Tired of Waiting
Camilla Cavendish writing in The Sunday Times made a radical suggestion on waiting times which is to abolish them for Accident and Emergency services, at least in terms of the large numbers of people who turn up for emergency treatment without a valid reason - 40% or so according to official figures.
Now that seems like an interesting ideas to me and I've heard many a doctor claims that arbitrary targets in the NHS can make things worse not better, and this may be a case in point given the big increase in A&E patient numbers in recent years.
So if doctors and nurses determined who to treat on the basis of clinical need, which they do already to some extent of course, then a wait longer than 4 hours would not be regarded as a terrible failure on the part of the NHS or individual hospital (which it is now), but the result of some people making ill-informed choices about their need for treatment and/or the best place to obtain such treatment.
Because why should hard-pressed NHS staff break their backs to treat people who have no proper reason to be in A&E in the first place?
Making the grazed knees and twisted ankles wait longer will help heal A&E
By Camilla Cavendish - The Sunday Times
Shortly before the crunch came, I met some junior doctors who work at a London A&E. These young students are exactly what you would hope: intelligent, dedicated, articulate, idealistic. They were also exhausted. A&E has long been one of the most gruelling places to work in the NHS. It is both exhilarating and slightly thankless, because you rarely see what happens to your patients. Now — as we know from the number of hospitals overwhelmed by demand — A&E has become a victim of its own success.
These young medics and their colleagues are working miracles. They are seeing 20,000 more people a week than a year ago. It is tough and there is too little time with overstretched supervisors, which may discourage many of them from eventually choosing an A&E career. But what really seemed to frustrate them was having to deal with people who are neither an accident nor an emergency. The official figures suggest that about 40% of visitors to A&E don’t need to be there. But one of the young doctors says it is 50%. Too many people, she said delicately, are “uneducated”. Or drunk.
Yet A&E is a totally logical choice. In a bewildering landscape of walk-in centres, urgent care centres and minor injuries units, with GP appointments fading and a 111 hotline that seems to be run by algorithms rather than trained nurses, people naturally seek refuge at the big red and white sign that symbolises some of the best care in the world. And that runs 24/7, when the rest of the NHS mostly runs five days a week. People can pop to A&E in the early hours with a poorly child and still get to work in the morning.
Canute-like attempts to turn the tide, by admonishing time-wasters, have failed. So here is my first suggestion to help doctors at the front line: abolish the four-hour waiting time target. While this has been useful in goading hospitals to be more efficient, it is far more demanding than in most other countries and has become a perverse incentive. Abolish the target and triage nurses could get back to prioritising by clinical need, not at the behest of some frantic manager with a clipboard. The young walking wounded, the “uneducated”, would find themselves waiting for such a long time that they might just start to behave differently.
That is, after all, how it used to be. Fifteen years ago I played tennis on a Saturday afternoon with a friend who twisted her ankle badly. A very nice A&E nurse told us we could either wait eight hours or go home, use an ice pack, and return if it got worse. We went home and never needed to go back. Today, that nurse would have waited three hours and 59 minutes, then admitted us to another part of the hospital to take up the time of a whole new bunch of staff.
Convenience is not the only reason A&Es are overwhelmed but it is striking that visits to A&E have grown exponentially since 2003-4, having barely budged for the previous 15 years. In 2003-4 itself, visits jumped by nearly 18% — partly because of a change in the way data was collected. But two important policy changes were also made. The Labour government required all hospitals to treat, admit or discharge at least 98% of patients in less than four hours. It also rewrote the GP contract, allowing GPs to opt out of providing out-of-hours care in return for a small salary decrease.
These changes simultaneously eroded reliance on the family doctor and made it increasingly attractive to attend A&E. Couple that with the influx of older, frailer patients, some of them being kept alive with statins, immuno-suppressant therapy and other techniques we did not have 15 years ago, and you have a perfect storm.
Elderly people who used to arrive with flu are now coming in with complex fractures, having had a fall. Many cannot go back to their homes alone afterwards; they need carers or to go into a nursing home, which local authority cuts have made far harder to find. Some hospitals are warehousing patients for more than 40 days because there is nowhere else for them to go.
For 10 years the mantra has been that patients should be looked after “in the community”, not in hospital. Hospital beds were closed in anticipation of swathes of people monitoring their own blood pressure at home, visited by jolly district nurses. But save for a few heroic examples — Airedale in Yorkshire has slashed A&E visits by giving elderly patients an iPad to communicate with hospital nurses — most people have no idea what “community” means. If you can’t get a GP appointment without having to redial for two days, “community” can sound cut-price and unreliable.
While we wait for more places to follow Airedale’s example, it might be better to start from where the patients are: at A&E. At the Royal Free Hospital in north London, GPs are stitching minor injuries, doing blood tests and x-rays and sobering up confused people before they reach A&E. Zealously, like old-style missionaries, they sign up the many eastern Europeans and under-35s who have never registered with a GP.
This kind of integration, I would suggest, must be the future. But privately, GPs and hospital doctors are often at loggerheads. It took the Royal Free GPs quite a while to convince the hospital consultants to let them in. The financial incentives of the NHS set GPs and hospital doctors against each other. They penalise popular A&Es by paying only 30% of the real cost when the number of patients exceeds a certain level. They even make it financially prohibitive for a hospital to build its own nursing home — as the innovative Queen Elizabeth Hospital in Birmingham recently discovered.
The system is riddled with perverse incentives that urgently need to be changed. It is also riddled with politics, which makes it hard to change anything. If the government dropped the four-hour waiting target, for example, Labour would no doubt call this the end of the NHS as we know it.
The shock withdrawal by Circle Holdings, a private firm, from running the NHS Hinchingbrooke Hospital in Huntingdon, Cambridgeshire, has only made the atmosphere more toxic. In advance of a damning report by the Care Quality Commission, the hospital regulator (on whose board I sit), and citing A&E pressures, the company announced on Friday that it would hand back the contract to run the hospital.
It always seemed to me that Circle was taking a hugely audacious gamble in taking on an indebted hospital on a contract that was almost certain never to pay off. But instead of a grown-up look at what lessons might be learnt from the experiment, Labour has now instigated an artificial row over who tendered the contract; when everyone knows that the private companies were shortlisted by Labour and the Circle contract was signed by the coalition.
The blame game is pointless. Instead of blaming patients, we should change their incentives. Instead of blaming GPs, we should put them into hospitals. Let good hospitals run community services. Along the way, let’s put up some statues to our heroic A&E doctors, before even more go to Australia.
camilla.cavendish@sunday-times.co.uk
Shortly before the crunch came, I met some junior doctors who work at a London A&E. These young students are exactly what you would hope: intelligent, dedicated, articulate, idealistic. They were also exhausted. A&E has long been one of the most gruelling places to work in the NHS. It is both exhilarating and slightly thankless, because you rarely see what happens to your patients. Now — as we know from the number of hospitals overwhelmed by demand — A&E has become a victim of its own success.
These young medics and their colleagues are working miracles. They are seeing 20,000 more people a week than a year ago. It is tough and there is too little time with overstretched supervisors, which may discourage many of them from eventually choosing an A&E career. But what really seemed to frustrate them was having to deal with people who are neither an accident nor an emergency. The official figures suggest that about 40% of visitors to A&E don’t need to be there. But one of the young doctors says it is 50%. Too many people, she said delicately, are “uneducated”. Or drunk.
Yet A&E is a totally logical choice. In a bewildering landscape of walk-in centres, urgent care centres and minor injuries units, with GP appointments fading and a 111 hotline that seems to be run by algorithms rather than trained nurses, people naturally seek refuge at the big red and white sign that symbolises some of the best care in the world. And that runs 24/7, when the rest of the NHS mostly runs five days a week. People can pop to A&E in the early hours with a poorly child and still get to work in the morning.
Canute-like attempts to turn the tide, by admonishing time-wasters, have failed. So here is my first suggestion to help doctors at the front line: abolish the four-hour waiting time target. While this has been useful in goading hospitals to be more efficient, it is far more demanding than in most other countries and has become a perverse incentive. Abolish the target and triage nurses could get back to prioritising by clinical need, not at the behest of some frantic manager with a clipboard. The young walking wounded, the “uneducated”, would find themselves waiting for such a long time that they might just start to behave differently.
That is, after all, how it used to be. Fifteen years ago I played tennis on a Saturday afternoon with a friend who twisted her ankle badly. A very nice A&E nurse told us we could either wait eight hours or go home, use an ice pack, and return if it got worse. We went home and never needed to go back. Today, that nurse would have waited three hours and 59 minutes, then admitted us to another part of the hospital to take up the time of a whole new bunch of staff.
Convenience is not the only reason A&Es are overwhelmed but it is striking that visits to A&E have grown exponentially since 2003-4, having barely budged for the previous 15 years. In 2003-4 itself, visits jumped by nearly 18% — partly because of a change in the way data was collected. But two important policy changes were also made. The Labour government required all hospitals to treat, admit or discharge at least 98% of patients in less than four hours. It also rewrote the GP contract, allowing GPs to opt out of providing out-of-hours care in return for a small salary decrease.
These changes simultaneously eroded reliance on the family doctor and made it increasingly attractive to attend A&E. Couple that with the influx of older, frailer patients, some of them being kept alive with statins, immuno-suppressant therapy and other techniques we did not have 15 years ago, and you have a perfect storm.
Elderly people who used to arrive with flu are now coming in with complex fractures, having had a fall. Many cannot go back to their homes alone afterwards; they need carers or to go into a nursing home, which local authority cuts have made far harder to find. Some hospitals are warehousing patients for more than 40 days because there is nowhere else for them to go.
For 10 years the mantra has been that patients should be looked after “in the community”, not in hospital. Hospital beds were closed in anticipation of swathes of people monitoring their own blood pressure at home, visited by jolly district nurses. But save for a few heroic examples — Airedale in Yorkshire has slashed A&E visits by giving elderly patients an iPad to communicate with hospital nurses — most people have no idea what “community” means. If you can’t get a GP appointment without having to redial for two days, “community” can sound cut-price and unreliable.
While we wait for more places to follow Airedale’s example, it might be better to start from where the patients are: at A&E. At the Royal Free Hospital in north London, GPs are stitching minor injuries, doing blood tests and x-rays and sobering up confused people before they reach A&E. Zealously, like old-style missionaries, they sign up the many eastern Europeans and under-35s who have never registered with a GP.
This kind of integration, I would suggest, must be the future. But privately, GPs and hospital doctors are often at loggerheads. It took the Royal Free GPs quite a while to convince the hospital consultants to let them in. The financial incentives of the NHS set GPs and hospital doctors against each other. They penalise popular A&Es by paying only 30% of the real cost when the number of patients exceeds a certain level. They even make it financially prohibitive for a hospital to build its own nursing home — as the innovative Queen Elizabeth Hospital in Birmingham recently discovered.
The system is riddled with perverse incentives that urgently need to be changed. It is also riddled with politics, which makes it hard to change anything. If the government dropped the four-hour waiting target, for example, Labour would no doubt call this the end of the NHS as we know it.
The shock withdrawal by Circle Holdings, a private firm, from running the NHS Hinchingbrooke Hospital in Huntingdon, Cambridgeshire, has only made the atmosphere more toxic. In advance of a damning report by the Care Quality Commission, the hospital regulator (on whose board I sit), and citing A&E pressures, the company announced on Friday that it would hand back the contract to run the hospital.
It always seemed to me that Circle was taking a hugely audacious gamble in taking on an indebted hospital on a contract that was almost certain never to pay off. But instead of a grown-up look at what lessons might be learnt from the experiment, Labour has now instigated an artificial row over who tendered the contract; when everyone knows that the private companies were shortlisted by Labour and the Circle contract was signed by the coalition.
The blame game is pointless. Instead of blaming patients, we should change their incentives. Instead of blaming GPs, we should put them into hospitals. Let good hospitals run community services. Along the way, let’s put up some statues to our heroic A&E doctors, before even more go to Australia.
camilla.cavendish@sunday-times.co.uk
