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.

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.

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.

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?