Hit or miss: Lessons from the best and worst A&E performers

NHS England has failed to meet the target of seeing 95 per cent of people who attend accident and emergency departments within four hours in 2014-15. Yet within this overall picture there are some health economies that have excelled and others that have struggled.

‘Some health economies have excelled and others have struggled’

Why do some trusts find it so hard to treat, discharge or admit patients within four hours while others do not? And are there opportunities to share some of the successes?

HSJ spoke to three trusts that were within the top of the league table for performance against the 95 per cent standard over the last year and three that were towards the bottom.

Broadly, they have faced the same challenge of increasing non-elective admissions but many see growing patient acuity - the intensity of care they require - as more of an issue than the numbers. And finding beds for those patients represents an additional challenge.

• Winter A&E analysis: More ambulance queues and cancelled operations
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• Emergency care summit: Sustainability remains A&E’s biggest issue

Peak performance

So what can be learnt from high performing trusts?

Ipswich Hospital Trust has been a strong performer over the last year, achieving 96.6 per cent (fifth best, measured to the end of January), despite an 11 per cent increase in non-elective admissions.

Chief executive Nick Hulme highlights an innovative trigger tool that warns senior staff of looming problems earlier on.

While many warning systems only give a few minutes’ notice when patients are likely to breach the four hour target, the trust has developed a methodology that gives three hours’ warning based on factors such as acuity and intensive therapy unit bed numbers. This gives the trust time to take action such as calling in extra staff and speeding up discharges.

‘Surges in A&E activity will be responded to across the organisation’

Ipswich is also willing to share this tool with other organisations.

Another important factor Mr Hulme identifies is that A&E performance is seen as a “whole trust” issue, rather than one that sits solely within the emergency department. Surges in A&E activity will be responded to across the organisation. And patients in medical wards will be graded as green or red each day according to whether anything has been done to speed their discharge.

However, the message to staff is do not hit the four hour target at all costs.

“The one question that executives are allowed to ask in A&E is: ‘Who is the sickest patient and are they safe?’,” says Mr Hulme. This concentration on safety and quality resonates with clinicians.

The trust has also put on extra beds over the winter period to cope with the rise in admissions - A&E attendance has been broadly stable but admissions have soared - but has also managed to reduce length of stay by managing patients better. Ironically, this has meant that, although the trust is admitting more patients, it has been paid marginally less money for them.

Children’s story

Some of the trusts with high performance against the four hour target are specialist children’s trusts.

Sally Gibbs, the clinical lead for the emergency department at Sheffield Children’s Foundation Trust (joint best performer at 97.9 per cent), says this may be because children are less likely to have comorbidities than the average A&E patient. In addition, their parents provide a readymade home care package.

But that does not mean children’s hospitals are immune to some of the pressures of the wider system.

“Our numbers in December were unprecedented,” says Dr Gibbs. “We had days when we fell below the four hour standard. The trust is good at managing its bed base, which is quite small compared with most acute trusts, but even so there were days when it was hard to find beds for children who needed to be admitted.

‘Approaching A&E as a hospital wide challenge rather than an isolated department may be important’

To help cope with demand, the trust has put on extra consultant led ward rounds at the weekend, extra nursing staff and kept open a short stay unit, where it can observe children who may not need admission but do need observation for more than four hours. Senior consultant presence in the emergency department has been enhanced from 8am to midnight.

When the department was under pressure in December, the issue - in contrast with many other acute trusts - was the numbers coming through the door, rather than the complexity of cases. Many children had respiratory issues that did not lead to hospital admission.

The trust has been using additional doctors with primary care experience to deal with these patients - many of which had worked in the hospital as junior doctors but then moved into primary care. This relieved pressure on other staff and is a measure that will be considered in the future.

Exit strategy

Epsom and St Helier University Hospitals Trust has been a high performer for most of last year, achieving 95.7 per cent, despite an 11 per cent increase in attendances in December and a slide in performance in January and February.

Chief operating officer Jackie Sullivan says the trust sought the input of the national emergency support team just more than a year ago to establish best practice. As a result of the advice, the decision was taken to treat a far greater proportion of patients through an ambulatory care approach that treated and discharged them quickly.

Having consultants on the “front door” has made a difference because patients are swiftly directed into appropriate pathways. Therapy hours have been extended to assist with patients who have had falls and need help to “get back on their feet” but do not need admission. Extra beds and a specialist registrar have been used to cope with paediatric cases.

‘University Hospitals of Leicester Trust has set up a “gold command” process with high level meetings four times a day’

Discharges at the weekend are being facilitated by dedicated specialist registrars. In the wider health economy there has been work to make discharge easier, such as night sitters and “step down” care, and delayed discharges at St Helier, which had crept up to 30 in November, have been reduced to 15-20. GP out of hours cover at St Helier has been extended.

But while these steps have enabled the trust to deliver good performance in the last year, Ms Sullivan is clear that it cannot rest on its laurels and that more changes may be needed if demand continues to increase.

“This year it has been relentless,” she says. “The staff have been incredible but have got really tired.”

Ms Sullivan believes the key to further improvement is reducing variability, so that patients seen at the weekend get the same service - in and out of hospital - as during the week. At the moment, for example, patients who need a complex home care package are less likely to be discharged at the weekend.

Winter pressures

In trusts that are struggling some of these issues are not significantly different. But sometimes there are additional issues.

Two poor performers - London North West Healthcare Trust and University Hospitals of North Midlands Trust - are the product of recent mergers.

Neither has existed for a full year, and their performance figures only cover autumn and winter, during which “winter pressures” were prevalent, so they may be misleading. Nonetheless, at 68.4 per cent (London North West) and 66.7 per cent (North Midlands) of A&E patients seen within four hours, their performance is well below target.

London North West has experienced a considerable increase in admissions - 8 per cent over the last year - but analysis has shown it is 103 acute beds short of those needed for its population.

‘Planning for next winter starts this month’

The problem is largely at its Northwick Park site - the smaller A&E at Ealing Hospital is performing better. The trust has approved a business case to build 63 additional beds in a new ward block close to the A&E department.

Tina Benson, director of operations, says the trust has a good idea of where the problems lie and has been trying to improve bed availability by ensuring patients are seen every day by a senior decision maker. More consultants have been put into A&E, and medical and surgical areas.

The trust has also looked at speeding up pathways for those A&E patients who are not going to need admission.

Extra beds in the community are being used for patients who need a short rehabilitation package, and the trust has managed to increase its bed base by taking steps such as remodelling some areas, which added 56 beds for the winter.

It is also very clear about the needs of patients who are discharged but need community support.

To prepare for next winter, the trust is working with partners on changes to community pathways to try to stop admissions in the first place - this could involve more pre-emptive visits to people at risk of admission.

Ms Benson says modelling suggests that this, together with the additional beds, should allow it to meet the four hour target next winter. However, this is against a backdrop of increasing demand, which could mean even more beds are needed.

Viral infections

At the newly formed University Hospitals of North Midlands Trust, pressures have been intensified by a severe outbreak of flu - at one point 96 beds were occupied by patients with the virus. Many were elderly and the average length of stay was long.

The trust was also hit by a virulent strain of norovirus. This put considerable pressure on the A&E departments - the trust had 444 12 hour trolley waits in January alone - reflecting the difficulties in getting patients into beds. The trust has responded by:

• increasing the beds available both in the acute sector and in other settings;
• calling on charity St John Ambulance to help with patients waiting in A&E; and
• bringing in staff from other areas within the trust to help manage patients in A&E - for example, by coming into the unit to review their condition.

In contrast with the main A&E department at the Royal Stoke University Hospital, the emergency unit at the County Hospital in Stafford has, however, performed well and recently achieved the 95 per cent target.

‘We can just fall off a cliff because of the high volume’

Helen Lingham, chief operating officer, says the tough winter has led to improved working within the local health and social care system. Partners have said no organisation will take out capacity without collective agreement (37 beds in a community hospital were closed in September because of staff shortages) and next winter’s needs will be modelled across the system.

“Planning for next winter starts this month,” she says. However, she adds that certainty about funding would enable new services to be planned and embedded, and staff recruited, before winter starts.

Speaking volumes

Leicester is one of the health economies that has struggled over a considerable time. A report commissioned last year examined the urgent and emergency care system in detail. The emergency department at the Leicester Royal Infirmary - the busiest single unit in the country - covers a population of 1.4 million. Over the last 12 months admissions have risen by 12 per cent.

Richard Mitchell, chief operating officer at University Hospitals of Leicester Trust, says: “We can just fall off a cliff because of the high volume.”

Fifty-five people in the department is the tipping point, he says, when patients become four times more likely to wait more than four hours.

Admission avoidance and the ability to discharge patients to appropriate care are essential to improving performance, but neither are wholly within the trust’s control.

Relationships with other parts of the health economy have improved recently and there has been progress on this. The trust has set up consultant led phone services for GPs, which operate until 10pm and allow them to discuss management options for patients, rather than sending them into hospital.

‘Ability to discharge patients to appropriate care are essential to improving performance’

However, much of Mr Mitchell’s work has focused on improving processes within the trust’s hospitals. It has been able to reduce its length of stay by 7 per cent, which has, in part, compensated for the increased admissions.

It has set up a “gold command” process with high level meetings four times a day to discuss and respond to developing pressures before they become acute. There is increased “inreach” into the A&E department from other clinicians who help move patients swiftly through the system.

And ward rounds have been improved to ensure decisions are taken on discharge as early as possible. There have been significant steps towards seven day working to prevent patients staying in the hospital over the weekend while they wait for tests or treatments.

The question is whether patients experience the differences. Many of the changes do not affect A&E performance overnight but there has been improvement.

Noticeably, after Christmas the trust suddenly started to treat more than 90 per cent of patients within four hours and in some weeks it has topped 95 per cent - a considerable improvement.

There is a new sense of energy among staff, reports Mr Mitchell. He adds that this improvement needs to be embedded and made sustainable, and work needs to continue on areas such as discharge.

But he warns that simply improving the trust’s internal processes may not be enough to deliver further sustainable improvements - some easy wins have been achieved and it cannot continue to absorb 12 per cent year on year increases in admissions. That additional work is likely to need the buy-in of the whole health economy.

Out of control

There are consistent factors in success and failure - but they may not be factors under the control of individual organisations.

Historic joint working with other parts of the health and social care system can help boost performance - but almost every trust is trying to ensure that joint working is improved year on year and that planning to meet surges in demand is system wide.

Approaching A&E as a hospital-wide challenge rather than an isolated department may be important, but most trusts are doing that. And a bad outbreak of flu and norovirus - which will stretch both acute and community services - could drive many trusts off course.

In a year’s time there is no guarantee the top and bottom trusts in HSJ’s analysis of winter performance will be in the same position.