Wednesday, 7 January 2015

We need to know why A&Es are in crisis

“Oh, the sad condition of mankind,” moaned the great Belgian pioneer of statistics, Adolphe Quetelet:

“We can say in advance how many individuals will sully their hands with the blood of their neighbours, how many of them will commit forgeries, and how many will turn poisoners with almost the same precision as we can predict the number of births and deaths. Society contains within it the germ of all the crimes that will be committed.”

It is a frightening thought, just as it was frightening for Quetelet’s contemporaries to hear him say it in the 1830s. But he and his contemporaries had been astonished by how regular the suicide statistics were. Year after year, you seemed to be able to predict how many there would be. There were the occasional bumper years, like 1846, 1929 and other economic crash periods, but generally speaking it was there. 

People didn’t seem to be able to help themselves. Amidst a constant number of individuals, the same number would take it into their heads to murder as much as get married. Statistics were powerful and also pretty predictable.  More about that in my book The Tyranny of Numbers.

I was thinking about Quetelet this morning listening to the closure of so many hospitals as, one by one, they were overwhelmed by the demand in their casualty departments.

The thing is that underlying demand doesn't change that much.  The basic need for emergency healthcare will always remain steady.  Yet something is clearly going on - I heard hospital managers talking about pressure of demand going up by 30 or 40 per cent this year.

Yet there is remarkably little agreement about why.  Here are some candidates:

1.  A growing elderly population.  This is true, but it doesn't explain the sudden weight of demand, unless this is a side-effect of a catastrophic breakdown in social care, which it could be.

2.  Younger people using A&E instead of making an appointment for a doctor.  This must be true too, but again - why so much now?

3.  People are particularly ill at the moment - because of all the bugs and the warm winter which failed to kill them.  This is possible but why should be have such an impact this year compared with others when there is no obvious epidemic.

4.  The difficulty about recruiting NHS staff for A&E.  This must be a factor but it doesn't explain the extra demand.

Whatever it is, Norman Lamb is absolutely right to be struggling to get some kind of cross-party consensus on the future of the NHS.  But that will depend on some kind of authoritative analysis on why demand has surged over the last year.

For me, only two explanations carry conviction about why this is happening now.  Both involve, as they would have to, some kind of tipping point in all these trends, but two in particular.

First, is there a some kind of breakdown in social care which is driving people to A&E, based on the cumulative changes over the past decade - the disastrous over-regulation and target-driven ineffectiveness ions of the New Labour years, and the recent funding reductions?  We urgently need to see how the failures in one part of the public service system impacts on other parts.

Second, is there some kind of cumulative effect of the narrowing of outputs to contract, caused by contracting out too many of the big outsourcing giants - whose main expertise is in meeting targets with the minimum of effort, spreading costs elsewhere in the system?  These extra costs will tend to come home to roost eventually at A&E because it is the only open-door in the public service system.  But are they coming come to roost?

I don't know, any more than anyone else, whether either of these goes anywhere near explaining it.  All I do know is that statistics of this kind only vary if something else very important is happening - the basic underlying demand will not change much, at least not year by year.

It is in the coalition parties' interests that we have some firm theory to rely on before the general election.  Otherwise people will believe what fits their mood at the time.  But something is going on - and we need to know what it is.


Anonymous said...

Drop the 4-hour A&E wait target, ensure people are assessed quickly on arrival and tell those who should have gone elsewhere that if they end up waiting 8 hours or whatever that's tough.

The 4-hour wait target is an open invitation to people with health problems which are not particularly serious to go to A&E instead of their GP

James Blanchard said...

The target should be done away with, but I don't see why a GP service can't be provided at or near to an A&E. Many hospitals colocate a walk-in centre on their grounds, or have a mobile GP on hand for big nights like 'Blackeye Friday' already so it's just a case of extending this practice and extending opening hours.

My experience as someone who works 20 miles from home is that it is not possible for me to see a GP without taking a day off, or by being really, really lucky on a Saturday morning. While that's fine for sickness, GPs' role as a gatekeeper to other NHS services mean that's not the only reason I might want to see one.

If people are turning up to A&E then the fight to convince them to use another service has already been lost, so they will wait and clog it up unless there is something they can be moved to on the spot

Anonymous said...

"My experience as someone who works 20 miles from home is that it is not possible for me to see a GP without taking a day off, or by being really, really lucky on a Saturday morning."

You might now be able to register with a GP near your place of work. See

Mark Treveil said...

I would add to the list:

"The inability of NHS staff, including doctors, to take responsibility, innovate, adapt to circumstances, and improve efficiencies."

For example, if people are turning up at A&E and shouldn't be, turn them away at a rapid, low-cost triage stage. If drunken friends are a problem, use the existing security staff to eject them.

The NHS debate needs to move away from "how much more?" to "how to make best use?" This is a question private business asks itself all the time. "More" may be necessary given changing demographics, but the NHS collectively needs to demonstrate it is making best use of what it has.

I believe part of the problem is the divide between doctors and management. In every sphere of private business, management is something technicians grow into. They learn about the issues of efficiency, staff management, and opportunity cost as they work their way up, and then use this, with their technical expertise to guide the organisation. The NHS trains doctors to be aloof, self-interested technicians how seem to refuse to take on board the responsibilities of organisational management.

chariscroft said...

Couldn't agree more with this post (and with the comments about ditching the 95% in 4 hours target as it doesn't help).

I'm always startled by how little comment or analysis there is on the WHY of these issues as opposed to hand wringing.

When it goes beyond 'look at how bad it is' pieces, the commentary proposes solutions - but without apparently understandign causes, so with no idea whether the solution will actually help. Bizarre. And worrying.