This last week has seen two stories that both help to show us the scale of the difficulties being faced by the A&E system throughout the country.
The first was the resignation of Dr Mark Newbold, a highly respected CEO from the Heart of England Hospital, and the second was the major incident declared at Colchester hospital
Both of these centred on the problems in meeting A&E waiting times.
A&E waiting times have enormous political significance, they are a recurrent theme in health questions and PMQs, they are taken as indicators of the performance of the health service. Because of this a considerable amount of pressure is placed on hospitals from further up in the system to meet these targets. As the General election approaches we might expect this pressure to increase.
This is actually quite surprising, given that one of the big themes of Andrew Lansley was that pressure to meet targets was a problem that should be avoided.
So when a hospital is failing to meet its waiting time targets what does it mean? - The immediate response of the media is generally that the hospital and hospital management bear responsibility for this. It is a problem to be fixed by the removal of a CEO or a manager or two – but is this right? Are we actually looking at something much more complex?
When people ask the right questions in cases of “failing” A&Es some of the following elements are common:
· Difficulties for patients in accessing GP appointment,
· Large numbers of elderly patients
· Seasonal variations,
· Major difficulty in recruiting Staff to A&E,
· Over reliance on agency staff leading to unstable teams.
· Bed shortages in the hospital,
· Difficulties in moving patients from A&E into hospital beds.
· Cuts in Community care funding
· Difficulties in discharging patients because of lack of community care,
What is interesting about Colchester is that the new interim CEO (What happened to the old one and why?) saw rapidly that they were not coping with the pressure and called in the CQC. This is perhaps progress in that it is now becoming possible, at least in certain circumstances, to say we are not coping and we need some support.
One of my favourite articles on the way hospitals approach A&E Targets is this http://gpaccess.uk/evidence/ae-has-a-mountain-to-climb/ which indicates that there may be a range of different approaches to managing A&E times. We need to understand why some hospitals may be coping with the pressures better.
The BBC Radio4 Today program on 17/11/14 had two slots on Colchester. The first talking to the MP Bob Russell. The second talking to a patient who had raised concerns about the attempts of hospital to send him home, the health correspondent, Hugh Pym, and Dr Cifford Mann from the college of emergency medicine.
The question that seemed to be exercising Bob Russell and John Humpries was should this be seen as a one off, perhaps due to management problems, or should it be seen as a systemic problem.
Hugh Pym and also Dr Clifford Mann were pretty clear in their response to this. A&E is under pressure throughout the country. Dr Mann points out that this is in part due to the Tariff system which does not cover the costs of emergency care, and now includes financial penalties to hospitals that fail to significantly cut hospital admissions
What I would like to see is the media, and especially important programs like Today, asking better questions. Whenever we get a crisis in A&E, and there will be many more, this needs to be seen not as a problem with an individual department in an individual hospital, but an indicator of what is happening within the health economy as a whole.
When the Mid Staffs public inquiry took place, I sat through nine months of evidence to try to understand why there were problems in A&E. The witness who finally made sense of all this for me towards the end of the Inquiry evidence was Dr Clifford Mann. Answering the big issues that DR Clifford Mann raised is still the focus of much of the work that is going on in Staffordshire to try to move towards better integration of services.
With Stafford it took around five years for anyone to really understand the importance of what emergency doctors were telling us. With Colchester, the BBC have interviewed Dr Clifford Mann less than an week after the declaration of a major incident. So well done BBC Today – That is Progress!