Brainstorming session: How to win the A&E battle

What would happen if you took 48 of the brightest brains from Europe’s top business schools, locked them up in a tower for a day and asked them to solve the “wicked” problem of the NHS’s overstretched emergency departments?

This was the scenario played out at Warwick Business School’s London base at the Shard one weekend in April.

Eight teams of six from business schools in the UK, Spain, Italy and the Netherlands took on the 2015 WBS case challenge, competing for a £4,200 prize.

Armed with a thorough briefing (with 235 references) about the way emergency departments function across Europe and the challenges facing them generally and in England specifically, the teams arrived ready to face the first challenge of the day.

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The exercise

The teams were to imagine that a philanthropist had donated £36m to a healthcare body in England, topping up an existing £9m funding pot set aside to build a brand new A&E unit – a pilot for the future of emergency care in England. The teams were to design the new centre and would be judged on their understanding, insight, innovation and creativity.

All the teams were international in their membership and included at least three Masters students. There was a vast range of industry backgrounds, as well as experience and knowledge of healthcare systems across the world.

As Mark Ebbens, senior partner for sponsors GE Healthcare Finnamore and one of the judges, pointed out, they were about to find out the unique challenges of redesigning health services.

“The challenges in healthcare are, more than in any other business, big and intractable,” he said. “But that is why inspiring our best young leaders to tackle them is so important.”

The event was intended as an innovative evolution of the Emerging Leaders Competition, which has been run by GE Healthcare Finnamore in partnership with the HSJ for the last three years, as a way of identifying and supporting future healthcare leaders.

‘Inspiring our best young leaders to tackle healthcare challenges is important’

The teams had four and a half hours, drawing on their background research and reading, the internet, and access to a group of experts, including healthcare management consultants, an A&E consultant, an A&E manager and a head of clinical informatics.

What did they ask?

Questions to the experts quickly began to highlight how most teams saw IT and apps as a key part of their solution. While certainly A&Es could benefit from better analytics, the experts also cautioned against smartphones as the total solution.

“They are very hung up on apps,” commented Chetan Trivedy, an A&E consultant and lecturer at Warwick Medical School. “I did point out that our patients are often elderly and confused and may not even speak English.

What are they proposing to do about the 83-year-old Bangladeshi woman if their only solution is an app on a smartphone?”

‘They see apps as the answer’

Veronica Devlin, consulting manager at GE Healthcare Finnamore with 20 years experience as an A&E doctor, added: “They are asking about the productivity of doctors and the primary care interface but they see apps as the answer.”

Questions to Esther Silva, emergency department manager at Harrogate and District Foundation Trust, showed some were thinking more widely, particularly around project implementation. One group asked who needed to be on a project team and how important nurses were.

Ms Silva carefully explained how any project in the NHS must engage early with clinicians or face failure. “They are the experts in their field,” she said. “If you go in telling them ‘this is what we are going to do’, they will disengage.”

Another group asked about incentives and what might replace the four hour target. Ms Silva said an interesting concept, and one she would like explored further, was around finessing the four hour target for elderly people with multiple problems.

‘I would caution against generalisations’

Was it the case, they asked, that the high level of admissions towards the end of the four hour wait (highlighted in their briefing) indicated that patients had not been dealt with earlier and admission was now the only option?

“I would caution against generalisations,” said Ms Silva. “We would never admit [a patient] to avoid a breach.”

In the first round of judging each team presented their solution for 10 minutes, followed by 10 minutes of questions from the judges.

They stood out

The two standout presentations considered A&Es as part of a system. A team from SDA Bocconi School of Management in Italy targeted “type 3 patients” – those who did not need an A&E. Take these out of the system, they said, and A&Es could do the work they were designed for.

Their first proposal was to improve NHS 111 and GP services so that patients could see a GP more easily. Controversially, they proposed a co-payment of £20 for a “fast track” service for patients who wanted an urgent primary care appointment quickly.

Integral to their plan was introducing lean thinking to A&E and empowering triage nurses to turn away patients who should be seen elsewhere. They wanted to reform the workforce by incentivising F1 and F2 doctors to rotate through the emergency department, using money from the budget currently spent on locums.

‘A public awareness campaign would be needed to stimulate behavioural change’

Pre-hospital care should also be improved, they proposed, with remote diagnostics such as ultrasound and blood tests available on ambulances. IT would also play a part: they proposed a new “iTriage” service based on phone contact with the patient coupled with past medical history from their record.

They wanted to add an e-booking app to allow visibility of GP appointments.

They also proposed a control centre that would bring together the IT and administration teams into one place. This, they said, would centralise bed management and booking services such as theatre and scans.

Finally, they said a public awareness campaign would be needed to stimulate behavioural change.

Big front door

The second outstanding presentation was from the team from Manchester’s Judge Business School, which took a similarly broad look.

They argued that the NHS’s A&E was a strong and trusted brand that is too often misused. It made sense to build the services that people want behind the brand, the group said.

They wanted to “change A&E to match people’s expectations” by removing the need for patients to navigate a complex system by managing flows better and creating a “unified care centre”.

‘They wanted to create a unified care centre by managing flows better’

So, for example, they proposed a “big front door” to the A&E, in which patients would be immediately streamed by a front desk staffed by senior clinicians, moving quickly to the right level of care.

Some patients would be diverted to self-care booths, modelled on self-service banking, where they could receive advice. They called this “medlink” and proposed that the booths would be available not just in A&E but also in pharmacies, allowing patients a video link to clinicians who could be based anywhere, even overseas, with access to patient records.

In time, these could be equipped with technology such as no needle blood testing and T-rays (an alternative to X-rays).

They also proposed a “Big Green Bus” to take hospital care to those who might be admitted for alcohol issues. These would provide frontline medical services and be equipped with voice recognition technology to remove the need for physical note taking.

At the end of the day – and following a final challenge to spell out which of their innovations could be introduced quickly – the team from Manchester won.

It was, said the judges, a very close call. As Nigel Edwards, chief executive of the Nuffield Trust, said: “If we were able to take elements of the two and put them together, then we really might have something.”