and A&E resources. A recent survey found that 80 per cent of users did not trust their out-of-hours GP services which, as a doctor helpfully explained, had had to cut costs to tender for contracts by putting junior, less experienced (read: cheaper) staff at the front end, in whom patients had little confidence Result: more failure demand, more pressure on A&E. NHS Direct and the new 111 phone line will have the same effect.
Scary thing three is that this pattern is replicated all over the NHS and social services. How much of the ‘remorselessly rising demand’ for adult social care is failure demand? No one knows, because it isn’t counted. Failure demand certainly forms a large part of the demand presenting in benefits and housing offices, whose failures often eventually show up in the NHS.
The scariest thing of all, is that the big-ticket items put forward as ‘solutions’ to the NHS’ problems – the NHS IT system (cost: upwards of £10bn) and the present reorganisation (cost: at least £2bn) do absolutely nothing to deal with the real live issues on the front line, of which A&E is just one exemplar, because they start at the wrong end. Treating all demand as ‘value’ demand, they set quantitative targets for dealing with it, put junior staff at the front end to sort ‘simple’ cases from ‘complex’ ones, and end up with the situation described above: a dumb system which knows less and less about the people it it is supposed to help and can’t learn.
Yet this cycle of despair can be broken. Management problems are simpler to solve than medical ones. So the first step is to acknowledge that it is a management issue and start analysing demand in preparation for devising a system to meet it; and the second to repeat the process to improve it. In complex systems results emerge from below; they can't be imposed from above. Progress may seem slow at first, but if you’re doing the right thing each step carries you further in the right direction. There, now that we know what the problem really is, maybe that chart isn’t quite so scary after all.