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In this transcript of his talk at a recent NHS England regional conference, Russell Emeny, Director of the Emergency Care Intensive Support Team, says that stabilising emergency department 4-hour performance requires reducing avoidable hospitalisation, focussing on home-based solutions and improving patient flows.

The performance issues that were experienced over the recent winter and spring were caused by the combined effect of long term trends and many smaller stimuli. The emergency care system in England has become increasingly fragile and vulnerable to small impacts. During 2012/13, the system lost equilibrium, causing many health communities to struggle to provide prompt emergency care. Recovery has been slow.

There were numerous signs that the system had become stressed: 4-hour arrival to departure performance in emergency departments reached its lowest level in ten years and patients waiting on trolleys for over 12 hours significantly increased. Time from initial assessment to start of treatment grew, along with time from start of treatment to decision to admit. Hospital occupancy, length of stay and waits for admission all increased.  Ambulance hand-over times were sometimes measured in hours rather than minutes.  

Many of the beds that had been closed during the summer of 2012 as part of QIPP programmes were reopened in ‘escalation’.  However, the established medical and nursing teams had been dispersed, so these beds were often managed by temporary staff and reluctant clinicians, so length of stay inevitably increased, leading to further pressure on beds. 

The roll out of NHS 111, while generally not causing major pressures in itself, contributed to a deteriorating position as ambulance conveyance rates increased and delays in passing calls to primary care out of hours services pushed more admissions into the evenings.

On the ground, problems manifested themselves in emergency department crowding; long waits for patients on trolleys to be admitted; hospital patients not on the correct specialty wards; and ambulance queuing.

There is strong evidence that the symptoms felt in emergency departments led to worse patient outcomes. We know, for example, that patients run a 43 per cent increased risk of death after 10 days if they are admitted through a crowded accident and emergency (A&E) department. (Richardson DB, 2006) Waiting for admission in A&E is also associated with significantly longer hospital length of stay – on average 2.35 days longer where a patient stays in A&E for more than 12 hours. (Liew D, Kennedy M, 2003)

We know that speed of treatment is vital in many conditions. For example, people with the most severe form of pneumonia have less than a one in two chance of surviving. Those chances improve considerably if effective treatment is started early.  However, research suggests that delays of more than four hours in administration of antibiotics to patients coming into hospital with pneumonia can affect 70 per cent of patients on days when an A&E is crowded. (Pine JM et al, 2005)This undoubtedly affects mortality.

There are, of course, a host of reasons for the strain on the system. First, there are well-known demographic issues, with rising life expectancy; a growing population; life style issues (obesity, inactivity, alcohol); increasing inequality (with lower skilled people less likely to adopt healthy life styles); and difficulties matching funding to demand growth.

Second – and very important - the NHS is characterised by considerable, unwarranted, variation in its performance around the country. Examples of this include a four-fold variation in admission rates for people over 65 years old; considerable variation in hospital length of stay for patients under different consultants for the same conditions(Kings Fund); and a 10 per cent higher mortality rate at weekends compared with weekdays (Dr Foster). We also know that medical professionals can be slow to systematically adopt good practice, even where proven (for example, it took years before beta blockers were consistently prescribed for heart problems despite overwhelming evidence for their effectiveness).

Third, there have been big changes in acute care. While there has been a 11.8 per cent increase in emergency admissions over past 10 years, only 40 per cent of this increase is due to aging (Nuffield trust). The rate of hospital intervention is also growing much faster than the rate of ageing. There are various hypotheses for these phenomena, including improved medical technology and knowledge, allowing more conditions to be managed producing  a reduced threshold for admission; and there is increased risk aversion among (usually junior) doctors, compounded by less experienced junior doctors managing admissions.

Fourth, there is the aggregate impact of small (negative) affects.  NHS 111 has already been mentioned as causing a small but significant increase in pressure on A&E departments. Public confidence has been damaged by well publicised adverse incidents in out-of-hours primary care, making people more likely to turn to A&E when their doctor’s practice is closed. The Francis report and early Government statements may have undermined the centrality of ‘targets’ and in particular the 4-hour A&E standard.  Budgetary pressures have led to more robust gatekeeping by social care and continuing health care and contributed to difficulty discharging into community beds. The effect has been to increase length of stay in acute hospitals and add more pressure to already stretched acute services. In addition, the very cold spring, which followed a relatively mild winter, prolonged and worsened the performance dip that is typical during the last two quarters of any year.

It seems clear that the combined effect of long term trends, financial pressures, medical practice and many small stimuli has created a fragile system and may explain the decline in performance over winter and into spring. However, we are not helpless. The NHS has an array of tactical solutions that if delivered systematically will reduce variation and optimise performance. While not directly addressing longer terms pressures, these solutions can help restabilise systems and increase their resilience.

We know that tackling avoidable hospitalisation, focussing on home-based rather than bed-based solutions and improving patient flow along the pathway and particularly through hospitals all work. The emergency care intensive support team has encouraged acute hospitals to focus on improving patient flow as a key to sustainable delivery of national standards.

The principles for improving patient flow are clear, and we focus here on just a few. Of particular importance is daily senior review of all admitted patients. The benefits are considerable. In one study, twice weekly consultant ward rounds in two general medical wards were compared with twice daily ward rounds. Average length of stay on study wards fell from 10.4 to 5.3 days with no deterioration in other indicators (readmissions, mortality, bed occupancy). However, only 50 per cent of acute medical units (AMUs) have twice daily ward rounds, so there is considerable potential for improvement nationally.  The evidence suggests that mortality rates are improved where there is continuity of care on AMUs.  However, only 9 per cent of AMUs have consultants on-take in blocks of greater than 1 day (Royal College of Practitoners, 2012), suggesting that there is considerable scope to reduce mortality by adopting good practice guidance.

We also need to focus on discharge. A simulation study at Warwick medical school showed that consistently prioritising discharge activities can significantly reduce length of stay in elective or emergency clinical care pathways. In contrast, prioritising discharge activities only when beds are full has little impact on patient throughput or average length of stay. Paradoxically, increasing beds may actually increase length of stay with no overall benefit to patient throughput.

The principle of speedy, experienced medical assessment should also be applied in primary care. GP visits to fragile patients need to be brought forward into the morning so that that those who are referred to hospital can be assessed early, treated and potentially returned home.

Can potential admissions be turned around? Most studies suggest that inpatient admissions can be avoided in 20-30 per cent of frail people, aged over 75 years. “Avoiding admissions in this group of older people depended on high quality decision making around the time of admission, either by GPs or hospital doctors. Crucially it also depended on sufficient appropriate capacity in alternative community services (notably intermediate care) so that a person’s needs can be met outside hospital, so avoiding ‘defaulting’ into acute beds as the only solution to problems in the community”. (Mytton et al. British Journal of Healthcare Management 2012 Vol. 18 No 11).

To make a real impact, we need to focus on key groups: the frail elderly at home; terminally ill patients; people in nursing  and residential homes; and some specific groups with particular chronic conditions such as heart failure.

To sum up, current performance problems arise from multiple factors and constitute a ‘wicked problem’. But we are not helpless. We need to apply known good practice systematically. We also need to understand complex trends and the impact of small effects on complex systems in order to achieve sustainable improvement.