Causes and cures for the Accident and Emergency crisis: a data perspective

There have been a number of excellent pieces on Slugger recently regarding Northern Ireland’s A&E crisis. A lot of suggestions have been put forward for how to tackle the crisis, and a lot of reasons have been put forward for why performance, in particular against the four hour waiting time target, has deteriorated in recent years. I have been sourcing data to see how some of these ideas stack up.

Too many bureaucrats and not enough doctors

It has been posited that Northern Ireland employs too many administrators and managers in its health service, and not enough clinical staff. Last September, the Belfast Telegraph reported that Northern Ireland has 42% more non-clerical staff than England, compared to its population. In fact, when the number of administrators and managers are compared in Northern Ireland are compared with numbers in Great Britain, the picture is even more striking.  Compared to England, Northern Ireland has over double the number administrative staff when compared to the numbers of staff in the workforce.

Admin Staff v2

The Appleby report of 2011 made it clear that Northern Ireland faces huge challenges in terms of both costs and productivity in the Health sector. The bloated state of the administrative side of the Health service is surely a symptom of this.  It is also interesting that Northern Ireland has added over 500 administrative FTE positions between 2011 and 2014.

A&E units have been deluged by an increase in demand

Much of the feedback from medical experts has focused on the fact that demand in A&E units has rocketed. Belfast is the area where performance against the four hour target has deteriorated the most since 2008, and this is the area where it is claimed demand has increased the most, in particular demand at the Royal Victoria Hospital. When viewed in isolation, it is undoubtedly true that the A&E at the RVH is a lot busier than it was four years ago. However, eagle-eyed readers may be able to infer what the reason behind this spike in demand might be.

Belfast A&E Units Avg Daily Cases

The coloured lines showing demand at individual hospitals use the axis on the left, showing average daily cases by month. The dashed lines, using the axis on the right, show average performance for Belfast-area hospitals and the 95% target. I have included the Ulster, even though it is not in the Belfast HSC Trust Area, due to the fact that it is in the Belfast area and has taken some of the excess demand caused by the closure of the Belfast City Hospital A&E in 2011.

Performance has varied seasonally, with waiting times at their worst in the winter and at their best in the summer.  Performance decreased steadily until 2011, and has flatlined since then.

Whilst demand at the Ulster, and in particular the Royal, have increased markedly since the BCH unit closed, city-wide demand has stayed flat, as can be seen in the chart below.

Belfast Total A&E Cases

Contrary to the belief that demand for A&E services spike in December, for the last three years demand has actually been lowest in December.  In the last five years, the quietest months in A&E units in Belfast have been December 2011, December 2012, and December 2013.

In any case, any perceived increase in A&E cases is caused by only looking at one individual hospital, and not at system-wide demand. And, whatever is causing the seasonal jump in waiting times, increased demand in winter is not the reason.

However, there may be one innovation that may help balance demand between Belfast A&E units. In July 2012, Gloucestershire Hospitals brought in a live online A&E waiting time system. Such a system could conceivably help shift demand between hospitals when one is under extreme pressure, and would help patients make informed choices about whether they should attend A&E, and which unit to go to.

A&E charges would reduce demand

Health Minister Edwin Poots has said that he is open to the idea of charging for A&E use. The idea of charging for A&E use has come under some criticism from some commentators, who maintain that “free at the point of use” is a core tenet of the NHS system that should be maintained at all costs.

In the Republic of Ireland, those without medical cards (68% of the population) must pay €100 to use A&E facilities. Prior to March 1994 patients who used arrived at A&E, having been referred by a GP, had to pay the charge to use the A&E (then IR£6) in addition to the IR£10-£20 GP’s fee, creating an incentive to go straight to A&E rather than to be referred by a GP.  This 1997 paper from the Journal of Family Practice shows what happened when this perverse incentive was removed; cases of non-medical card holders going straight to A&E decreased by 1.32%. This must be taken in the context of 5% annualized growth in demand for A&E services overall, a figure higher than the increase in demand in Northern Ireland today. The same paper quotes a California study that shows that demand for A&E services decreases by 15% when charges are introduced.

As powerfully put by Dr George O’Neill, the health system in Northern Ireland faces a crunch. The situation is extremely complex, but very serious questions about the state of the Health system need to be asked. Do we really need five health trusts in Northern Ireland? Should there be fewer administrators and more clinical staff? How can technology be used to help patients make more informed choices? And, most of important of all, should the sacred shibboleth of “free at the point of use” be replaced by a more pragmatic discussion in the context of an ageing society with ever more complex healthcare needs?

, ,

  • jimjam

    A lot of good stuff here, but unfortunately the productivity issue was
    lost sight of to some extent. There are just far too many clerical and admin
    staff. (Just look around you next time you are in a hospital) It beggars belief
    that admin posts have actually increased since Appleby. If their numbers
    were reduced it would be possible to recruit more doctors, nurses etc.
    Organisational change such as reducing the number of trusts is not the answer –
    a few very senior admin posts may disappear, but the bulk of the overmanning
    will remain. Also introducing charges may have to be considered at some stage,
    but that is demand management – which should not get in the way of attempts to
    improve productivity.

  • hugh mccloy

    Why have you left out RBHSC and the other Belfast urban hospital Antrim ? Postocde attendances show it is used by Belfast residents.

    Again some good stats but still not the full show going on here, take McBrides statement that there was 1,800 more attendances over a 15 day period across A&E’s, this is rough and only averages as full data is not released but it works out at:

    Using the type 1 A&E’s only, – 1800/15 = 120 extra patients a day over 10 type 1 A&E’s = on average 12 extra patients a day collapsed the system,

    Or Take into account the two type 2 A&E units, that will bring the average to an extra 10 per day.

    Was he taking into account the type 3 units as well, in that case thats 19 units in total bringing the average down to extra patients per day.

    Is our emergency care network so fragile that it cannot deal with one of the above scenarios??

    And McBrides statement does not state the true problem he which is admission to the wards via A&E because that is what is blocking the system. People with minor injuries in a major unit will flow through albeit slowly, they are not the problem on any level. I sat in countless board meetings where the blame has never been on actual attendances the fault is in failure in the ability to admit patients from A&E.

    Do we have too much clerical staff? we already had RPA and CSR which nipped some admin and we already seen Dr O Neill support TYC which has already created 17 new boards that will all need administered.

    People need to know that Dr O Neill is yes a doctor of many incomes including DLA appeal panels, he is well feathered and is a supporter of TYC which is 99 recommendations but no actual answers

    2014 data is jan to june and it looks like its going to be a big one as well

  • Andrew Dunlop

    Random idea: how about instead of patents getting charged for A&E attendance you charge doctors if their patents present at A&E with something minor or inappropriate. That would encourage GPs to educate patents, make getting appointments easier and make out of hours care easier to use. Obviously this would have to coincide with increased funding to GPs to help with the provision of increased services.

  • salmonofdata

    On Antrim, had to draw the line somewhere, and I don’t have access to postcode data. The Children’s Hospital has a differerent clientele to the other EDs, so I left it out to avoid cluttering the chart.

  • Sharpie

    Productivity is an interesting place to start the conversation. Throughout the Health Service there are professional jealousies and fiefdoms that prevent new working practices being generated and implemented. These are largely driven by the medical staff themselves and in general split into the specialism that they work in.

    On a personal experience level staff further down the chain are amazing but the status crap you bump into as you move up the levels is startling. The whole edifice is extremely top down. Perhaps the fraughtness of relationships is due to pressures sent down from the finance people and the data measuring people.

    The other thing is that the health system doesn’t seem to learn or have a learning culture. Individual consultants do experiment, but there seems to be little opportunity to sit and examine what is or isn’t working with regards to how to improve the service itself. Each discipline is a specialism on its own but if it were to compare notes with other parts of the system it would quickly find improved models of delivering health care.

    This may be hard to achieve because everyone is fire fighting with no space to stand back and see the big picture.