What’s driving A&E 4 hour performance? Its probably not the A&E department!

4 hour breaches and beds

Here at VVSS Online we think its important to start with looking at the facts, and taking the mythology and folklore out of the planning and decision making process for A&E. In this blog we have prepared some visualisations showing the correlation (or not) between 4 hour performance and a number of other variables at a national level. You can look at your local picture by clicking on the charts and accessing our free interactive tools.

Firstly its important to pre-warn readers that being able to show that two variables are correlated does not infer causation. While A and B may appear to follow the same pattern, this no more proves that A causes B than it does that B causes A nor indeed that both A and B don’t have a common cause, C.

That said however, correlation of variables should give us something of a smoking gun or, at the very least help us reject causes that clearly have no correlation whatsoever.

We’ll start with the issue of the number of people visiting A&E. Much is quite rightly made of the crisis in relation to the number of GPs in the UK meaning more people choosing A&E as their first point of access to healthcare.

In its publication ‘The State of Medical Education and Practice in the UK’ available here, the GMC said…

between 2012 and 2017 our data tell us there has been a 3% increase in the number of doctors on the GP register – below the 4% increase in the overall UK population in that period. This is significantly below the increase in people aged 65 years and over… which ranged from 11.4% and 13.2% (across UK countries)’.

So how has this affected A&E demand? The chart below shows the monthly trend between April 2014 and December 2017 in the number of arrivals at A&E departments (blue) and the 4 hour wait breach rate % (orange).

A&E activity v breach rate

The data is taken from NHS England’s monthly A&E dataset available here, with the volatility in the A&E activity in the early months being due to historic weekly rather than monthly reporting meaning there are some 4 week and 5 week months. The chart is part of our VVSS Online service, some free insights from which are available by clicking the chart to access our Public area.

While we see a general increase in monthly A&E attendances of around 10% over the 4 year period, which resonates with the GMC data on increases in the older population, it’s clear that 4 hour performance is not explained by patterns of attendances alone. It instead shows a seasonal pattern of winter pressure.

Next given the seasonality clue and annual flu cycle we look at the admission rate via A&E to see how this compares to the 4 hour breach rate.

A&E admission rate v breach rate

The two lines are very similar, the rate of emergency admissions via A&E and the breach rate are closely aligned. Although we can see that while successive winters show a rise in the 4 hour A&E breach rate, admission rates at these seasonal peaks are actually falling so its not the whole answer. Seasonality is clearly a contributing factor and this chart may well be quantifying how the winter flu epidemics drive the 4 hour performance of A&E.

Admissions require beds so the analysis above therefore points at bed availability. Again however, this is a national average and our experience tells us that localised conditions in individual A&E departments may vary significantly.

In our final chart then we look at the relationship between the number of available beds and 4 hour breaches. Availability of beds affects the flow out of A&E and as patients awaiting admission typically require a greater level of care and monitoring than patients with a less serious ailment we’d expect bed availability to affect both admitted and not-admitted patients.

We’ve used out VVSS Online tools to compare two different datasets, A&E performance and admissions available from NHS England here and overnight general and acute bed availability and occupancy, also published by NHS England and available here.

4 hour breaches and beds

Here we have to acknowledge that the data isn’t as perfect as we’d like it to be. Firstly the bed availability data is presented as a quarterly daily average and published quarterly, whereas the A&E data is issued as monthly totals. So we’ve had to make some assumptions to stitch the data together and make sense of it.

That aside we think the chart is however quite persuasive in demonstrating a link between bed availability and 4 hour A&E performance. The chart presents the national picture for England, but you can interact with the chart to understand how this comparison looks for your local hospital here.

Our significant experience working in A&E across the country has shown us that there are clearly some departments who have constraints in terms of size and resource in their A&E departments. However, there are many more who appear constrained and are under performing because they cannot move patients from the department.

So what’s the answer?

Access to more beds, critically at the right times of day, would be a significant driver of improvement for many trusts. Of course this would take money, nurses and doctors which are already constrained and require a lengthy lead time to manifest.

However, as we clearly demonstrate in our DTOC blog here, the local picture regarding who is responsible for the delay of patients shows that there is still a lot trusts can do to free up capacity without the need for additional resource. The best practice models around delivering social care assessments and therapies at home instead of in hospital are hugely impactful, but many trusts are slow to adopt them due to current legacy ways of working.

At the local level the solutions required will depend entirely on the root cause of the failure to perform and this root cause could reside in many other areas than the actual A&E department. Only when you can see the whole picture can you deliver the right interventions.

Our VVSS Online analysis tools allow the charts in this blog to be recreated at a local level. They also allow a wide range of separately published variables to be combined and compared so a broad system wide understanding of local issues can be evidenced and the true drivers of performance understood so local solutions addressing local issues can be developed. Our free insight tools are available here.