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Rising demand in the NHS is as much a management as a medical issue

Sun, 24th Mar 2013

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. 

 

 

 

 

 

 

 

 

 

 

 

 


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User comments

Andy Lippok :: 26th Mar 13
This is scary stuff Simon, but worst of all the fact that neither the NHS nor the politicians know any of this stuff!
Donal Carroll :: 2nd Apr 13
Terrific piece Simon -campaigning, free-flowing and rooted in the realpolitik! How are you getting these to a wider audience? Any new ways into the politocrats, the habit-ensnared agenda-setters -ie those who control all this but who, in fact, are not affected?
Mark Scarfe :: 4th Apr 13
Pretty graph at the top of the page... looks a bit 'neat' and needs more explanation. For example, what does '% resource consumed' mean? Is this staff time, number of cubicles in the department....? The x axis of % people, implies that the patients have been put in an 'order' of complexity based on the chaotic nature of their lives... would love to see how this is done! The second graph - I'm completely on board with this one... The graph I would like to see is how, this exemplar A&E department has analysed patient attendance by hour of the day against its medical rotas. Has it actually balanced its patient demand to its capacity to see those patients!
Mike Davidge :: 5th Apr 13
As someone who works in the NHS, and has done for over 30 years, I must say that you have described the situation beautifully. And in Wales we are just about to tackle this very issue. Wish us luck.
Harry Longman :: 19th Apr 13
There is a lot of truth in here and I support the overall message. However, some of it is oversimplified and you will not win arguments by leaving these holes. It is not true to say that the 5% of patients making 40% of demand is all failure demand, nor that the rest of the demand is by implication not failure demand. A good deal of it across the spectrum could be labelled as failure demand, but a precise number cannot be stated because the reasons for attendance are often too subtle and complex. I suspect that a number higher than 40% may be true, but to find that out would take a proper study. In any system like this, a lot of resource is used by a few, that is a repeating observation and not of itself "wrong". The top chart is suspiciously smooth, more like a mathematical function than a measurement of data, so we really need to know exactly how it was created to give it credibility. The second chart also looks somewhat mathematical, and again we are not told its provenance. Which hospital or man
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